LECTURES 
ON THE 
PRINCIPLES OF SURGERY, 
f 
BY 
JOHN HUNTER, F.R.S. 
WITH NOTES 
BT 
JAMES F. PALMER, 
SENIOR SUUGEOS TO THE ST. GEORGE'S AND ST. JAMEs's DISPENSARY, FKUOW 
OF THE ROYAL MEDICAL AND CHIRURGICAL SOCIETY OF LONDON, 
ETC., ETC. 
Wlatotyhta: 
HASWELL, BARRINGTON, AND HASWELL, 
293 MARKET STREET. 
1841. PREFACE. 
The following Lectures are printed from a very full 
and accurate copy, taken in short-hand by Mr. Henry 
Rumsey of Chesham, to whom I am indebted for the per- 
mission to make them public. They were delivered in 
the years 1786 and 1787, after which period I have not 
found any copy, excepting a very short and imperfect one 
in the Museum of the Royal College of Surgeons, dated 
1791, by Mr. James Pearce. There are also in the Col- 
lege Museum five other copies, which are respectively 
attributed to Mr. Twigge, Mr. Hopkinson, Mr. Parkinson, 
and Mr. R. Keate; the fifth being only a partial transcript 
of a copy by Dr. Joseph Adams, Mr. Hunter's biographer. 
Of all these, Mr. Parkinson's is by far the most full and 
accurate, although in these respects it falls very far short 
of the accuracy and fullness of Mr. Rumsey's copy, from 
which the ensuing lectures are printed. Indeed, from the 
fullness of the latter, one might almost suppose that the 
writer had had access to the Hunterian manuscript; for, 
besides being generally more full, it never omits examples 
and illustrations in proof of opinions, which the former 
ones frequently do. The style also is characteristically 
Hunterian. 
I am also indebted to Sir. Benjamin Brodie, to Professor 
Macartney, and to Mr. Frederick Tyrrel, for the use of 
copies in their possession, the first of which is ascribed to 
Mr. Howison, the second was taken by the Professor him- 
self, and the third by Mr. Robert Lees. The last of these 
(bearing date 1785 and 1786) is the most valuable, being 
not only the most full, but abounding with interlineations, 
which there is every reason to believe were added during 4 
PREFACE. 
an attendance upon a second course of the same Lectures. 
These last-mentioned copies, as well as Mr. Parkinson's, 
have been had recourse to whenever occasion required, but 
in general, and with very few exceptions, the printing has 
been conducted from Mr. Rumsey's. Occasionally it has 
been found necessary to retrench redundancies and repeti- 
tions, and to substitute one word for another having a 
synonymous signification. 
The value of these Lectures, I suppose, will not be 
questioned, nor the interest which attaches to them denied. 
Besides the luminous general views on Physiology and 
Pathology which they contain, they also abound in useful 
facts and the most valuable practical suggestions. In 
some respects they may be regarded as amplifications 
of his published opinions, but in other respects they enter 
upon entirely new subjects of the greatest interest to the 
Surgeon. 
The notes which accompany these Lectures are not nu- 
merous ; for as many of the subjects treated of will again 
come under consideration in the course of the Treatises, it 
seemed more convenient to refer any observations that 
might be required, to those parts of the work, in which 
the Author has expressed his opinions in his own un- 
doubted language. In the few observations which the 
Editor has deemed it necessary to make, he has sometimes 
had recourse to authorities, which he has not always 
thought it necessary to mention particularly. He trusts, 
however, that this general acknowledgment will obviate 
the suspicion of his wishing to appropriate unjustly the 
labours of other men. 
JAMES F. PALMER. 
38 Golden Square, April, 1835. CONTENTS. 
Chap. I. Introductory Remarks on the Study of Physiology, and on 
Physical and Vital Laws. 
II. Of Life. 
III. Of the Blood. 
IV. General Views of Organization and Action, 
V. Of the Functions of Nutrition and Absorption. 
VI. Of the Brain and Nerves, and of Sleep. 
VIL Of Susceptibility of Impressions ; of Stimuli; of Dispositions 
of the Body ; of Habit and Custom. 
VIII. Of the Heat of Animals. 
IX. General Principles of Disease. 
X. Of Sympathy. 
XI. Of Local and Constitutional Diseases. 
XII. General Principles of Inflammation, and of Ecchymoses. 
XIII. Of Adhesive Inflammation. 
XIV. Of Suppurative and Ulcerative Inflammation; Granulation; 
Skinning; Hectic Fever, and Dissolution. 
XV. Practical illustrations of the preceding subjects; Hernia ; 
Ruptured Tendons ; Phlebitis, &c. &c. 
XVI. Of Hydrocele; Diseased Testicle, &c. 
XVII. Of Gunshot Wounds and Injuries of the Head. 
XVIII. Of Diseases of the Bones and Joints ; Fractures ; Dislocations, 
&c. &c. 
XIX. Of Hemorrhages and Aneurism. 
XX. Of Specific Diseases ; Varicose Veins ; Tumours; Hydatids, 
&c. &c. 
XXL Of Scrofula; Lumbar Abscess; Scrofula of the Testicle and 
Breast, &c. &c. 
XXII.' Of Mortification and Carbuncle. 
XXIII. Of Poisons ; Itch ; Cancer; Fungated Ulcers, &c. &c. LECTURES 
ON THE 
PRINCIPLES OF SURGERY. 
CHAPTER I. 
INTRODUCTION. 
Introductory remarks.-These lectures to contain the results of Mr. Hunter's own 
observation;-intended to explain the general principles of the art;-these the 
necessary guides to practice.-Mr. Hunter's opinion of operations;-motives 
for lecturing.-To commence with some account of physiology.-Preliminary 
observations on matter;-its general properties;-our perception of matter: - 
attraction ;-repulsion;-properties added to constitute organized matter.-Of 
animal and vegetable matter ;-its origin in, and return to, common matter ;- 
but distinguished from it by peculiar properties ;-growth;-propagation of 
the species:-existence under two states, the living and the dead;-three 
modes in which it may be considered : 1st, Living; §d, Chemically when 
dead; 3d, Ina state of decay, and return to common matter.--Errors of for- 
mer physiologists, in explaining vital actions by mechanical or chemical ope- 
rations;-this error to be corrected.-Consideration of animal matter in par- 
ticular ;-and especially of the human body;-but information to be drawn 
from other animals and vegetables;-also from diseases and malfornaations. 
Mr. Hunter used generally to commence by stating that it was 
his intention, in these lectures, to give only the results of his own 
observations and experience, because the opinions of others might 
be found in their works. I do not mean, said he, that all I say in 
this course will be entirely new, and that none of the opinions and 
observations which I shall deliver are to be found in any publica- 
tions, for there are many facts too obvious to have been overlooked 
in the most ignorant days of physic. I intend in this course to in- 
clude some of the most interesting parts of surgery, principally those 
subjects on which I have had opportunities of making many new, 
and I hope useful observations, so as to put our art, in many re- 
spects, in a new point of view. Many of my ideas, and the ar- 
rangement of my subject, are new, and consequently my terms 
become in part new, for two ideas cannot be expressed in the same 
terms. I am led to suppose my ideas are just, because they have 8 
HUNTER'S PRINCIPLES OF SURGERY. 
in some measure stood the test of time; and what is the most in- 
contestible proof of their correctness is, that they have been adopted 
by others ; and I hope my terms will be found expressive of the 
things meant, and that they are so appears evident, from their 
having been employed in several late publications on surgery. 
I do not intend to give my lectures as a regular course, but rather 
to explain what appear to me to be the principles of the art, so as 
thereby to fit my pupils to act as occasion may require, from com- 
paring and reasoning on known principles. I shall suppose you 
already acquainted with the structure of the parts of the human 
frame, and must observe, that a knowledge of the healthy and 
diseased actions, or, in other words the principles of our art, are 
not less necessary to be understood than the principles of other 
sciences; unless, indeed, the surgeon should wish to resemble the 
Chinese philosopher, whose knowledge consisted only in facts. In 
that case the science must remain unimproved until fresh facts 
arise. In Europe philosophers reason from principles, and thus 
account for facts before they arise. Too much attention cannot be 
paid to facts ; yet too many facts crowd the memory without ad- 
vantage, any further than that they lead us to establish principles. 
By an acquaintance with principles we learn the causes of diseases. 
Without this knowledge a man cannot be a surgeon. Surgeons 
have been too much satisfied with considering the effects only; but 
in studying diseases we ought not only to understand the effect, as 
inflammation, suppuration, &c., but also the cause of that effect; 
for without this knowledge our practice must be very confined, and 
often applied too late, as in many cases it will be necessary to pre- 
vent the effect. In the bite of a mad dog, for instance, the disease 
will be prevented by removing the part; in the venereal disease, in 
the case of chancre, we must not only know how to cure the chan- 
cre, but also to prevent its effects on the constitution, which is done 
by giving mercury internally. On the other hand, it would be often 
proper to increase the effect, which can only be done when we 
know the cause.* In many cases, where the effect could not be 
* [By the " law of nature" is meant the invariableness or uniform constancy 
of certain results following certain given conditions, the agents (which for the 
most part are unknown and invisible), being denominated the cause, the resulting 
phenomena the effect, and the conditions under which that effect is produced, the 
law. Thus, all bodies fall to the earth, and all bodies also suffer an expansion 
of their particles by the application of heat. Here the principles of gravitation 
and heat are the causes, the descent and expansion of the bodies, the effects, 
and the rates according to which these effects take place, the laws of gravitation 
and heat. Causation is attributed merely in consequence of the invariableness 
of the phenomena, and not in consequence of any knowledge which we possess 
of the intimate relation of causes and effects. 
It is not in general difficult to deduce the laws of physical agents, in conse- 
quence of the power which we possess of simplifying and varying the condi- 
tions of our experiments, so as in the first instance to separate all extraneous 
influences or disturbing causes, and in the second place to verify the results thus 
obtained by every possible combination of opposing circumstances. Such cer- 
tainty, however, is rarely attainable in regard to organised bodies in consequence INTRODUCTION. 
9 
prevented, or afterwards either removed, diminished, or increased 
with advantage, it will be proper to change it to some other more 
in our power to remove, as, for instance, by converting the vene- 
real into common inflammation. If the disease is already formed, 
we ought to know the modes of action in the body and in parts, in 
their endeavour to relieve themselves; the powers they have of 
restoring themselves, and the means of assisting those powers. Or, 
if these prove insufficient, we judge, by all the attending circum- 
stances, how far excision may be necessary, and what condition of 
the constitution is most favourable for an operation. To determine 
on this last point is exceedingly difficult, and in some instances 
exceeds our present knowledge. I lately saw a patient die in a few 
hours, of no other operation than the excision of a small tumour 
from the arm ; another, by the removal of one from the abdomen; 
a third, by castration; and within these two days I assisted at an 
operation for fistula in perinseo, sixteen hours after which the pa- 
tient died. Now all these patients seemed previously in good health, 
and perhaps the cause of death, and the particular circumstances 
of the constitution which render operations thus hazardous, will 
never be understood. 
This last part of surgery, namely, operations, is a reflection on 
the healing art ; it is a tacit acknowledgment of the insufficiency 
of surgery. It is like an armed savage who attempts to get that 
by force which a civilized man would get by stratagem. No sur- 
of the reaction of the parts of which they consist upon one another, and the 
consequent impossibility of observing the effects of organic agencies in their 
simple state. The conditions under which any given class of phenomena are 
observed are continually varying, and a variety of extraneous causes are mixed 
up in almost every case, so that, from the most careful experiments, it is still 
extremely possible to mistake the conclusion, and to deduce laws which are 
expressive only of a part of the facts. These circumstances afford no just 
ground for under-valuing physiological principles, although they are calculated 
to inspire a wary caution in arguing with too much positiveness from principles 
of this kind. We would say, " Est quodam prodire tenus si non datur ultra." 
It is scarcely necessary to observe that causes differ greatly among themselves. 
It would be absurd to confound the principle of heat, the expansion of steam, 
and the machinery by which the power thus generated acts, as causes of the same 
kind. The remote and the proximate cause in such a case have no immediate 
relation, but are connected together by a number of intermediate circumstances 
which, like the steps of an argument, unite the conclusion to the premises. It is 
very necessary to bear this in mind in physiological reasoning, in consequence of 
our almost total ignorance of these intermediate links in the chain of causation. 
In the instance above adduced by the author, we have no knowledge of the mode 
in which the poison of a rabid animal, or the poison of syphilis, produce their 
effects on the animal body ; nor how mercury and other medicines should tend to 
eradicate the latter from the constitution. We are unable in these cases to 
advance a step further than to perceive the necessity of absorption of the poison, 
after which all is conjecture. A full perception of the whole sequence of effects 
would doubtless at once discover the precise nature of the remedy, as well as 
the proper cases in which it should be administered. 
These few observations have been made in consequence of the indefinite and 
not very philosophical manner in which Mr. Hunter sometimes employs the 
word cause. The final and efficient causes are frequently confounded.] 10 
HUNTER'S PRINCIPLES OF SURGERY. 
geon should approach the victim of his operation without a sacred 
dread and reluctance, and should be superior to that popular eclat 
generally attending painful operations, often only because they are 
so, or because they are expensive to the patient. 
Mr. Hunter next mentioned his motives for lecturing; showing 
that he did not do this with a view to pecuniary gain, since the 
time thus expended might be employed more profitably in extending 
his connexions and enlarging his practice. I have seen, said he, 
as much practice, and made a larger collection of diseased prepar- 
ations than perhaps any man in Europe, all of which I find to cor- 
respond with the opinions I have formed of the nature of the re- 
spective diseases. In the years 1761 and 1762, having been already 
engaged ten years in the profession, I attended the army, without 
which I should have been unable to give my opinion concerning 
gunshot wounds, which rarely occur in civil practice. Tn the year 
1768 I was called upon to be a teacher of anatomy, but I congra- 
tulate myself that I did not become so, as it could not have failed 
of engaging my attention too much to admit that general attention 
I have been able to pay to surgery; and the necessity I should 
have been under to read might have occupied me too much, and 
prevented my forming habits or established modes of thinking.- 
In the years 1772, 1773, and 1774, I had frequent opportunities of 
giving my opinion in private, and had generally the satisfaction to 
be heard with candour. Since I have lectured, I have scarcely 
found a pamphlet without some of my opinions, and often my very 
language, as adhesive and suppurative inflammation, &c. But 
what more than all induced me to lecture, was the great advantage 
every one finds by putting his thoughts into writing. A man can 
never tell how much he knows till he arranges his knowledge, and 
then he can tell how defective it is; hence it is that almost all the 
authors of any consideration in physic have been public teachers. 
In the present lectures it is my intention to begin with the physi- 
ology of the animal economy in its natural or healthy state ; and 
then to come to pathology, or the physiology of disease, which 
may be called the perversion of the natural actions of the animal 
economy. Amongst the lattei' I shall treat first of accidents the 
most simple or natural, or diseases spontaneously arising; next, of 
the means of restoration, on which I shall be particularly full,-of 
these the first is adhesive inflammation, commonly called healing 
by the first intention ; then of inflammations tending to suppura- 
tion, granulation, and cicatrization: after these I shall consider the 
specific diseases, as locked jaw, scrofula, &c.: the poisons next, as 
the venereal disease, cancer, &c. 
Of Matter; and first of the Distinction between Animate and In- 
animate Matter. 
I must now beg the close attention of the gentlemen present, as INTRODUCTION. 
11 
I shall be a little abstruse in the present lecture, which I intend as 
an introduction to all animal matter. 
Before we endeavour to give an idea of an animal, it is neces- 
sary to understand the properties of that matter of which an ani- 
mal is composed; but the better to understand animal matter, it is 
necessary to understand the properties of common matter; else 
we shall be often applying our ideas of common matter, which are 
familiar to us, to animal matter, an error hitherto too common, but 
which we should carefully avoid. 
By our senses alone is matter demonstrable. If a man did not 
see, he would have no conception that there was such a thing as 
light; if he was deaf, he could have no idea of sound ; if he had 
no touch, no taste, no smell, in short if he had no sensation at all, 
(which is easily conceivable), he would not know that there is 
such a thing existing as matter. On the other hand, it is from 
matter alone that we come to a knowledge of our senses ; so that 
the only proof of the existence of either is by their reciprocal 
effects. 
An animal, then, must be composed in such a manner as to be 
susceptible of impression, which impression consists of an alteration 
in the part impressed ; and matter must make the impression on us 
before we can become sensible of its existence. Matter is in itself, 
however, only an abstract idea, and it is not the matter itself but 
some of its properties which make the impression, as sourness, 
heat, &c. When we see a man, it is not the man himselr or the 
matter of the man that makes the impression, but the light which 
he reflects, and which our eye has the power of collecting to one 
point, so as to give a determinate shape on the organ of sight. 
Now the act of seeing is that impression made on our eye which 
gives us an idea of a body exterior to us, exactly similar to touch; 
it is an impression made of a given figure. Every man might be 
able to see simply with every part of the body as well as with the 
eye; for if you were to place before my skin a refracting glass, so 
that the image should be thrown on my body of the same shape as 
that which is exterior, if my feeling was so very delicate as to dis- 
tinguish this shape, it would give me the same idea as seeing. A 
drum has no sound in itself, but it has the power of putting the 
matter of the air into action, which produces the idea of sound by 
its impression on the organ of hearing. The sense of touch would 
appear most to contradict the above statement; but touch only 
arises from the resistance of matter, which resistance alters the 
form of the part touching, and the alteration causes feeling. If it 
was the matter itself which caused the sensation, we ought to have 
as many kinds of matter as we have of sensation ; but our sensa- 
tions correspond with the different properties of matter, not with 
the different kinds. 
But to return to my subject: by matter we mean all that com- 
poses this globe of the earth on which we live, and which is pro- 
bably formed of only a few substances differing in specific pro- 12 
HUNTER'S PRINCIPLES OF SURGERY. 
perties from each other, but which when compounded produce a 
very great variety, and of course these cause a great variety of 
sensations in us. Matter, thus compounded, appears to us in one 
of the three following states, a state of solidity, fluidity, or vapour. 
The first, or solidity, appears to be the natural state of matter; 
the other two seem to involve a kind of force, especially vapour. 
The first of the various properties of matter is attraction: of 
this there are many kinds, of which I shall first mention elective 
attraction, which is a disposition in all matter to unite with some 
particular kinds of matter rather than with others, forming with 
them a compound, which at the same time that it is a compound, 
seems homogeneous. Elective attraction can only take place when 
bodies are in a fluid state or in vapour; it would appear to be a 
kind of choice, and it is one of the most refined properties of com- 
mon matter, producing new compounds by a species of generation, 
but annihilating the old by the same action. This property is given 
to matter for the purpose of forming various regular solids and 
fluids of which the world is composed, and it is this that gives us 
such variety. 
Secondly. By a particular attraction, or by an increase of the 
same attraction, these parts are brought into closer approximation: 
this we call the attraction of cohesion, by means of which attraction 
bodies are kept in one mass. When bodies are so subdivided as 
to be reduced to their constituent particles, still each particle has 
its centre of gravity on which it may be said to move, from whence 
arises fluidity* So that a fluid would appear to be a body reduced 
to its original parts ; the attraction of cohesion is destroyed, but 
each particle has its centre of attraction or gravitation. As the 
centre of the globe attracts every particle of matter that is in it, 
so every mass of matter, simply as matter, has an attraction in its 
centre, by which it can bring bodies to it or keep them in contact 
with it. If we were to let drop some quicksilver, and it met with 
no resistance, it would assume a globular form : this is not from 
the attraction of cohesion, but from the attraction of gravitation. 
It must be observed, however, that where the attraction of cohe- 
sion is but slight, as in fluids, this will not take place, unless there 
is some affinity, as between acids and water, spirits of wine and 
water, &c. Water and oil will not unite by this species of attrac- 
tion when in a fluid state. 
There are other general properties which arise out of the attrac- 
tion of cohesion, such as figure, magnitude, &c. These properties 
are those which make bodies fit subjects for mechanics, but they 
are not the only ones necessary. A clock may be made correctly, 
but yet it will not go until we bring in some active power, such as 
gravitation, the raising of water into steam, &c. Thus we find 
something like the life of mechanics, which is not matter, but a 
property belonging to it; what is simply mechanical, that is made 
of inert matter, must have, as it were, a soul to put and continue it 
in motion. INTRODUCTION. 
13 
When all these properties have their full effect they produce va- 
rious other effects, and become the regulators of the whole mass, 
confining its motion, space, &c. 
These are some of the properties of common matter. How far 
repulsion is a universal principle I am not able to determine ; I 
should much suspect that it is not so general as the others. That 
there is such a principle in nature is evident, because neither flui- 
dity nor vapour could take place without it; perhaps heat is the 
great repulsive property, at least it counteracts attraction and 
produces repulsion amongst the particles of matter when diffused 
through it. 
Thus the matter of the globe is in general so regulated, by pro- 
perties stamped on it at first, that in its common actions it cannot 
err. But we find that matter has been carried much further in 
some other properties than in those just mentioned ; it has under- 
gone changes not in the least connected with oi' arising out of them, 
and its properties are of course entirely different; seeming, as it 
were, a monstrosity in the combination of matter. Its mode of 
continuance, by preparing within itself matter similar to itself, is 
entirely different. 
These changes produce the animal and vegetable or organic 
portion of the world. 
Of the Matter of Animals and Vegetables. 
Animal and vegetable matter has certainly arisen out of the 
matter of the globe, for we find it returning to it again. Both are 
subject to the laws mentioned above as regulating common matter, 
but they are so different, from their peculiar modification, as to 
appear at first like originally distinct species of matter; but they 
will be found, on investigation, to be only a new modification of 
matter. 
This change in the original principles of matter seems to be 
equally distinct both in animal and vegetable matter, and the first 
principle of action of those two substances seems to be in great 
measure the same ; however, there are marks by which they can 
be distinguished. The connexion of these two modifications of 
matter with common matter has never yet been traced, noi' has 
the gradual transition from one to the other been imagined ; and if 
those substances had not reverted into common matter by their 
decomposition, it never could have been suspected that they were 
originally composed of the same materials. For these reasons they 
have been ranked by themselves. 
Animal and vegetable substances differ from common matter in 
having a power superadded, totally different from any other known 
property of matter, out of which arise various new properties. 
Animals and vegetables have a power of action within them- 
selves, are capable of increasing their own magnitude, and possess 14 
HUNTER'S PRINCIPLES OF SURGERY. 
the power, as it were, of working themselves into form and a higher 
state of existence. This power of action and capability of increase 
requires a supply of materials, as well for the increase as for the 
waste arising from action. This supply appears not to be wholly 
the same in both, though perhaps it may be. The idea of a supply 
always supposes a resource distinct from the thing supplied, and no 
waste parts can ever perfectly revert into the thing itself without 
first going through all the changes which first brought it into a fit 
state. 
This supply is furnished by the materials of the globe. Vege- 
tables alone appear to have a power of immediately converting 
common matter into their own kind. Animals probably have not 
that power, therefore are removed further from common matter; 
so that a vegetable seems an intermediate step between common 
matter and animal matter. But observation will show that vege- 
tables can readily convert both animal and vegetable matter into 
their own substance, as in the case of dung, which increases the 
natural growth of plants.* 
Both have a power in propagating their kinds by a production out 
of themselves, by which means the stock is replenished. 
Both are capable of being in two states: one of these is the living 
state, which we have been considering, the other is the dead state. 
Hence both animals and vegetables are capable of being con- 
sidered in three ways. 1st, In their power of continuance and 
production, when possessed of their natural powers of action or 
life. 2d, In their nature chemically as matter, which can only be 
considered when they are dead. 3d, In their decay, or sponta- 
neous reduction to common matter, when life is gone.j In all 
these operations they are totally different from common matter. 
*[It is highly probable that the different proximate elements of vegetable and 
animal substances hold different ranks in the scale of organised substances, in 
the same manner that one animal ranks higher in the scale of organised beings 
than another. Thus, starch, sugar, and woody fibre among vegetable substances, 
and gelatin, albumen, and fibrin among animal substances, are raised, as it were, 
from one to the other by successive processes in the animal or vegetable econo- 
my ; so that fibrin may be regarded as the substance most highly animalized, or 
as possessing the distinctive properties of an animal substance in the highest 
possible degree. In this view, vegetable life, which subsists almost exclusively 
on carbonic acid gas, and graminivorous animals, which are able to extract nutri- 
ment from vegetable substances, may be regarded as subservient processes, 
intended to prepare the common elements of matter as nutriment for the more 
perfect animals,-which, however, afterwards undergoes a series of further pro- 
cesses in the bodies of these animals, in order to fit it for all the purposes of the 
economy. Sennebier and Saussure have satisfactorily shown that decayed 
organic remains do not nourish plants by being absorbed in their unmodified 
state, but by affording a more abundant supply of carbonic acid gas, which, in 
combination with water, forms the principal aliment of vegetables. There is 
no process in vegetables corresponding to digestion in animals, and hence the 
food of plants is spontaneously evolved by the natural processes of fermentation 
and putrefaction.] 
f [There are many other distinctions between organised and inorganised 
bodies, which, however, it is unnecessary to consider in this place.] INTRODUCTION. 
15 
The first distinction, or life, in which consists the power of self- 
preservation, is the antidote to the two last, since before either of 
these can take place the whole part must be deprived of the living 
principle. When in the first state, their actions are either natural, 
the whole being in harmony, and every part acting in concert with 
the rest, which is called health; or they are unnatural, which con- 
stitutes disease, the tendency of which is to destroy the whole. 
When chemically considered, both animal and vegetable matter 
are found to be acted on by different substances, or are capable of 
solution in other bodies, as concentrated acids, alkalies, &c., in 
which respect they are pretty similar to one another. Both are 
capable of being acted on by fire; but in this process we find each 
yielding some substances peculiar to itself;-animal matter when 
distilled yields water, volatile alkali, empyreumatic oil, and cal- 
careous earth;-besides these there is a small proportion of iron, 
which does not appear, however, to be a constituent part of the 
whole animal body, being chiefly procurable from the blood ; a small 
proportion of their substances may also be found in the blood.* 
In their decay, both animals and vegetables go through a series 
of regular spontaneous changes, the succeeding one arising entirely 
out of the first, and the next out of this, until the whole return to 
common matter from whence they arose, for to the earth they must 
return from whence they came. In this natural process we find 
animals and vegetables yield many substances not to be found in 
them before these changes, also not to be found in common matter. 
This process I call fermentation, and it is peculiar, I believe, to 
vegetable and animal matter. 
The processes carried on by chemistry and fermentation, which 
can only take place when the parts are dead, have been intro- 
duced by physiologists into the living animal economy; and, not 
satisfied with this, they have brought in mechanics to account for 
many of the operations of vegetables and animals. But, for the 
purpose of distinguishing more accurately between mechanical, 
chemical, and vital operations, and the circumstances under which 
the two first are applied to the living body, let us consider them a 
little further. 
The actions and productions of actions, both in vegetable and 
animal bodies, have been hitherto considered so much under the 
prepossessions of chemical and mechanical philosophy, that phy- 
siologists have entirely lost sight of life; and perhaps they have 
* [Vegetable substances are nearly all composed of oxygen, hydrogen, and 
carbon,-carbon, for the most part, being the preponderating ingredient. In 
some few examples nitrogen is likewise present. The proximate principles of 
vegetables, or those substances which exist ready formed in plants, are exceed- 
ingly numerous, as gum, starch, sugar, &c., amounting in the whole to not less 
than forty-five or fifty substances, characterised by different properties. Animal 
substances, on the contrary, at least all the principal animal substances, contain 
nitrogen as well as oxygen, hydrogen, and carbon, and the proximate elements 
are not so numerous as those of vegetables. The animal fats, which are consi- 
dered by many as a natural store of nutriment, contain no nitrogen, and therefore 
approximate to vegetable products.] 16 
HUNTER'S PRINCIPLES OF SURGERY. 
been led to this mode of reasoning because these properties are 
much more familiar, more adapted to our understandings, and more 
demonstrable than the living properties of organized beings. But 
unless we consider life as the immediate cause of all actions oc- 
curring either in animals or vegetables, we can have no just con- 
ception of either vegetable or animal matter. No wonder, then, 
that the theories of the older physiologists are ill built and ill sup- 
ported, their principles being false. Many of the effects both in 
animals and vegetables might at first sight appear to be chemical, 
or the consequence of fermentation. The production of many 
juices of plants, such as gums, acids, sugar, &c., would seem to be 
of this kind ; but all arise from natural actions of the vegetable, and 
do not belong to chemistry. No chemist on earth can make out of 
the earth a piece of sugar, but a vegetable can do it. Digestion, 
the formation of the blood, and all the secretions of an animal, might 
at first appear to be of this sort; but that they really are not chemi- 
cal products I am clearly convinced. If an ingenious man under- 
took to account for every change in matter by fermentation, there 
is no change in nature that might not be brought within his definition. 
The living principle itself would be shown to arise from fermenta- 
tion ; brain, muscles, bones would grow from fermentation, since 
they are all formed from the blood, and yet the blood is not found 
in them.-Of all things on the face of the earth definitions are the 
most cursed; for if you make a definition you may bring together 
under it a thousand things that have not the least connexion with 
it.* 
* [By the fermentation here spoken of is not meant that process of sponta- 
neous decomposition, occurring under the conditions of heat and moisture, to 
which the appellation is restricted by modern chemists, but a vague chemical 
disturbance, in the course of which a new and undefined arrangement of the 
elements was imagined to take place. 
Mr. Hunter, in his zeal for the vital principle, has probably gone too far in 
excluding the agency of chemical causes. There is not the least reason for sup- 
posing that the vital principle is able to confer new properties on matter, or to 
transmute one matter into another, so as indiscriminately to employ other sub- 
stances than those which it does for the repair of the body and its various secre- 
tions ; on the contrary, there seems every reason for believing that the elementary 
particles exert the same affinities under the influence of vitality that they do in 
the laboratory of the chemist, and that if it were possible to present these to 
each other out of the body under precisely the same circumstances that they are 
presented in the body, and in the requisite states and proportions, the same 
combinations would take place, and the same results would be produced. The 
vital principle may not perhaps improperly be compared to the principles of heat 
and electricity, which exert an influence over the affinities of matter without 
essentially altering its nature ; but the great distinction between organic and 
ordinary chemistry is not less in the nature of the agent than in the minute and 
appropriate apparatus by which that agent operates. All the processes of 
organic life, referable to this head, are executed, as it were anatomically, by an 
arrangement of parts infinitely small ; by which the affinities of the acting 
bodies are brought together in modes which cannot artificially be imitated by the 
chemist. The following observations by the reviewer of MM. Tiedemann and 
Gmelin's Treatise on Digestion apply to the present question:-"Je suis loin 
de nier qu'il y ait dans les actes du corps vivans quelque chose de special, INTRODUCTION. 
17 
What I call fermentation, only takes place in animal and vege- 
table matter when dead. It is that change which takes place in 
the substances themselves out of their own spontaneity, without any 
external assistance. Chemistry is a kind of force on things to de- 
compose them. In the process of fermentation, vegetable matter 
goes through intermediate stages, in which it is neithei' vegetable 
nor common matter; the same with animal matter during putrefac- 
tion. But in all the productions of a living animal or vegetable, 
the substances produced are animal or vegetable matter. The 
only substance produced in an animal which cannot be called ani- 
mal matter is the earthy matter of bones, and of some diseased 
parts :* it appears also that, in some of the secretions of animals, 
the products produced have none of the original properties of ani- 
mal matter, as the sugar of milk, the bitter principle in the bile, 
these not having been found in any of the natural solids or fluids 
by any process whatever. But this does not come up to my notion 
of fermentation, for no process of fermentation of animal or ve- 
getable matter ever produced either one or the other ; and even in 
vegetables, where sugar seems to constitute part of the plant, it is 
formed by the action of the vegetable. If ever any matter is formed 
in any of the juices secreted in any part of a vegetable or animal 
body similar to what arises from fermentation, we may depend on 
it it arose from that process, but we may also depend on it that 
there is a defect of the living principle in those cases, 
The conversion of water into vegetables, which is vegetation, or 
of vegetable and animal matter into animals, which is animalization, 
is not a change taking place according to the nature of the sub- 
stance, but is effected by the actions of the vegetable or animal. 
The different juices formed from the blood, called secretions, differ 
not from the nature of the blood as animal matter, all giving nearly 
the same substances when analysed, or subjected to fermentation. 
Nor can the substances formed in a vegetable be formed, by any 
process that we know of, from water.f We might suppose that 
fermentation would produce an animal from a vegetable, because 
in this change " a decomposition of matter and a new combination" 
is effected; but fermentation never could bring back dead animal 
or vegetable matter to living, so that it does not correspond to the 
quelqtie chose qui reconnait d'autres lois que celles qni regissent les corps bruts ; 
mais ces dernieres interviennent, sans aucun doute, plus qu'on ne le pense gene- 
ralement dans les functions de nutrition ; et c'est mieux servir la science de la 
vie de reconnaitre cet intervention, et de 1'etudier jusqu'a sot) extreme limite que 
devoir partout de la vitalite sans attacher a ce mot un veritable sens."] 
* [It is a question with some geologists whether linje is not essentially an 
animal product,] 
t [The refinements even of modern chemistry have not yet enabled us to form 
any animal or vegetable principle ab origine from any combination of the 
ultimate elements. The substance called oxalamide, obtained by Professor Fara- 
day from the oxalate of ammonia, approaches in character to an animal product, 
although it is not actually so. A few other examples of the same sort might be 
mentioned.] 18 
HUNTER'S PRINCIPLES OF SURGERY. 
above definition which has been given of it. This single circum- 
stance throws more light on the power of the stomach than we are 
yet aware of, for dead matter subjected to it is not obliged to un- 
dergo any change as matter, but goes through that process which 
produces life.* 
In treating of an animal body I shall always consider its opera- 
tions, or the causes of all its effects, as arising from the principle 
of life, and lay it down as a rule that no chemical or mechanical 
property can become the first cause of any of the effects in the ma- 
chine. But as all animals have form and motion, which motion is 
directed by that form, these motions become mechanical, so that 
every motion may be truly called mechanical. Mechanics are 
therefore introduced into the machine for many purposes. The 
living principle, however, in itself is not in the least mechanical, 
neither does it arise from, nor is it in the least connected with, 
any mechanical principle. 
Having thus given a general idea of these singular combinations 
of matter, I shall now confine myself to animal matter. But before I 
treat of the diseases of the animal body, which is the intention of 
these lectures, it will be necessary to give such general ideas of the 
subject, and to lay down such axioms and propositions, as will 
enable you to follow me through all the necessary descriptions of 
preternatural actions of the machine. This matter we must consider 
in two points of view: 1st, in its production; 2dly, in its con- 
tinuance. This leads me into a new field, and exhibits properties 
very different from all the other properties of matter. It will be 
necessary, I say, to have clear and distinct ideas of the difference 
between animate and inanimate matter, in order to know when and 
where the animal principle acts, and when other principles are made 
use of in an animal body in accomplishing all the different purposes 
of life. The human body is what I mean chiefly to treat of; but I 
shall often find it necessary to illustrate some of the propositions 
which I shall lay down from animals of an inferior order, in whom 
the principles may be more distinct and less blended with others, oi' 
where the parts are differently constructed, in order to show from 
* [There are grounds, I think, for believing that the first rudiments of life, or 
the revivication of dead animal matter, actually commences in the stomach.- 
Digestion, however, is a complicated chemical process, and not of that simple 
kind that might be inferred from Mr. Hunter's language. (See Tiedemann and 
Gmelin, and Prout.) The transformation or passage of common matter under 
the empire of physical laws to living matter which exists in defiance of those 
laws, is a mystery which will perhaps never be completely understood. So far 
as observation has gone, the steps of this transformation are gradual and compli- 
cated ; the products of each successive process always advancing from a lower 
to a higher degree of animalization. If therefore we regard life as a super- 
added principle, we cannot but observe that it is communicated to common matter 
only in proportion as this matter is animalized. In short, certain conditions of 
the recipients of life seem necessary before it can be communicated, and the 
higher the manifestations of life the higher are these conditions. The manifes- 
tation of intellect in proportion to the development of the brain presents an 
example very analogous.] ON THE VITAL PRINCIPLE. 
19 
many varieties of structure, and from many different considerations, 
what are the uses of the same parts in man; or at least to show 
that they are not for the uses which have been commonly assigned 
to them; and as man is the most complicated part of the whole 
animal creation, it will be proper in the first place to point out 
general principles common to all this species of matter, that I may 
be better understood when 1 come to the more complicated machine, 
namely, the human. Besides having recourse to many of the inferior 
orders of animals for the elucidation of some of the phenomena of 
the more complicated orders, we are also obliged to Disease for 
many of our hints on the animal economy, or for explaining the ac- 
tions of parts, for the wrong action of a part often points out what 
the natural action was, and itself gives an idea of life. Disease 
often corrects our imagination and opinions, and shows us that such 
and such parts cannot have the uses commonly attributed to them, 
and therefore brings us a step towards the knowledge of the true 
use. Monstrosities contribute to rectify our opinions in the same if 
not in a more intelligible manner. A monster is either from a defi- 
ciency of parts which can be produced from art (and often is from 
necessity, as in operations), or else from a modification caused by 
a wrong arrangement or construction of parts, which will produce 
an unnatural action, by which means the natural action may be 
known. 
CHAPTER II. 
ON THE VITAL PRINCIPLE. 
Difficulty of conceiving of this principle ;-complex in its effects, but simple in 
its essence; not the result of any perceptible arrangement of matter;-may 
result from a peculiar arrangement of the ultimate particles, giving rise to a 
principle of preservation;-this the simplest idea of life;-illustrated by 
magnetism in iron.-Erroneous comparison of life to mechanical powers.- 
Action not an essential property of life.-Life without action ;-vitality of 
an egg;-experiments;-but action promotes the continuance of life.-Seem- 
ing exceptions to the preservative power of life;-peculiar form of putrefac- 
tion in certain bodies; death of a part of the body previously to general death. 
Animal matter is endowed with a principle called, in common lan- 
guage, life. This principle is, perhaps, conceived of with more 
difficulty than any other in nature, which arises from its being more 
complex in its effects than any other; and it is therefore no wonder 
that it is the least understood. But although life may appear very 
compounded in its effects in a complicated animal like man, it is as 
simple in him as in the most simple animal, and is reducible to one 
simple property in every animal.* 
* [It is considered by many, and perhaps truly; that we are not yet prepared 
for a generalization of so high a kind, or at least that it would be more conve- 
nient for the analysis of vital phenomena to consider life as made up of several 
principles differing in their nature.] 20 
HUNTER'S PRINCIPLES OF SURGERY. 
I have observed that animal matter may be in two states; in one 
it is endowed with the living principle, in the other it is deprived of 
it. From this it appears that the principle called life cannot arise 
from the peculiar modification of matter, because the same modifi- 
cation exists where this principle is no more. The matter ab- 
stracted from life appears at all times to be the same, as far as our 
senses and experiments carry us. Jf life arose out of this peculiar 
modification, it would not be destroyed until the modification was 
destroyed, either by spontaneous changes, as fermentation, or by 
some chemical processes ; and were it destroyed by the last, it 
might sometimes be restored again by another process. Life, then, 
appears to be something superadded to this peculiar modification of 
matter; or this modification of matter is so arranged that the prin- 
ciple of life arises out of the arrangement, and this peculiar dispo- 
sition of parts may be destroyed, and still the modification, from 
which it is called animal matter, remain the same. If the latter be 
the true explanation, this arrangement of parts, on which life 
should depend, would not be that position of parts necessary to the 
formation of a whole part or organ, for that is probably a me- 
chanical, or at least organical, arrangement, but just a peculiar 
arrangement of the most simple particles, giving rise to a principle 
of preservation ; so that matter so arranged could not undergo any 
destructive change till this arrangement were destroyed, which is 
death. This simple principle of life can with difficulty be con- 
ceived ; but to show that matter may take on new properties without 
being altered in itself as to the species of matter, it may be not im- 
proper to illustrate this idea by such acquirements in other matter. 
Perhaps magnetism affords us the best illustration we can give of 
this. Iron appears at all times the same, whether endued with this 
property or not; magnetism does not seem to depend on the for- 
mation of any of its parts. A bar of iron without magnetism may 
be considered like animal matter without life; set it upright and it 
acquires a new property, of attraction and repulsion, at its different 
ends. Now is this any substance added; or is it a certain change 
which takes place in the arrangement of the particles of iron giving 
it this property ? If we take a piece of glass, it is transparent; we 
break it into a thousand pieces and it becomes white. Whiteness 
is not a new matter added to it, but a property arising from its being 
composed of a number of small pieces. 
It was not sufficient that animal matter should be endowed with 
this first principle, the principle of preservation, it was necessary 
that it should have action or motion within itself. This does not 
necessarily arise out of the arrangement for preservation; on the 
other hand, the arrangement for preservation, which is life, becomes 
the principle of action, not the power of action, for the power of 
action is one step further. The power of action must arise from a 
particular position of those living parts, for before action can take 
place the matter must be arranged with this view. This is generally 
effected by the union of two or more living parts, so united as to ON THE VITAL PRINCIPLE. 
21 
allow of motion on each other, which motion the principle of action 
is capable of effecting when so disposed. A number of these sim- 
ple acting parts, united, make a muscular fibre; when a number of 
these are put togethei' they form a muscle, which, joined with other 
kinds of animal matter, as tendon, ligament, composes what may be 
called an organ. Thus, too, by the arrangement of the living par- 
ticles, the other organs of the body are formed, their various dis- 
positions and actions depending on the nature of the arrangement, 
for action is not confined to muscle, the nerves also have action 
arising from the arrangement of their living particles.* 
The principle of life has been compared to the spring of a watch, 
or the moving powers of othei' machinery; but its mode of exis- 
tence is entirely different. In a machine the power is only the 
cause of the first action or movement, and thereby becomes the 
remote cause of the second, third, &c.; but this is not the case 
with an animal; animal mattei' has a principle of action in every 
part, independent of the others, and whenever the action of one part 
(which is always the effect of the living principle,) becomes the 
cause of an action in another, it is by stimulating the living prin- 
ciple of that other part, the action in the second part being as much 
the effect of the living principle of that part as the action of the first 
was of the living principle in it. The living principle, then, is the 
immediate cause of action in every part; it is therefore essential to 
every part, and is as much the property of it as gravity is of every 
particle of matter composing the whole. Every individual particle 
of the animal matter, then, is possessed of life, and the least ima- 
ginable part which we can separate is as much alive as the whole. 
The first, and most simple idea of life, I have observed, is its 
being the principle of self-preservation, preventing matter from 
falling into dissolution,-for dissolution immediately takes place 
when matter is deprived of it; and the second is its being the prin- 
ciple of action. These are two very different properties, though 
arising from the same principle, the first being capable of existing 
independently of the second; for it may be observed, that it is not 
necessary for the preservation of animal matter that there should 
be action in all parts, for many parts of an animal appear to have 
* [This opinion concerning- the unity of the principle of life has already been 
shortly adverted to. It may perhaps be illustrated by referring to the powers 
of common matter, which are not one, but many. There seems good reason for 
considering the different kinds of attraction as modifications of a higher principle, 
and the best reason for believing that magnetism, common electricity, and 
galvanism proceed from the same source, or at least are essentially identical ; 
the same is highly probable in regard to the powers of life; in analysing 
physical phenomena, however, it is found far more convenient to consider the 
powers above mentioned separately, and it cannot be doubted that physiologists 
would derive equal advantage from pursuing a similar method. According to 
the author's representation, the modifications of life result simply from differ- 
ences in the organised apparatus, through which it manifests its effects, nearly in 
the same way as mechanical force may be made to produce the most different 
effects, according to the kind of machinery which is employed.] 22 
HUNTER'S PRINCIPLES OF SURGERY. 
little action, yet they are as much endued with life as the more 
active parts; such, for instance, as tendons, elastic ligaments, &c. 
A fresh egg is a body which, it must be allowed, has no vital 
action; yet an egg is as much alive as an animal, which I shall 
endeavour to illustrate by observation and experiment. I was led 
to this opinion in the year 1757, when I was making drawings of 
the growth of the chick in the process of incubation. I then ob- 
served, that whenever an egg was hatched, the yolk, which is not 
diminished in the term of incubation, remains sweet to the last, and 
that part of the albumen which was not employed in the growth of 
the chick was perfectly sweet some days before the hatching, 
though both had been kept at a temperature of 103° in a hen's nest 
for three weeks. But if the egg did not hatch, I observed that it 
became putrid nearly in the same time that other dead animal 
matter does. 
To determine how far eggs would stand other tests of the pre- 
sence of the living principle, I made the following experiments: I 
put an egg into a freezing mixture about zero, and froze it, and then 
allowed it to thaw. From this process I conceived that the pre- 
serving power of the egg must be lost, which proved the case. I 
then put the egg into a freezing mixture at 15°, and with it a new- 
laid one, to make the comparison on that which I should call alive, 
and the difference in the time of freezing was seven minutes and a 
half, the second one taking so much longer to freeze. 2d. I put a 
new-laid egg into a cold between 17° and 15°; it took about half an 
hour to freeze: when thawed I put it into an atmosphere only at 
25°; it froze in half the time, which it should not have done, nor 
even in half an hour, if had not been killed by the first experiment, 
for the atmosphere now was not so cold as in the first experiment 
by nine degrees. These experiments show that the egg, when 
living, has a power of resisting cold, which, when killed by freezing, 
it has not. 
To determine the comparative heat of a living and dead egg, 
and to determine whether a living egg be subject to the same laws 
with the more imperfect animals, I made the following experiment. 
I took a fresh egg, and one which had been frozen, and put them 
into a cold mixture at 15°. The thawed one soon came down 
to 32°, began to swell and congeal: the fresh one sunk to 292°, as 
happens to living animals, and in twenty-five minutes after the dead 
one froze. Another reason for supposing it dead was, that before 
freezing took place it rose to 32°, as other fluids do which are 
brought below their freezing point. 
From these observations and experiments, it must appear that a 
fresh egg has a power of resisting heat, cold, and putrefaction ; and 
similar results are come to by similar experiments on some of the 
more imperfect animals, which we shall have occasion to notice 
hereafter. 
It would appear, then, that life is not action, but it is continued or 
supported by it when it takes place. Action creates a necessity of ON THE VITAL PRINCIPLE. 
23 
support, and furnishes it. It is not necessary that action should 
continue in all parts ; in some it is only necessary that the principle 
and power of action should be continued, but in others it is necessary 
that action should take place even for the preservation of the prin- 
ciple of action. Action is necessary for the various purposes for 
which the animal is intended, and if one species of action takes 
place, it brings the whole into action, as all the parts and actions of 
an animal body are dependent upon one another. If the heart acts, 
the lungs must fulfil their part; the stomach must digest, the other 
parts subservient to this organ must be put in motion, and the secre- 
tory organs, nerves, and voluntary muscles. The whole is thus set 
in motion to produce some ultimate effect, which appears to be the 
propagation of the species, for preservation (of the individual) can- 
not be called the ultimate effect. 
I have asserted that life simply is the principle of preservation in 
the animal preserving it from putrefaction; but there is a curious 
circumstance attending life which would appear to be contradic- 
tory to itself. Life is the preserver of the body from putrefaction, 
and when life is gone putrefaction would appear soon to begin. 
But this is not uniform ; it is sooner in some cases than in others; 
therefore there must be some other cause than the simple depriva- 
tion of life to account for this difference of time. In the most 
striking instances of rapid putrefaction after death, it does not 
appear to arise from the process of putrefaction having gone to 
some length before total death took place, for in those who die of 
putrid fever the smell becomes less offensive before death, and 
when life is gone they do not go into putrefaction as soon as might 
have been expected, and not nearly so fast as many who had not 
the least tendency this way before death. The tendency to putre- 
faction in those whilst living would appear to be part of the disease, 
but does not become putrefaction, and on dying they appear to lose 
that tendency, and to become like other bodies. However, it is 
disputed whether, in putrid fever, there is really any putrid matter 
formed.* 
But there is a process or an action in life which predisposes the 
body for many diseases, and which becomes the remote cause of 
them ; and there is an action in life which disposes the body for a 
species of putrefaction (or decomposition) when dead, and very 
probably death is the effect of this action in these cases. In these 
cases the body immediately after death becomes emphysematous; 
this emphysema, though it does not occur during life, would yet 
appear to be an effect of life, for it depends on disease as the body 
is dying. It is not genuine putrefaction; for, when the process is 
ended, the body keeps nearly as long as if no such process had 
taken place. It occurs immediately after death, or perhaps in the 
act of dying. The process itself seems to continue when the body 
* [The offensive exhalations here alluded to may probably, in great part, be 
referred to the excretions, which show a great tendency to run into rapid decom- 
position.] 24 
HUNTER'S PRINCIPLES OF SURGERY. 
is warm; after a time it stops, and the body remains stationary, 
until it sets out, as it were, for a second time to become putrid. 
What diseases this is to be classed with I do not know. To ascer- 
tain the causes of it with precision, it would be necessary to know 
the persons when alive, the disease of which they died, and the 
time when the putrefaction occurred after death. I have myself 
seen several very remarkable instances of its occurrence. The first 
was that of a young lady about four months gone with child, who 
in March or April, about two or three in the afternoon, was sud- 
denly taken ill with a fit, of which she shortly died. She was 
opened the next morning at seven o'clock, when the body was 
found swelled with air extravasated in the cellular membrane; the 
mesentery, intestines, liver, and heart were loaded with air, the 
blood worked out of the larger vessels mixed with air, and the body 
had become very offensive. 
Another case of the kind occurred at St. George's Hospital, in a 
man who had an encysted tumour in the upper belly of the right 
rectus muscle, which contained a fluid: it was opened on Friday, 
and on the Monday following, in the evening, he became ill, and 
died at one o'clock. He was opened seventeen hours after death, 
and was found emphysematous, just as in the former case. 
This appears to be similar to what is commonly termed sphacelus, 
being a species of mortification occurring before death, or in the 
act of dying. 
That the mode of dying assists the process of putrefaction is 
evident in common mortification, which will be noticed when on 
that subject, and I may illustrate it further by relating what took 
place in a case of operation for aneurism. 
A man at St. George's Hospital had the operation for popliteal 
aneurism performed. The artery was tied just where it passes 
through the tendon of the triceps muscle. The case went on well 
till the sixth day, when ulceration took place in some part of the 
artery which was not united: considerable bleeding took place, 
and recurred several times afterwards, by which so much blood 
was lost as to become in the end the cause of death. Immediately 
after the first bleeding, I observed the foot and leg of the diseased 
side to become cold as high as the middle of the calf, while it was 
warm about the knee, ham, and upper part of the leg. The lower 
part of this leg ever after remained cold, and did not in the least 
change in appearance, from which I conjectured that it was dead, 
not mortified (for there is a material difference). I suspected it was 
dead as in common death. He became weaker and weaker every 
day, and died about four days after. Before he died, the upper 
parts of the leg, which had gone on with life a little longer, were 
mortified, that is, they showed evident signs of such a change 
taking place; a vesication formed, discharging a bloody serum, and 
they became darker, as if blood was diffused in the cellular mem- 
brane, and oedematous, or, rather, emphysematous. A very short 
time after death these parts became putrid, while the lower part of ON THE VITAL PRINCIPLE. 
25 
the leg and foot remained unaltered as in common death. Here 
was a part which just died for want of circulation, therefore no 
action took place in that part; but above, where there was action, 
a very different change took place, producing a tendency to putre- 
faction after total death had taken place. The part which died 
naturally without any action did not become putrid, while the part 
in which that peculiar action took place became putrid directly, 
though it died later. I took off the two feet, to see which of them 
would become putrid first; for some time it was difficult to perceive 
any difference, but about sixteen days after, the foot on the sound 
side began to turn green, and went on to putrefy much faster than 
the other. 
The whole of this part of the case is extremely curious. First, 
that part of the leg which retained life longest became putrid 
immediately after death, because during life it took on actions 
which were productive of putrefaction. The foot of the diseased 
side, which died early, was not allowed time to take on any actions 
while living, excepting perhaps that resulting from the stimulus of 
death, and did not become putrid so soon as the foot on the sound 
side, which may be said to have died a natural death, and which 
died later. This I think may be accounted for by supposing that 
the latter, from surviving some time longer, took on some of those 
actions which gave the tendency to putrefaction. It may be neces- 
sary to explain what I mean by the stimulus of death. Death itself 
produces an action in all the muscular parts when there is nothing 
to prevent it. If a man's head be cut off, he becomes stiff; he is 
not stiff while there is real life: for there is a difference between 
visible life and real life. A part may be living though notin action; 
but whenever death takes place it excites an action in every part 
that is muscular: they contract, and this is the action of death. To 
cease breathing is not the action of death, though certainly it is the 
first step towards it, and gives rise to the other. The action of 
real death is that which takes place in the stiffening of the body, 
and till then it is not dead (except when killed in a peculiai' man- 
ner-killed universally before the stimulus of death can be given,- 
and then it remains lax). 
I suppose, then, that this foot, which died first from the loss of 
blood, became stiff; that is, took an action resulting from the stimulus 
of death, all the muscular parts contracting;-that in the other foot 
the stimulus of death was in some measure lost, from the longer 
continuance of the diseased state, and the consequent action was 
less strong. What would be the consequence of this ? I take a 
man in perfect health, and cut off both his legs; to one I give a 
stroke of electricity sufficient to kill the part before it contracts, and 
no contraction takes place; the other I leave to itself and let the 
stimulus of death produce contraction: this latter shall not become 
putrid so rapidly as the former. 26 
HUNTER'S PRINCIPLES OF SURGERY. 
CHAPTER III. 
THE BLOOD. 
Reasons for its fluidity ;-erroneous views respecting its nature.-Animaliza- 
tion and vivification two distinct steps in the conversion of foreign matter into 
part of a living body.-Blood not merely fluid animal matter;-has also 
become vivified ;-arguments for this opinion.-Coagulation of blood ;-its 
importance in determining the nature of blood;-varieties in the process.- 
Case proving the life of the blood.-Death of the blood preventing coagula- 
tion. 
What I have had hitherto principally in view has been the solid 
animal matter, its formation, and its arrangement by which it is 
endued with life, composing, as it were, the whole visible body. 
The fluid part of the compound now remains to be taken notice of. 
Blood is the material out of which the whole body is formed and 
out of which it is supported.* It is fluid that it may be capable of 
moving to the very minutest part of the solid with ease, and may 
with less difficulty be divided for the increase and repairs of the 
different parts of the machine; easy of division and separation, to 
form various secretions, and also to bring back what was supera- 
bundant, and to carry off the parts which were useless. 
This part of the body has been considered as a passive, inanimate, 
moving fluid, found everywhere in the body, deriving motion from 
the heart for the various purposes of the whole, then returning to 
the heart to be sent out again. Those who have formed this idea 
of the blood have no adequate notion of the manner in which it is 
capable of performing those great uses above mentioned. Some, 
in considering this fluid, have been in a great measure satisfied 
with examining the spontaneous changes which it undergoes out of 
the circulation. This might have led them to draw some natural 
conclusions, since all natural phenomena are facts, and teach 
enough of a thing to enable us to draw sound conclusions. Others 
have attended to the chemical analysis, which teaches nothing with 
respect to its use in the living body; for blood gives no analysis 
excepting that of common animal matter.! Some inquirers have 
laid great stress on its appearance when viewed with a microscope, 
as if forms of parts would explain first principles: this they cannot 
do unless in operations that are mechanical. This inquiry could 
* [The expression of Borden is peculiarly elegant: 11 Le sang est de la chair 
coulante"] 
f [This observation is no longer true. Some important additions to physiology 
have of late years been obtained from chemical investigation of the blood with 
the present improved means of analysis; and with further improvements we 
may expect still more light to be thrown on the subject. The subject will be 
more fully considered when the ' Treatise on the Blood,' &c., comes before us.] THE BLOOD. 
27 
be carried no further than to investigate such parts of the blood as 
have form and opacity, if there are such, and that which appears 
to have both is called red blood: in a great number of animals, 
therefore, the knowledge of the operations of the blood in the animal 
body rests nearly in the same state that it did some centuries ago. 
The two last points of investigation, namely, the chemical analysis 
of the blood and the form of the blood globules, though very proper 
to be made by physiologists, have hitherto explained nothing in the 
animal economy- 
Before I explain my opinion of the blood, it may not be improper 
first to state some facts from which I draw my conclusions. 
I have endeavoured to show that animal matter differs from 
common matter in many circumstances ; that this animal matter 
has a principle peculiar to itself, which I call life, and this life is 
the second step or process of animal matter. Animalization is the 
first; vivification the second. To prove this, I observed that an 
animal is increased and supported by many substances, which pre- 
viously had not the properties of animal matter, and of course not 
the principle called animal life ; I observed, too, that it was also 
supported by substances which were of animal origin, but which 
had not then the living principle ; in other words, an animal can be 
supported on dead vegetable and animal matter. In the next place 
it was remarked that these substances, before they can increase or 
support the animal, must all be converted into animal matter; and 
lastly, that the substances must be so prepared, or animalized, as 
to become part of the body, and of course to be endued with the 
living principle. 
It is now necessary to trace these changes in the food till it 
becomes part of our solids, rand observe as we go along when it 
is most probable that life begins. 
Blood is not simply fluid animal matter, it is animal matter parti- 
cularly arranged, for it differs in every respect from fluid animal 
matter produced by art. The first change that takes place with 
vegetable matter before it is rendered blood is its conversion into 
animal matter. This change I call animalization. With animal 
matter it might be supposed that no change was necessary to pro- 
duce animalization; but we find the change, whatever it may be, 
the same in both; and the process in both is probably similar, for 
the produce from the digestion of animal matter is as different from 
common animal matter as anything can be: were it not so, animal 
substances rendered fluid by chemical operations, as jellies, &c., 
would answer the same purpose as blood. But the necessity for a 
total and similar change in both is evident, for out of this change 
life is to arise, digestion being the first step towards vivification. It 
may be supposed that the first step in the digestion of vegetables is 
that of animalizing them, and that they go through the next of 
chylification with animal matter; but this we cannot allow, for it 
would be supposing two different actions going on in the stomach 
at the same time, which I should very much doubt. 28 
HUNTER'S PRINCIPLES OF SURGERY. 
The second process, vivification, must take place somewhere 
before the blood becomes an active part of the machine. We shall 
first premise that animalization may take place without vivification, 
-(how far this is the case is not easily determined,)-however, we 
may say with certainty that vivification cannot be prior to anima- 
lization. Let us first trace animalization. 
Animalization begins in the stomach, and in common language 
is called digestion, the immediate produce of which is called chyle. 
In the change of food into chyle we do not see why it may not have 
received the living principle, for the change is such as renders it 
capable of becoming alive. But it may be supposed that this process 
is reserved for the lungs, where the chyle is so much exposed to the 
air : the air may be imagined to act on it like heat on an egg, or 
moisture and warmth on seeds, giving a power of growth to their 
particles. In these cases, however, it is not the principle of life 
which they give ; they only give life its action. 
Again, blood may be supposed not to become alive till it be made 
into a solid, when it becomes part of our body, and loses the property 
of blood, and there its life is indisputable; but I am apt to believe 
that the living principle takes place sooner, which I imagine will 
appear in investigating the properties of the blood, with the many 
phenomena that- attend it in the living body. 
I have already observed that the organization of animal matter 
is not necessary for life,* only for its actions ; therefore fluidity is 
no objection to the blood being alive. My reasons for supposing 
the blood to be alive in a fluid state are the following: 1st, It may 
be observed that it appears to carry life to every part of the body, 
for whenever the whole or a part is deprived of fresh blood it very 
soon dies. This blood, however, must be such as has undergone 
some change in the lungs; for if the blood did not undergo this 
change it would probably soon die, therefore would not be capable 
of keeping up the living principle in other parts. This effect arising 
from the want of fresh blood is so evident that it needs no illus- 
tration; I may therefore conclude that it is the only cause and 
support of life, the nerves having no other part in it but to produce 
some of the actions,-not life itself, for without this support the 
nerves themselves die. 2dly, We may observe that whilst cir- 
culating, or in useful motion, it is always found in a fluid state.- 
Hence I think I may be allowed to say, as it is never found in a 
solid form in the cavity of the blood-vessels, that it has not the least 
tendency to become solid; that such a state is contrary to its nature. 
* [This has ever been a qusestio vexata with physiologists, and will pro- 
bably long continue so. The instance of the egg which has been already 
adduced, and of the blood, which now comes under consideration, were supposed 
by Mr. Hunter to demonstrate the existence of vitality independently of organi- 
zation. Although, however, the fact of the vitality of the blood and of the egg 
should be admitted, it yet remains to be proved that the globules of which they 
both appear to consist do not present incipient traces of organization ; but the 
question is not one which can be entered into here.] THE BLOOD. 
29 
This must arise from some principle which is probably both in 
the blood and the vessel. The want of disposition to coagulate 
whilst moving in the living vessel does not arise from the motion, 
for in many places where the motion is extremely slow the blood 
remains fluid. We have instances of this in the veins of the leg, 
where the crural artery has been tied, in which case the blood 
only moves through a few small collateral branches below, and 
back again by the larger veins. Now, a small quantity of blood 
being sent into these larger vessels, the motion in them must be 
next to stagnation; yet, while there is any degree of motion, the 
irritation of imperfection is not given : there is consciousness of its 
being an useful part; by which is meant that the harmony between 
the solids and fluids is kept up. It is curious often to see the small 
quantity of motion which shall keep up this mutual harmony. In 
cases where, people have been days, or even weeks, in trances, 
where there is not the least perceptible motion in the blood, it has 
retained its fluidity, because both solids and fluids retained their 
life, though not their actions. The want of disposition to coagulate 
in such situations does not arise from any property in the blood 
simply as animal matter, for simply as animal matter (whose alter- 
ations arise out of its composition, as fermentation,) it would not 
vary in its effects from circumstances that do not in the least alter 
the nature of the compound. 
Dead animal matter acts on the living body as any other foreign 
or extraneous matter ; therefore, the blood being in perfect harmony 
with the living principles of the solids when both are in perfect 
health, is a presumption that the blood is alive. However, this 
argument is not conclusive, for we find in the blood heterogeneous 
parts which do not destroy this harmony: most probably those 
heterogeneous bodies are introduced simply as stimulants to the 
living principle, as extraneous objects are to the sensitive. 
This harmony of the blood with the solids is more observable in 
some parts than others. The parts with which it is in the greatest 
harmony are the vessels ; this is evident from its retaining its flui- 
dity longer in contact with them without motion than in any other 
part of the body, though equally inclosed in living parts. 
All the diseases which act on the solids act on the blood, causing 
it to effect those changes which arise spontaneously from rest out 
of the body; so that blood is as capable of diseased actions as the 
solids are. If the blood did not change in the diseased states of the 
solids, it would lose the natural harmony I have been speaking of. 
This change is according to the state of the solids, which shows 
the intimate connexion between the two; it is not primary diseased 
alteration of the fluids, but a consent with the diseased disposition 
of the solids.* 
* [How far the blood can originate an action within itself, for the purpose, as 
it were, of bringing itself into harmony with the changed condition of the solids 
is a question which I think will generally be answered in the negative. That 
the blood does harmonize with the solids is an incon testible fact; butthen the HUNTER'S PRINCIPLES OF SURGERY. 
30 
On the other hand, the solids are affected by diseases of the blood: 
I even suspect death in the blood can take place independently of 
the solids ; but the death of the solids will soon follow. 
The blood when at rest has a disposition to separate into several 
parts, viz. coagulable lymph, red particles, and serum; the red part 
being retained in the coagulable matter, and the serum squeezed out 
in the act of coagulation. This disposition in one of the parts to 
coagulate when at rest, from whence the above changes are pro- 
duced, is more or less strong, according to circumstances. 
This property of the blood deserves particular attention, as it 
throws more light on its nature than any point of view in which it 
can be considered, it being spontaneous and natural. It is by this 
change that the solids are formed, and it seems to me so important 
that I think it almost the only thing necessary to be considered 
more fully; indeed the power of coagulation in the blood throws so 
much light on the nature of a disease, so far as the blood is con- 
cerned, that it is almost the only part we have recourse to in the ex- 
amination of the blood after bleeding, when we look to see whether 
or not the blood is buffy, that is, whether there has been a disposi- 
tion for the red globules to sink faster in such blood; or rather, per- 
haps, that from such blood being longer in coagulating, the red 
globules have time to sink to the bottom, and leave the coagulable 
lymph atop free from red globules, and this causes the buff of the 
blood.* It is by this coagulation also that we perceive whether 
the blood is cupped or not, that is, whether the coagulum draws 
cause of this harmony is in the solids themselves, either directly by an impres- 
sion communicated to the blood by the vessels, or indirectly from some defect in 
the processes of nutrition and sanguification; some retention or vitiation of the 
secretions; some introduction of deleterious matter, or some fault in some one 
or more of the vital actions. According to Mr. Hunter's own definition (p. 28), 
action requires organization, and yet the great difficulty which he is even now 
combating is, how the blood, an unorganized fluid, should possess life. In 
short, there is the strictest kind of reciprocity between the solids and fluids ; 
not, however, arising as parallel effects, but as cause and effect; the solids, 
being altered, necessarily modify the blood, and the blood, being modified, as 
certainly reacts upon the solids. In this point of view, to employ the words of 
Andral, " On ne trouve plus de sens aux disputes des solidists et des humoristes ; 
1'economie ne parait plus qu'um grand tout, indivisible, dans 1'etat de sante 
comme dans 1'etat de maladie."] 
* [The buffy coat is undoubtedly mainly due to the cause which Mr. Hunter 
has assigned. Dr. Davy, however, has remarked, and I think the observation 
will be borne out by the experience of every one, that this phenomena is some- 
times exhibited, even in a marked degree, although the coagulation shall have 
taken place more rapidly than usual; nay, a bluish and transparent lymph may 
often be observed to have separated from the other parts within thirty seconds 
after the blood is drawn, and consequently much sooner than under ordinary 
circumstances. There seems, therefore, reason for believing that the buffy coat 
is referrible in some measure to a greater relative d fference in the specific gra- 
vities of the coagulable lymph and red globules than natural, as well as to the 
slowness of the coagulation. Mr. Hunter partly also accounted for the appear- 
ance of buffy blood, by supposing that "the blood has an increased disposition 
to separate into its component parts a supposition which I cannot but think is 
borne out by many facts.] THE BLOOD. 
31 
together and its edges rise; and then we say that the blood is not 
only inflammatory, but highly so, showing great strength in the con- 
stitution : if, on the other hand, it lies flat in the cup, and makes an 
even uniform surface, we know it is rather loose in its texture 
(although it may be still buffy), which shows that the powers of the 
constitution are weak. 
The red globules abstracted, or the red blood abstracted from 
the other parts, need hardly be considered, as they hardly explain 
anything. 
The serum also explains but very little ; there may be more or 
less of it than common, but in itself it explains very little. 
The power of coagulating in the blood is greater when out of 
the circulation and exposed to common air,'even more than when 
extravasated in some cavities of the body, the necessity or use of 
which is evident, for by this it becomes more effectual in stopping 
extravasation. A striking instance of this kind happened in the 
crural artery of a boar. I cut it through and allowed it to bleed ; 
but before the animal became weak, or at least had the appearance 
of weakness, the bleeding became less and less, till at last it stopped. 
On examining the artery, it was found to have a quantity of coagu- 
lated blood opposing and surrounding its cut end like a mop, 
through which the blood could not pass. 
This power of coagulation, especially when exposed, enables the 
blood to unite external wounds more readily, and of course pre- 
serves the living principle better, and keeps the internal parts from 
exposure in many wounds which otherwise would become external: 
by this means they are united by the first intention. 
In all inflammatory dispositions in the solids, whether universal 
or local, the blood has an increased disposition to separate into its 
component parts, the red globules become less uniformly diffused, 
and their attraction to one another becomes stronger, so that the blood 
when out of the vessels soon becomes cloudy or muddy, and dusky 
in its colour, and when spread over any surface it appears mottled, 
the red blood attracting itself and forming spots of red. This is so 
evident in many cases that it is hardly necessary to wait till the 
whole coagulates to form a judgment of it. I think I can say 
when the blood is coming from the vessel, by its appearance in the 
stream, whether it will be sizy or not. When the blood has not 
an inflammatory disposition, the stream has a degree of uniformity 
and transparency in its appearance ; but it is only an eye accus- 
tomed to it that can make this distinction. 
If the inflammatory disposition of the solids arises from fever, 
this disposition in the blood is universal. If there is universal in- 
flammatory disposition, from some local irritation, the blood 
is still universally affected. But if the inflammation is local, and 
the constitution is not affected, the disposition in the blood is 
not universal: how far there is local inflammatory disposition of 
the blood I do not know, but there is reason, however, to suspect 32 
HUNTER'S PRINCIPLES OF SURGERY. 
it, from the ready union of parts under inflammation. If the blood 
does become inflamed in passing through an inflamed part, we 
must suppose that it immediately loses that disposition when it 
meets with parts in perfect health.* 
These properties, namely, increase disposition to separate, and 
a disposition to become a firmer solid, always show increased dis- 
position for action in the living principle, and also, most probably, 
increased power. It is one of the signs of strength of the living 
powers although the materials for action are weak. 
The use of this change in the blood is evident, since it is made 
fitter for uniting parts by this means ; and it is from this disposition 
that the blood retains its living principle sufficiently long till union 
takes place. Unless the stimulus of necessity for coagulation is 
given by the solids, the extravasated blood will not coagulate, it 
will only act as an extraneous body, which often happens where 
union is unnecessary, improper, or hurtful, as in cases of contusion 
where the blood remains fluid in the cellular membrane. 
This disposition to coagulate when out of the vessels, or when 
retained in them without motion till the consciousness of the use 
of motion, and of course of fluidity, is lost, in one of the effects of 
the life of the blood. 
I have used the word consciousness because wTe have no language 
existing answerable to all my views of the animal economy, and 
to coin words would not answer the purpose, because then I must 
have a dictionary of my own. I have not a word for expressing 
the cause of those actions which take place in the body, as if it 
was conscious that such and such things were going to take place. 
There are actions in the body which come the nearest to conscious- 
ness of the mind of anything that I can conceive, and therefore I 
make use of this word; but it is commonly applied by philosophers 
only to the mind. 
Coagulation is a species of attraction arising out of this irrita- 
tion.! It may be considered as a species of generation, for it is 
* [That the blood undergoes peculiar changes, losing its globular character, 
its transparency, and the vividness of its colour, as well as its motion, in the 
vessels of inflamed parts, it is evident from the observations of Levret, Kalten- 
brunner, Dollinger, and others, who have microscopically investigated this subject. 
These changes are most likely due to the influence of the vessels upon their 
contents ; but to suppose that the blood itself can be the subject of inflammation, 
is to suppose it endowed not only with life and organization, but with life and 
organization of a high degree, for from the best observations which have been 
made it does not seem probable that those animals which are lowest in the 
zoological scale are capable of inflammatory action. Certainly we can form no 
definite idea of inflammation, except as connected with vascular and organised 
parts, although, from what is said further on, Hunter did not carry his ideas of 
the blood to that extent.] 
f [Hunter uses the term irritation in place of the exciting cause. His meaning, 
therefore, seems to be that the consciousness of necessity is the exciting cause of 
coagulation, or that coagulation arises from the irritation of this consciousness. 
This is an instance of false logic, or of reasoning from final causes, which he THE BLOOD. 
33 
the first action or establishment of a power of action within itself, 
so as to form itself into muscular fibres, the only powers in an 
animal; these, again, with other parts, form organs to act on the 
materials from which they arose, for their own support. 
I will relate a case in proof of most of the arguments which 
I have employed respecting the life of the blood. It is one of 
many. 
A man came to St. George's Hospital who had a hydrocele, for 
which he was tapped with a lancet. The water was clear serum: 
when this was evacuated, the testicle to the feel was found to be 
larger than natural. About a month after, the tunica vaginalis 
became as full as before ; the radical cure was now determined on, 
the tunica vaginalis was slit up its whole length, and the fluid, 
which was now bloody, was evacuated. The testicle, on being 
exposed, was found larger than natural, and was extracted. On 
the body of the testicle, and nearly in the direction of its long axis, 
and opposite to the orifice in the sac made by the lancet when the 
water was first evacuated, lay a coagulum of blood, dark in colour, 
almost like a leech when that animal is shortened, about two inches 
long, and of the thickness of a common sized little finger. In the 
angles between the epididymis and body of the testicle lay another 
coagulum, adhering in some places to the epididymis, in other parts 
loose to the body: it was attached only at one end. The adhesions 
of the large coagulum to the body of the testicle were firm, although it 
would admit of separation. This was made at one end, when fibres 
were plainly seen running from the testicle to the coagulum. The ad- 
hesion of the small coagulum was in many parts still firmer. All over 
the tunica vaginalis there were a great many vessels full of blood, 
and in many parts coagula of blood-like extravasation. In this state 
I had a drawing made of it, and a small part magnified, to show 
the vessels and the dots of extravasation as they then appeared. 
By being put into water all these vessels and dots disappeared, 
and the parts became white. I then injected the testicle by the 
spermatic artery, which succeeded extremely well. On ex- 
amining the part I observed the following appearances. The sur- 
face of the testicle and tunica vaginalis had resumed the former 
appearance, only with this difference, that the injection was 
of a lighter red than the blood to the naked eye, and much 
more so to a small magnifier. The vessels on the surface were 
very distinct, and the dots, where the extravasation of injection 
was as if there had been extravasation of blood. The coagulum 
on the tunica vaginalis now appeared vascular; the surface of the 
adhesion, for about one twentieth of an inch, was injected and ex- 
tremely full of distinct vessels. The smaller coagulum was injected 
not unfrequently displayed : he has described the objects to be attained by 
coagulation, and he here states that the necessity of affecting these objects is the 
cause of the coagulation, which is much the same as to say it is so, because it is 
so. It is evident that this does not in the least help us to discover the proximate 
causes of coagulation.] 34 
HUNTER'S PRINCIPLES OF SURGERY. 
in many places through and through its whole substance, in the 
other only for a little way. 
If it should be asked, How came those coagula there ? The answer 
is the blood from the wound made by the lancet in the tunica 
vaginalis passed into the cavity, and then coagulated on the testicle 
directly opposite to the wound, and a small quantity of the blood 
which got down to the chink between the testis and epididymis 
coagulated there also. That this is the most probable way of 
accounting for it is, I think, strengthened by another case, where 
the tunica vaginalis was found adhering to the testicle, when per- 
forming the radical cure, at the very part where he had before been 
tapped. In half a year probably this coagulum would have become 
wholly vascular, and probably in a little longer time the whole 
would have been taken away; because, being vascular, it would 
have had absorbents, which would have taken it all, as a useless 
part, into the constitution. 
The tunica vaginalis filling again so rapidly in this case was per- 
haps the reason why it did not adhere to the coagulum on the other 
side, so as to produce a union between the two parts. 
Quaere, For what purpose did this coagulum become vascular?* 
for no visible purpose could be answered by it, as absorption, we 
may suppose, might have taken place as easily in a coagulum as in 
the cellular membrane. But perhaps absorption not going on 
here was the cause of the collection of water; and adhesive 
inflammation evidently took place here that it might be able to 
absorb itself. 
Thus, then, the materials of which the blood is composed are 
joined with the living principle: in consequence of which the blood, 
if properly disposed, is capable, when extravasated, of forming itself 
spontaneously into parts fit for motion, and for performing all the 
offices of any part of the living whole, successively receiving the 
stimulus of nature from the surrounding parts to form itself into a 
similar part, as bone, cartilage, &c. 
In many diseases not inflammatory, namely, those called putrid, 
where the solids have a tendency to fall into those changes natural 
to animal matter deprived of its preserving principle, the blood has 
no disposition to coagulate, nor the solids any power of raising 
* [The opinion that coagulated blood can become vascular, and so afford the 
common basis of union by the first intention, was firmly entertained by Mr. 
Hunter; but the proofs which are here adduced in favour of such an opinion are 
by no means so conclusive as they should be to establish so important a doctrine. 
For, not to mention the length of time which elapsed, in the present cases, 
between the injuries received and the appearances observed, the situation and 
definite form of the coagula would rather favour the idea that they proceeded 
from effused lymph, which became more or less intermixed with effused blood. 
Such an intermixture is generally observed in cases of wounds and operations, 
but I am not aware of any unequivocal example of pure coagula which have 
been observed to become vascular, although it is scarcely possible that this should 
have escaped observation if it were at all frequent. See Plates I. and IL for 
the appearance alluded to in the text.] THE BLOOD. 
35 
inflammation, both having taken on the same disposition. In such a 
disease both the principle and power are diminished, so that life is 
hardly able to preserve the matter from falling into its natural 
changes, though it has still a disposition to keep the vital parts or 
body moving. 
Many kinds of death as well as putrid diseases produce this effect 
on the blood: an instance of which was met with in a gentleman, 
who being in perfect health, died instantaneously from passion, this 
having been so violent as to produce death in every part at once, 
and his blood did not coagulate. 
A healthy woman was taken in labour of her fourth child. As 
the child was coming into the world the woman died almost instantly. 
On opening the body next day, there appeared no cause for death 
whatever, every part being natural and sound ; but the blood was 
in a fluid state, nor did it coagulate on being exposed. 
A soldier, a healthy young man, confined for desertion, received 
a blow on the pit of his stomach from one of his comrades, from 
which he dropped down, and died almost instantly. On opening 
the body, no preternatural appearance was observed, but the blood 
was in a perfectly fluid state, and did not coagulate when taken out 
of the vessels and exposed a considerable time. 
In animals struck dead by lightning the blood does not coagulate 
nor the muscles contract, both being killed at once. 
There are other instances. Two deer were hunted to death, in 
which case they acted until the very power of action ceased, and 
of course death ensued. On opening them the blood was fluid, 
only a little thickened, and the muscles were not rigid, as we find 
them, where they are capable of acting, from the stimulus of death. 
In both cases the life of the solids and of the blood was destroyed 
at the same time and at once.* 
The observation that animals hunted to death are tenderer than 
those killed by other means, is not uncommon. 
There is a natural action of the living body which destroys the 
life of the blood in the act of extravasation; this is the discharge 
of the menses in women. If that discharge is natural and healthy, 
the blood does not coagulate; but, on the other hand, if the extra- 
vasation is not a healthy one, the blood coagulates as it is 
extravasated, and comes away in clots. This perhaps is best de- 
monstrated in cases where the hymen is unperforated and the 
menses are accumulated. This observation leads us to understand 
* [The diversity of circumstances under which the blood remains fluid after 
death at present renders any generalization upon the subject impossible. This 
is so much the case that many able physiologists of the present day are disposed 
to ascribe the incoagulability of the blood to a cause the very reverse of that 
assigned by Hunter, viz. to a greater residual vitality in the blood and vessels 
than in ordinary death, by virtue of which the fluidity of the blood is preserved 
until the disposition to coagulation is lost. But this explanation, like the former, 
explains only half of the cases. See Notes to the Treatise on the Blood and 
Inflammation.] 36 
HUNTER'S PRINCIPLES OF SURGERY. 
something of the nature of the menses; for, depend on it, where a 
woman has her menses come away in clots, it is not a natural but 
a diseased discharge. 
To prove that the blood and the solids correspond very much in 
theii' actions of death, we shall only generally observe, that when an 
animal dies in the common way, it is by the vital actions being first 
destroyed; but life still exists, for the muscles contract and the 
blood coagulates. But if we destroy life instantaneously, or along 
wTith the vital actions, then the muscles will not act, and the blood 
will remain fluid.* 
These changes in the blood, which appear spontaneous, are not 
really so ; they arise from irritation in the blood itself as much as 
any actions in the solids. This irritation excites the natural action 
of the blood, which produces these effects and all the properties we 
see the blood possesses in either a healthy or diseased state. 
We cannot suppose the blood has a power of communicating 
sensations, as it cannot have nerves; its living powers are there- 
fore those of simple life, and it is similar in that respect to the 
solids of many animals. 
As sensation is a principle superadded, and intended to convey 
fixed intelligence, it is necessary for a moving part to have it; but 
when it becomes a fixed and solid part it opens a communication 
with the mind. 
Thus far I have endeavored to show that the blood is as much 
endued with life as the solids are; and the only difference between 
the two is that the solids have construction, called organization, 
producing considerable visible effects, while the blood, not having 
this construction, does not produce these visible effects. The truth 
of this theory will appear more evident in treating of the diseases 
of the animal body.! 
* [In Bichat's language, the animal life dies first, and after that the organic 
life. The muscles stiffen by organic contractility.] 
f [The reader will form a better idea of the greater copiousness of the present 
copy of Lectures as compared with Mr. Parkinson's " Reminiscences," when he 
is informed that the whole of the preceding pages are comprised in less than 
seven pages of the latter. The consideration of the blood is less fully entered 
into here than in the Treatise on the Blood and Inflammation; but the reader 
will not fail to observe that Mr. Hunter often speaks with less reserve on many 
points in the former than in the latter; although in judging of his opinions, 
those contained in the Treatise on the Blood should undoubtedly be preferred, as 
being the result of his last and most deliberative judgment.] ORGANIZATION AND ACTION. 
37 
CHAPTER IV. 
ORGANIZATION AND ACTION. 
General views of organization and action.-Arrangement of matter into certain 
forms to answer the end required ;-these structures combine to form organs ; 
-organs arranged according to certain laws constitute animals.-Organization 
and life distinct from each other.-Action exists in every part of an animal;- 
depends on contractility.-Of two kinds ;-common-and peculiar.-These 
are mutually dependant;-of the first kind, all involuntary ;-of the second, 
nearly all so;-cessation of the latter in disease;-Mr. Hunter's own case.- 
Of the second, digestion, circulation, and respiration are most closely con- 
nected with the first;-others, as motion of the limbs, more distantly.-Mo- 
tion may be caused by elastic forces reacting, as in ligaments.-Conclusion. 
From what I have said above, it must appear that original or 
common matter has been first so decomposed, and then again so 
combined, as to become animal matter. This animal matter next 
became so arranged as to become alive. Now I shall observe that 
these combinations and arrangements are differently modified, so 
as to produce the various kinds of animal substances ; some of which 
have their parts so disposed as to have motion among themselves, 
as muscles; others to have sensation, as brain and nerves ; and in 
others the living parts are so disposed as to acquire other proper- 
ties, as elasticity, rigidity, &c. 
Solidity, in a certain degree, is necessary for self-motion ; for 
parts cannot produce motion in one another without some resist- 
ance or fixed point of motion. We therefore find the acting parts 
of an animal composed of solids, or the parts which compose them 
could not coalesce together by the attraction of cohesion ; and it is 
necessary that it should be so, as without this no determined action 
could be produced. 
Now we have gone so far with the materials of an animal, let us 
next examine how these materials are disposed so as to form an 
animal. These materials may now be considered in a mechanical 
point of view, like the component parts of a machine, each of which 
has its destined use and own peculiarity of form. These are united 
with each other to form parts, the whole forming organs of various 
kinds to produce the mechanical effects required. These organs, 
again, united according to certain established rules, form animals. 
This compounding of animal matter is what should be understood 
by organization. 
Now if this idea of organization is just, organization and life are 
two different things; for, according to this definition, a dead body 
is as much organized as a living one, for in the dead body the same 
mechanism exists as in the living one. 
Organization, then, comes nearest our ideas of the mechanical 38 
HUNTER'S PRINCIPLES OF SURGERY. 
formation of parts, and the ultimate effect must be mechanical; for 
it is impossible to produce motion in matter without having a me- 
chanical effect. 
Having considered simple life, and the general idea of what is 
called organization, we shall next consider the Actions of an Animal. 
We have said that animal matter is so constructed as to be endued 
with a power of self-motion, as in a muscle ; and as we can hardly 
conceive any part of an animal entirely passive or free from mo- 
tion, since all parts grow and are nourished, we must suppose this 
muscular structure very universal in an animal body, though this 
power has been considered principally in regard to muscles, pro- 
perly so called, whose actions are plainly visible to the eye.* 
The different necessary circumstances attending the composition 
of a muscular fibre, with the mode of action of a muscle, we shall 
not touch upon, the field being too large for my present purpose. 
I shall only observe that they are the animal powers by the im- 
mediate actions of which every, the smallest, part of an animal is 
moved.f 
Every machine has its power; a clock has either a spring or 
weight, and so on. In mechanics the parts are dependant on one 
another, so that some one power is necessary to put the whole in 
motion; in mechanics too there is commonly but one ultimate effect 
produced, whereas in an animal body there are a thousand. The 
powers therefore of an animal body are differently placed and cir- 
cumstanced from what they are in an inanimate machine : it is not 
one power that is setting the whole to work, because if that were 
the case an animal's actions would always be the same, but he is 
at rest in one part, moving in another, and so on; and as this is the 
case, he must have power in every part, so that his powers are 
diffused through the whole animal, which is almost composed of 
powers. 
The actions of an animal, considered as a whole, should be di- 
vided into two kinds. 1st, Those actions common to every part 
alike, such as those which are employed in the internal operations 
of the machine, as growth, alteration, building up, taking down, 
&c., every individual part (the smallest conceivable J) acting for 
* [The author has elsewhere (see Introd, to Inflam.) defined life to bethat 
power which renders the body " susceptible of impressions which excite action 
a definition which, however brief, exhibits in miniature the leading features of 
Bichat's celebrated hypothesis, according to which all the actions and pheno- 
mena of life are ultimately referred to two primary principles-namely, sensi- 
bility and contractility.] 
t [The reader is referred to Mr. Hunter's Croonian Lectures on Muscular 
Motion, in the fourth volume, where will be found a more full account of this 
subject.] 
[It seems now to be generally admitted by microscopical observers that 
even the globules of the blood possess an inherent power of motion, in their 
quality of organized parts. Wolff, Dollinger, Treviranus, Kaltenbrunner, &c. 
have noticed a variety of movements of this kind, which are principally of a 
rotary or volvular kind. See Revue Med. vol. ix. 1828, and Journ. des Prog, 
des Sciences Med. vol. viii. 1828, and also the Treatise on the Blood and Inflam- ORGANIZATION AND ACTION. 
39 
itself only, which actions may be called immediate. These are 
probably performed by the ends of vessels, whether the termina- 
tions of arteries or the beginning of absorbents ; likewise the ac- 
tions of the brain are of this kind. 2d, Those actions which are 
of whole parts, and which vary according to their composition or 
construction, being employed chiefly respecting othei' matter, not 
for the immediate use of themselves, as in those above mentioned, 
but still absolutely necessary for the first. These actions are of 
whole parts, as the stomach, heart, organs of respiration, organs of 
sensation, mind and will. That these actions differ from the first 
is evident, because the organs in which they are found have also 
the first, and are indebted to the first for their existence, in the 
same way that the first are indebted to the second for their con- 
tinuance : the stomach, lungs, heart, and other organs of life, may be 
said to be continually supplying materials with which the first are 
employed in building and repairing the system. The second kind 
may be called labourers, being subservient to the first, which, as 
being engaged in laying down and taking up parts, may be called 
the bricklayers. It is the first which compose the movements of 
the true animal, being those which are immediately employed 
about itself. It is the operations of these which properly constitute 
the animal economy respecting itself, and it will be principally 
these which I shall consider. 
The whole of the first kind of actions are involuntary, the will 
having no power over them, the mind being not even conscious of 
them, although it has involuntarily considerable influence over 
them under circumstances of diseased and irregular action. Most 
of the actions of the second kind are subservient to the first, and 
are absolutely necessary to the continuation of their existence. 
These have therefore a certain degree of regularity, and according 
to the relationship or immediate necessity of the second to the 
first are these second permanent and constant: indeed we seldom 
find in them any intermission, perhaps never in health; however, 
in disease they are sometimes stopped. There have been instances 
where the motion of the heart has ceased, and also the involuntary 
action of breathing :-this once happened to myself. 
I had the gout in my feet three springs successively, and missed 
it the fourth. In the fifth spring, one day at ten o'clock in the 
forenoon, I was attacked suddenly with a pain nearly about the 
pylorus : it was a pain peculiar to those parts, and became so vio- 
lent that I tried every position to relieve myself, but could get no 
ease. I then took a tea-spoonful of tincture of rhubarb, with 
thirty drops of laudanum, but still found no relief. As I was 
walking about the room, I cast my eyes on a looking-glass, and 
mation, where this subject is further considered. Tiedemann calls the blood- 
globules "the elementary organic forms;" and several of the French physiolo- 
gists have thought that they might not improperly be classed with the infusorial 
animalculae.] 40 
HUNTER'S PRINCIPLES OF SURGERY. 
observed my countenance pale, my lips white, and I had the ap- 
pearance of a dead man looking at himself. This alarmed me. I 
could feel no pulse in either arm. The pain still continuing, I 
began to think it very serious. I found myself at times not 
breathing ; and being afraid of death soon taking place if I did not 
breathe, I produced a voluntary action of breathing, working my 
lungs by the power of my will. I continued in this state three 
quarters of an hour, when the pain lessened, the pulse was felt, 
and involuntary breathing began to take place. During this state 
I took madeira, brandy, ginger, and other warm things ; but I 
believe nothing did any good, as the return of health was very 
gradual. About two o'clock I was able to go about my business. 
Here, then, was a suspension of the most material involuntary 
actions, so much so that the involuntary action of breathing stopped, 
while sensation and all the voluntary actions were as strong as be- 
fore. 
Quere, What would have been the consequence if I had not 
breathed ? At the time, it struck me that I should have died ; but 
that most probably would not have been the consequence, because, 
most probably, breathing is only necessary for the blood when it 
is circulating ; but as there was no circulation going on, so no good 
could have arisen from breathing.* 
The stomach appears to have been the seat of this affection. 
Affections of the stomach appear to have more influence on every 
part of the body than any other one part has on another; and this 
sympathy is reciprocal, for every part has a power of affecting the 
stomach, which shall be more fully treated of hereafter. 
Of the second kind of actions, those which may be considered 
as having the nearest relationship to the first, are digestion, cir- 
culation, and respiration ; these are all secondary actions of the 
machine. Those which are not so closely connected with the 
first, but respect more the actions of othei' parts of the same body, 
or what may be called remote parts of the animal economy, are 
the actions of muscles in moving the limbs, sensations, and 
voluntary actions employed on external objects, as progressive 
motion, modes of catching food, &c. We may just observe, that in 
a muscle itself which has the power of moving othei' parts, we find 
the two kinds of actions ; first, growth and support as in every other 
part; and secondly, the action peculiar to the muscle itself. The first 
kind of actionsarise immediately from the living principal, and have 
* [It is probable that the circulation, although enfeebled, still continued to be 
carried on in this case as in Lipothymia, occurring from severe and sudden 
injuries to vital parts. It would be contrary to every fact with which we are 
acquainted to suppose that the animal and organic functions could be executed 
or maintained in an active state without a due supply of fresh blood. The 
respiration is almost if not altogether suspended during the state of hybernation ; 
but then the animal functions, and as far as we know the organic functions also, 
are suspended. The same thing likewise occurs in those states which have 
been denominated trances and in cases of Asphyxia.] ORGANIZATION AND ACTION. 
41 
always been ranked as involuntary actions; the second are either 
involuntary, as the actions of whole organs,-the stomach, the 
heart, &c.,-or are voluntary and dependent on the will, as com- 
mon muscles, &c.: but these last I shall leave till I have spoken of 
the brain and nerves. 
Besides this action in parts, which I have said is confined to 
muscles, there is another mode of action introduced, that of parts 
having the living principle which yet have not a power of self- 
action like muscles; these are the elastic ligaments. 
The elasticity of these parts does not depend on life, for it exists 
equally in dead as in live parts. Ligaments are employed to assist 
muscles in keeping certain parts in their places, the position of which 
is long continued. They may be considered as producing a se- 
condary action in the machine. These are more common in some 
parts in some animals than in others; such as the neck of quad- 
rupeds, especially those with long necks, as the camel; and on the 
abdomen of some animals, as the elephant: this power is also intro- 
duced in the vascular system. 
There are other parts introduced into the machine which possess 
no action that can affect any other part, but have a kind of passive 
use in the machine. These vary in their consistence according to 
the uses made of them, some being extremely firm, as bones, 
tendons, &c., which sustain the actions of different parts of the 
animal, and without which it could not subsist; others are less 
firm, and are employed in uniting the various parts as cellular mem- 
brane. 
From all that has been advanced, we see that by the juxtaposi- 
tion or union of living parts organs are formed, which gives us the 
first mode of action, and the form of bodies gives the secondary 
mode. By the union of these various parts compound motion is 
produced. In this manner the whole of the most complicated 
animal machine is produced. The power of self-action which 
animal and vegetable matter possesses, distinguishes it from matter 
endued with any other properties than life, and also distinguishes 
living from dead matter.* 
* [Muscular contractility, which bears not the slightest analogy to any 
other power of matter, was yet frequently confounded at the time of Hunter 
with the principle of elasticity. Hunter was the first to show that this was 
never the source of actual power, like muscles, but depended on a reaction in 
bodies in a contrary direction to the original impressing force, and always in 
proportion to it. 
It is still, however, very difficult to refer to their true causes many of the 
phenomena presented by skin, membranes, fibrous coats, &c. which obviously 
contract and relax in various degrees under different conditions of the system. 
Most frequently these phenomena are to be accounted for on the principle of 
tonicity, a power analogous to muscular contraction. Some, however, have been 
disposed to assign elasticity as the sole cause. (See Bostock's Phy., Vol. I. 
ch. iii. and Majendie's Leet. 8-10, apud Lancet, Vol, I. 1834-5.)] 42 
HUNTER'S PRINCIPLES OF SURGERY. 
CHAPTER V. 
FUNCTIONS OF NUTRITION AND ABSORPTION. 
The Stomach;-peculiar and essential to animals;-intimately connected with 
other vital organs;-less with parts not vital;-sympathy with internal parts 
greater;-compared with the sympathy of the brain with external parts ;- 
greater with ligaments and tendons than with muscles.-Sympathy of the 
stomach with the mind. 
Vascular System;-its actions necessary to be understood.-Arteries:-secre- 
tion.-Veins ;-formerly supposed absorbents.-Absorbents.-Relative offices 
of the three systems of vessels.-Various kinds of absorption;-modelling 
absorption, as during the growth of bones;-absorption of entire parts.- 
Supposed solvent.-Mouths of absorbents.-Alterations of matter absorbed.- 
Table of absorption. 
Of the Stomach.-Every animal body, however compounded, must 
have the means of support, especially as it is by gradual increase 
to complete its own magnitude. To this end the living parts fitted 
for preparing nourishment are thrown into the form of a bag, which 
is adapted for retaining the food; and this bag is endued with the 
power of secreting a matter which has the property of converting 
many vegetable, and all animal, substances into a substance of one 
kind. This part is called the stomach, and in the less perfect ani- 
mals it not only makes a considerable part of the whole animal in 
respect to size, but also in respect to its use in the machine, being 
the most considerable part of the whole. It may be considered as 
the first part of an animal, ever becoming more and more simple 
as the animal becomes more simple; and also as the animal be- 
comes more simple, becoming proportionately the larger part of 
the animal. 
The stomach is the distinguishing part between an animal and a 
vegetable; for we do not know any vegetable that has a stomach 
nor any animal without one. It is the converter of the food by 
hidden powers into part of ourselves, and is what may be called the 
true animal, no animal being without it; and in many, perhaps in 
most, it is what constitutes the principal part of an animal. A 
polypus is little more than stomach. An animal can exist without 
any senses, brain, or nervous system, without limbs, heart, or 
circulation, in short, without anything but a stomach. But for the 
continuance of the species you must have parts of generation; and 
a polypus is a stomach and parts of generation in one ;* and the 
complicating an animal is no more than adding other parts for 
* [" Nothing more is necessary to complete an animal than the power of 
continuing the species, which power is superadded to this bag in many."- 
Hunterian (MS.) Cat. Phys. Series, vol. i. p. 113.] FUNCTIONS OF NUTRITION AND ABSORPTION. 
43 
various purposes.* To one^animal which has a brain and nervous 
system, you have ten thousand without them. 
The power and operation of digestion is perhaps as curious a 
part of the animal economy as any whatever; at present, however, 
it is not for me to explain these operations, but it is necessary for 
me to take some notice of the connexion between this viscus and 
the animal economy in general; in doing which we shall find it to 
be as much the seat of universal stimulus and irritability as the 
brain is of sensibility. This connexion, as in the case of sensibility, 
is much greater in some parts than in others; the connexion that 
all the vital parts have with the stomach is much greater than 
between the others, which may be called voluntary, which is only 
saying in other words that the connexions among the vital parts is 
more immediate than between the vital parts and those which are 
not vital. 
In diseases the brain seems to be intimately connected with the 
stomach, and vice versa. It was as necessary for the stomach to 
be connected with the whole body as for the brain, although not 
in so marked a manner; but that it is as immediately connected 
with the body as the brain we may certainly say. The affections 
of the stomach with the body are not so strong as those of the 
brain, the mind being made sensible of the least injury done to a 
part, while the stomach is not at all affected under many partial 
injuries of the body. 
The stomach is more affected from the internal economy of the 
animal than from external influence, which is the reverse of the 
brain ; for external influence in general can only be local, and local 
injury does not affect the stomach unless it be previously disturbed, 
or unless the injury is in certain parts, as the brain, the testes, and 
many of the vital organs, which, as I observed, have a more inti- 
mate connexion with the stomach. 
The strongest natural affections of the stomach, as respects the 
body, are those connected with nutrition. These are of the greatest 
consequence in the machine, and may be said to be of two kinds, 
namely, want, and the contrary. Want has often been known to 
produce madness: the contrary may be divided into two kinds,- 
repletion, and the want of health rendering nourishment unneces- 
sary ; and under such circumstances of the machine it is refused to 
be taken in. Perhaps repletion may be only a negative affection of 
the stomach with the body; the other is a positive one, and is often 
* [Nothing can be more simple than the apparatus for digestion in the lowest 
animals; but in the higher animals "the parts preparatory and subservient to 
digestion become more complicated, and indeed so much so, that there is hardly 
any system in an animal more complicated in itself; and when we consider the 
varieties of these complications which take place in the various animals, they 
appear to be almost without end. 
" The parts subservient to digestion in the complicated animals bear a great 
relation to the other properties of the animal," so that " animals in general might 
be tolerably well classed by these organs."-Ibid.] HUNTER'S PRINCIPLES OF SURGERY. 
44 
carried so far as to produce a sensation in the stomach, namely, 
sickness. 
The stomach is affected by injuries in parts of the body which 
have no connexion with nutrition, and more especially with parts 
which have the least action in the machine. Although it may be 
difficult to understand why it should happen, yet we find that the 
stomach is more readily affected by injuries done to tendinous parts, 
and those which have little sensibility, than by injuries of muscular 
parts, especially of muscles under the control of the will. This is 
very remarkable in strains of tendons and ligaments. 
The stomach is no less connected with the brain in the internal 
operations of that viscus concerning external objects or mental 
operations than in cases of real injury done to that part. A man 
cannot hear a horrible story or behold distressing circumstances but 
he will often experience sickness, vomiting, or purging, especially 
the latter. 
The Vascular System.-In many animals, especially the more 
perfect, the nourishment, or whatever is taken into the system, is 
taken up and carried-from the stomach to the heart, and from thence 
is thrown out to all parts of the system, through tubes; and from 
the system it is again returned to the heart by other tubes or vessels. 
It is absolutely necessary for the surgeon to have a tolerably clear 
idea of the operations of these vessels. The teaching of the struc- 
ture and offices of these different vessels more properly belongs to 
the anatomist than to the surgeon; but as there is one use of the 
absorbent vessels not generally known, and which is of great im- 
portance in many local diseases, and has also an immediate con- 
nexion with the original formation of the body, it wall be necessary 
that I should explain this: at present, however, I shall do so but 
slightly, and trace the action more at large in speaking of local dis- 
eases. For the better understanding the whole action of the 
absorbents, it will not be improper to give a short sketch of the 
vascular system. 
An animal body has in general been considered under the idea of 
an hydraulic machine, because it appears to be almost wholly com- 
posed of tubes in which fluids move. I shall not at present enter 
into all the different opinions concerning the uses of these tubes, 
especially of that system called arteries; how they are variously 
affected, and how they produce their various actions, according to 
the different stimuli either of health or disease; but shall only give 
some general ideas of the most important uses of the three different 
sets of vessels, namely, arteries, veins, and absorbents. 
Arteries.-These carry the blood from the general reservoir, the 
heart, to all the different parts ; the veins bring it back again. The 
arteries constantly dispose of a part of the fluid which they contain 
in the different operations of the body, according to the different 
functions of the parts: adding to the whole where growth is neces- 
sary; making up losses where the whole is either improper or 
destroyed; and throwing out of the direct line of motion parts FUNCTIONS OF NUTRITION AND ABSORPTION. 
45 
of that fluid, which, according to the different affections and actions 
of these arteries, become considerably altered in the process : this is 
called secretion. 
Juices so secreted are intended for various purposes in the 
machine: some for stimulants, as the bile ; some for mechanical pur- 
poses, as the tears, synovia, saliva, &c.; some for a store of nourish- 
ment, as the fat, &c.; while others are thrown out of the body as 
useless, because they have already performed all their purposes, as 
the urine, &c. 
Feins.-The other set of vessels, the veins, are considered as less 
active, being principally employed in bringing back the red part of 
the blood, after it has lost its most salutary parts, or done those 
offices, whatever they are, for which it was sent out. This, of car- 
rying back red blood, was not considered as the only office of the 
veins; many of their beginnings was supposed to arise, not from the 
terminations of arteries, but from most if not all the surfaces of the 
body, internal and external; making so many inlets into the general 
system, and bringing matter into the common mass of fluid for the 
support of the whole, and also to bring back many of the parts 
secreted by the arteries from the blood for the different purposes of 
the machine, such as synovia and lubricating fluids of all kinds; 
which fluids, having answered their different purposes, and having 
become unfit for every other use in the machine, were obliged to 
be brought back again into the circulation, to be thrown out of the 
circulation by the arteries. 
Absorbents.-Such were considered to be the uses of the veins 
before the discovery of the lacteals; but by the discovery of these 
they were deprived of part of their supposed offices, namely, that of 
absorbing the chyle; still they were thought to absorb matter from 
the cavity of the intestines for the secretion of bile. The other part 
of the absorbent system, called the lymphatics, though long known, 
was not in the least suspected of performing the operation of absorp- 
tion, but was still supposed to be the terminations of the extreme 
ends of the arteries, not large enough to carry red blood but only 
serum or lymph, though from their similarity to the lacteals, which 
were known to be absorbents, it became at last evident to common 
sense that they must absorb. 
Before this idea was started, the general opinion of the vascular 
system ran thus. The arteries were supposed to carry blood for 
nourishment, secretion, &c. throughout the machine; the veins to 
return the red blood, as also to absorb from every surface of the 
body; the lymphatics to return the lymph or blood which came 
along the arteries; and the lacteals to absorb part of the chyle from 
the intestines. 
But some experiments which I made to ascertain whether the 
veins of the mesentery absorbed, proved that they had not the power 
of absorption.* I do not suppose the veins, even in an erection of 
* [See the details of these experiments in Vol. IV.] 46 
HUNTER'S PRINCIPLES OF SURGERY. 
the penis, to have the power of absorption; but I consider the 
corpora cavernosa as veins through which the blood is constantly- 
flowing from the arteries, and that other veins carry off the blood 
from the corpora cavernosa; that in erection there is a spasm on 
the extremities of these veins, which prevents the blood from flowing 
into them, in consequence of which an accumulation and distension 
takes place, which causes an erection, and this ceases with the 
spasm on the veins. By tying the veins of a dog's penis, I found I 
could cause an erection at pleasure, while the arteries continued 
free.* Now, therefore, the offices of the three systems of vessels 
were as follow: The arteries remain as before ; the veins reconvey 
the blood to the heart, for a continuance of the actions of the ar- 
teries as before, but have lost their supposed power of absorbing ; 
the absorbents alone are employed to take up whatever is to be 
carried into the circulating system. Now let us consider what are 
the substances always allowed to be absorbed. 1st, Extraneous 
matter, in which is included nourishment. 2d, Secreted, superfluous, 
and extravasated matter, whether natural or diseased. 3d, The 
fat. 4th, That portion of parts w7hich, being absorbed, causes the 
waste of parts, as muscles becoming smaller, bones lighter, &c. 
Although these two last effects were perhaps not expressly said to 
be carried on by absorption, either by the veins or the other system 
of vessels, yet we must suppose it was understood. 
So far the absorbents have been considered as an active part in 
the animal economy; but, from a further knowledge of these vessels, 
we shall find that they are of much more consequence in the body" 
than has been imagined, and that they are often taking down what 
arteries had formerly built up, thus becoming modellers of the body; 
and that they are also removing many diseased parts, which were 
beyond the power of cure. 
As these vessels are productive of a vast variety of effects in the 
animal economy, which are very dissimilar in their intention and 
effects, they may be viewed in a variety of lights, and admit of a 
variety of divisions. We shall first consider them under two views. 
1st, As absorbing matter which is not part of the machine. 2d, As 
absorbing the machine itself. 
* [In 1830 Mr. Houston announced the discovery of a muscle in the human 
subject which arises from the ramus of the pubes, and, crossing the dorsum of 
the penis to unite with its fellow in the mesial line, effectually compresses the 
dorsal vein whenever this muscle is brought into action. (Dub. Hosp. Rep. 
Vol. v. p. 459.) A similar muscle, but more perfectly developed, was much 
earlier discovered by Cuvier in several of the mammalia, to which that eminent 
anatomist assigned the true use (Anat. Comp. Vol. v. p. 102); in addition to 
which we may mention that the tongue of the chameleon possesses a highly 
erectile tissue, and is provided with a similar pair of muscles adapted to fulfil 
the same object. 
Tiedemann, Cuvier, Moreschi, &c., have confirmed the accuracy of Hunter's 
opinion respecting the structure of these tissues, namely, that they consist of 
veins enlarged at their origins, and not of a system of cells as has generally 
been supposed.] FUNCTIONS OF NUTRITION AND ABSORPTION. 
47 
The first is a well known office of the absorbents, and is of two 
kinds : a, the absorption of exterior matter, in which may be ranked 
everything that is applied to the skin, as also the chyle; b, the ab- 
sorption of interior matter, such as many of the secreted fluids, the 
fat, the earth of bones, &c. It may be necessary to observe that 
I do not consider the fat and earth of bones as part of the animal, 
as they have no action within themselves, and have not the principle 
of life.* 
These actions of absorption are principally employed with a view 
to the nourishment of the animal, as also to answer many other pur- 
poses, as in the absorption of foreign matter, which is extremely 
extensive and is very important; for besides its salutary effects, it 
is often the cause of a thousand diseases, especially from poisons ; 
all which is not to our present purpose. 
The second office of the absorbents which we are to consider, is 
that of removing parts of the body itself, which may be of two 
kinds. The first of these is where only a gradual wasting is pro- 
duced, either of the whole machine, as in atrophy, or of a part, as 
in the muscles of a leg or arm, from an injury done to a nerve, 
tendinous part, or joint: this I call interstitial absorption, because it 
is the removing a part of the body out of that part which remains, 
leaving the part still a whole or complete part; a muscle, for in- 
stance, that is wasted remains still a perfect muscle. The second 
is where the absorbents are removing whole parts of the body, and 
this may be divided into natural and diseased. In the natural, these 
vessels are to be considered as the modellers of the original con- 
struction of the body; and if we were to consider them fully in this 
view, we should find that no alteration can take place in the original 
formation of many parts, either in natural growths or in parts 
arising from disease, without the absorbents being in action to 
take a considerable part in it. This kind of absorption I shall call 
modelling absorption. If I was to consider this function in these 
lights, it would lead me to a vast variety of facts, as extensive as 
those connected with any principle in the animal economy, for 
bones cannot be formed without it, nor probably many other 
parts. 
A part which was of use in one stage of life, and becomes entirely 
useless in another, is removed. This is evident in many animals; 
the thymus gland is removed, the ductus arteriosus and membrana 
papillaris are removed. This process is perhaps more remarkable 
* [In regard to the earth of bones, we may observe that its particles are 
arranged in a determinate and specific manner-constituting an organized body 
in the most extensive acceptation of that word as distinguished from inorganic 
matter generally, and from the amorphous ossific depositions which sometimes 
occur in membranes, muscles, glands, tumours, &c., in which no definite struc- 
ture is observable. The peculiar stratification and fibrous texture of bone may 
easily be observed by calcination. This being the case, are we warranted in 
saying that the earth of bones, forming an organised part of the body, is not 
alive ?] 48 
HUNTER'S PRINCIPLES OF SURGERY. 
in the changes of insects than in any other animals. The changes 
in an insect are very curious. The insect is first a maggot or cater- 
pillar, then goes into the chrysalis state, and comes out a but- 
terfly. Whilst in the chrysalis state it is totally changed, the old 
parts are almost wholly taken up, and new parts formed ; and it is 
this modelling process that occasions these changes.* 
Bones do not grow by having new particles put into the interstices 
of previously formed parts, so as to remove these to a greater 
distance from each other, by which means they should grow larger,- 
as, for instance, if I put a sponge into water, the water getting into 
all the interstices makes it larger,-but they grow by the addition 
of new bone on the external surfaced 
I took a pig of a very large breed when young, bored two holes 
in the tibia, and put a shot into each, measuring on a card the 
distance of each from the other. I allowed this pig to grow up to 
its full size, then killed it and took out the bone, and I found the two 
holes at exactly the' same distance from one another as at first. 
Now if the bone had grown in all its parts these two shot would 
have been removed to a distance from each other proportionate to 
the growth of the bone. 
This fact is also ascertained by feeding animals on madder at 
different intervals, by which means we shall get strata of red and 
white bone. 
Since we know that bones do not grow by fresh matter being put 
into all parts, so as to push the old matter to a greater distance, but 
by new matter laid upon the external surface, let us see whether it is 
possible for bone to grow and retain its form without being taken 
down. Let figure 3, Pl. III., represent the head of the thigh-bone 
of a foetus. Now if the increase was accomplished by superim- 
posed layers, one over the other, as in figure 4, the head of the bone 
would necessarily become of an enormous size, and in time would 
come down so as to occupy the middle of the bone, while the cavity 
in the centre would not be enlarged. Absorption, therefore, must 
necessarily go on to keep the bone of its proper shape. Hence I 
call this the modelling process, for without this combined action 
of absorption and deposition the animal could not grow as it now 
does. 
The absorbents possess the power of removing complete parts of 
the body, in consequence of disease, an operation which is some- 
what similar to the first of this division, or the modelling process, 
* [It must be remembered, however, that in insects, where these changes, as 
Hunter observes, are the most striking, no proper absorbent vessels exist, and 
indeed the vascular system generally is very imperfect. The changes that take 
place in the insect transformation have been since ascertained to be rather a 
development of parts previously existing in a rudimentary state than a total 
change of parts. In the caterpillar are to be found the rudiments of the future 
butterfly.] 
f [See Vol. IV. for a paper detailing the whole of Mr. Hunter's experiments 
on this subject.] FUNCTIONS OF NUTRITION AND ABSORPTION. 
49 
but very different in the intention, and therefore in the ultimate 
effect. This process of removing whole parts in consequence of 
disease, in some cases produces effects unlike what it produces in 
others, one of which is a sore or ulcer; in other cases no sore or 
ulcer is produced, although the whole part is removed. The first I 
call ulcerative absorption ; but for the other I have not been able to 
find a term. 
This process of the removal of a whole solid part of the body, or 
that power which the animal economy possesses of taking part of 
itself into the circulation by the absorbent vessels when necessary, 
is a fact that has not been in the least attended to, nor even been 
supposed possible ; and as I now mean to give a general idea of it, 
I may just be allowed once more to observe, that the oil or fat of 
the anima], and the earth of bones, have always been considered as 
subject to absorption, and some other parts of the body most liable 
to waste have been supposed to suffer by absorption ; but that any 
solid part should be totally absorbed is a new doctrine. This use 
of the absorbents I have been able to demonstrate. The first hint 
I received of it was in the waste of the sockets of the teeth, and also 
of the fangs of the shedding teeth, which was in the years 1754 
and 1755 (see Treatise on the Teeth, first and second parts). This 
opinion was strengthened by what I observed in the process going 
on in the exfoliation of bones. 
It may be difficult to conceive how part of the body should re- 
move itself, but it is just as difficult to conceive how the body can 
form itself. They are both equally facts. The knowledge of their 
mode of action would perhaps answer but little purpose. 
This, at least, I may assert, that when any solid part of the body 
undergoes diminution, brought on in consequence of disease, it is 
the absorbent system that has done it; they are the thieves. 
The remote cause of absorption of whole and living parts implies 
the existence of two conditions, the first of which is a consciousness, 
in the part to be absorbed, of the unfitness or impossibility of 
remaining under such circumstances, whatever they be, and 
therefore they become ready for removal, and submit to it with 
ease. The second is a consciousness of the absorbents of such a 
state of the parts. Both these concurring, they have nothing to do 
but to fall to the work.* 
Now the part that is to be absorbed is alive, it must feel its own 
inefficacy and admit of absorption. The vessels must have the 
stimulus of imperfection of this part, as if they were sensible that 
this part were unfit; therefore take it up. There must be a sensa- 
tion in both parts. 
* [The reader, I imagine, will scarcely refrain from smiling at the naivete 
with which our author here ascribes consciousness and intelligence to an animal 
body, to an extent little inferior to Boerhaave, Van Helmont, or even Stahl. It 
were devoutly to be wished that the body politic possessed a similar conscious- 
ness of what ought to be done, and an equal will and power to carry its reso- 
lutions into effect.] 50 
HUNTER'S PRINCIPLES OF SURGERY. 
When the part to be absorbed is a dead part, as nourishment and 
extraneous matter of all kinds, then the whole disposition is in the 
absorbents.* 
This is the only mode in which this power is capable of produ- 
cing such effects, and, like all other operations of the machine, 
arises from either stimulus or irritation, all the other modes of 
destruction being either mechanical or chemical. 
[It is by the progressive absorption that matter, or pus, and extraneous bodies 
of all kinds are brought to the surface of the body. It is by this process that 
bone exfoliates and sloughs are separated. It is the absorbents which remove 
whole bones while the arteries are forming new ones. It is this operation that 
removes the alveolar processes when the teeth drop out of themselves, or are 
taken out by art; as also the fangs of the shedding teeth, which allow them to 
drop out; and it is by this means also that ulcers are formed. 
It becomes in many cases a substitute for mortification, in which cases it seems 
to depend upon a degree of strength and vigour superior to that where mortifica- 
tion happens; and in many cases it finishes what mortification had begun, by 
separating the dead part. From all this, we must see that the causes of the 
absorption of whole parts are many. 
Pressure appears to be one of the greatest causes of absorption, and it is com- 
monly a cause of the progression. It produces its effects not in all cases in 
proportion to the pressure, but according to the pressure and other circumstances 
combined; for we find very different effects from the same quantity of pressure: 
thus, under one circumstance, pressure shall give signs of strength, and produce 
an increase, or thickening; but under another circumstance the same quantity of 
pressure shall produce waste, or an absorption of the parts. This difference in 
effect, from the same quantity of pressure, depends upon the pressure being from 
without or within, for the first effect of the irritation of pressure from without is 
the disposition to thicken, which I have asserted is rather an operation of strength ; 
but if it exceeds the irritation of thickening, then the power appears to give way 
to it, and the absorption of the parts pressed gives way to it. 
Pressure produced by an extraneous body surrounded on all sides, such as pus 
in an abscess, acts equally on every side of the surrounding parts, and therefore,' 
every part being pressed alike, ought, from this cause singly considered, to pro- 
duce absorption of those surrounding parts equally on all sides, supposing the 
parts themselves similar in structure, or, which is the same, equally susceptible 
of being absorbed : but we find that one side only of the surrounding living parts 
is susceptible of this irritation ; therefore one side only is absorbed, and this goes 
on in regular progression. The side of the cavity which is susceptible of this 
irritation is always that which is next to the external surface of the body; there- 
fore we have always extraneous substances of every kind determined to the skin, 
and to that side of the body on which the extraneous substance lies, or to which 
it is nearest, and that without having any effect upon, or producing the least 
destruction of, any of the surrounding parts. From this cause we find abscesses 
whose seat is in or near the centre of a part readily determined to the surface or 
side in preference to another; and whenever the lead is once taken, absorption 
goes on there only. But as some parts of the body are more susceptible of this 
irritation than others, we find that such parts are often absorbed, although they 
are not in the shortest road to the skin; and of such structure is the cellular 
* [It is difficult to conceive how the absorbents can act on detached solid 
substances, incapable of solution, as bone for example ; yet portions of dead 
bone are often observed to be entirely absorbed in cases of necrosis; and in 
some experiments made by Mr. Thomas Blizard, in which disks of bone were 
bound on over ulcers; the surfaces of these disks were found to be eaten out, or 
destroyed, just as in common caries.] FUNCTIONS OF NUTRITION AND ABSORPTION. 
51 
membrane. We find exfoliations of bones, as well as all other extraneous bodies, 
approaching the skin in like manner, and from the same cause. But the pro- 
gressive absorption is always more or less attended with the interstitial, and 
assisted by it. 
The vessels in general would appear to have more powers of perfecting them- 
selves when injured than any other part of the body, for their use is almost 
immediate and constant, and it is they which perform the operation of restora- 
tion on the other parts; therefore they themselves must first be perfect. They 
would seem to have more of the polypus in them than any other part of the 
body. This is perhaps more in the absorbents than in the arteries and veins, for 
we can conceive a part injured by accident, and, as it were, standing still for a 
little while; but we see ulceration going on very rapidly, which proves an 
immediate formation of vessels for absorption.*] 
The knowledge of the use of the absorbent vessels is of late date, 
and the knowledge of their different modes of action still later. 
Physiologists have endeavoured to account for their modes of action 
on the principle of capillary tubes at their beginning, and this is the 
most common notion, because it is a familiar one. But this is too 
confined an idea for an animal machine; nor can it account for 
for every kind of absorption. But as solids are often absorbed, as 
indurated tumours, coagulated blood, earth of bones, &c., they 
were driven to the necessity of supposing a solvent. This may or 
may not be so it is one of those hypotheses that can neither be 
proved nor disproved, and must for ever rest as an opinion. My 
idea is, however, that nature leaves as little as possible to chance 
alone, and that the whole operation of absorption is performed by 
one action in the mouths of the absorbents. 
But even under the idea of capillary tubes, physiologists were 
obliged still to have recourse to the actions of these vessels, to carry 
on the matter absorbed; therefore they might as well have extended 
the action to the mouths of the vessels. 
As we know nothing of the mouths of these vessels, it is impos- 
sible we can form any opinion that can be relied on; but as they 
are capable of absorbing substances in a state of solidity and 
fluidity, it is reasonable to suppose that they have different modes 
of action; for although any construction of parts that is capable of 
absorbing a solid may also be such as is capable of absorbing a 
fluid, yet I can suppose a construction capable of absorbing a fluid 
that is not fitted for the absorption of a solid, though this is not 
likely. 
To see the possible correctness of this notion more forcibly, let 
us only recollect the variety in the mouths of different animals, and 
* The preceding paragraphs are transcribed from the Hunterian Catalogue 
(Phys. Series, vol. ii. p. 5), and are also partly repeated in the work on Inflam- 
mation. They are in Mr. Hunter's own words, and serve to complete this 
subject. 
A long and interesting note is added to this part of the Catalogue by the 
author, asserting the claims of his brother, Dr. William Hunter, to the discovery 
of the lymphatics, in opposition to the pretensions of M. Noquez. The whole 
note is very characteristic, and affords an excellent specimen of critical and sound 
judgment, of a certain combativeness of disposition, and of that homely but vigor- 
ous mode of expression for which Hunter was distinguished. 52 
HUNTER'S PRINCIPLES OF SURGERY. 
I will venture to say that the mouths of all the different animals 
have not a greater variety of substances to work upon than the ab- 
sorbents have ; and it may be observed, that with all the variety in 
the mouths of different animals, this variety is only for the purpose 
of adapting them to the forms of solids, which admit of great 
variety, every one being capable of absorbing fluids, which admit of 
no variety. 
I have often said, on this point, that if we could see the mouths of 
these vessels, we might perhaps class the modes of absorption as 
animals have been classed, by their teeth, &c. 
Matter taken into the constitution by the absorbents is capable of 
being altered in its nature from what it was out of the constitution. 
Although this may have been conjectured or imagined, it never has 
been absolutely known, and even now the only proof we have of it 
is the change produced in venereal matter. If the matter of chancre 
or gonorrhoea be absorbed, it produces disease ; this disease is not 
similar to the original; it is not pocky matter which is produced 
from the ulcers, but this matter has been changed from its original 
nature in the circulation; although the change was of such a kind 
asstill to retain its power of stimulating and producing disease: 
but as it was changed, the disease produced was not similar to that 
from whence it came. 
That there is a change in venereal matter is very evident, for if 
venereal matter out of the constitution be applied to a living part, it 
always produces an effect according to the nature of the part, which 
part may be one of two kinds, either, 1st, a secreting surface, pro- 
ducing then gonorrhoea; or, 2d, a non-secreting surface, producing 
then a chancre. 
That this process of altering substances in the constitution is not 
a universal principle and common effect of all kinds of matter which 
enter the circulation, is evident; for we do not as yet know, for 
certain, of any other matter being altered. 
Extraneous matter to become useful, as chyle, fat, &c. 
Interstitial absorption of parts of the body itself, as cellular 
membrane, muscles, &c. 
TABLE OF ABSORPTION. 
Absorption connected with growth. 
Absorption for 
nourishment. 
Absorption of 
useless, in- 
convenient, < 
or hurtful 
parts. 
Extraneous, that have been useful, as synovia and other 
secretions, become useless. 
'Producing wasting of a part, as a leg, 
an arm, &c.; or wasting of the whole 
body. 
Parts of the body 
itself. 
'As modellers in 
the time of 
growth. 
In consequence of 
weakness, as in 
the removal of 
calluses. 
From parts beco- 
ming wholly 
useless, as the 
alveoli. 
Absorption of the 
whole parts. OF THE BRAIN AND NERVES. 
53 
of a leg or an arm, &c.; or of the whole 
body, as in atrophy. 
of a callus of a testicle. 
Absorption inconsequence 
of disease. 
Interstitial 
absorption. 
Partial wasting 
As when pus or any extraneous body^ 
is brought to the skin. 
In the process of exfoliation of bones, ' 
In the process of sloughing, 
In the formation of ulcers, J 
In the removal of the fangs of the 
teeth. 
Total wasting of calluses, alveoli, testicles, &c. 
Progressive 
absorption. 
Attended with sup- 
puration. 
Mixed, 
without suppuration. 
Asin the progress of pus, tumours, &c. to the skin. 
CHAPTER VI. 
or the Brain- and nerves. 
Passive and active states of the brain;-too much influence attributed to the 
brain in the bodily actions;-actions of the brain;--five modes of impression 
on the nerves, or senses. Voluntary action becoming involuntary, as in 
chorea.-Of sensation. Connexion of the actions of the brain and nerves 
with life.-Of sleep ;-its importance in the animal economy. 
We have hitherto traced animal matter from its change from com- 
mon matter to animal matter, the particles of which have possessed 
such an arrangement as to produce life ; still it has other modes of 
arrangement, out of which arise other modes of action, and which 
only take place in some animals. These are the brain and nerves, 
which produce sensation, out of which arises mind and reason; for 
without sensation the mind could not be formed, nor could we rea- 
son ; it being always about some object that the mind is affected, or 
that we reason. 
In sensation the brain is passive, only receiving the impression 
from the nerves, according to their actions, called so many sensa- 
tions. In mind it is active. Mind arises from a peculiar quality 
in the sensation, being expressive of some quality in the body 
which is the object of sensation, and which gives an action to the 
brain answering to those qualities, as agreeable and disagreeable, 
with all their different species, as love, joy, hatred, anger, &c.; 
which actions of the brain, or states of the mind, become the causes 
of particular modes of action in the body affecting both involuntary 
and voluntary actions. The heart beats quick or slow according 
to those states; sickness may be produced; purging, contraction 
of the bladder shall take place ; the voluntary muscles hardly obey- 
ing the will, but performing involuntary actions, according to the 
state of the mind. 
Reason, by influencing the will, becomes the cause of the volun- 54 
HUNTER'S PRINCIPLES OF SURGERY. 
tary actions ; and by this connexion all these principles can affect 
one another. 
Now the brain appears to be capable of two modes of action, 
and out of these arises every property of the brain. We may call 
the actions of the brain, mind ; objects shall affect our senses so as 
to form a peculiar state of mind : this I call mental impression. 
Again, the mind can reason and exercise volition respecting ob- 
jects. The former is involuntary, and belongs also to brutes ; the 
latter is voluntary. For instance, I am challenged to fight a duel, 
volition, and reason determine me to go to it; but when at the 
place, my joints tremble, my stomach turns sick : this is the effect 
of mental impression, or feelings of the mind. The two operations 
are very different; and in general the feelings of the mind, if strong, 
will prevent all reasoning. 
Much more has been given to the brain and nerves than they 
deserve.* They have been thought to be the cause of every 
property in an animal body; that independent of them the whole 
body was a dead machine, and that it was only put in action by 
them. 
But although their actions are absolutely necessary in the ma- 
chine, they are not so universally so as has been imagined. They 
are not the cause of growth, nor do they even preserve a part 
from death, although the whole as a whole cannot live without 
them. 
The nerves have but one mode of action, namely, that of con- 
veying impressions ; but this in two different directions: one from 
* [It may here be remarked, that the author, on the whole, lays less stress on the 
nervous system in his physiology than it probably deserves, at the same time that 
he gives disproportionate importance to the stomach. Modern experiments have 
shown that the functions of digestion, nutrition, secretion, circulation, respira- 
tion, &c. in the higher animals are intimately dependent on the integrity of the 
brain and nervous system ; and though in some of the lower animals no traces of 
this system are discoverable, yet may we safely infer, from the irritability which 
these animals manifest, that something corresponding to a nervous system 
actually exists, constituting the materia vitae diffusa of the author. Something 
analogous to this has been suspected in regard to the stomach itself, in certain 
species of zoophytes, in which either there are no visible stomachs, or else the 
parts which are generally considered as separate and independent animals are 
regarded by others as merely a multiplication of stomachs belonging to the same 
individual. Some experiments also have lately been performed in America 
which show that undressed animal food undergoes a species of imperfect diges- 
tion when inclosed in fresh wounds : from which it seems probable, that not- 
withstanding the centralization of the vital organs in the higher orders of 
animals, the separate parts still exhibit traces of those vital endowments which 
in the lowest order of animals are diffused through the whole body, very much 
in the same manner as in vegetables. The proper objects of comparison, how- 
ever, in the present case, are the stomach with the great sympathetic nerve or 
nerves of the viscera rather than with the cerebral masses. The superaddition 
of the latter has reference principally to the organs of external relation, very 
few of which exist in zoophytes and the simpler forms of beings. Physiologi- 
cally, it is as difficult to conceive of sensibility and contractility without a 
nervous system, or something analogous to this system, as it is to conceive of 
nutrition without digestive and circulatory organs.] OF THE BRAIN AND NERVES. 
55 
their extremities in the body towards the brain, conveying im- 
pressions made on them to the brain, in order to excite actions 
suitable to these impressions ; the other, from the brain to the ex- 
tremities, conveying the mandates of the will, &c. 
That mode of action which is from the body towards the brain 
is of two kinds. One is the internal feel of the body, of perfection, 
imperfection, power, want, &c. The other is of those feelings of 
the body which are to call forth the powers of the will to perform 
what are called voluntary actions, for the subsistence of the body, 
or to effect the actions which it cannot perform. 
The actions of the brain towards the body are also of two kinds: 
one in consequence of the feelings or state of the mind at the time, 
whether the actions of fear, courage, anger, love, &c.; the other, 
in consequence of the command of the will, called voluntary ac- 
tions. 
Those of the body to the brain are the first in order; for it is the 
receiving the impressions that gives rise to the others. Of the 
latter, the first are the feelings of the mind, and the Second the 
will and its consequences, namely, voluntary actions, or all those 
actions, directed principally to external objects, for which muscles 
are provided. 
As the nerves are perfectly passive till impressed by external 
objects, no one could have any sensation except while an impres- 
sion is made on some of the senses. Therefore a man should not 
feel that he exists but in thought; nor could he do that if he had 
never received impressions to think about, for thinking is no more 
than the memory of impressions put into order by the mind; nor 
should he have those actions which naturally arise from the brain 
till the brain makes the impression on the nerves. 
The impression is made on the body, but the sensation is in the 
brain, for the effect (of a person's feeling in a part to which a nerve 
is distributed) on cutting or otherwise injuring a nerve, proves that 
sensation is in the brain, and not in the body; for if it was in the 
body, the sensation would be referred to the part injured ; but sen- 
sation being in the brain, and brought from the brain by the action 
of the nerves, or sensation being formerly in the brain, the action 
of the nerves we find is referred to the beginnings of that action by 
the combinations of the other senses ; otherwise it would be only 
in possession of the sensation without any reference. The refe- 
rence produces a feeling in the mind receiving sensation, by joining 
it with the seat of impression. 
There are five modes of impression of nerves, or perhaps rather 
five modes of construction of parts, which are adapted to so many 
kinds of impression. These are called the five senses ; but there 
are a great many kinds of sensation conveyed to the brain or sen- 
sorium. 
The five senses are no more than parts constructed so as to be 
capable of receiving impressions, or so many properties of matter. 
Perhaps all are capable of receiving the impression of touch, or 56 
HUNTER'S PRINCIPLES OF SURGERY. 
pressure, if it could be applied to all, so that every nerve may be 
said to feel.* 
But, besides pressure, there are othei' properties of matter. Many 
bodies have qualities besides being tangible ; some only when in 
solution making an impression on the tongue and causing taste; 
the same bodies when thrown into vapour give smell: air, besides 
being tangible, has a peculiar motion, arising from its repulsive 
quality, called vibration, which strikes the ear and produces hear- 
ing. There arises another property in another species of matter, 
called light, which we know less of than any other, which has a 
power of pervading some bodies, called transparent, and gives us 
the sensation of sight; and from peculiarity in the formation of 
those transparent parts light becomes more determined in its direc- 
tion. 
The sensation of the glans penis, tickling, and itching would 
seem to belong to feeling. The first, however, is certainly a dif- 
ferent mode of action of the nerve from common feeling, and both 
itching and tickling require a particular mode of impression to pro- 
duce them. 
An animal can bear with ease a certain quantity of common 
sensation, which quantity being particularly applied W'ill give 
pleasure; but if common sensation be increased beyond certain 
bounds, it gives great pain ; so that pain is no more than an in- 
creased . sensation, such as the sense of violence committed to a 
part, f 
All the five senses are subject to the same mode of sensation 
when applied in the same way, namely, by touch, and if the impres- 
sion is too strong, give the sensation of pain. For instance, if the 
retina be hurt, it gives pain, but not light; if the ear be hurt, it 
gives pain, but not sound ; if the nose be hurt, it gives pain, but not 
smell. J But there are exceptions to the two first, for a blow on 
* [It would seem that Mr. Hunter thought that all the nerves of the senses 
were capable of conveying the sensation of touch or pressure, in addition to the 
sensation which they are specially fitted to convey. This opinion is not war- 
ranted by more recent discoveries. An impression on the retina, of whatever 
kind, excites the sensation of light. Maiendie found that on touching the retina 
with a couching-needle no pain was excited, but the sensation of light: a blow 
on the eye has the same effect. If pressure be made with the finger on the scle- 
rotic, a dark spot will be seen immediately at the point of pressure, where the 
function of the nerve is probably impeded, with a hallo of light surrounding it. 
Of the auditory nerve we know little; and on the tongue and nose the gustatory 
and olfactory nerves are so intermixed with the fibres of the fifth or nerve of feel- 
ing, that it is not easy to distinguish between their actions in such an experi- 
ment; but galvanism, which excites a pricking sensation in the skin, causes a 
peculiar flavour when applied to the tongue; and the smell of the electric fluid is 
well known.] 
f [If this were the case, we should expect to find pain differing only in degree, 
but not in kind. Some structures, as bone, ligament, and the fibrous structures 
generally, exhibit no common sensation, although they are actually alive to pain 
under circumstances of injury and disease.] 
$ [To each of these organs are distributed branches of the fifth nerve, or the OF THE BRAIN AND NERVES. 
57 
the eye often produces light, and on the ear sound. And besides, 
those senses are subject to diseases, where the sensation often 
arises without impression from without. 
The common actions of the body, that commonly arise from the 
will, often become involuntary, as in palsies, St. Vitus's dance, &c.; 
but I suspect that these actions still arise from the brain or mind, 
though not the will, because they do not take place in sleep ; nor do 
we find the same diseases in any animal but the human. 
Our senses being such, have their peculiar degree of sensation 
and their peculiar mode of receiving impressions, and when this is 
carried to too great a length, they become extremely uneasy : but 
it is an uneasiness different from pain ; it is the peculiar sense carri- 
ed beyond what the mind can bear. 
Sensation is in proportion to the impression made on a part, joined 
with the susceptibility with which the nerve is ready to act. But 
for distinct sensation two things are necessary, namely, time and 
space. It is necessary that the impression should be some time in 
performing, because an impression may be too quick to excite sen- 
sation, or quicker than any action in the nerves, such as a ball 
passing through a man's body without his feeling it; but he is 
capable of feeling it afterwards, which arises from an action of the 
injured part, not from the violence itself. Neither must the time be 
too long, for an impression or an injury may be so slow as not to 
affect the nerves at all, so as to throw them into any action. A 
person, for instance, shall become dropsical, and the belly shall fill 
with watei' so gradually as to give no pain from the stretching of 
the muscles, peritoneum, &c.: but if you were to attempt to stretch 
the belly of another person in a given time to such a degree, it 
would produce pain in proportion to the violence. 
The space must also be determined, for a given quantity of im- 
pression may be concentrated so as to be within bounds of sensa- 
tion ; for it would appear that a single nerve or a very few nerves 
are not capable of conveying sensation, however affected; for in- 
stance, a given quantity of light may be concentrated into such a 
small point as not to be seen. 
Every sensation, every mode of sensation, and every sense ap- 
pear to depend on the quantity of nerves acted upon, and in a given 
time; therefore we have a great quantity of nerves going to parts 
that are allotted for strong sensation, that no impression may be 
made without affecting a great many nerves at the same time. 
The uneasiness arising from too strong impressions we can easily 
assign a reason for, as it becomes a means of avoiding that vio- 
lence; but itching and tickling appear not to be so very necessary: 
however they must be of a service in the animal economy. I can 
conceive itching becomes a cause of our keeping ourselves clean, 
free from vermin, &c., and becomes a substitute for pain: it na- 
nerve of sensation ; it is by means of these that common sensation is furnished to 
the organs of sense, and through them that lesions excite the feeling of pain. 
See the preceding note.] 58 
HUNTER'S PRINCIPLES OF SURGERY. 
turally leads us to the cure, which gives pleasure ; and the perfor- 
mance of it is almost similar to the indulgence of our natural appe- 
tites. 
This principle of sensation is our director with respect to all 
other external actions, but has no absolute power over the internal 
economy of the machine. But this first principle we shall find can 
influence the others very materially, and thus a compound principle 
will be produced. 
The brain and nerves also give the body a consciousness of its 
own muscular powers. This is more remarkable in other animals 
than in man : thus, a horse will at once know what he can leap, 
and will leap no more, nor attempt it; and indeed a man can for 
the most part tell. A nobleman (the Duke of Queensbury) who had 
broken his tendo-Achillis was fearful of walking about his room; 
but I advised him to do it as well as he could, assuring him that his 
gastrocnemius muscle, knowing its own business better than its 
master, would refuse to act if he walked, and that the action would 
be performed by other muscles. This he found to be true. But in 
the night time, I told him, I could not be answerable for what his 
muscles would do, therefore I thought proper to put the leg into a 
fit posture and secure it by a bandage. 
As the brain and nerves are composed of animal matter, and as 
that animal matter has life, or the first principle of action, in 
common with all the other matter composing the whole body, there 
arises necessarily an intimate connexion between those principles, 
and, though totally different in their peculiar actions, yet they be- 
come blended with each other, so that one seldom acts perfectly 
unless the other is in perfect order, each of them calling on the other 
to do its part; and when both these principles are in vigour and in 
perfect harmony the whole machine is in health. 
Life is coeval with the existence of the animal or vegetable 
matter itself; but sensation is a later principle, does not take place 
until birth, when a new economy is set up, in which sensation is 
called in by the living principle for the support of the whole, begin- 
ning first in the stomach by sympathy, and then going on in a series 
of actions. These compound actions, therefore, cannot take place 
until sensation takes place ; and it is reasonable to suppose that a 
child in the womb has no sensation, for it is just as well formed in 
all its parts without brain as with it, and the nerves are indebted to 
the brain for their formation.* 
* [This statement is incorrect. The nerves may exist without the brain or 
spinal marrow, which are accessory, not the fundamental parts. The same law 
obtains in regard to the heart and blood-vessels: and indeed it may be observed 
generally in regard to the progressive development of the higher animals, that at 
first they follow the type of inferior animals, but afterwards advance to those 
which are still higher and higher in the zoological scale. Hunter in the main 
was well acquainted with this law of development as regards the higher animals, 
as will appear from the following passage, in which we may remark that he has 
anticipated many of the leading discoveries on this subject by modern anatomists. 
The passage occurs in the introduction to the description of the drawings relat- OF THE BRAIN AND NERVES. 
59 
But the moment a new mode of action takes place, actions 
arising from sensation must be performed for the support of this; 
and an animal must die if these sensations are not produced, which 
cannot be produced if there is no brain.* 
Actions arising from the union of the two principles, life and 
sensation, are extremely evident; being all those actions which 
constitute a state of mind, or those feelings of the mind from which 
instinct arises. 
Sleep.-A singular result of our being possessed of the sensitive 
principle is sleep. Perfect sleep is an annihilation of the power of 
present sensation, of the power of thinking, and all traces of the 
past, or what we call memory. We find that there is, of course, a 
cessation of all voluntary actions; the will itself is in every respect at 
perfect rest, and we are at this time, in respect to ourselves, in a state 
of non-existence. But sleep has its degrees; perhaps in all cases there 
is a loss of these considerable principles, especially sensation; but the 
effects of sensation are not always lost, namely, those operations 
of the mind which produce actions which are very nearly volun- 
tary. During sleep, therefore, the mind may be thinking, which 
forms what we call dreams; but as our present sensations do not 
become directors of those actions which the mind is employed 
about, no such action takes place as the mind forms to itself. It 
is even possible to dream when awake ; it is only necessary for the 
thinking power to take possession of the mind, and to proceed with 
an action with which the present sensation has nothing to do, so 
that a person neither sees objects, hears sounds, nor feels anything 
that touches him; and when the mind ceases to act and sensation 
returns, we call it a dream. Now whenever the body loses the 
consciousness of its own existence, it may be called a waking 
dream, and this is often the case when people are in deep thought. 
Sleep appears to be to the sensitive what I have already described 
to take place in the living principle, when I mentioned my own 
case; but that arose from disease, while sleep is necessary. 
When both these principles undergo a cessation of theii' actions 
it is called a swoon. Here there is a cessation of all actions which 
naturally arise in the body, but still a capability of having them 
ing to incubation. " If we were capable" (he says) "of following the progress 
of increase of the number of the parts of the most perfect animal, as they first 
formed in succession, from the very first, to its state of full perfection, we should 
probably be able to compare it to some one of the incomplete animals themselves, 
of every order of animals in the creation, being at no stage different from some 
of those inferior orders; or, in other words, if we were to take a series of animals, 
from the more imperfect to the perfect, we should probably find an imperfect 
animal, corresponding with some stage of the most perfect." (Hunt. Cat. Phys. 
Series, vol. ii. p. 4.) Many other passages might be adduced which evince 
that Mr. Hunter's extensive acquaintance with comparative anatomy had enabled 
him to deduce the true principles which regulate the formation of the body and 
the coexistence of the different systems of parts in the same individual organism.] 
* [Mr. Hunter must have been aware of many examples of fcetuses without 
brains which have lived for some time after birth. He must here mean the me- 
dulla oblongata, without which respiration cannot take place.] 60 
HUNTER'S PRINCIPLES OF SURGERY. 
reproduced, Now in a fainting fit there seems rather a cessation 
of the actions of sensation, the animal becoming totally insensible 
to itself; but in a swoon we have this carried further; the cessa- 
tion takes place not only in the sensitive but in the living principle 
itself, for we shall have people fall into a trance or swoon, and 
they shall remain in it without any kind of motion,-respiration, 
circulation, digestion, and every operation of the body at total rest; 
and if the disease, or the cause of cessation of that action, should 
continue a long time, they may lose the power of reproducing this 
sensation again. Fainting from bleeding, fear, &c., is a swoon in 
a certain degree, for these principles are diminished, especially the 
sensitive. Sleep is not only a cessation of voluntary action, but 
produces cessation of involuntary action of voluntary parts, arising 
from their diseases, as in St. Vitus's dance, &c. 
Sleep is of such material consequence to the sensitive principle 
of the constitution,-namely, sensation, mind, and will,-that it may 
be said to constitute one third of its duration. As it is only an 
annihilation of sensation and all its consequences, one might suppose 
that it was of little consequence to the machine; but it is as essen- 
tial to it as food. 
Sleep, or rather a cessation of sensation, thus taking place, while 
the action of life is going on, shows that there must be a peculiar 
structure, and a principle arising out of that structure superadded, 
making a compound which is endued with life; for life for a time 
can go on without sensation, but cannot always go on without it. 
Sensation, then, is a fatigue to life; and in proportion to the exer- 
tion of sensation, in a given time, the sooner is life wasted. For 
this reason, when we are in health, sensation stops at proper times; 
life then appears at ease. This slighter effect of health is often 
increased preternaturally, as in cases called lethargy.* 
* [Dr. Marshall Hall found that the muscular irritability of hybernating ani- 
mals was greatly increased during their state of torpor. In the same way, sleep, 
" nature's second best course," seems to be intended to recruit the exhausted 
irritability of the system after the labours of the day ; and accordingly during the 
condition of sleep the organs both of animal and vegetative life are in a state of 
repose, the one completely, the other only partially so. Various causes have 
been assigned for this state, none of which is completely satisfactory.] OF SUSCEPTIBILITY TO IMPRESSIONS, ETC. 
61 
CHAPTER VII. 
OF SUSCEPTIBILITY OF IMPRESSIONS ; OF STIMULI ; OF DISPOSITIONS OF THE 
BODY ; OF HABIT AND CUSTOM. 
Difference between impressions on animate and inanimate matter; of internal 
susceptibilities.-Of stimuli;-carried too far they become irritants ;-animals 
susceptible of stimuli at one time and not at another.-Of dispositions of the 
body ;-less well understood than those of the mind;-in health arising from 
impression;-in disease without it.-Of dispositions in the mind;-their 
ultimate effects are on the body.-Of dispositions of the body compared with 
the preceding;-both compared with the actions of machines.-A^ant of 
balance betwixt the parts of animals ;-parts weakest when at a distance from 
the sources of power;-why.-Of the memory of impressions;-to be found 
in the body as well as the mind ;-example.-Of the effects of repetition of 
natural actions.-Definition of habit and custom.-Of custom;-lessened 
effects from repetition of impression ;-increased effects. 
Every species of matter, whether inanimate or animate, is capable 
of impressions, and the effects of the impressions, are according to 
the nature of the impression and the part impressed. All matter is 
not capable of acting or reacting according to the impression, which 
passiveness belongs to inanimate matter, though not to all. A piece 
of dough receives impressions, but seems chiefly passive, not having 
the power of reacting, and making but little resistance. Elastic 
bodies receive impressions, which they restore in a contrary di- 
rection, producing ultimately various effects, which I have said are 
the soul or life of mechanism. 
In animal bodies the effects of impression are more various and 
complicated than in inanimate matter, because the most simple 
animal is more various and complicated in its susceptibilities of 
impression, and of course more complicated in its dispositions for 
action. 
In inanimate matter there are no actions within itself excepting 
the disposition to reinstate itself, as in elasticity; therefore im- 
pressions are not rising up within itself, in consequence of its own 
actions, as in animals, so as to produce consequent dispositions and 
actions, unless we could conceive that chemical and fermentative 
operations were of this kind. But animal matter having internal 
actions, these actions are producing impressions which are forming 
dispositions to action in the parts impressed; and, secondly, it is 
capable of being acted upon or impressed by common inanimate 
matter, in both which cases the impressions will be according to the 
nature of the impressions and part impressed conjoined. 
When a man is so affected as to feel within himself that he cannot 
live, which is very common, it arises from the mind being made 
acquainted with the state of the body; the living powers are be- 62 
HUNTER'S PRINCIPLES OF SURGERY. 
come weak, inactive, &c., and the nerves are communicating the 
intelligence. Accordingly, their actions are expressive of the ex- 
tinction of life going on, and the action of brain is expressive of 
such actions of the nerves; and as death is a something we know 
takes place, and this sensation of ours is not such as we feel in 
health, we conclude, from an habitual species of reasoning, that we 
cannot live, and we are often not deceived. This effect is often so 
quick that it may exceed the sensation of it, or at least may hardly 
afford us time to communicate these sensations to others. 
The internal susceptibilities, with the consequent impressions and 
dispositions, are, first, of want, and, second, of repletion; and all the 
other internal operations of the machine arise naturally from these 
two, especially repletion, as digestion, circulation, respiration, se- 
cretion, the intercourse of the sexes, &c. But the first movement of 
these actions appears to require the impression of external matter, 
the powers of digestion being excited by food being thrown into 
the stomach, in consequence of which circulation, respiration, se- 
cretion, &c., all follow, arising out of the internal operations of the 
machine ; all which have nothing to do with the sensitive principle, 
but are wholly dependent on the living principle. The desire of 
food, or susceptibility of the stomach to digest it, arises not from 
external objects, but from its own organization. 
The second kind, susceptibility of external impressions, affects 
principally the sensitive principle, but may also affect the living 
principle, as in medicines. These are called stimuli; and when 
both principles are affected they may be said to have the man- 
agement of the machine.* 
Impression or stimulus, produces a disposition to act, or rather 
action may or may not take place. But all impressions, either on 
the living or sensitive principle, are not stimuli; some go beyond 
stimulus, and become irritants ;f and other impressions are from 
their nature not stimulants, but produce a disagreeable impression 
either to the mind or body, and are also irritants. 
Stimuli-An animal, I have observed, is susceptible of impres- 
* [It is impossible to avoid remarking here the similarity of this view of 
Hunter's to Bichat's division into organic and animal actions.] 
f [It may safely be said that almost all stimuli, when applied in excess, ope- 
rate as irritants, and, if carried to their utmost point, as direct sedatives. Thus, 
electricity, which in a moderate degree irritates the system or rouses it to an 
unusual degree of action, in a concentrated form immediately extinguishes life. 
Cold and heat have the same effects, and so have most other stimulants. The 
same remark applies to those stimuli which in a healthy state proceed from the 
mind and produce agreeable impressions; as, for instance, joy, which may be 
exalted to ecstacy, and so occasion sudden death. 
It is probable that the same principle obtains in regard to the internal economy, 
and that those powerful sympathies which are the result of disease are many of 
them merely to be regarded as exaltations of natural impressions primarily 
subsisting between the different parts, which may be carried to any conceivable 
extent, so as to produce increased action, pain, or an entire destruction of the 
function. A different class of affections, will, on the other hand, arise from a 
deficiency in these impressions.] OF SUSCEPTIBILITY TO IMPRESSIONS, ETC. 
63 
sions; which impressions, I shall now observe, are to become 
causes either of immediate or remote disposition to action, either 
in the part impressed, or some other by sympathy. These impres- 
sions, which excite or increase the disposition, are called stimuli; 
therefore we may say that a part is stimulated, or such an appli- 
cation, substance, or object is a stimulus ; and a part either readily 
increased in action by impression, or brought into action, we say 
is very susceptible of stimuli. I could wish we had some one word 
expressive of this condition of the part stimulated, as stimulable, 
and also of the stimulus, as stimulative, to answer to irritable, sen- 
sitive, &c. 
An impression which becomes a stimulus by sympathy may have 
been carried so far as to have been an irritator of the part to which 
it was applied, as a mote in the eye irritates the tunica conjunctiva, 
which irritation acts only as a stimulus to the lachrymal gland, for 
this gland can only act by sympathy. The power of a stimulus 
must be according to the nature of the stimulus and of the part 
jointly, for as almost every part of a body has a peculiarity in its 
mode of action, every part must have its peculiar stimulus. 
An animal is so constructed as to have its parts susceptible of 
stimuli at one time and not at another. An animal has a power of 
improving its parts so as to make them susceptible of such stimuli 
as are adapted to the disposition of the parts; for instance, an 
animal improves all those parts peculiar to the sexes. When those 
parts are perfect, which is called the age of puberty, they stimulate 
the mind and various other parts connected with that, giving rise 
to the passion of love or the appetite of lust. 
On the other hand, want becomes the cause of impression: a 
part becomes susceptible of such want, so that the ultimate effect 
or stimulus is completely produced, and an appetite arising from 
such stimulus takes place. Thus, the stomach when empty is sus- 
ceptible of the stimulus of hunger. This kind of stimulus may be 
carried so far as to excite a diseased action, and must then be con- 
sidered as an irritant. 
Of Dispositions of the Body.-It may be difficult to define a 
disposition of the body, but that the body has dispositions is un- 
deniable ; and without knowing this, and therefore coming at or 
endeavouring to come at the knowledge of these dispositions of the 
body, a man must be a very confined surgeon in his practice. 
But the term disposition is more commonly applied to the mind 
than the body. In the mind it is more easily comprehended, be- 
cause the mind has the power of investigating its own feelings or 
dispositions, also the power of communicating them, by means of 
the body, to the minds of others, so as to be understood or felt by 
those minds. 
Every man has felt perhaps every disposition that can arise in 
the human mind, and is therefore perfectly sensible of those dispo- 
sitions when they occur in others. But in the present inquiry the 
mind has no intelligence of the feelings or dispositions of the body, 64 
HUNTER'S PRINCIPLES OF SURGERY. 
and is obliged to compare the effects of the one with those of the 
other, and where they are similar to suppose that the causes are 
also similar. 
A disposition either in the mind or body, when in health, always 
arises from some impression; but as both mind and body are ca- 
pable of seemingly spontaneous actions, these may arise from dis- 
eased dispositions in both, producing madness in one case and 
strong disease in the other. 
As disposition may arise in consequence of some impression, it is 
capable of being destroyed by a counter-impression, which in dis- 
ease is the method of cure that wTill be called specific. Many 
dispositions weai' themselves out, or are such as the body or part 
cannot go on with. 
A disposition is different from a visible action, yet it is possible 
it may be itself an action. If wre compare the actions of the body 
with those of the mind (which is comparing from analogy, and per- 
haps the only mode we have,) we shall gain a pretty good notion 
of them. 
A disposition of the mind, then, certainly arises either from some 
action of the brain, or a certain position of the parts of the brain 
takes place, giving them an inclination to action. But this action, 
or the position which produces the inclination to action, we know 
nothing of; it is only a sensation of the mind, or rather a con- 
sciousness of the mind of such inclination, which sensation or con- 
sciousness, is different from the sensation of the brain, arising from 
other actions of this viscus : and also knowing that such action of 
the brain as produces such sensation in the mind, is endeavouring 
to set other parts of the body into action which may be called 
voluntary, or rather actions in voluntary parts ; and that when 
such actions of the brain have taken place, such dispositions of 
the brain are lost; I say, knowing so much, we may, knowing from 
analogy, form some idea of bodily dispositions. But the dispositions 
of the body appear to differ in this respect from those of the brain, 
that in the brain there is only the disposition, the ultimate or con- 
sequent action taking place in the body. But this is, perhaps, 
because we are not much acquainted with the immediate effects 
of the disposition in the brain, being led away by the visible actions 
which take place in the body. 
To explain this, let us suppose that I have an impression made on 
my body in such a manner that my sensitive principle is sensible of 
it; if, for instance, a man gives me a knock on the head that makes 
me angry, I form a disposition from that for resenting fit: that dispo- 
position in my mind produces an action in my brain which forms a 
peculiar state of the mind, which is anger. If it was an action of 
some othei' kind, it might be affection or gratitude. The brain can 
do nothing by way of retaliation, whether it be gratitude or revenge 
which directs, but to set parts of the body to work. Having received 
a blow on my head, the disposition in my brain to produce the 
action of revenge sets my hands to work to give my enemy another . OF SUSCEPTIBILITY TO IMPRESSIONS, ETC. 
65 
blow, and then the disposition is at an end. So that whenever the 
action has taken place, the disposition is gone.* The ultimate effect 
is made sensible to us, and we are apt to imagine that it is the imme- 
diate act of the disposition of the brain; but it is only that the immediate 
action which took place in the brain made other parts of the body 
act secondarily, so that three actions are necessary to the ultimate 
effect; but they are not all three actions of the brain. There is, 
1st, the action which produces the disposition: 2d, the action of 
the nerves in consequence of the disposition: 3d, the action of the 
voluntary muscles in consequence of the action in the nerves; but 
only the two first actions belong to the brain.t 
Let us see how far this disposition and consequent action of the 
brain correspond with the dispositions of the body and the actions 
arising in consequence of these dispositions. 
If on any part of an animal an impression is made, a disposition 
is formed suitable to that impression, which is the first; and an 
action in the same part suitable to that disposition may take place, 
which is the second, and is the ultimate; but if a sympathetic action 
takes place, it becomes somewhat similar to the ultimate effect on 
the body, arising from a disposition in the brain. 
We may, with great propriety, compare the disposition and action 
of either the brain or the body with the disposition or action of an 
elastic body. An elastic body, when acted on, (which is similar to 
an impression made on the body,) acquires a disposition or inclina- 
tion, which, if allowed, will produce action in all parts of the elastic 
body, which destroys the disposition, The disposition to action, 
and the action, are two very different things in themselves, even in 
the elastic body: when the elastic body has performed its action, it 
remains at rest until acted upon again ; but it always acquires action 
to destroy disposition. 
We must make a material distinction between a disposition and 
an action in diseases, for what will cure an action will have no 
effect on a disposition. 
Every machine is composed of very different parts, yet all tend 
to some ultimate effect. Every machine, whether natural, as an 
animal body, or constructed by art, however simple it may be, yet 
is always composed of more parts than one; and it must be observed, 
that no two parts have the same action, although all are tending 
even in the most complicated, to produce some one ultimate effect, 
* [The disposition does not cease because the action has taken place, but be- 
cause a new feeling, that of gratified revenge, has arisen in the mind, and taken 
the place of the previous disposition. Had the blow of retaliation missed its 
aim, the disposition would have continued, notwithstanding the action had taken 
place, until a second and more effectual one had been given. This mode of rea- 
soning from metaphysics and false analogy is extremely unsatisfactory, although 
it must be admitted, that many striking analogies exist between the powers and 
actions of the mind and those of the body, which Hunter seems to have studied 
with attention, and of which he has adduced some apt examples.] 
t [Or rather to the sensitive principle, which he supposed to be seated in the 
whole of the nervous system.] 66 
HUNTER'S PRINCIPLES OF SURGERY. 
For instance, some machines of art are intended for the division 
of time, as a clock, which may be so simple as to perform that 
effect by one wheel, the effect being expressed by an index. Some, 
again, are much more complicated, all the parts, however, being 
employed to the same ultimate effect, namely, the movement of this 
index, which expresses the ultimate effect; and the different parts 
composing the clock may be called organs. 
So it is with natural machines ; some animals are so simple as to 
have apparently but one operation, and that is support, and these 
may be called one organ. Others are complicated, being composed 
of different parts, whose actions and effects appear complete in 
themselves, as the action of a kidney, a liver, &c.; yet all combine 
to produce an ultimate effect in the machine, namely, the preserva- 
tion and continuance of the species. 
To produce the ultimate effect in any machine, there must be a 
succession of actions, one naturally arising out of another, each 
part taking on the action peculiar to itself; the preceding action 
being always the stimulus to the next succeeding one ; and thus the 
parts go on acting in regular succession until the ultimate effect is 
produced, and then the whole is at rest until stimulated into action 
again. In some parts this is almost immediately, as in the heart, 
organs of respiration, &c.; thus, when the heart has thrown out its 
blood, it has done its business; when we inspire and expire, the 
organs of respiration have done their business, but there is a ne- 
cessity for a recurrence of the operation again, and so immediately 
that it seems almost constant. But in others there is a greater 
distance of time before the action is renewed, as in hunger, evacu- 
ation of the faeces, urine, &c. 
An animal body so constructed, gives us an idea of perfection, 
for as each part has its particular appointment, one should natu- 
rally expect equality or powers suitable to these appointments 
would be found through the whole. But this certainly is not the 
case, at least in the more complicated animals, whatever it may be 
in the more imperfect and simple. We find this in the more per- 
fect, where life depends for support in the action of some one part, 
as the heart; also where many actions of the animal depend on the 
powers of another part, as the voluntary actions on the brain ; and 
not only the simple voluntary actions of the body depend on this 
viscus, but their real strength depends on it, for whenever the 
power of the brain is taken off, they waste; and this wasting does 
not arise from the brain supplying these parts with nourishment, 
and that being now cut off they lose their future support, but it 
arises from want of necessity to keep these parts in a state fit for 
action* when action cannot take place, because the will cannot 
* [If the exercise of every part is its natural stimulus to perfection, as it cer- 
tainly is, by exciting the natural actions of which every part is capable, then the 
want of exercise is the cause of this wasting. Tne same effect would equally be 
produced, although the parts should be supposed perfectly capable of executing 
their proper functions if called upon to do so. The stomach that has long fasted, OF SUSCEPTIBILITY TO IMPRESSIONS, ETC. 
67 
now stimulate them to action; and the same thing takes place in a 
proportionate degree when a joint is simply rendered, either wholly 
or in part, unfit for motion, where no injury has been done to the 
nerves. Hence it must appear, that as the power of support is in 
one part of the machine, and the power of many actions in another 
part of the machine, it is possible that all parts of the body may 
not be equally served by the first, namely, the heart; nor equally 
influenced by the second, namely, the brain; and we do find that 
the more distant parts from these sources of power are the weakest. 
This, perhaps, is better illustrated in disease than by any actions of 
health. We may just observe, that all the vital parts are near the 
one, and all the acute sensations near the other. In disease we see a 
mortification arising in the extremities more than in the other parts, 
and more especially if the person is tall, so that the heart is not 
capable of propelling the support of life to those distant parts in 
such a state of the constitution. 
How far the blood may lose its power of nourishment before it 
reaches the extremities, I will not say. If our acute sensations are 
near to the brain, it is reasonable to suppose that proximity of parts 
adds to the power of the nerves in communicating sensation; if so, 
it is reasonable to suppose that proximity of parts will also add to 
that power which the brain has over the actions of voluntary parts 
by means of the nerves. 
On Habit and Custom.-Memory, or recollection of past im- 
pressions, has, I believe, principally been applied to, or supposed to 
be an attribute of, the mind only; but we know that every part 
endued with life is susceptible of impressions, and also that they 
are capable of running into the same action without the immediate 
impressions being repeated. Habits arise from this principle of 
repetition of, or becoming accustomed to, any impression, and the 
same thing exactly takes place in the mind. The memory of the 
body is of much shorter duration than that of the mind. The mind 
not only goes more readily into action the second time of an im- 
pression, though a considerable distance of time has taken place 
since it went into the same action before, but seems to take up the 
action with more ease, from merely collateral causes, from a re- 
collection of the similarity, or often without any possible recollec- 
tion whatever, as if the actions, in consequence of the former im- 
pression, were taking place in the brain again. This does not 
appear to be so much the case with the memory of the body, for 
this only arises from immediate impression, but goes into action a 
second time more readily than at first. Possibly, however, the 
action arising from the first impression may be repeated from some 
•r the eye which has long been deprived of light, lose the power of performing 
their ordinary functions just in the same manner that a joint which has long been 
confined in one position loses its suppleness and strength, and the muscles waste. 
This tendency on the part of our author to suppose a sort of intelligential under- 
standing subsisting among the different parts of the body has been already ad- 
verted to.] 68 
HUNTER'S PRINCIPLES OF SURGERY. 
collateral or similar impression to the first; if so, it comes very 
near to that of the mind, though not so strong. 
A gentleman rubbed in mercurial ointment for the reduction of 
two buboes; he had only used it a few times when it affected his 
constitution so much that he was obliged to leave it off: he became 
feverish, the fevei' being of the hectic kind, with a small quick pulse, 
debility, loss of appetite, no sleep, and night sweats. He took the 
bark, with James's powder. As the effects of the mercury went 
off, and his buboes were advancing, it was necessary to have re- 
course to mercury again; he now rubbed in a considerable quan- 
tity without its having the least effect on his constitution or mouth; 
but the buboes spreading, made me order it to be left off again, and 
they were opened. He had recourse to the ointment the third time 
without its producing any disagreeable effect. The buboes took 
on a healing disposition, but then became stationary. I ordered 
him to leave off the ointment, to go to the sea, and bathe, and then 
they began again to heal. In about three weeks it was thought 
necessary to rub in again: when he began, it almost immediately 
affected his mouth very violently ; he left it off till his mouth was a 
little better, when he began for the fifth time, and it had not so 
much effect, and he was able to pursue the mercury. Now in this 
case he had lost the mercurial habit during the time he was at the 
sea, the parts had forgotten the mercury altogether, and the mer- 
cury coming on such a state of constitution, produced the same 
effect as it would have done if he had not taken mercury. So that 
the body had, as it were, lost the remembrance of the effect of the 
mercury on it in so short a time; but the mind would not have 
lost it. 
Custom is with me the negative of habit; by custom comes an 
insensibility to impression, the impression diminishing although the 
cause is the same, and the parts becoming more and more at rest; 
whereas from habit there comes an increased facility to go into 
action, as also an acquired perfection in the action itself, the im- 
pression continuing the same though the cause is diminishing. 
These may be reckoned as secondary principles in an animal, 
and produce two very opposite effects, both according to their 
modes of impression. 
Habit is the continuance of actions we have been accustomed to 
produce, without any immediate assistance, or even continuance, 
of the first cause, as a body set in motion continues to move after 
the cause of motion has ceased to act. 
Custom arises from external impressions, either in the mind or 
body, and is of two kinds, one when, the cause continuing, the im- 
pressions and consequently the actions, are diminished, the parts 
becoming habituated to the impression. We shall see the effect of 
this in oui' applications. If we apply a medicine to a sore, which 
shall affect it in one way or another, (it is immaterial which for the 
principle, but we will suppose it heals,) from becoming accustomed 
to that application, it shall lose the impression, and shall at last do OF SUSCEPTIBILITY TO IMPRESSIONS, ETC. 
69 
nothing; therefore you will be obliged to make the application 
more stimulating, more active, or change it for something else. It 
is exactly so with the mind; if a man goes into a strange place he 
is affected by the new objects about it; the next time he goes he is 
less struck; the third time less, till at last, when he goes into the 
place he can hardly perceive anything strange in it. These very 
different effects arise from a difference in the degree of impression 
resulting from the state of the mind or body at the time. In 
the first instance, if the impression or cause be very slight, so 
as hardly either to alarm the part or the constitution, they will 
get familiar with it, and will become insensible to it; a ring on 
the finger, the use of snuff, our very clothes, and physic itself 
are striking and daily instances of this. The habit of insensibility 
will soon be formed if the sensations of the mind and body be 
not very acute. If the first impression be violent, and such as 
produces considerable effect, it is not necessary that the same 
degree of violence should be inflicted to produce a similar effect 
the second time. One can easily imagine that these impressions 
may be continued until the parts continue to act without the im- 
pression, which would then become habit. If a dose of an emetic 
be given, which affects the stomach much, the same quantity is not 
necessary a second time to produce the same effect; the second 
must be given, however, before the stomach has lost the impression 
of the first perfectly.* 
The same effect is produced on the mind as on the body, for 
whatever has made but a slight impression, soon wears out, and 
we think no more upon it. On the other hand, if an animal has 
met with anything that has affected its mind much, as fear, &c., it 
is not necessary for the object to appear in the same manner to 
produce a similar effect. 
Those effects will be more or less, according to the state of the 
body or mind at the time of the first affection; the more irritable 
or the more ready it is to fall into the first action at the time, the 
more readily will it take it up the second time, although it may not 
be particularly irritable or susceptible of this particular action. 
Habit.-A habit of acting arises from a repetition of acting, which 
repetition of acting is custom, and which becomes the cause of the 
continuance of the same action. So that custom is always prior to 
habit, or, as it were, forms habit, which may be ranked as one of 
the secondary principles in the machine. 
* [This arises partly from habit and partly from the fact that the emetic has 
produced an irritable state of the stomach, which renders it more susceptible of 
the action of any irritant. It would appear that mere impressions, or the passive 
part of habits (called by Mr. Hunter custom), always diminish in intensity by 
repetition, but that the actions or thoughts that are put in train by those impres- 
sions recur more easily the oftener the impressions are repeated. The reader 
who is desirous of pursuing this subject is referred to Bishop Butler's admirable 
treatise on the Analogy of Natural and Revealed Religion, Part I. Chap. V., a 
book which, like Hunter's Treatise on Inflammation, was the product of upwards 
of twenty years' labour, and is stamped in every page with characters of the 
most profound genius.] 70 
HUNTER'S PRINCIPLES OF SURGERY. 
The first action being produced by a disposition in, or force upon, 
the part, this being repeated or continued a sufficient length of time, 
the action at length goes on, when that original disposition or force 
is gone, until some other power counteracts it, or it wears itself out. 
The more we have been in the habit of thinking on any object, the 
more readily does the train of thinking relating to that object occur. 
This principal in the animal is similar to the vis inertice in matter, 
for by it a motion begun is continued, and their remaining at rest is 
from the same cause. This principle becomes the cause of the 
actions of the mind; it does not allow men to think differently from 
what they have been accustomed to think. Men in general go 
through life with the same modes of thinking, and thus it becomes a 
cause either of the retardation or improvement of the understanding. 
It retards improvement, because it gets the better of even present 
sensations, and does not allow men to wander into novelty. It 
promotes improvement, because it makes men perfect in what they 
have been long employed about. 
CHAPTER VIII. 
OF THE HEAT OF ANIMALS. 
The principle of heat a great principle of action in nature;-nature of, unknown; 
-opposed to cold ;-unequal distribution of on the earth ;-measures of sensi- 
ble heat;--absolute heat of bodies, unknown;-of the sensation of heat;- 
destructive when in a high degree, as is cold.-Natural heat of animals capa- 
ble of diminution without loss of life;-certain functions first cease ;-propa- 
gation of the species first;-digestion in some animals, as reptiles.-All animals 
endowed with heat, but in different degrees ;-erroneous notions of its causes ; 
cases in which the function was remarkably deranged ;-experiments, showing 
the power of animals to generate heat in proportion to the necessity;-order of 
cessation of functions from cold;-diminution of heat during sleep.-Experi- 
ments on hedgehogs.-Heat of lower animals varying with temperature of the 
air-Standard heat of higher animals not exact.-Experiments to ascertain 
whether cold acts as a stimulus to the production of heat.-Resistance to ex- 
ternal heat;-experiments;-those by Fordyce.-Observations on animals 
having a standard heat;-differences in the capability of different animals to 
produce heat.-On differences of climate resulting from temperature;-other 
causes also act. 
The principle of heat is one of the first principles of action in nature; 
it is that which unlocks matter, and allows it to act according to its 
natural properties, or according to its combinations. It may be 
even said to compel matter to action. But that idea arose, I imagine, 
more from the effects which extreme heat has both on our sensa- 
tions, and its immediate effects on our bodies seeming to produce a 
species of violence, for we do not annex this idea to moderate heat, 
although moderate and immoderate heat act on the same principle OF THE HEAT OF ANIMALS. 
71 
of putting matter in such aposition that certain actions in the matter 
must take place, all which arises from the nature of the part heated. 
How far it is an active principle is not easily ascertained, though 
we must allow it has every appearance of being one. 
The term heat meant originally simple sensation, arising from a 
property of matter capable of producing that sensation, which is 
only an effect of that property. But philosophers having inquired 
into the causes and effects of this matter, have, from a poverty of 
language, applied the word which was at first only expressive of a 
quality to the thing itself, so that by heat now is also meant the 
matter of heat abstracted from the sensation which it occasions.* 
This is so much the case, that Dr. Blackt makes use of the term 
latent heat to signify that heat which a body contains without 
imparting it to the senses, as we might call the water which goes 
into the formation of salt latent water: in other words, that water 
which the salt contains without losing its solidity. 
It has been much disputed whether heat is matter, or only a pro- 
perty of matter. If it is simply matter, then, wherever there is heat 
there must be that matter present. If heat is a property of matter, 
there must be both matter and property present. If heat is only 
an action in a particular matter, then there is that matter with 
its action, as also the body which throws this matter into the 
action, f 
Heat and cold are opposite principles, and cannot inhabit the same 
place.§ They occupy different parts of the globe, and in some 
places alternately; these, therefore, are subject to the variations of 
temperature, which cause varieties of climate. These will be further 
spoken of hereafter. 
Heat, although not equally distributed all over the globe, yet 
* [The sense of this inconvenience has given rise to the general use of the 
term caloric for the agent which produces the sensation of heat."] 
f [In connexion with the name of Dr. Black, we may mention that it was not 
until this able philosopher had completed his train of researches on the subject of 
heat that the true theory of respiration began to be understood, or the connexion 
which subsisted between this function and the production of animal heat. Pre- 
vious to this time the lungs were considered merely as the agent for cooling the 
blood.] 
p [Whether heat consists of a highly attenuated subtle matter which pervades 
all things, or of a vibration among the atoms of matter, has not yet been decided. 
Its leading feature is evinced in the repulsion which it produces among the par- 
ticles of matter, in which respect it is the proper antagonizing force to attraction. 
Whatever it is, we do not know anything of the principle itself, or of the manner 
in which it produces its effects. 
The subject of animal heat occupied a great deal of Mr. Hunter's attention, in 
consequence of which he made it the subject of two express papers in the Philo- 
sophical Transactions, besides recurring to it again very fully in the Treatises on 
Inflammation and the Animal (Economy. The reader is referred to these works 
in the third and fourth volumes for fuller information.] 
§ [Cold was formerly thought by philosophers to be a positive principle, like 
heat, instead of a mere negation or absence of heat, as it is at present almost, if 
not quite, universally considered. It is in the former view that Mr. Hunter 
speaks of it.] 72 
HUNTER'S PRINCIPLES OF SURGERY. 
exists in such a degree as to pervade all matter, and is therefore to 
be found in some proportion everywhere. Heat destroys attractions 
of all kinds, by which means it becomes the principle of fluidity, 
and consequently the reverse of the cohesive attraction, or principle 
of solidity. By means of this effect, motion is allowed to take place 
among the particles of matter. We have no other idea respecting 
the variations of heat, except as regards quantity. The quantity 
of heat has always been estimated by some visible effects, at first 
probably by our sensations alone, but afterwards by its effects on the 
expansion of bodies, especially of metals,* all of which is called sen- 
sible heat. But it has been discovered lately that many bodies 
retain more heat than can be made sensible by any of the commonly 
constructed instruments; therefore a body may have the matter of 
heat in it without its producing any sensible effects. Hence heat 
has now been divided by some into sensible and absolute heat. It 
may be possible that many bodies may have their whole heat made 
sensible; if so, then their sensible and absolute heat are the same. 
But it is most probable that the absolute heat of a body can never 
be known, for the measure of the quantities of heat from every expe- 
riment is always by sensible heat, which can never be a proof of the 
absolute heat in a body. 
The real increase of heat must alter the position of parts so as 
to produce the sensation called heat; and as this heat is diminished, 
the texture or position of the parts is altered the contrary way, 
which, when carried to a certain degree, becomes the cause of the 
sensation of cold. Now these sensations could not take place 
without a real increase or decrease of heat in the parts. When 
heat is applied to the skin, it becomes hot in some degree, according 
to the application. This may be carried so far as actually to burn 
the living parts. On the contrary, in a cold atmosphere a man's 
hand shall become so cold as to lose the sensation of cold altogether, 
and change for that of pain.t 
• [It has lately been discovered that minute variations of temperature, utterly 
inappreciable by the ordinary instruments founded on the principle of expansion, 
may be rendered evident and estimated by means of electro-magnetical currents, 
which are found to traverse certain arrangements of the metals when unequally 
heated. The degree in which the needle deflects from its mean position indicates 
the quantity of caloric which has entered the heated body, and may be measured 
by an index of degrees.] 
t [It is improbable that the sense of heat and cold depends simply on an 
"alteration in the [texture or] position of the parts," for if this were the case 
the same temperature, by inducing the same condition of parts, should always 
produce the same sensation, although it is well known that this is far from being 
the case. What to one hand, just removed from a vessel of hot. water, feels very 
cold, shall feel very hot to the other hand just removed from a vessel of cold 
water; or a part shall feel hot or cold when the reverse of these states is actually 
present. The sense of change, or the intensity of the impression, is estimated in 
relation to the previous state rather than to its absolute quantity, or else depends 
on some peculiar and morbid condition of the sentient organ. Thus, the eye 
which has long been secluded from light is oppressively affected by the common OF THE HEAT OF ANIMALS. 
73 
Real heat and cold may be carried so far as to alter the texture 
of parts on which the actions of life depend. Nature has allowed 
the heat of most animals to come much lower than the heat neces- 
sary for performing all their natural functions. This is most so in 
the more imperfect animals, although it exists in a considerable de- 
gree in those possessed of a better regulated standard of heat, as 
the most perfect. 
This answers the wisest purposes, for by allowing the heat to 
come to that degree in which many actions are suspended, or anni- 
hilated, the state of the animal is adapted to the state of the atmo- 
sphere, which is such as would render the effects of those actions 
unnecessary or of no effect. 
The first action that is suspended is the propagation of the spe- 
cies ; for if birds were to hatch, or animals to bring forth their 
young, in winter, there would soon be an end to propagation in the 
temperate and frigid zone, as animals in general only breed once a 
year. 
Cold also annihilates the powers of digestion in all those animals 
whose food is rendered impossible to be procured in the winter, and 
which have not power of emigration, such as frogs, lizards, snakes, 
bats, hedgehogs, &c. 
The power of generating heat was the first considered; the pos- 
sibility of generating cold being hardly suspected, because most 
people who made observations on this subject lived in an atmo- 
sphere colder than their own body. They observed, that in almost 
all animals there was a standard of heat, which in common language 
has been called blood heat. However, they extended their obser- 
vations a little further, and called a certain number of animals the 
cold-blooded animals, but made no experiments either to ascertain 
the effects or the principle on which they depended. 
If we examine any class of animals, we shall find them, more or 
less, endowed with this principle, though varying from one another 
very materially in this respect. The heat of the human body being 
always considerable, even in the coldest climate, it has necessarily 
attracted a good deal of the attention of philosophers and physiolo 
gists, and various have been the opinions which they have formed 
respecting its cause. 
Friction being a cause of the production of heat in many bodies, 
was supposed to be the cause of heat in animals, especially, too, as 
they thought it could be easily explained on this principle, for they 
observed there was sufficient motion in the body for such an effect, 
which motion was principally that of the blood. They calculated 
the size of the internal surfaces of the arteries, which increases as 
light of day ; and the same thing may be asserted of stimulants and their effects 
universally. 
It is a singular fact that excessive cold should produce effects very similar to 
those produced by excessive heat. Frozen mercury, for instance, occasions a 
sensation of burning, and destroys the life of the part which touches it if the 
contact is prolonged only a few seconds. 74 
HUNTER'S PRINCIPLES OF SURGERY. 
they divide. They calculated the size and number of the red 
globules; all of which furnished an amazing extent of surface for 
friction; and when they calculated the velocity of the blood moving 
on this extent of surface, as also of the globules on one another, 
they thought they saw a sufficient cause for the heat of the body, 
especially as they saw that when this motion was increased, as in 
fevers, the heat was to appearance greater. But w'e may say at 
the same time, that they did not see the objections to this theory, 
which are many. 
Dr. Stevenson* observed, that there was another cause for the 
production of heat besides friction, viz. fermentation, and on this 
principle he accounted for animal heat. But the fermentation of 
animal substances does not produce'heat. 
The superstructure built on the foundation that the friction, from 
the motion of the blood, is the cause of animal heat, falls immedi- 
ately to the ground on the observation that fluids have no powei' of 
generating heat; nor have two solids, if kept asunder by the inter- 
vention of a fluid of any kind. If this had not been a fact, still fric- 
tion probably would not have accounted for all the variety in the 
production of animal heat. Nor could the principle of fermentation 
account for all the phenomena which attend the heat of animals; 
therefore some other principle must be referred to as the cause. 
It being discovered that the absolute heat of bodies differs very 
much in different substances, and perhaps in the same substances 
differently combined, it was thought that this would account for the 
production and continuation of animal heat. It is supposed that the 
air which we inspire has much more absolute heat than the same 
air has when we expire it, and that the superabundant heat of the 
inspired air is given to the animat But this chemical method of 
accounting for heat will not account for all the varieties in the heat 
of animals at different times, especially in disease, when the breathing 
docs not equally vary or correspond with the heat of the animal. 
A remarkable case fell under my observation of a gentleman 
who was taken with an apoplectic fit. He lay insensible in bed, 
covered with the blankets. I found his whole body would become 
extremely cold in every part, and continue so some time, and in a 
short time would become extremely hot. While this was going on, 
several hours alternately, there was no sensible alteration either in 
the pulse or the breathing. 
A man fell from his horse, and pitched on his head, and produced 
all the symptoms of a violent injury. There was concussion and 
perhaps extravasation of blood, but no fracture could be seen. The 
pulse was at first 120°, but came to 100, and sometimes to 90, and 
* [Edin. Med. Essays, vol. v. Part II. p. 806, et seq. These can only be re- 
garded as specimens of the opinions and modes of reasoning adopted by the me- 
chanical and chemical physiologists of the last and the preceding centuries, to 
the subversion of which the efforts of Hunter, united with those of Haller, Stahl, 
and Cullen, mainly contributed.] THE HEAT OF ANIMALS. 
75 
was strong, full, and rather hard. He was very hot in the skin, but 
breathed remarkably slow, only half the common frequency. 
His breathing, pulse, and heat therefore did not correspond with 
this theory of heat. 
February, 1781.-A boy about three years old appeared not 
quite so well as common, being attacked with a kind of shortness 
of breathing in the night. It had become exceedingly oppressive 
about five o'clock on Sunday morning, so difficult that he appeared 
dying for want of breath. In this state he lay till ten o'clock 
when I saw him. He was breathing so slowly that I thought every 
breath would be his last, about two and a half inspirations, oi' even 
less, in a minute. (The common rate of breathing in such a boy 
is about thirty inspirations in a minute, and about twenty in a man.) 
When he drew his breath it was with a jerk; but his expiration 
was extremely slow, generally continuing through five seconds. I 
often could not distinguish the pulse, at other times it was very 
manifest, although very faint and slow, not more than sixty. On 
tying up the arm the vein did not rise in the least, so that the blood 
did not go its round. His eyes were turned under the upper eyelid ; 
while his body had a purple cast, especially the lips, which is easily 
accounted for,-it was owing to the blood not getting the scarlet 
red in its passage through the lungs, and whatever it might get 
there was lost in its slow motion through the arteries of the body. 
He had a fine warmth on the skin all over the body, although in a 
room without a fire, not covered with more clothes than common 
in the month of February, with snow falling at noon. 
Here it cannot be said that the heat of the body, which was neither 
great nor deficient, could arise from the constant supply furnished 
by respiration. 
It appears from the account given in the Philosophical Trans- 
actions of the experiments made in the heated room, under the 
direction of Dr. George Fordyce, that Dr. Cullen long ago suggested 
many arguments to show that life itself had a power of generating 
heat, independently of any common mechanical or chemical means; 
though we may observe, that the experiments here related only 
tend to show the power of producing cold, which they effec- 
tually do. 
I own I had formed an opinion on this subject. I rather sup- 
posed that animal heat was owing to some decomposition going on 
in the body, and in pretty regular progression, though not the pro- 
cess of fermentation. 
In consequence of an experiment made on two carp, to explain 
another principle in the animal economy, (where every common 
action was meant to be wholly suppressed, or so far suppressed as 
to render them incapable of producing heat,) I found an effect pro- 
duced while the animals were under the experiment which I did not 
suspect. I began, in consequence, to suspect some other cause of 
heat than the common or natural actions of an animal; for during 
the experiment I observed a remarkable reproduction of heat taking 76 
HUNTER'S PRINCIPLES OF SURGERY. 
place in these two animals. Until this time I had not an idea that 
there was a possibility of calling the principle forth, or that cold 
could excite it. 
Experiment. In the year 1766 two carp were put into a glass 
vessel with common river water, and the vessel was put into a 
freezing-mixture. The water surrounding the fish froze very 
rapidly on the inside of the glass all round. When the freezing- 
process approached the fish it became, as it were, stationary ; and 
the remaining water not freezing fast enough, in order to make it 
freeze sooner, I put in as much cold snow as made the whole thick. 
The snow round the carp melted. I put in more snow, which 
melted also. This was repeated several times, till I grew tired, and I 
left them covered up to freeze by the joint operation of the mixture 
and the atmosphere. After having exhausted the whole power of 
lite in the production of heat, they froze; but that life was gone 
could not be known till we thawed the animals, which was done very 
gradually. But with their flexibility they did not recover action, 
so that they were really dead. Till this time I had imagined that 
it might be possible to prolong life to any period by freezing a per- 
son in the frigid zone, as I thought all action and wraste would cease 
until the body was thawed. I thought that if a man would give up 
the last ten years of his life to this kind of alternate oblivion and 
action, it might be prolonged to a thousand years: and by getting 
himself thawed every hundred years, he might learn what had hap- 
pened during his frozen condition. Like other schemers, I thought 
I should make my fortune by it; but this experiment undeceived 
me.* 
This experiment laid the basis of many of my future conjectures 
on animal heat. 
I think we may observe in the common occurrences of life that 
for the actions of an animal a certain quantity of heat is necessary; 
and this quantity I find to be in some degree according to those 
actions, the greatest degree of heat being always wanted for the 
least essential action in every order of animals. However, every 
order of animals in general requires a heat peculiar to itself, though 
not always so, some admitting of a much greater variety than 
others even of the same order, as in the insect tribe. 
The actions of an animal may be placed in the following order 
with respect to its heat, wdflch is the inverse order to that of their im- 
mediate use in the machine. Propagation first; digestion; sensa- 
tion, in which maybe included wakefulness ; secretion ; circulation; 
each requiring its degree of heat for complete action. Propagation 
♦ [Blumenbach observes that the pup® of many insects are in winter so tho- 
roughly frozen as to ring like glass or icicles when allowed to drop on the 
ground, and yet without any injury to the torpid animal within. "The 
eggs of silkworms and butterflies hatch after exposure to a cold of 24° below 
zero. On the other hand, insects may be frozen repeatedly, and recovered as 
soon as thawed." (Elliotson's Physiology, p. 247.) This faculty of enduring 
cold is infinitely less surprising than that referred to by the last-mentioned au- 
thor, which allows beetles and other insects to survive being boiled. See note.] OF THE HEAT OF ANIMALS. 
77 
requires the greatest, digestion may be carried on with a degree 
less, secretion in two degrees less than propagation, and so on. 
In the insect tribe there is a difference between a bee and a 
wasp and many flies. A bee at all times requires a heat above 
90 (?) degrees* to support life with ease, while a wasp can allow 
its heat to vary with the atmosphere without losing life. 
When the external heat is so much diminished that it does not 
assist the natural powers of an animal, and it is obliged to vary 
its proper standard and become colder, then many of the actions 
are either lessened or totally suspended, not being necessary: gen- 
eration is suspended, and insensibility takes place, commonly called 
sleep ; but it is not sleep. Sleep is an effect which takes place in 
all degrees of heat and cold, though when a man is asleep he is 
colder than when he is awake, and I find in general the difference 
is about 1$ degree, sometimes less.j This difference in the degree 
of heat between sleeping and waking is not the cause of sleep but 
the effect; for many diseases produce a much greater degree of 
cold in an animal, without any tendency to sleep. Besides many 
of the operations of perfect health are going on in the time of 
natural sleep, at least in the perfect animals, as digestion, secretion, 
&c., while none of these operations are going on in the tribes 
called sleepers during their torpid state.f In these animals, where 
a great many actions are suspended, it appears an effect arising 
from a certain degree of cold acting as a sedative. 
Now this degree of cold in some cases seems to act as a stimu- 
lant ; the animal powers are roused to action for self-preservation, 
It is probable that most animals are under the influence of cold, 
and that every order has its degree of cold in which many of their 
actions can be suspended 
In some countries, where there is summer and winter, there are 
some animals whose actions are suspended during the winter. 
* [Hunter found the thermometer rise to 93Q or 98° in a hive of bees in spring ; 
to 104° in summer; to 82° when the air was at 40°, and to 73° in winter. (See 
his Paper on Bees in Vol. IV.)] 
f [There is the same close relation between the ordinary sleep of animals in 
general and the ordinary sleep of hybernating animals, as there is between this 
last and absolute torpor. In the 1st, the respiration is diminished and the tem- 
perature lessened 1^°; in the 2d, the respiration is still further diminished, and 
the temperature reduced to within a few degrees of the external medium; and in 
the 3d, the respiration is altogether suspended, and the temperature reduced to 
the surrounding medium. Cold is evidently a predisposing cause to all these 
states. Cuvier, however, has remarked that in some warm latitudes, as, for ex- 
ample, in the Isle of France; there are certain animals which fall into a state of 
torpor only during the hot months.] 
± [There is a good deal of difference in this respect in different animals. The 
hedgehog and dormouse awake every three or four days when the weather is 
mild, and during the interval of activity pass the urine and faeces freely, which 
could not be the case if they did not digest and secrete during their state of tor- 
por. This has never been observed of the bat, because the bat is an insectivorous 
animal, and would awake in vain if there were no insects. The circulation, 
however, is continued even in the bat at the rate of twenty-eight strokes in the 
minute during the state of torpor. (See Phil. Trans., 1832.)] 78 
HUNTER'S PRINCIPLES OF SURGERY. 
This suspension of several of their actions seems natural to them, 
being part of the economy of such animals. In other animals, 
where a suspension of several of their actions takes place from cold, 
it seems a force on those actions, as it rather seems to lead to the 
destruction of the animal than the preservation of life. We cannot 
give a stronger instance of the forcible power of the suspension of 
actions in animals from cold than what happened to Dr. Solander 
and others in their voyage round the world. 
Returning from a hill in Terra del Fuego, they were suddenly 
surprised with a degree of cold beyond what they ever felt before. 
Dr. Solander advised that they should immediately make their way 
to the ship as fast as possible, and he himself would bring up the 
rear. However unnecessary it might appear, Dr. S., who had 
crossed the mountains in Switzerland, well knew the danger of 
being left, and told them that they would soon be attacked with an 
almost irresistible propensity to sleep ; that whoever gave way to 
the feeling would sleep, and whoever slept would die. But after 
this very serious caution, the doctor was the first who felt the sen- 
sation he described, and could scarcely be persuaded by the united 
efforts of Mr. Banks and the others to proceed. Mr. Banks's black 
servant, Richmond, was the next whose desire of sleep was very 
great, so much so that, notwithstanding the consequences, he begged 
that he might be left to die. The Doctor only begged to sleep a 
little, and promised that he would then proceed. Mr. Banks, find- 
ing the case grow more serious every moment, sent forward four 
of the company to the first place where they could light a fire, the 
rest staying and endeavouring to bring up the few who had lain 
down. The Doctor was awaked, but their efforts were less suc- 
cessful on poor Richmond. In the midst of their endeavours to 
rouse him, they felt the same symptoms stealing on themselves very 
fast; it was in vain to attempt carrying, every one being scarcely 
able to carry himself. Having proceeded about a quarter of a 
mile, they met two of their party with the welcome news of a fire 
being kindled at the distance of half a mile. These two were des- 
patched in search of Richmond. Having warmed themselves, and 
becoming apprehensive for the fate of the two, a party set off in 
search of them. They had missed their way, and become victims 
to the malady from which they had endeavoured to restore the black. 
Richmond was found just crawling, and brought back, but no means 
had the least effect on the other two.* 
* [Many thousands of Napoleon's army are reported to have perished nightly 
from the same cause during the retreat from Moscow. 
Sir B. Brodie classes the effects of cold in the following order: 
"1st, It lessens the irritability and impairs the functions of the whole ner- 
vous system. 
" 2d, It impairs the contractile power of the muscles. 
" 3d, It causes contraction of the capillaries, and thus lessens the super- 
ficial circulation and stops the cutaneous secretion. 
"4th, It probably destroys the principle of vitality equally in every part, and 
does not exclusively disturb the functions of any particular organ." 
(MS. Notes of Lectures by Sir B. Brodie apud Paris.)] OF THE HEAT OF ANIMALS. 
79 
Winter.-I took two hedgehogs, not full grown, from their huts; 
the weather for some days preceding had been severe and frosty; 
the heat of the atmosphere was 44°. In one the thermometer was 
introduced at the pelvis, and the mercury stood at 45°; and at the 
diaphragm at 48°. In the other I found the heat in the pelvis 46°, 
and at the diaphragm 50°. 
The degree of heat of these animals being so low, it was com- 
pared with the heat of a puppy. The heat of the atmosphere during 
this experiment being 50°, a thermometer was introduced into the 
belly and pelvis of the puppy ; the mercury stood at 101°, and also 
at the diaphragm. 
Summer.-Atmosphere at 78°. A thermometer was introduced 
into the belly of a freshly-caught hedgehog. In the pelvis the mer- 
cury rose to 95°, at the diaphragm to 97°. 
From the foregoing experiments we find that the temperature is 
allowed to fall lower than the standard, which is productive of no 
evil excepting suspending such functions as require the standard 
degree of heat for their actions. 
Animal matter endowed with the living principle, whether en- 
dowed with action or not, or whether of the first or second order 
of animals, as far as I am acquainted, admits of the temperature 
going somewhat lower than would serve for the congelation of the 
same matter in a dead state. 
The more imperfect animals vary their heat according to the at- 
mosphere in some degree. 
I made the following experiments on fowls, which I considered to 
be one degree above the amphibia, and one degree below what are 
commonly called quadrupeds. 
I introduced the ball of the thermometer successively into the 
rectum of several hens, and found the mercury at 103°, 103^°, or 
104°. Cocks furnished the same results. In hens during incu- 
bation the heat was the same. Living eggs under the same hens 
raised the thermometer to 99°; an addled egg only to 97°. So 
that the living egg had some power of generating heat. In the 
more perfect animal, as the fowl, the heat is not allowed to come 
so low as in the more imperfect. 
The power of generating heat keeps the highei' animals as near 
one standard as possible ; but it was not necessary that this stan- 
dard should be very exact, therefore we find that they are in some 
degree influenced by external heat and cold, somewhat similar to 
inanimate matter and the more imperfect animals.* 
As parts recede from the common mass, as extremities, fingers, 
• [In the more perfect animals the temperature of the vital parts is more 
easily elevated above the natural standard than depressed below it. Thus, it 
was found in Capt. Parry's second voyage, that out of sixteen foxes, which were 
killed while the thermometer was from 3° to 32° below zero, the temperature of 
eleven varied from 100° to 106$° ; and so in other cases it has been observed 
that the temperature of the blood at the heart bears no relation to the external 
cold ; a fact which cannot equally be affirmed in regard to heat.] 80 
HUNTER'S PRINCIPLES OF SURGERY. 
toes, the combs of cocks, &c., they are more subject to be affected 
by cold, and will raise or sink the thermometer in some measure 
according to the external degree of heat or cold applied; though 
not in a proportional degree to this application, as would be the 
case in inanimate matter. 
I put the ball of the thermometer under my tongue, and kept it 
there for some minutes, when it rose to 97°, but would not go higher. 
I then took several pieces of ice and put them in the same situation, 
allowing them to melt. This I continued ten minutes, and found on 
introducing the thermometer that it fell to 77°, and gradually rose 
again to 97°. 
I thought the urethra would do still better, and I introduced the 
ball of a thermometer into a man's urethra. At one inch from the 
extremity the mercury rose to 92°, at two inches to 93°, at four to 
94°; at the bulb of the urethra it rose to 97°. Thus we see that 
projecting parts are subject to have their heat lowered by sur- 
rounding cold. 
To render this experiment more conclusive, I endeavoured to 
render this part colder by applying a colder medium to the penis than 
the common situation. This part was immersed in water at 65° for 
a minute. The thermometer, introduced an inch and a half, rose 
to 79°. 
To find if there was any difference in the quickness of heating 
and cooling between living and dead parts, as also what difference, 
I made the following experiments. 
I procured a dead and a living penis : the heat of the living penis, 
an inch and a half in, was 92°. I heated the dead one to the same 
degree, then immersed both in water at 50°. The dead one cooled 
fastest, but only two or three degrees; the living one coming down 
to 58°, while the dead one came down to 55°. I repeated the same 
experiment several times with the same result. 
The standard heat of the human body is about 99, and I believe 
that degree is pretty regular; however, this regularity in some 
degree arises from there being in every body a considerable mass 
of matter which causes less consumption of heat. This standard is 
necessary for the more material actions of life. 
The heat of the more imperfect animals is not the same in every 
part of the body, even when there appears an equal mass of matter. 
To ascertain this, I took a healthy dormouse, the atmosphere being 
at 64°. I put the thermometer into the belly, nearly in the middle 
between the thorax and the pelvis; it rose to 74°: at the diaphragm 
it rose to 80°, against the liver to 81^° 
As there is some difference between the heat of an animal at the 
source of the circulation and that of the mouth, pelvis, and rectum, 
we must make an allowance in judging of the heat of the heart by 
that of these parts. 
I next wanted to ascertain if cold applied to an animal would act 
as a stimulus, and therefore greater heat be produced than the 
common standard. THE HEAT OF ANIMALS. 
81 
I took a healthy mouse,-atmosphere 64°,-introduced the ball of 
the thermometer between the thorax and pelvis. The mercury rose 
to 74|°, at the liver to 81^°. I put the mouse into an atmosphere 
at 30°, and when the ball was again introduced into the belly the 
mercury rose to 92°, at the liver 93°, the animal being still very 
lively. Here was an increase of 174° in the belly, and 112° at the 
liver, and this produced by the application of cold to the skin. 
Of the Resistance to foreign Heat above the standard.-We have 
found that animals evidently possess a power within themselves of 
producing heat when in a cold atmosphere, so as to keep their bodies 
in a temperature suitable to the economy of the animal. But as 
animals are often placed in an atmosphere much hotter than their 
standard heat, I wanted next to see how far they have a cooling 
power, or, if they have not, to wrhat degree the heat of an animal 
might be increased, and what might be the consequence of that in- 
crease, supposing it possible; for a priori we should suppose that 
the standard heat, or that heat at which all the animal functions are 
best carried on, would be the medium heat of the animal. But I 
find from experiment that the standard is generally within a degree 
or two of the ultimate heat that the animal can bear. As allowing 
the heat to rise above the standard could answer no wise purpose, 
Nature has put a check to it by making the stimulus of heat the 
cause of its own annihilation, just as the stimulus of cold produces, 
on the other hand, an increase of heat.* 
This would appeal' to take place in two different ways: one is by 
evaporation, which arises from the action of the living powers; and 
the other by an immedate power of destroying heat. So that 
animals have two means of destroying heat, while it would appear 
that they have only one for the production of it. 
I put a viper into an atmosphere at 108°, and allowed it to stay 
in seven minutes, when the heat in the stomach and anus was 925°, 
beyond which it could not rise in the above heat. 
The same experiment was made on frogs with nearly the same 
success.f 
I now tried to what degree of heat I could bring a more perfect 
animal; and as I found the penis the best part for trying the experi- 
ment with cold, I imagined it would be the best for the trial of heat. 
The experiments were made in the same manner with the former, 
only the water was now hotter than the heat of the man. These 
were only simple experiments, but I chose to make a comparative 
one with a dead penis. 
A living and dead penis were immersed in water gradually made 
warmer and warmer, from 100° to 118°, and continued in this heat 
* [The cause of animal heat is considered in the Treatise on Inflammation, 
Part II., chap. iii. sect. 3; and the mode by which the temperature is regulated, 
at sect. 4. The reader is referred to this part of the Work, as well as to the 
author's paper on this subject in Vol. IV. 
f [According to De la Roche, the temperature of frogs does not rise above 
80° to 82° in a medium of 110° or 115°. (Journ. de Phys., tom. Ixiii.)] 82 
HUNTER'S PRINCIPLES OF SURGERY. 
for some minutes. The dead penis raised the thermometer to 114°, 
while the living could not raise it higher than 102|°. It was 
observed by the person on whom the experiment was made, that 
about a minute after the part was put in water the water did not 
feel hot, but on the water being agitated it felt so hot that he could 
hardly bear it. On applying the thermometei' to the sides of the 
living glans, while in the water, the mercury fell from 118° to about 
104°, while it did not fall above a degree when put close to the dead 
penis, so that the living glans produced a cold space of water about 
it.* This experiment may furnish a useful hint about bathing in 
water, whether colder or warmer than the heat of the body; for 
if it is intended to be either colder or hotter, as it will soon be of 
the same temperature with that of the body, the patient, if in a 
large bath, should move from place to place, and in a warm bath 
there should be a constant succession of water of the intended 
heat.f 
The experiments made by Dr. G. Fordyce in heated rooms 
prove, in the clearest manner, that the body has a power of de- 
stroying heat. 
The action of evaporation produces cold, and in proportion to 
the quickness of the evaporation is the cold produced; and from 
experiment we find that the evaporation of spirits of wine produces 
cold faster than that of water, and of aether faster than spirits of 
wine. On this principle we suppose that evaporation is one means 
of producing cold in the living body. J 
It appears from Dr. Fordyce's experiments that the living powers 
were very much assisted in generating cold by evaporation, but 
that evaporation was not the sole agent in keeping the body cool. 
There is therefore a further provision of Nature for enabling ani- 
mals to support great heat. In order to keep up a just balance of 
temperature, it is probable that the living powers exert greater 
effort as evaporation is deficient, and less effort as evaporation in- 
creases. In emergencies, evaporation is not sufficient: when a 
greater power of producing cold than ordinary is required, the 
powers of the animal are called forth. 
As animals can only destroy a certain quantity of heat in a given 
time, so the time they can continue the full exertion of this de- 
* [These experiments on parts of the body are evidently inconclusive, inas- 
much as any elevation of temperature is necessarily prevented by a continual 
influx of fresh blood, which carries off the heat.] 
f [Upon the same principle the sirocco and scorching winds of the African 
deserts are so destructive of animal life. In the expedition to discover the 
N. W. Passage, the sailors found a temperature at zero attended with a breeze 
far more difficult to resist than a temperature at 50° below zero attended with a 
calm atmosphere.] 
£ [The influence of evaporation in producing this effect has been fully inves- 
tigated by De la Roche, who arrived to the general conclusion that evaporation 
from the lungs and skin is the main cause by which the temperature is regula- 
ted in all cases, and the sole cause by which this effect is produced when the 
body is exposed to a temperature above its own natural standard. (See Journ. 
de Phys., tom. Ixiii. Ixxi, and Ixxvii. See also Treatise on Inflammation, loc. 
cit.)] OF THE HEAT OF ANIMALS. 
83 
stroying power seems also limited. It is probable that both the 
power of destroying heat, and the time in which that power can 
be exerted, may be increased by frequent exercise. 
When Dr. Fordyce was in the heated room, his hand became so 
hot as to make his body feel cool to it.* It is probable that that 
part, from its habit of changing its degree of heat, is more ready to 
take on different degrees of heat applied. It is found from experi- 
ment, in the application of cold, that all the extremities are more 
subject to the laws of inanimate mattei' than the body; and the 
nearer the source of circulation, the greater the deviation is from 
these laws. Possibly the same may be observed with regard to 
heat. 
In animals which have a standard heat it would appear to be 
more natural to form than to destroy heat, (although the power of 
destroying it appears to be much greater than that of producing it.) 
for we may observe that they live with much more ease to them- 
selves when in an atmosphere considerably lower than their stan- 
dard, in which they must constantly be generating heat, than in an 
atmosphere even of their own temperature, in which it cannot be 
necessary for them to form heat; so that either this action simply 
of generating heat, or being in such a degree of cold as makes this 
action necessary, proves salutary to the constitution, f Perhaps the 
medium between their extreme heat, which is 98°, and the lowest 
degree they can come to, is the proper and most wholesome tem- 
perature of the atmosphere, and this is about 63°. 
Some of these animals which are endowed with this property of 
a standard heat have this power of generating heat much stronger 
than others, and are always best in those situations where this 
power can be exercised: we should naturally suppose that this 
power always requires a necessity for that exertion equal to its 
power, so that the power and the necessity should always be pro- 
portioned. This cannot be the case with those imperfect animals 
which have little or no power of forming heat, but are obliged to 
the atmosphere for heat. 
When we consider the white bear, the fox, and wolf, in the more 
northerly climates, inhabiting countries where the temperature is 
below zero, yet having a power of preserving their noses, feet, tails, 
&c., while man, with all his care and art, loses his extremities in 
the same degree of cold, we must acknowledge that those animals 
have by much the greater power of generating heat of the two. 
When we compare the above animals with the lion, tiger, monkey, 
&c., we find the proportion in the power ofgenerating heat between 
* [This effect probably arose from the superior denseness of the cuticular 
covering of the hand preventing perspiration.] 
f [It is certainly a remarkable proof of Hunter's penetrating sagacity that he 
should have been able to arrive at so general a truth without being acquainted 
with the true cause of animal heat, or the intimate connexion which subsists 
between this function and that of respiration. (See Treatise on Inflammation, 
loc. cit.)] 84 
HUNTER'S PRINCIPLES OF SURGERY. 
those two classes of animals still greater; for if the human species 
finds it impossible to generate heat like the white bear, &c., the 
lion and tiger must .find it impossible to generate heat equal to man: 
for though they may not lose parts of their bodies when in cold 
that is tolerable to the human species, they lose their lives in the 
end.* 
It may be desirable to inquire into the proper temperature for 
each of those classes above mentioned, that is, the temperature in 
which they carry on their ultimate actions.! This must be ascer- 
tained with great difficulty; perhaps the temperature suitable to the 
white bear, &c. is about 50° ; for the human species about 60° ; for 
the lion, tiger, &c. about 70°; and there may be some which require 
a still higher temperature, though probably none will require a lower 
than 50°. 
On the Effects of Climate.-By climate we mean that state of the 
atmosphere which is peculiar to any particular part. Climates vary 
as much as anything in nature. Their difference may be said to 
arise chiefly from the influence of the sun, from their moisture or 
dryness, which will depend partly on the shape of our globe and its 
oblique direction with regard to the sun, and also from the nature 
* [Habit in this instance has great influence, so that the calorific function 
actually increases or strengthens in winter and diminishes in summer, (Edwards, 
De 1'influence, &c., pp. 162 seq., 242 seq.) an effect which we cannot but observe 
in those.who have resided in the East and West Indies returning to an Euro- 
pean climate.] 
f [By ultimate actions Hunter probably means generation, as he has stated 
the continuance of the species to be the ultimate end for which the vital powers 
are given to animals.] 
f ("Vegetables and animals are prepared for almost all climates, and for 
temperatures higher than the heat of any country. Dr. Reeve found larvae in a 
spring at 208° ; Lord Bute, confervae and beetles in the boiling springs of Albano 
that died when plunged into cold water. A species of chara will flower and 
produce seed in the hot springs of Iceland, which boil an egg in four minutes. 
One plant, uredo nivalis, which is a mere microscopic globule, is said to grow 
and flower under the snow. 
"Some cold-blooded animals bear heat very badly. Dr. Edwards says that 
frogs die in a few seconds in water at 107°, [but Dr. Marshall Hall states that a 
frog plunged into water at 120°, "first struggles violently, then experiences 
convulsive movements, and then promptly dies, whilst the limbs become exceed- 
ingly and permanently rigid. After apparant death, all sensibility and motion 
having ceased, the heart is found to beat for a considerable time, presenting the 
singular phenomenon of an animal dead to animal life and maintaining a sort of 
vegetative existence only." (Hall on Circ., p. 174.)-Editor.] Yet a species 
of taenia has been found alive in a boiled carp ; but then the carp which it inhabits 
will live in water as hot as human blood. 
" The germs of many insects, &c. are unaffected by a great range of tempera- 
ture, I know a gentleman who boiled some honeycomb two years old, and after 
extracting all the sweet matter, threw the remains into a stable, which was soon 
filled with bees. Body lice have appeared on clothes which had been immersed 
in boiling water. Spallanzani found long ebullition in the open air favourable to 
the appearance of the animalcules of vegetable infusions; and the application of 
great heat in close vessels, although it prevented the appearance of a larger kind 
of animalcule, did not that of a smaller."-Elliotson's Phys., p. 246. See note, 
p. 284.] OF THE HEAT OF ANIMALS. 
85 
of the surface, whether hilly, or flat, or woody. The different sea- 
sons are dependent on the form of the earth and its motion round 
the sun. Between the tropics the variations of seasons are less; 
still there are kinds of seasons, and the climates are very various. 
The greatest variety of climate is near the tropics. The world 
there, being chiefly, if not altogether, heated by the sun, works very 
hard to gain as much of its influence as possible; it exposes itself 
to it as much as possible in every direction. The air of the equator 
is very different from that of the poles; few can live in the climate 
of the poles, either animals or vegetables, and even of those which 
can live many become torpid during the winter. It is wonderful, 
considering the necessity of heat to animalization and vegetation, 
and how partial Nature has been in the distribution of it, how both 
these processes go on so well as they do.* Nature, however, has 
been obliged to adapt animals to their different climates as well as 
vegetables, except the bramble, which lives between the tropics and 
at the poles. 
Some animals become torpid during the cold, others even of the 
same order do not; this seems to be because the food of the first is 
not to be found during that season: so Nature formed them either 
animals of passage, as some birds ; others she constituted so as to 
become torpid. Animals of passage, however, seem to have their 
peculiar climate ; fish, which wander more than most animals, have 
their climate, and the general cause of their moving south is for the 
purpose of propagation. So herrings come from the North Pole 
to the coasts of Europe and America, for no other purpose than to 
lay their spawn. Quadrupeds seem the best formed for variations 
of climate, though their heat is more stationary. There are ex- 
ceptions, as the dormouse, bat, &c.; but men, dogs, deer, horses, 
&c., live tolerably well, though not without disease, between the 
tropics and also far north. Nature has furnished some animals with 
mechanical means for adapting them to climate, as hair, feathers, 
&c. The use of hair is clearly to preserve warmth : the porcupine 
of Italy has no hair, but only quills; and the southern bears have 
only bristles, without hair. There are some animals furnished with 
proper non-conductors of heat, as seals, sea-cows, &c., whose hair 
can be of little use to them while living in the sea, and is therefore 
only useful to them perhaps while on land. Those animals, as 
whales, which, from living constantly in water, could derive no ad- 
vantage from hair, have an immense quantity of fat, which is a 
worse conductor of heat than water by nine to one.t 
* [Cold, however, interrupts the growth and nutrition of organized bodies, as 
may be seen in the short stature and small size of the Greenlanders, Laplanders, 
Esquimaux, &c., as well as in all the plants and animals of cold and mountainous 
regions.] 
f [The white hair, white skins, and white flowers which characterize the pro- 
ductions of the frigid zone are designed for the same purpose, in as much as heat 
radiates from white bodies more slowly than from those which are coloured. In 86 
External heat and cold produce diseases peculiar to themselves. 
Men are the only animals which go to climates not congenial to 
themselves, and consequently they are alone subject to the conse- 
quences of an unfit climate. Too much heat produces diseases of 
the liver, though, as Dr. Blane observes, this must depend on some 
other cause than mere heat, as these complaints are not so frequent 
in the West Indies as in the East.* Diseases of the bowels and 
tetanus are also often produced by heat; it also tends to produce 
fevers. The diseases produced by cold are chiefly those of debility, 
as chilblains, scurvies : also diseases of the lungs, which are more 
dangerous than those of the liver. Cold also increases some diseases, 
as the lues venerea: and changes from heat to cold produce some 
diseases, as scrofula. 
As heat is able to volatilize almost all bodies, the impurities of the 
atmosphere must very much depend on it; but, as Dr. Blane remarks, 
the same heat which volatilizes bodies will very often decompose 
them. The plague has not been known between the tropics, nor the 
jail fever, and very warm climates abound much less with diseases 
of a putrid kind than temperate climates. How does the atmosphere 
affect the body 1 Is it by the lungs or by the skin ? This ques- 
tion it is perhaps impossible to solve. The purest air seems, caderis 
paribus, to be the coldest: and the worst, the warmest, especially 
when moist, where the situation is low, and where animal substances 
suspended in it are allowed to putrefy. In a very hot air substances 
may be volatilized so rapidly that decomposition cannot take place; 
this air will prove destructive by different modes: 1st, By preventing 
respiration; for if many substances are volatilized, the air containing 
them will not reach the lungs, except in too small quantities for the 
support of animal life.t 2dly, By specific poison, producing a 
variety of diseases, often sedative, as debility and agues, in marshy 
grounds; in other places, fluxes and different kinds of poisons. 
3dly, The effects of an impure atmosphere are found in jail dis- 
tempers and hospital diseases ; very few of the former places are 
ever free from foul air, and most hospitals are more or less affected 
with it. There are different modes in which these poisons may 
affect. A stranger in a marshy country is much sooner affected 
HUNTER'S PRINCIPLES OF SURGERY. 
the same manner, all the finer furs and downs come from the high latitudes, 
whereas cats, rabbits, and other animals change their fur into hair when they are 
transplanted to a meridional climate.] 
* [If, as Tiedemann and Gmelin conjecture, the functions of the liver and lungs 
are, in one sense, correlative, viz. that they both tend to free the blood of its 
carbon, then it is not difficult to understand the greater tendency to diseases of 
the liver in these climates. The blood equally requires purification, and yet this 
cannot be effected by the lungs without the production of more animal heat than 
is required; in consequence of which the liver is called upon to fulfill this extra 
duty, and from over-exertion falls into disease. In the West Indies the sea- 
breezes materially tend to prevent those consequences which take place in the 
inland continents of the East.] 
t [It is extremely improbable that a case of this kind ever occurred, considered 
merely in respect of climate.] OF THE HEAT OF ANIMALS. 
87 
than a native or an inhabitant. A person'who has not long been used 
to a jail will earlier, and with more certainty, be affected with jail 
distemper. An instance of this occurred at Salt Hill in 1760. The 
effects were at first attributed to the wine ; but they were evidently 
caused by a few paupers, who were examined by some gentlemen, 
although the paupers did not appear to be affected. In 1775 some 
prisoners were examined at the Old Bailey who infected the whole 
Court, and many died ; the judge on the bench, the jury and evi- 
dences, &c. Many poisons are of this kind : a person may carry 
the infection about with him without being affected himself.* The 
air is capable of carrying most poisons, and communicating their 
irritations. The venereal poison cannot be thus raised in a state 
of vapour, or if it can, it loses its effects in the change. 
Perhaps next to never coming within the influence of such efflu- 
via at ail, it is safest to live surrounded by them in large cities, 
where, either from the habit of being exposed to their action, or 
from one effluvium destroying another, the effects are prevented 
from taking place to the extent that might be expected. However, 
if the atmosphere, being impure, produced an effect only on those 
coming into it, all the old residents would be equally healthy as the 
strangers who come to reside for a time only; yet this is not the 
case, for they are by no means all robust; therefore what may be 
styled its unfitness produces a debility, and the persons are neither 
so strong nor so healthy as those resident in a healthy atmosphere, 
though they feel not the sudden effects with which strangers are 
attacked.f 
We have a kind of atmosphere which spreads over various coun- 
tries oi' climates in particular seasons only, as lately over England. 
These have had different names at different times; we call it the 
influenza; it affects at first dogs, then horses. In 1775 the dogs were 
all ill; and afterwards the horses, before men, felt the influence of it. 
The atmosphere is the menstruum for various substances, some 
of which are held in a state of solution, and others in a state of 
mixture only. Water is held in solution in the atmosphere, and 
when much of this is suspended, it renders it heavier, as the baro- 
meter shows ; and when a decomposition of the solution takes place, 
the water is precipitated as rain or snow, and the air is made 
lighter, as the barometer also shows. This decomposition may take 
place, although neither snow nor rain is produced, and this in con- 
sequence of a fresh combination taking place before the ultimate 
* [The catalogue of infectious diseases is much curtailed in modern times, 
actually as well as speculatively; at least, the non-contagionists are now the 
prevailing sect. The infectious miasm probably consists of some compound in 
which hydrogen is an ingredient. This appears from the facility with which the 
odour and noxious qualities of putrid exhalations are destroyed by the vapour of 
chlorine.] 
f [The late population returns have exhibited in a striking light the serious 
effects of crowded houses and a crowded population, in doubling, and in some 
instances in trebling, the rate of mortality, a fact which is still more strongly ex- 
emplified in some of the capital cities of Europe. See Count Chabrol's statisti- 
cal account of the department of the Seine.] 88 
HUNTER'S PRINCIPLES OF SURGERY. 
end is produced. When the above decompositions take place, the 
birds and beasts seek their shelter; and an effect is produced on 
wounds, particularly when in a healing state, and in diseases and 
ailing parts of the human body, so that persons become, as it were, 
a weather-glass. We have lately been informed by a German that 
the variations of the magnetic needle have appeared so much to 
take place with change of weather, that as much might be 
learned from it respecting the prognostics of the weather as from 
the barometer itself. Winds may be easily supposed to bring with 
them the effluvia of disease. Extraordinary effects are produced 
by the Harmattan wind, a wind which blows off the interior part 
of Africa to the coast of Guinea. It generally comes three or four 
times a year, at certain seasons ; it is always attended with a fog, 
which has no taste, nor could anything be discovered in it by means 
of glasses thinly covered with molasses. The fog is thickest on the 
beach, and gets tolerably thin about four miles inland. It lasts often 
for a fortnight, and produces a pain and dryness in the mouth and 
nostrils, not as if from mere dryness, but from some acridity: if it 
continues three or four days, the scarf skin falls off, and the tongue 
applied to that part of the skin denuded of cuticle is sensible of an 
acrid taste. Though very prejudicial to vegetable life, it is salu- 
tary to animals, curing fluxes and other epidemic disorders, and 
often restoring weakened constitutions. Fevers which had been 
imprudently reduced by bleeding, got well in spite of the doctor. 
The small-pox always yields to it, while it prevented the inoculation 
from taking effect in some African slaves. Such as were inocu- 
lated before the Harmattan set in had the small-pox, and all did 
well; but such as were not then seized with the symptoms, and 
these were sixty in number, never felt any other affection but a 
slight fever and nausea during the continuance of the wind; after 
which it showed itself in twenty of them: the others were reinocu- 
latcd, and all did wrelh GENERAL PRINCIPLES OF DISEASE. 
89 
CHAPTER IX. 
GENERAL PRINCIPLES OF DISEASE. 
Disease the consequence of unnatural impression;-may arise from faulty pri- 
mary arrangement.-Diseased actions often established on the same principles 
as healthy actions;-some diseases end with the cause;-others continued 
from habit-Diseases common to all parts, or peculiar to some ;-obscurity 
of the physiology of disease-Of susceptibility to impression and consequent 
action ;-difference of susceptibility in different individuals.-Distinction 
between susceptibility and disposition;-predisposing causes only suscepti- 
bilities.-Susceptibilities of constitution and of parts for different actions.- 
Universal susceptibility producing local diseases.-Susceptibilities almost 
specific.-Temperament.-Of diseased dispositions.-Dispositions unnatural, 
but not diseased ;-dispositions for restoration ;-of necessity ;-and of disease. 
-Diseased dispositions have an allotted time for action.-Action.-Disease a 
disposition for wrong action ;-action the effect of disposition ;-symptoms the 
result of action.-Action, healthy or diseased ;-diseased action of two kinds.- 
First symptoms of disease.-Diseased actions arising without proper stimulus. 
-Too great action too little action.-Diseased actions simple.-Of wrong 
actions.--Habit of diseased actions.-Of sedatives and stimulants.-Irrita- 
bility. 
Now that I have treated of some of the properties of the animal 
in health, I shall go on to treat of its imperfections, or diseases. 
To understand these it was necessary, in the first place, to describe 
its perfect or healthy state. To describe the parts in a healthy state 
belongs to the anatomist; their actions in this state to the physiolo- 
gist ; but the diseased state of these actions, and the restoration of 
parts to health, to the physician and surgeon. 
It is hardly to be supposed that disease is ever natural to an 
animal; it can only be the consequence of some unnatural impres- 
sion which interferes with the natural action of the body, which 
impression may take place at the very first formation, or original 
arrangement of the animal, so as to stamp a permanent unnatural 
action; or it may take place in the first life, namely, in utero; but 
much more frequently after birth, when it is exposed to a thousand 
variations, all which are impressions, and are contrary to the 
natural actions of the animal, or are, as it were, a forcing it to take 
on actions which are either to remove those impressions or to 
destroy itself. 
It is most probable that diseased actions are established on nearly 
the same principles that the actions of health are. They are at 
least similar in a great many of their principles; they destroy the 
dispositions of parts; they produce growth; they produce the 
power of removing natural parts; they are ruled by habit; they 
are affected by every external influence. 
An animal is so constructed as only to continue some diseases 
so long as the immediate cause lasts, as in scrofula, when it arises 
from climate; or which is so constructed as to continue other HUNTER'S PRINCIPLES OF SURGERY. 
90 
diseases from habit, as a gleet, so as to go on with a disease, 
although the first cause is gone; and this may be only for a time, 
as in gonorrhoea; or it may be for ever, as in lues, cancer, &c. 
Diseases are either' common to all parts alike, or are peculiar. 
They are common to all parts alike, as inflammations of all kinds; 
as, also, tumefaction, scirrhus, dropsies, &c. The peculiar are 
those in which there is a fault in the peculiar actions of a part, as 
involuntary action of voluntary muscles, too much or too little 
secretion from any of the glands, in short, wrong actions of any 
part in its peculiar mode of action. 
After the disposition, the action which should destroy the dispo- 
sition takes place; the action having taken place, the disposition 
ceases and the natural action of the parts returns. But this is not 
always the case. The disposition may be affected in one of the 
following ways: 1st, The action may destroy the disposition, for 
instance, in gonorrhoea (and perhaps in many other complaints); in 
this case the action destroys the disposition, or the inflammation 
destroys the disposition of the virus. 2dly. The disposition is destroyed 
for a time, and returns at intervals, or after certain spaces, as in all 
periodical diseases, or others where the disease ceases for a time, 
and the disposition continues. 3dly. Where the action takes place, 
yet does not destroy the disposition, as the venereal disease, which 
goes on till it is cured or kills, and the action of it never destroys 
the disposition.* 
Many diseases often require their full action before they produce 
their effects, as the gout and many agues. Vomiting is the action 
following the disposition to sickness, and is often its cure, for 
without it the nausea and disposition will continue. Sometimes 
chronic diseases will be cured by acute ones, in which case, the 
full action being given, the disposition is removed. 
General Observations on Susceptibility and Disposition, consti- 
tuting Constitutions, and on Actions forming Symptoms.-The phy- 
siology of disease is more extensive, more obscure, depends less on 
general laws of nature (being often a prevention or perversion of 
those laws), and is therefore more irregular than any part of 
science, and is of course less understood. 
The most simple idea I can form of an animal being capable of 
disease is, that every animal is endued with a power of action and 
a susceptibility of impression, which impression forms a disposi- 
tion,f which disposition may produce action, which action becomes 
* [It is scarcely necessary to observe that this dogma respecting the venereal 
disease is no longer entertained ; and indeed it may be questioned whether there 
is any disease, unattended with actual change of structure, which is not suscep- 
tible of a natural cure. This at least seems to be the broad and leading distinc- 
tion between curable and incurable diseases, although in practice it is often 
extremely difficult to say what does and what does not constitute change of 
structure, the simple consequences of inflammation being always excepted.] 
f Susceptibility has been too often called disposition. A man is said to be 
well disposed, or parts are said to be well disposed when they are only suscep- 
tible. Disposition is a degree further than susceptibility. GENERAL PRINCIPLES OF DISEASE. 
91 
the immediate sign of the disease ; all of which will be according 
to the nature of the impression and of the part impressed. 
That every action, whether natural, preternatural, or diseased, 
arises from this susceptibility of impression, I think we must allow, 
which susceptibility may exist without even disposition or action, 
if no impression or stimulus is made ; for the disposition is only 
formed in consequence of some impression, and the action is only 
the consequence of the disposition being so strong as to incline a 
part for action rather than for resolution. Therefore action is the 
ultimate consequence of impression being made on a part endued 
with a susceptibility of impression and the power of action, which 
impression gives them the disposition to act. For from what was 
said above, parts having susceptibility do not necessarily have the 
disposition; the disposition arises from some impression, which 
will, in its turn, produce the action, and this action, or disposition 
to action, must be sufficient to overcome the natural and habitual 
actions of the part or whole, just as force overcomes the vis inertice 
of matter. But susceptibilities are in some so strong as almost to 
approach a propensity to act, which is probably as strong as the 
disposition, or often probably stronger.* 
The actions of the body, and the cause of these actions, with 
their effects, are exactly similar to those of the mind, and as we 
are sensible of the actions of the mind themselves, abstracted from 
their causes or effects, we reason about them as much as we can 
reason about their causes and effects. This is not the case with 
the actions of the body, for in them we are only acquainted with 
the causes and effects, not the action itself; therefore our minds 
are only reasoning about them from analogy. 
The susceptibility for action of the mind is not known to the 
mind itself, but by the consequence of such susceptibility. Some 
minds are much more susceptible of certain actions than others ; 
thus, some men are more susceptible of anger, others of love. But 
this does not imply that one mind is always in anger, another in 
love, &c. 
* [The reader will probably agree with the Editor that the distinction which 
is here drawn is not tenable. The author, for instance, says, (p. 99) that action 
is not disease, but the effect of disease ; but what proof is there that the dispo- 
sition (which according to the author seems identical with the disease), exists 
at all, except from the action which it produces and the visible effects of that 
action 1 And, particularly, what proof is there that this latent disposition differs 
from susceptibility! A part may be more or less prone to or susceptible of in- 
flammation, but can a part have the disposition to inflammation (in Mr. Hunter's 
sense), without showing the action of inflammation ? If it can, then where is the 
proof of its existence, except from the proneness or readiness of the part to act 
in that particular manner I which is the idea conveyed by the term susceptibility. 
I offer this criticism with diffidence; at the same time I cannot but regard the 
whole argument, so far as it is founded on this distinction, as based on a meta- 
physical subtlety which ought not to be admitted in philosophical discourse. 
As there can he little doubt that Mr. Hunter formed these opinions from ob- 
serving that the disposition (so called) to the venereal disease often remained 
after the visible symptoms had been apparently cured, the reader will naturally 
turn to this part of his works for further information.] 92 
HUNTER'S PRINCIPLES OF SURGERY. 
With this susceptibility of mind, a stimulus must be applied to 
produce the disposition to action. A stimulus of one kind will 
produce anger, of another kind, love. The action of the mind em- 
ploys other parts to complete the whole, as w'hen the actions of the 
mind are employing other parts to produce the ultimate effects. 
But these are not necessary to the action of anger, for anger could 
exist without the action of employing other parts, and indeed con- 
tinue longer ; for this tends to destroy the action of anger, because 
the effect being produced the cause ceases. 
Every animal has a variety of susceptibilities which admit of a 
variety of impressions, each impression producing a disposition 
peculiar to itself. Also every animal has some of those suscepti- 
bilities stronger than it has others, out of all which a vast variety 
of diseases is produced. Each tendency to a peculiar mode of 
action gives the character of the animal respecting disease. The 
sting of a bee, for instance, affecting some people much more than 
others, demonstrates that there is a susceptibility in some for such 
actions more than in others. In many the susceptibility will be so 
strong as only to require a stop to be put to the natural actions, 
when the disposition and the disease too will take possession of the 
part or of the whole. An instance of this we have in scrofula, for 
it often happens that common accidents, as strains, bruises, fevers 
of all kinds, produce the disease even in situations the most calcu- 
lated to prevent it, as in the West Indies. Even poisonous dispo- 
sitions are produced in this way, a blow on the breast or testicle 
shall produce a poisonous mode of action, e. g. cancer. 
From this account no animal is formed with a disposition for the 
action of disease. The natural actions are for the good of the 
animal; but they can be perverted, they can be made to destroy 
the whole. These circumstances are similar to those of the mind ; 
some minds are more susceptible of some impressions than they are 
of others, which produces a disposition to act, which action will be 
according to the impression. The susceptibility of the constitution 
may be increased, so as almost to be similar to a new formation, 
but is never originally formed, by art.* Where the susceptibility 
is weak, it may be increased and kept so much on the brink of 
forming the disposition, that it shall only require the least increase, 
or some other immediate cause, to produce the effect or form the 
disposition, as a man not naturally fearful may be worked upon so 
* [If by art Hunter means the influence of external agents, this statement does 
not appear to be correct. When, for example, hospital gangrene is prevalent in 
a ward, probably three-fourths of the inmates would be attacked by this disease, 
after any operation performed on them. The susceptibility of the disease has 
surely here been generated, yet they would probably have escaped, if the opera- 
tion had not come to convert this acquired susceptibility into action. The 
operation under different circumstances would not have been followed by similar 
consequences ; the body, that is, is not naturally susceptible of this disease, in 
the same way that it is susceptible of inflammation or small-pox, without pre- 
vious preparation ; a new state of the constitution must first be induced,-a 
point which is clearly admitted by the author in his Treatise on Inflammation.] GENERAL PRINCIPLES OF DISEASE. 
93 
that the least thing may alarm him. Susceptibilities may be so 
increased as almost to deserve the name of acquired; constitutions 
long habituated to particular climates will form a scrofulous habit, 
or an aguish habit, and a certain way of life will produce a rheu- 
matic or gouty habit. On the other hand, persons naturally sus- 
ceptible may be made by degrees considerably less so, by being 
gradually accustomed to the immediate cause, beginning within 
the degree of impression necessary to excite disposition to action. 
There is no such thing, strictly speaking, as a predisposing 
cause. What is commonly understood by a predisposing cause is 
an increased susceptibility to form disposition to action. When I 
say I am predisposed for such and such actions, it is only that I am 
very susceptible of such and such impressions, which impressions 
must form the disposition; or if it is intended to dispose a person 
for such and such actions, it is only to render him more and more 
susceptible of such and such impressions. The susceptibility must 
always precede the disposition. A disposition is a determined 
thing,-a thing formed,- a kind of resolution. 
Of Susceptibilities of Parts and Constitutions for different Ac- 
tions.-Every constitution is more susceptible of some constitutional 
actions, both natural and diseased, than it is of other actions, 
whether natural or diseased; and every constitution is more 
susceptible of some local actions, natural and diseased, than it is of 
others. 
Every constitution is compounded of parts whose natural actions 
are very different from one another. Thus, the natural actions of 
the liver are very different from those of the lungs. Therefore we 
also find the diseased actions of one are often different from those 
of the other; although every part of the body may be subject to 
some one or more common diseased actions, as e. g., the liver Land 
lungs, which may be subject to common inflammation, or they may 
both have the same specific disease, as scrofula. 
Every constitution being composed of different parts, whose na- 
tural and diseased actions are different from one another, as above 
mentioned, these actions being according to the nature of each part, 
and each part in some constitutions being more susceptible of natural 
actions peculiar to.itself than the same part in other constitutions, 
so also in some constitutions each part is more susceptible of its 
diseased actions than the same part is in other constitutions. Thus, 
as the liver in some constitutions is more susceptible of secreting 
bile, which is its natural action, than it is in others, so also it is 
more susceptible of its peculiar diseases in some constitutions than 
it is in others. Constitutions may be said to be more or less sus- 
ceptible of this or that universal action, among the first of which 
may be marked the irritable and the indolent. 
Secondly, some constitutions are more susceptible of some diseases 
than others are of other diseases. 
Thirdly, some constitutions are more susceptible of some diseases 
than others are. And those constitutions not susceptible of this or 94 
HUNTER'S PRINCIPLES OF SURGERY. 
that disease may be at the same time more susceptible of some other 
diseases than the first-mentioned constitutions are. For example, 
some constitutions are more susceptible of inflammatory fevers than 
of any other fevers; others are more susceptible of putrid fevers; 
while either one or the othei' of these constitutions might have 
some other disease, either violently or mildly, as small-pox, mea- 
sles, &c. 
Constitutions may be more susceptible of some one specific disease 
than the same constitution of other specific diseases, e. g., some 
constitutions are more susceptible of small-pox than of measles, or 
vice versa. 
Some constitutions may be more susceptible of some specific 
diseases than other constitutions are, e. g., some constitutions are 
more susceptible of the small-pox than others are, and yet have the 
disease mildly. 
All of which characterize the constitution at large. 
Of universal Susceptibility to produce local Diseases.-Bodies 
may be said to be both constitutionally and locally susceptible of 
diseased action. The erysipelatous fever, which is constitutional, 
being attended by the erysipelatous inflammation, which is local, is 
a strong instance of this. 
Constitutions are more or less susceptible, both universally and 
locally, of the same disease, as the small-pox fever, when violent, 
has more violent and extensive local effects; when mild, more mild 
local effects. 
Constitutions may be said to be more or less universally suscep- 
tible of this or that local action, when one part takes on action 
without any visible immediate cause, or when any injury (whether 
constitutional, as fever, or local, as accident), makes parts so in- 
jured run into a much worse diseased state than the same injury 
would have done in others ; many parts even taking on specific 
diseases, whenever the immediate cause is produced, as scrofula, 
venereal gonorrhoea, &c. 
Constitutional susceptibilities for diseased actions may be divided 
into three kinds, and there are also others which are mixed.* 
* [There is probably not a more abstruse subject in physiology than that of 
susceptibilities, which most frequently depend on causes with which we are en- 
tirely unacquainted. Mr. Hunter has classified susceptibilities according to their 
effects and remote causes, without attempting to explain the physiological con- 
ditions on which they depend. But we ought not, I conceive, to repose here, as 
if further progress were impracticable, but to ascertain, if possible, the actual 
conditions of the organization on which they depend, or the particular manner in 
which the functions reciprocally react on one another so as to produce them. 
The pathologist should seek to trace the remote cause to its utmost effects, so as 
to arrive as near as possible to the immediate efficient cause of the susceptibility 
in question. 
An example of this kind has been already adduced in regard to the suscepti- 
bility of the liver to disease in hot climates, (see note, p. 86,) arising from a re- 
ciprocity of function between it and the lungs, of which many similar instances 
might be given in respect of the other organs. The heart and the brain are said 
to be more susceptible of disease now than they were formerly, although this GENERAL PRINCIPLES OF DISEASE. 
95 
1st, An original constitutional; that is, where there is a uni- 
versal susceptibility for diseased action of one kind or another, in 
which, however, the whole must be in action, as inflammation, 
fever, small-pox, &c.; also sympathetic fevers of all kinds. Persons 
may be very susceptible of the whole of these, or only of one or 
more. 
2d, Original local; that is, where the whole is so constructed as 
to be universally susceptible of going into diseased action in any 
one part; but the actions will be always local and independent of 
every other part, as scrofula, gonorrhoea, or chancre. Hence the 
venereal disease is worse in one than in another, and yet is local; 
the same with scrofula. 
3d, A susceptibility to fall into universal indisposition, as if there 
was something teazing the whole ; which then can call on a part, 
and that relieves the whole, as in gout, rheumatism, and perhaps 
all those diseases where the local action is critical. Most of these 
can be relieved by a universal facility to action, or retarded by the 
contrary, which will affect either the local action or the constitu- 
tional one. 
Strong susceptibilities of a constitution to take on diseased dispo- 
sition and action, whether of the whole as such, or a local effect of 
a constitutional disease, (which last I call an act of the constitu- 
tion), only require the impression of the immediate cause for the 
disposition and action peculiar to these susceptibilities to take place. 
These immediate causes may not be the same in two constitutions, 
although both have a strong susceptibility for the same action ; for 
what will produce the action in one constitution may not produce it 
in another. One constitution will require one immediate cause and 
another another, though both constitutions may have a susceptibility 
for the disease. Two men equally susceptible may be exposed to 
the cause of an ague : one may have the disease the other not. It 
is exactly similar with the mind : two men may be naturally or 
constitutionally equally susceptible of anger, but each must have 
his immediate cause ; what will bring forth action in one will have 
but little effect on the other, and c contrario. It is the same thing 
with every effect of the mind. 
Most susceptibilities are so much of a specific nature in them- 
selves that each susceptibility shall be brought into action, in nine- 
teen people out of twenty, in one way, and probably in the twentieth 
it has been prevented by what produced it in the others. This 
accounts for the same diseased action in people arising from so 
many different causes, and also accounts why such disease, though 
having a specific mode of action, may be varied in the same person 
may solely depend on the complicated interests and passions of modern life, 
which necessarily induce particular physical conditions of these organs which 
directly tend, on known principles, to the production of disease. The constitu- 
tional susceptibilities are, in general, far more obscure, and scarcely at all admit 
of this mode of explanation.] 96 
HUNTER'S PRINCIPLES OF SURGERY. 
in different ways, still more in different people, and even often 
require different modes of cure. 
This theory may be illustrated by every disease that takes on 
full specific action ; whether a full constitutional action, as an 
ague, or a local one, as the gout. As an ague is a well-known and 
well-marked disease, this theory will of course be illustrated by this 
disease. 
Every constitution has more or less susceptibility to fall into an 
aguish habit; but there must be in all an immediate cause to pro- 
duce the disease. The immediate cause may be such as will make 
nineteen people out of twenty fall into aguish action ; but many 
constitutions, though they have a susceptibility of falling into an 
aguish habit, yet wThcn the immediate cause takes place, may have 
no disposition to take on the full action of that disease; by which 
means the constitution is teazed by what is called a badly-formed 
ague. If the immediate cause be some local disease in the body, 
as diseased liver, spleen, &c., then the cure must be effected by the 
cure of the liver, &c. 
This reasoning may be taken in another point of view. Suppose 
twenty people having different susceptibilities;-introduce some- 
thing that shall endanger the constitutions of the whole number, 
and each shall take on the disease that he was at that time most 
susceptible of, whether ague, gout, or any other. 
But often that which would become the immediate cause in those 
already susceptible of action, or already predisposed to it, by repe- 
tition or continuance becomes the predisposing cause in others not 
susceptible. If two men, one so susceptible as only to wTant the 
immediate derangement, the other not at all susceptible of an ague, 
be sent into the fens of Lincolnshire, the first shall have an ague 
immediately, because he only required the immediate cause of it; 
the other, if he does not get the better of the climate by habit, 
shall become aguish in time, because the country wrill become 
both a predisposing and an immediate or exciting cause. 
We may substitute for the disease of ague some other disease, 
and the whole of the above reasoning will be perfectly applicable. 
But where it is the nature of the disease to take on local action, as 
in gout, there must not only be a universal disposition for such 
disease, which is the original, but there must also be a local prefer- 
ence, ox* rather a local susceptibility superior to the rest; and when 
the immediate cause takes place, so as to form the disposition, that 
part takes on the whole action, which relieves the constitution of 
such disposition, except it should produce another constitutional 
effect by a vital part taking it up, by which means it would effect 
the whole constitution similarly to any of the affections of this vital 
part, where a diseased disposition is formed, but does not take on 
the regular type of the disease, or does not take on the full and 
complete action; as in the aguish disposition not having gone 
through the regular stages of the ague, or gout not having formed 
a regular fit. GENERAL PRINCIPLES OF DISEASE. 
97 
In those diseases that become local, as gout, some attention is to 
be paid to the seat of action ; for if a vital part takes it up, it must 
be much worse than when there is only a constitutional affection. 
The qualities of periodicity and regularity in constitutional 
diseases, or the power of a constitutional affection to become local, 
are, I believe, but little understood. 
Susceptibilities for dispositions and actions appear to me to be 
the same with what are usually understood by temperament. Tem- 
perament is the state of the body fitting it for the disposition or 
action it is then in, whether it is only a state of susceptibility, of 
disposition, or action. The action is always the best test of that 
state : but, although the action is the best test, yet there are some 
circumstances attending animals that either dispose them for, or are 
concomitant upon, such and such susceptibilities; and from these 
circumstances we can say beforehand, although only in a general 
way, what are the most predominant susceptibilities for certain 
actions in this or that animal. We see that even colour in animals 
depends on a difference in their temperaments, or is concomitant 
with temperament; for animals with fair skin and hair are more 
susceptible of cold than the dark, as also of pain. This is well 
known in the army, where we find that the power of bearing vio- 
lence committed on the body is in proportion to the darkness of the 
individual. Fair people are more irritable in their minds, more 
susceptible of anger, and probably of all other passions. Fair 
people are also more susceptible of certain diseases than the dark, 
as of scrofula. This may arise from their not being able to bear 
the vicissitudes of climate; for it is in changeable climates, espe- 
cially where there is cold, moisture, &c., that scrofula is more pre- 
dominant. The irritable inflammation also is more common in the 
fair than the swarthy. As the fair are less able to resist cold than 
the dark,* it might be supposed that the dark are less able to resist 
heat, therefore more ready than the fair to run into diseases which 
warmth has a tendency to bring on. But from the estimate made 
by Dr. Young in the Island of St. Vincent's, it would appear that 
there is some reason to suppose the contrary; from which it would 
appear that the dark-coloured are rather fitter for all kinds of 
climates. 
Of diseased Disposition.-Dispositions are natural or unnatural, 
including diseased. The natural belong to the healthy animal, 
therefore are not to our present purpose. 
Dispositions maybe unnatural (and of course the actions arising 
from them unnatural), and yet not diseased. 
* [This must be understood with some limitation. The inhabitants of high 
northern latitudes, who are often very fair, are far less susceptible of scrofula 
than the darker-complexioned races of more southern countries ; as, on the other 
hand, the African and the half-caste are more liable to this disease when trans- 
planted to a northern latitude than the natives. It is not merely cold, but cold 
and moisture, associated with a variable climate, which predispose so strongly 
to this disease.] 98 
HUNTER'S PRINCIPLES OF SURGERY. 
Unnatural dispositions and actions we shall divide into three 
kinds, or they may arise from three causes, which are remote. 
1st. The disposition of restoration, in consequence of some injury 
done, which is also a consequence of every disease which is curable. 
2d. The disposition arising from necessity, as the thickening of 
parts from pressure, ulceration of every kind. This includes a 
great variety. 
3d. Diseased dispositions of all kinds, which also includes a vast 
variety. 
From this division we see that there are two preternatural dis- 
positions that are not diseased, so much so that the first may be 
reckoned a disposition of health; therefore there is but one preter- 
natural disposition to action, which can be called diseased, namely, 
the disposition to destruction, and which is to be cured by substitu- 
ting the first disposition. 
Diseased dispositions may arise from some fault in the animal 
powers themselves, or some extraneous matter in the constitution 
or circulation, as in the case of many poisons, or from many sub- 
stances acting on the stomach called poisons, or from some 
substances being applied externally to the body which disagree with 
animal life in genera], as too much cold, too much heat, &c. 
Every diseased disposition most probably has its allotted time for 
action after the impression, or after the formation of the disposition. 
This is remarkably the case in specific diseases; but yet this will 
differ according to the susceptibility. The same with poisons: the 
small-pox is about six, seven, or eight days at a medium; the measles 
the same. The venereal disease has a medium, although it varies. 
But some specific diseases shall remain a considerable time before 
the action takes place; and this will be much longer in some than 
in others, according to the nature of the diseased disposition and 
parts. In cancer it is often very tedious. I have seen instances 
where it was years after all continuance of the cause was removed 
before the glands in the armpit had taken on diseased action after 
contamination. 
A girl at St. George's Hospital, fourteen years of age, born in 
the West Indies, left that part of the world when ten years of age. 
About a twelvemonth ago she had an eruption on the skin in several 
parts of the body, especially on the face, arms, and hands. The 
eruption arose like warts, or like large moles, about the size of half 
a crown piece, above the surface of the skin, irregular in their base, 
some standing single, others running into one another, of a browner 
colour than the common skin, which was clear and of a firmer 
texture. 
Now this was a West Indian disease; therefore I say that the 
girl was contaminated in the West Indies. The impression was 
made there which was the first cause, and the disposition was 
formed; but the disposition did not come into action for three years 
after. The removal to a cold climate, though it could not remove 
the disposition or prevent its effects, yet protracted them. 
It may be further remarked, in specific diseases and in poisons, GENERAL PRINCIPLES OF DISEASE. 
99 
that if the specific disease or poison is such as is capable of con- 
taminating different parts, whose powers or readiness to act is dif- 
ferent, the same disease will show itself at different intervals in 
these places in the same person, though perhaps every part is con- 
taminated at the same time. Thus we have the venereal disease 
appearing in different parts at different intervals in the same person, 
arising from the natural susceptibility for action in some parts being 
greater than in others. The skin and tonsils being most susceptible 
of contamination, as also of action, are therefore affected soonest; 
the bones and tendons less so, and are therefore later in taking on 
the action. The disposition simply does not seem to affect either 
the constitution or the part, (see note, p. 91) for either shall go on 
well with all their natural functions, and powers of restoration 
when injured or affected with diseases of every other kind, although 
at the same time in the disposition of some other disease. 
Dispositions of one kind may be restored after being destroyed 
for a time by a more powerful impression, or such as the constitu- 
tion is more susceptible of, which shall supersede the first disposi- 
tion, and go on with its actions; and when its action is completed, 
the first disposition shall again take place, as will be illustrated when 
we come to talk of actions simply. 
Action.-I have explained that a disease is a disposition for a 
wrong action, and that the action is the immediate effect of the dis- 
position, and that either the actions, or the effects of those actions, 
produce the symptoms which are generally called the disease, such 
as sensations, which are commonly pain of all kinds, sickness, altera- 
tion visible or invisible in the structure of the part or parts that act, 
and sympathy. 
The animal, or part disposed to act, generally takes on action, 
which is of three kinds: natural, restorative when injured, and the 
diseased; each arising from the corresponding class of dispositions, 
and therefore divisible into the same. 
The actions of health arise from a disposition to act properly, 
that is, according to the combined laws of the machine, which may 
be either universal or only partial; for a man may be wholly in 
health, or only so in part. The actions of restoration are for the 
falling back into the above natural actions, and which will be 
according to the nature of the injury done and the parts combined. 
The diseased actions are many, but may be ranked under the fol- 
lowing heads: 
1st. Improper actions of natural parts, as spasms of muscles; irre- 
gularity in the times of action of a compound part. The nerves 
have the credit for being the remote cause of all these. 
2d. Unnatural or improper actions of the vessels; and these may 
be either attended with an increased or diminished action. 
The ultimate and visible effect of disease is action ; but this is not 
the disease, for the action is only an effect, a sign, or symptom of 
disease. But the disposition being only discovered by its effects, we 
are apt to go no further in our inquiry, the cause being to many 100 
HUNTER'S PRINCIPLES OF SURGERY. 
only an object of curiosity. However, the effect must be attended 
to, for it is this which leads us to the cause. These actions may 
arise from poisons, or substances improperly applied to the surface ; 
from cold; from substances taken into the stomach: these usually 
give a sensation to the animal, so that it can judge that the parts 
are diseased. But sometimes the action is too slow to give an 
alarm to the part; or the disease is felt through the irritation; or 
by a part remote from the diseased part sympathizing, as worms in 
the intestines, producing convulsions, an itching at the nose, &c. 
When the hip or loins are affected, the sympathizing part, before 
the disease is felt in the original seat, is the knee. Passing a bougie 
has caused sickness before it was felt in the urethra, as has a clyster 
before the rectum was sensible of any inconvenience. 
Often the internal feeling of health is the forerunner of disease. 
People just before a disease shall be in better spirits, and feel strong, 
so as to take notice of it themselves. 
A gentleman had better health before a spitting of blood came on. 
A boy had more spirits than usual the night before he was at- 
tacked with the cold fit of fever. 
Perhaps the cause of disease gives the first feeling of health or 
vigor: the animal powers are called up on the first alarm of disease; 
and when they sink, which is the second stage, they produce cold, 
or shivering, which is generally supposed to be the first symptom. 
In children I have often observed that the smell is affected before 
diseases. • The first impression here is made on the olfactory nerves. 
Some diseases come on extremely rapidly, producing at first very 
violent symptoms, called acute: others come on very slowly, and 
do not produce any sensible first symptom. 
I have already observed, that all the actions in a healthy state 
are only produced by their proper stimulus; but sometimes we have 
actions without proper stimulus, which are diseased actions. In all 
organs I have observed there is a regular succession of action, as 
in the secretion of different substances, according to the wants of 
the parts which become the stimuli; but they may perform this 
office without the stimulus. The vessels are very active parts, and 
have often wrong actions, producing diseases in a great variety of 
parts, and are peculiarly active in the operations of disease. 
Too great action will produce disease, according to circum- 
stances. As the powers are equal, or greater, the action is universal or 
local: if universal, as in inflammatory fever, it will either produce 
resolution or death; if local, as in inflammation, either resolution or 
suppuration; or if the action is greater than the power, irritability; 
or it may keep up a constant inflammation; or if very violent, pro- 
duce mortification. Too great action will often in the end produce 
too little action; but not often vice versa. General action or fever 
may produce local, as inflammation; or local inflammation will pro- 
duce general, as fever. They often attend one another from acci- 
dent, and then they generally increase one another. 
Too little action arises from a disposition to act within the neces- GENERAL PRINCIPLES OF DISEASE. 
101 
sary bounds of health, which produces real weakness and a bad 
state of health, with debility, without any visible state of disease, as 
we often see in fine ladies. If the part debilitated be not necessary 
to life, it only produces its effects on that organ. Too little action 
may subject the person to many more diseases than what the active 
are subject to. Even the habit of indolence in the mind, joined with 
inactivity of the voluntary actions (which is generally produced 
from an indolent state of the mind), produces the same effects, es- 
pecially as we see in women. So that weakness is attendant on 
many diseases, and although somewhat necessary to many, yet it is 
not actually the disease itself. For instance, weakness attends the 
scurvy, and is necessary before the full effects of the specific disposi- 
tion, namely, the action, can take place. The same in locked jaw, 
scrofula, &c. Weakness becomes one of the causes of irritability, 
as will be explained. Weakness, too, produces an increase of the 
disease. Jt may be local or universal, for many parts of an animal 
body may be weak, while others are strong; and if the weak parts 
are not essential to life, then the effect is only debility in performing 
the function, and the vital parts may not suffer, If the nerves are 
weak, the voluntary parts suffer; if the stomach, then the whole 
will suffer, or there may be a weakness which includes the whole 
without destroying it. It sometimes seems that the suspension of 
action for a time, increases the pow7er afterwards; and lessening 
the power of action, increases the real strength at othei- times. 
All diseased Actions are simple.-A disposition of one kind may 
and shall exist in a part or whole, while an action of another kind 
is going on; and when the action ceases, the disposition, or dormant 
action, if we may be allowed to call it so, shall then come into 
action. 
There are certain natural actions arising in an animal body in 
consequence of every irritation, whether appearing as a spontaneous 
injury or from accident. These common actions I shall illustrate 
by inflammation. 
Inflammation, then, is one of these simple actions; but we find 
inflammation may be joined with a specific quality which shall not 
alter its apparent mode of action, yet shall cause its ultimate effect 
to vary ; thus, though the mode of action is altered, the action itself 
is not altered. 
It appears to me that every disposition must be simple, and there- 
fore be only capable of producing simple action. Parts so disposed 
may be irritated by something that alters the disposition. If the old 
disposition be destroyed, a new one must be produced: but if the 
disposition be only altered in part, there may be the two dispositions 
in the same part, the old in part and the new in part. But it is 
possible that a new disposition may be formed out of the two, dif- 
ferent from either of the two which formed it; still it must be con- 
sidered as a simple disposition. 
This is plain in the cure of the venereal disease ; a third disposi- 
tion (namely, the healthy,) arises out of the two, that of the disease HUNTER'S PRINCIPLES OF SURGERY. 
102 
and that of the remedy. This is likewise shown in the action of 
Dover's Powder, for neither vomiting or sleep is produced, but a 
third action, namely sweating. 
But a constitution or part may have equally a susceptibility to a 
variety of diseases, as venereal, scrofula, &c., some of which may 
have a common cause, others a specific, as lues ; yet the constitution 
can have at the same time only one specific action. As there are 
susceptibilities for dispositions, so there must be also dispositions for 
actions; yet two of these cannot exist at the same time in the same 
part or constitution. 
Two children were inoculated for the small-pox. Their arms 
inflamed ; but about the third or fourth day from the inoculation 
symptoms of fever arose, and the measles appeared, and went 
through their progress as usual. During this time the inflammation 
in the arm was arrested; but when the measles were completely 
gone, the small-pox took place, and went through its progress. 
Here a disposition for the measles had taken hold of the body, but 
although it had done that previously to the small-pox, yet it was 
not in such a way, as stopped the progress of the small-pox. The 
small-pox matter was capable of contaminating, and produced 
inflammation, which went to a certain length, but the moment the 
measles changed their disposition into action, as the two actions 
could not go on together, the action of the small-pox was sus- 
pended till the measles had gone through its action, and the mo- 
ment the constitution got free of this, the small-pox began to act 
again. 
A lady of rank was inoculated by Mr. Sutton. A few days after 
a fever came on, of the languid or putrid kind, but without any 
eruption, except a few petechias on the breast: she went through 
the process of a low fever, and afterwards the small-pox com- 
menced ; yet when the pustules maturated they spread wide and 
were very large : also a different set of eruptions succeeded, so that 
thirty days passed before the skin was cleai' of the eruptions. 
These cases show that but one mode of action can take place at 
the same time; yet I could conceive that two actions might produce 
a third one, which might have been a new poison, as the last case 
in some measure seems to show. 
Of wrong Actions.-I have already mentioned, under the animal 
economy, the two different kinds of action in an animal: 1st, The 
natural powers of growth, modelling, &c.; 2d, The powers pecu- 
liar to each part, voluntary or involuntary. Now, the first may act 
improperly: it may push forth unnatural and unnecessary growth 
in some parts, and too little in other parts. They may also act in 
such manner as to obstruct the necessary actions of the machine, 
as by unnecessary masses called tumours, increase of the bones, 
&c. The second may also act wrong, that is, may act without the 
necessity for action, as in spasms, locked jaw', over-secretions, pal- 
pitation of the heart, &c. This is in every respect similar to the 
former, only the improper action is on a different part. If, then, GENERAL PRINCIPLES OF DISEASE. 
improper actions fall on a part of importance to the machine, they 
produce disease: or they may act too little, and thus produce 
diseases of a different kind. 
Diseased actions, like the actions of health, become accustomed 
to impressions, and we see many of them subject to the same laws. 
This is of two kinds: first, where the diseased part becomes less 
and less affected by stimulus, from a continuance of the applica- 
tion ; second, where the whole body, or a part, becomes more 
easily effected by the stimulus, from a repetition of the application. 
People constantly exposed to the cause of certain diseases become 
less aflected, or less liable to be affected. Perhaps the best way 
to prevent being affected by some infectious diseases would be to 
live constantly where the infection was. People coming out of the 
country into the town are more liable to be aflected by certain 
infections, as the small-pox, than those who live constantly in large 
towns. The constitution having once felt the stimulus of the small- 
pox, is not afterwards affected by it; yet I can readily conceive 
that if a man were to live two hundred years he might arrive at 
that period when he would again be susceptible of the impression. 
Of Sedatives and Stimulants.-Perhaps there is no idea of any 
principle, simply as an idea, more correct than that conveyed by 
the word sedative, stimulus, irritation ; yet I think it is probable that 
there is no idea so little understood in practice ; and it may be a 
very difficult task, and next to an impossibility, to say what real 
state the body or part is in, or can be brought into, to be affected 
in either one or the other way- This arises from our imperfect 
knowledge of the true state of the body oi' parts, or of their eco- 
nomy ; for what might act as a sedative at one time, might be a 
stimulant at another, or even an irritant; or what might be a 
sedative to one part, might be either a stimulant or irritant to 
another, which we shall see to be really the case, for whatever 
will excite action, even the common action of parts, will be a 
stimulus, and whatever will excite actions beyond the real strength 
of the body will be an irritant; and this cause of excitement beyond 
the common action may be no more than what at another time would 
act as a sedative. 
For example, without heat, probably no action could take place 
either in common vegetable or animal matter. Heat admits of 
becoming an exciter to action ; but as heat, in so far as it can, 
only excites natural actions, and, in due proportion to the strength 
of the parts, it may be called sedative ; for we may suppose that 
by sedative is not meant an unnatural reduction of action (for 
which, indeed, we have no expression), but the production of 
a natural action from too great an action. It may increase or 
diminish action, according to circumstances. But to ascertain the 
precise degree of heat suitable to every state of body or part, so as 
neither' to increase nor diminish action, is probably impossible. 
When animals are extremely weak, their actions should be suit- 
able to their strength. Or if an animal is only moderately weak 
103 HUNTER'S PRINCIPLES OF SURGERY. 
104 
in the whole, considered as a whole, yet there will be parts that 
will be very weak ; and if those parts are under disease, care 
should be taken that those parts are not thrown into action above 
their strength. 
The temperature of the body, or parts respecting heat and cold, 
should be in proportion to this weakness, which will regulate the 
action, and to apply warmth at such time would be applying a 
stimulus ; and if the body was still more reduced, warmth might 
become an irritant; or if the body was not able to act up to this 
stimulus, it would be an irritant. 
To lower actions suitably to the state of the constitution, what- 
ever this may be, is the use of a sedative; but in some constitutions 
it may be requisite to bring it even lower. So it is often necessary 
to produce fainting; but this cannot be called a sedative ; it is 
probably only weakening. 
Irritability.-There is no word perhaps more improperly applied 
than irritability ; it is often used for stimulus, and stimulus often 
used in place of it. Indeed we must allow that there is a resem- 
blance between them in several of their properties, both exciting 
actions of the living parts ; but they differ very much in the con- 
sequent action, as, indeed, irritability appears to be nearly allied to 
susceptibility. 
I have already explained, when on the animal economy (p. 62), 
that stimulus excites or increases natural actions ; but an irritation 
either excites an unnatural quantity of a natural action, or an entire 
new one ; and susceptibility is the readiness with which they can 
be excited. 
Some constitutions are so easily excited, or in other words, so 
susceptible of diseased impression, as to take up actions so readily 
as to make them appear natural, which in others are only brought 
on by disease. That a natural action may be increased beyond its 
natural bounds we see every day. Salivation is an instance of this. 
That irritation produces new action is perhaps more evident than 
the former. Accidents of all kinds are of this kind. Blisters act 
on this principle. In short, every new action which takes place 
may be said to arise from an irritation produced in the part, or 
something similar. Irritations are often producing salutary effects, 
and therefore may be said to terminate in a stimulus, which is 
owing to a kind of irritation, such as those which are in conse- 
quence of many accidents, which new action produces a restoration 
of the part injured, as in wounds, compound fractures, &c. 
There are new modes of action taking place every day that 
would appear to arise spontaneously (therefore from no possible 
irritating cause, which, on the contrary, most probably arises from 
this new mode of action). The immediate cause may be so slight as 
hardly to approach to an irritation. Such constitutions are called 
irritable, which is only saying that one part may be irritated by what 
would have no effect on another. Those unnatural spontaneous ac- 
tions often arise from a want of power to act properly, with a strong OF SYMPATHY. 
105 
disposition to action, which is the reason why weakness, or want 
of power, becomes the cause of irritation, which produces new 
action, which new action will be according to this want of power 
and the nature of the part combined. 
Necessity often becomes the cause of irritation, as when a small 
opening is made into a large cavity, and not allowed to heal by 
the first intention, the whole becomes under the necessity of taking 
on a new action to restore the whole ; therefore irritation often 
produces salutary effects. 
Many of the preternatural actions are so slow in their motions 
that we can hardly make them accord with our ideas, which ascribe 
them to irritation, especially in those that seem to arise spontane- 
ously, as the formation of many wens, encysted tumours, &c. 
Irritation may be divided into common, specific, and poisonous: 
1st, Common, is that which will affect all animals ; 2d, That which 
will affect only the same species ; 3d, Is also very much confined 
to species; one only, as far as I know, being excepted,-the bite 
of a mad dog. So that the disease of one animal, although com- 
municable to another of the same species, is not so to one of an- 
other species. Small-pox, chicken-pox, venereal disease, measles, 
hooping-cough, jail-distemper, itch, scrofula, are peculiar to the 
human. The disease of black cattle is confined to them ; the rot 
to sheep ; glanders to horses ; mange to dogs.* 
CHAPTER X. 
OF SYMPATHY. 
Disposition to action arising' from sympathy;-without direct impression.- 
Sympathy of two kinds ;-connexion of principles of action in the living body; 
-sympathies of sensation doubtful.-Sympathy between different bodies.- 
Sympathy natural or diseased ;-not always reciprocal between parts ;-gene- 
rally single;-common or uncommon;-similar or dissimilar;-partial or 
universal.-Varieties of partial sympathy;-varieties of universal sympathy; 
-fever, inflammatory, hectic.-Certain parts sympathise more strongly than 
others.-Of similar and dissimilar sympathies ;-of simple sympathies ; 
difference of sympathies from modes of impression.-Sympathy of body with 
affections of the mind ;-of the mind with the living principle;-use of sym- 
pathies-Of delusion ;-explanation of it;-delusion in dreams. 
I have endeavoured to show that there are two principles in the 
higher animals, namely, life and the action of the nerves, which 
last is called sensation and volition; or rather, perhaps, there is but 
one principle, life, which becomes the basis of the other and of 
* [There are some of the above diseases which are now known to be commu- 
nicable to other animals.] 106 
HUNTER'S PRINCIPLES OF SURGERY. 
every action of the body. T also endeavoured to point out that 
sensation arose from feelings in the mind, which produce action in 
the body. I attempted to show that the more simple actions arose 
independently of sensation or of the actions of the nerves; that the 
nerves, from their specific actions, only become the cause of many 
actions, but are not the principle of those actions; that from their 
termination in the brain they produce sensations there from which 
is formed mind, and that they also give rise to the will, and form 
the basis of reasoning. I showed that the mind becomes the cause 
of many involuntary actions in the body, as reason becomes the 
cause of the voluntary; and that thus the actions of life, of the 
nerves, of the mind, and of the will arise from impressions being 
made on each so as to affect their principles. 
In speaking of the general principles of disease, I divided the 
living power into susceptibility of impression, impression, dispositions 
arising in consequence of such, and action consequent on disposi- 
tion ; all which I observed were immediate or primary. But there 
is a secondary susceptibility, disposition, and action arising from, 
or in consequence of, all, by necessity, called sympathy; actions, 
as it were, playing amongst themselves, each becoming a stimulant 
to the other, or each being affected by the other. 
By this principle of action, called sympathy, an action arises 
without an immediate impression in a secondary way, either acting 
in conjunction with the part immediately impressed, or taking the 
whole action on itself. This action without immediate impression 
is one of the most complicated principles in the animal body, espe- 
cially the more complicated animals, because it is the compounding 
of actions. 
Sympathy may be divided into two species: 1st. A local with a 
local disease; 2d. A universal with a local. The first maybe 
called local sympathy; the second universal. But all sympathies 
must arise from a local cause. Sympathy is not confined to the 
same actions of the same person, but is transferable from one 
person to another.* 
In the investigation of this subject, we shall find all the princi- 
ples of action in an animal, even in the most complicated, have a 
connexion with one another; for instance, the living principle, the 
action of the nerves, and the mind: and that the same principle in 
one part shall be affected by the same principle in another ; and this 
* [For some curious examples of this sort, see Dugald Stewart's " Elements of 
the Philosophy of the Human Mind," p. 153, et seq., and Edin. Med. and Surg. 
Journ., vol. iii. p. 434, et seq., respecting the mode in which some convulsive 
diseases were propagated in Scotland. A strong collateral argument may be de- 
rived from this species of sympathy in favour of that opinion which makes the 
intervention of the sensorium commune a necessary condition to the existence of 
sympathy. See Whytt's Works, p. 140, and Dr. Alison in Edin. Med.-Chir. 
Trans., vol. i. p. 165. That the nerves, however, are capable of a reflex action 
through the medium of the spinal marrow as well as through the brain, is ren- 
dered certain by the experiments of Dr. Marshall Hall and by many morbid 
phenomena. See Med. Gaz., vol. ii., 1832-3, p. 769.] OF SYMPATHY. 
107 
is the simplest kind of sympathy I can conceive. Thus, the living 
principle of one part sympathises with the actions of life in another 
part, as must be the case in all animals which have no nerves.* 
The nerves of one part sympathise with the actions of the nerves 
in another, which may produce sensation. The mind sympathises 
with the mind, which of course can only take place in animals 
that have mind, and perhaps not in all of them; and it is more than 
probable that such minds as are capably of sympathy are capable 
of other complications of affections. Probably what might be 
called the disposition to action of one principle in one part may 
produce action of another principle in another part. Thus sensa- 
tion in another part may be produced, while simple life only is 
affected in the part immediately impressed. This would appear to 
be owing to the nature of the sympathizing part. Thus, if an injec- 
tion is thrown into the urethra in a man, it shall not give pain in 
the urethra, not even the common sensation of the part, yet the 
stomach shall be affected and sickness produced, which last is a 
sensation. I have known a stimulus in the rectum, which did not 
produce pain in the part, produce sickness and pain in the small 
intestines, and even stop digestion. Such pain certainly arises from 
action in the part. On the contrary, simple pain in the finger shall 
produce a greatei' action of the living principle in another part, as 
making the heart beat oftener. 
The principle of sympathy itself I shall call a genus, of which the 
above make three species, namely, sympathy of the actions of life, 
of the nerves, and of the mind. Each of these have their varieties 
in action, each being susceptible of varieties of impressions, affec- 
tions, and actions, and all being capable of sympathizing with one 
another. 
It may admit of dispute, and probably will be difficult to settle, 
whether there is sympathy between sensation and sensation simply; 
for sensation must arise from some impression made on a part, or 
some action of nerves similar to those arising from impression. 
Therefore every sympathy which only produces sensation must still 
arise from impression on, or action of, the nerves; and the same 
with the sensation in the sympathizing part. Sensation is only the 
natural consequence of such action, for sensation is only the intelli- 
* [What the real conditions of the organization are on which sympathies de- 
pend are unknown, although there seems every reason to ascribe this agency 
solely to the nervous system. To ascribe it to the living principle is merely 
eluding the question by a sort of abstraction. The difficulty still returns-what 
is the intermedium through which distinct and dissimilar parts are thus asso- 
ciated! Some intermedium there must be ; and as to the difficulty respecting 
those beings which have no nerves (p. 54, note), the same is equally felt in 
regard to the higher animals, in which the most powerful sympathies exist, al- 
though no anatomical connexion is to be traced between the parts, nor any 
relation of function or structure observable. Indeed, those structures, such as 
fasciae, membranes, &c., which apparently have no nerves, are those very parts 
which give rise to the strongest and most marked sympathies.] 108 
HUNTER'S PRINCIPLES OF SURGERY. 
gence of action, either from impression or arising from the sponta- 
neous action of the nerve itself. 
I suspect that all those which would appear to be sympathies of 
sensation only, without action, are a delusion of the mind, a wrong 
reference of the mind to some other than the part affected, which I 
shall explain when upon the subject of delusion. 
From what has been said above, it must appear that sympathy is 
a principle in animal bodies so intimately connected with every pos- 
sible impression, affection, and action, that we cannot have a proper 
conception of the animal economy respecting diseases without 
taking this principle into consideration. It is one of the secondary 
principles when applied to the body itself, being the effect of some 
impression, affection, or action in some other part of the same body. 
Sympathy arises from every part of the body being ready to fall 
into affections and actions in consequence of an impression, affec- 
tion, or action having taken place in some other part. Sympathy 
is one part taking part in the impressions, affections, and actions of 
another part. 
Sympathy is not confined to actions of the same persons amongst 
themselves, but is transferable from one person to another, in whom 
it cannot be called a secondary action, as it arises from an impres- 
sion being made on some of the senses. 
Yawning is a species of sympathy; and all actions peculiar to 
country, places, family, &c., are so many sympathies. Dancing may 
be included among the sympathies, for it is not simply an imitative 
action arising from the will, but it is an irresistible impulse arising 
from a state of mind produced by musical sounds. If there were no 
sounds, or, in other words, not a sense of hearing, there would be 
no dancing: for seeing would not produce it, probably rather re- 
tard it. There is, first, sensation; then a state of mind formed in 
consequence of that sensation; and then the action of the limbs ex- 
cited by that sensation. 
The idea of sympathy may be stated differently: instead of say- 
ing a part sympathizes with another, we may say one part under 
stimulus oi' irritation is capable of stimulating another part of the 
same body into sensation, action, &c., which I think is the most 
natural idea or position. 
Sympathy may be divided into two kinds, the natural and the 
diseased. The diseased is when sound parts sympathize with the 
diseased, and probably the diseased with the diseased, which is 
what I mean to explain. 
The sympathy of one diseased part with the diseases of another 
part will include the idea of revulsion, as revulsion consists in the 
production of a disease in one part to cure a disease in another 
part; which shows that this one part, while under disease, can be 
affected by a diseased action being produced in another part, or the 
cessation of one action in consequence of another having taken 
place in another part. 
Natural sympathy takes place more readily, and its actions are OF SYMPATHY. 
109 
more strongly marked, in proportion as the powers of the machine 
are capable of repairing an injury received. On the other hand, it 
takes place more slowly, and is less evident, as the powers of life 
are more languid. 
In many diseased states the condition of the whole body is often 
such that it more readily falls into sympathy at one time than at 
others. Thus we find people at particular periods much affected by 
slight causes, while at other times considerable mischief received 
will hardly affect them. 
Some people are naturally more readily affected than others, as 
will be evident in disease. 
Sympathy sometimes proves fatal, as in children from teething. 
But this depends in great measure on the parts sympathizing, or the 
number of parts that sympathize. 
Sympathies are often not reciprocal: the liver never sympathizes 
with the shoulder, nor the urethra with the testis; nor when the 
glans penis is affected does any irritation pass to the bladder ; 
but often they are, as, for example, between the head and the 
stomach. 
Sympathies are generally simple ; wze hardlyever find two parts 
sympathizing with the same cause : however, the spasmodic convul- 
sion of both hands and feet, &c., as sometimes takes place, may be 
called a double sympathy. 
Sympathy is common and uncommon. The first is where it takes 
place more readily between some parts than it does between others, 
as between the stomach and head, the stomach and the skin, the 
testes and the urethra. Sympathy may be called uncommon w'hen 
parts sympathize with diseased parts that were never known to 
sympathize in health. 
A gentleman had a sore on the inside of his thigh, which itched 
so intolerably that he could not avoid scratching it, and when he 
did, it always produced tightness in his chest and shortness of 
breathing, which he never had but at these times. 
Lord Cavendish's father always felt pain in the left arm from a 
stone in the bladder. This pain was the only indication of a want 
to make water. 
Sympathies are either similar to the cause or dissimilar. The 
similar can be but of two kinds: where the modes of affection or 
action of the sympathizer are either wholly similar to the modes of 
affection or action of the parts diseased, or the sympathizer has one 
of its modes of affection or action similar, and which is the one that 
sympathizes. Dissimilar sympathy may be of so many kinds that 
it is probably hardly possible to be completely master of the whole 
of the particular varieties. 
Sympathy may be said to be either partial or universal. Sym- 
pathy is partial, from local diseases, when the causes of action in 
one part become the cause of action in a distant part, as when any- 
thing tickles the nose the muscles of respiration act; or it may be 
partial from a universal disease. But local sympathy with the 110 
HUNTER'S PRINCIPLES OF SURGERY. 
constitution has its order of parts, as the stomach sympathizes with 
the whole body in an incipient fever. 
Sympathy is either natural or diseased. Natural sympathy 
always tends to produce some salutary purpose, as the breasts of 
women increasing with the size of the uterus during gestation. 
As no part of the body is entirely independent of the rest, in all 
particular injuries the whole must sympathize more oi' less ; but 
as every individual part has a more intimate connexion with some 
particular part than with others, these parts sympathize more 
readily. 
Local or partial sympathies we call continuous, contiguous, or 
remote. Continuous is only an extension of the same action, as in 
most inflammations spreading from the centre ; otherwise, in an 
injury, the part which received the first impression would alone 
become inflamed. Contiguous is where one part sympathizes with 
another where the parts are only in contact with each other, with- 
out any continuity of parts, as the contents of the abdomen with 
the abdominal muscles.* Remote is where one part sympathizes 
with another part, though at some distance from it. 
Universal sympathy is when the whole becomes affected in con- 
sequence of a local disease, and is of two kinds. One is where 
every part of the body sympathizes with any one part stimulated, 
as the sympathetic fever in consequence of local inflammation, as 
also eating substances that disagree with the stomach, convulsions 
from worms, teething, &c.; or, secondly, where particular parts, 
being stimulated, more readily produce universal sympathy than 
any other. 
Constitutional sympathy may arise in many cases from local 
sympathy, and not from the effect of the first injured part. This is 
very remarkable when the sympathizing part is a vital part, though 
the first injured part be not vital. If the stomach sympathizes 
strongly with any part of the body, this sympathy of the stomach 
produces a morbid state of the constitution. 
In universal sympathy there appear three stages, but all equally 
belonging to this principle; 1st, inflammatory fever; 2d, hectic 
fever; 3d, dissolution. These take their rise from the different 
stages of the local disease. There may be marked a fourth, which 
may be called nervous, spasmodic, or hysteric ; but this is not par- 
ticular to any one of the states of the local disease from which the 
others arise, but from peculiarity of constitution, and sometimes it 
exists when the others do not. 
Local or partial sympathy is found more in old than in young ; 
whereas universal sympathy is more in young than in old. Sym- 
pathy is less determined in young persons, every part being then 
ready to sympathize with other parts under disease. This is re- 
* [Of this kind also are the actions of membranous muscular cavities, as the 
heart, stomach, or intestines, when their lining membranes are stimulated, and of 
the muscle of the skin in animals when the skin is irritated.] OF SYMPATHY. 
111 
markable in the teething of children, for in them universal sympathy 
seems the first mode of sympathy arising from local irritation. 
When a local disease takes place in a part when the patient is 
very young, it is capable of giving a general disposition to sym- 
pathize, by which means symptoms become more uncertain than 
in those of more advanced age, often putting on the appearances of 
a great variety of diseases. 
As the child advances, the power of sympathy becomes partial, 
there not being now in the constitution that universal consent of 
parts, but some part, which has greater sympathy than the rest, 
falls into the whole irritation ; therefore the whole disposition to 
sympathy is directed to some particular part. The different organs 
acquire more and more of theii' independent actions as the child 
grows older. 
We find in children the symptoms from sympathy often more 
violent than those of the parts affected. In adults when cutting 
teeth there is only an affection of the part, or only a continued 
sympathy, that is, a swelling of the cheek, &c. In adults the pain 
is often very great, but in children the pain is little, and the action 
of the part moderate, but the action in the sympathizing parts is 
very great, namely, in the voluntary muscles. 
Sympathetic Inflammatory Fever.-In consequence of considera- 
ble local injuries, as a compound fracture, or operation of conse- 
quence having been performed, that accident or operation shall be 
followed by inflammation, suppuration, &c. In consequence of this 
local injury fever shall arise in the system, which is universal sym- 
pathy, commonly called symptomatic fever. 
Convulsions often arise from considerable local injuries called 
irritation. Permanent contractions are also often the consequence 
of local injuries or irritation, as tetanus. 
If another mode of action takes place in the part sympathized 
with, namely the cure of the injury, then the inflammatory sympa- 
thetic fever will subside. 
Sympathetic Hectic Fever.-If parts have not a power to effect 
a cure, the constitution sympathizes in another way: it is teazed, 
as if conscious that the disease is incurable ; and this teazing 
constitutes the greatest part of what has been called hectic fever. 
But if this incurable part is removed, the hetic fever will cease. 
I have seen a wound in the knee keep a man awake several 
nights with pain and constant purging, and the patient becoming 
hectic ; and by amputating the part he slept well the same night 
without opium, the purging immediately ceased, and costiveness 
ensued. A man had a wound in the elbow-joint, and was affected 
exactly in the same way, the pulse quick and hard : within ten 
minutes after the removal of the arm the pulse became slower and 
softer. 
This universal sympathy, of whatever species, is greater when 
certain parts are diseased. The sympathetic fever will more 
readily take place from an injury done to the involuntary parts, as HUNTER'S PRINCIPLES OF SURGERY. 
112 
the stomach, intestines, testicles, &c., than if the same mischief 
had been done to the voluntary parts, as the muscles of the arm, 
for instance. 
When vital parts are diseased, there is more sympathy among 
vital parts than among others. 
Universal sympathy is greater if the injury received is further 
from the source of life, namely, the heart, than near it, provided it 
be a part of the same nature in both cases. 
Sympathy is similar to sensation, action, motion, &c.: it can, 
and often does, cease instantaneously. Every sympathy ceases 
after the cause is gone, although its effects may remain, as tume- 
faction.* 
Some parts of the Body sympathize more than others.-The sto- 
mach appears to have this connexion with the body more than any 
other part. It would appear that the stomach was the seat of uni- 
versal sympathy, sympathizing with every part of the body, and 
most parts of the body sympathizing with the stomach. 
Every part of the body seems to have some susceptibility of 
sympathy; but although there is universal sympathy between the 
stomach and whole body, yet the stomach sympathizes more readily 
with a complaint in the head than with one in the toe ; more 
with the testicle than with many other parts. Also some parts of 
the body sympathize more readily with the stomach than many 
other parts, as the head, skin, &c. The skin sympathizing with 
the stomach is often very evident, from the effect some food has 
on the stomach, producing disease of the skin. A glass of cider 
in some shall produce a flushing in the face immediately ; and 
spirits, in the end, we know, produce inflammation and suppura- 
tion over the whole face, called pimples, especially on the nose. 
But whether the stomach loses part of this property I am not 
certain. It appears that other parts lose that susceptibility to sym- 
pathize w'ith the stomach, as the skin, for that part does not seem 
to be so readily affected in the old as in the young. 
The stomach sympathizes with the skin in many of its affections. 
Cold or wet feet will immediately affect the stomach. But the 
most striking instance is seen in the leech when its stomach is full 
of blood, by throwing salt on it, when, from sympathy of the 
stomach with the skin, it immediately rejects all the blood. 
The intestines, especially the upper parts, have also sympathies 
over the wdiole body. Cases of worms show this perhaps more 
than anything. 
Observations on Sympathies of the different Principles with one 
another, producing similar and dissimilar Sympathies.-Continued 
sympathy is more commonly similar than the remote, as it is an 
extension of the same action, and commonly in a similar part w7hich 
can act alike, as indeed most parts do in most of their common 
* [It often happens, however, that parts acquire a habit from long-continued 
sympathy, which does not cease upon the cessation of the cause.] OF SYMPATHY. 
113 
actions, although the peculiar actions of the part may be dissimilar.* 
Thus, chancre on the scrotum, if it was to spread to the testicle, 
would produce the same mode of action in the testicle as in the 
scrotum, though it might at the same time produce effects peculiar 
to the testicle, as stoppage of the secretion, &c. 
But the remote, local, or partial, is both similar and dissimilar, 
varying according to two circumstances: 1st, According to the 
nature of the part deceased and the nature of the sympathizer. 2d, 
According to the species of properties in each part; as one pro- 
perty in the part diseased producing sympathy in another property 
in the sympathizer: disease in one part producing increased na- 
tural discharge in another part, which makes sympathy very com- 
plicated. 
Let us take sensation as an illustration: although we have no 
sympathetic sensation, it being wholly delusive, yet sensation is an 
absolute guide. We know that the sensations in the brain are not 
similar to any other sensations in the body, at least not similar to 
many of them; also the sensations of the stomach are unlike to 
many of the brain, if not to the whole of them; also that many of 
the sensations of the stomach are not similar to the sensations of 
other parts; also that all sensations of the stomach are not the same; 
also that an action of one part shall produce sympathy of another, 
whose mode of action is not similar: we must see therefore at once 
why the two modes of action become not similar, and why the sym- 
pathy is not similar to the cause, producing by this means another 
cause of complication, and consequently a variety in the first prin- 
ciples of sensation and action respecting sympathy. Again, differ- 
ence of properties may produce dissimilar sympathies between two 
different principles, as the principle of life and that of action. For 
as sensation in one part may produce sympathy in a part whose 
actions are dissimilar from that other part, the sympathy produced 
will be dissimilar, and this resulting from the difference in the 
properties of the principle of action. 
Also when we consider that many parts have more modes of 
action than one, as the stomach, which has a variety of actions, 
and of course is capable of producing a variety of sympathies in 
other parts, or can sympathize in a variety of ways with other 
* [To this head may be referred, 1st, Those sympathies by virtue of which 
parts become successively diseased in pairs, as two eyes, two similar parts of 
the skin, or two testicles. 2d, Those which give rise to disease in consequence 
of similarity of function, as ulceration of the cartilages, inflammation of the syno- 
vial membranes of joints, &c. 3d, Those which affect particular organs from 
forming parts of the same general system, as disease of the bladder affecting the 
kidney, of the uterus affecting the breast, or the spinal marrow of the brain, &c. 
And 4thly, Those which arise from similarity of structure, as inflammation of 
fibrous and mucous membranes, &c. 
We may observe, once for all, that any philosophical classification of sympa- 
thies is impracticable. Mr. Hunter has probably made his division of sympa- 
thies too complex; but he has amply redeemed this fault, if it be one, by the 
able manner in which he has treated the subject.] 114 
HUNTER'S PRINCIPLES OF SURGERY. 
parts, so that any one of these peculiar actions in one shall produce 
an action or sympathy in that suitable to the first action of the 
disease, which of course will be similar to the action of the diseased 
parts; while another action in the same part, and from the same 
principle, shall produce another mode of sympathy in the sympa- 
thizer; when we consider all these, they will at first sight appear 
inexplicable: as an illustration, we may observe what a variety of 
sympathies are produced from one mode of irritation, as teething, 
or worms in the intestines. 
This connexion of every part of the body with the others, by 
sympathy, becomes one of the extensive principles of action in the 
animal economy, indeed is the basis of most of the compound im- 
pressions, affections, and actions. 
Similar Sympathy.-Sympathy must be similar to the affection of 
the part first affected when between parts whose affections are 
wholly similar; similar inaction when between parts whose actions 
are wholly similar. 
Sympathy may be similar in disease when between parts endued 
with a variety of affections and actions, provided they are endued 
with the same affection or action, as irritation in one part produc- 
ing irritation in another, which thus produces inflammation, as an 
injection into the urethra producing swelling and pain of the tes- 
ticle. 
Continued sympathy, I believe, in all cases is similar to the 
disease, at least the action is so, even though it may spread to a 
dissimilar part. If inflammation attacks the diaphragm, and ex- 
tends to the liver from continuity, that inflammation of the liver will 
be similar to that of the diaphragm. The same also if disease ex- 
tends from the testicle to the scrotum, &c. 
Dissimilar Sympathy.-Sympathy is dissimilar when the affections 
or actions of the part impressed are not similar to the actions or 
affections of the part which sympathizes; thus, sickness at the 
stomach cannot produce sickness any where else; or, secondly, 
where parts diseased are susceptible of a variety of affections or 
actions of which the sympathizer is not; or, thirdly, even in parts 
where both the part diseased and the sympathizer are susceptible 
of the same varieties of stimuli and modes of action, which varie- 
ties in themselves are similar to one another, yet the sympathizer 
shall not be the corresponding affection or action to that which is 
excited in the part diseased; for example a medicine taken into 
the stomach shall produce flushing of the face or inflammation, 
though the stomach is liable to the same disease as that of the face, 
namely, inflammation. So that in this case the difference does not 
arise from the mode of action being different from that of the 
stomach, only that the face does not run on the same degree of ac- 
tion as the stomach. In inflammation of the liver the pain in the 
shoulder is different from inflammation, though the shoulder and 
liver are equally susceptible of inflammation. So that many parts 
have a variety of actions in themselves which are similar to soma OF SYMPATHY. 
actions in other parts; therefore sympathy shall or shall not be 
similar to the action of the diseased part, being according to the 
stimulus applied to such part, or mode of action of the diseased 
part joined with the mode of affection. Therefore simple stimulus, 
action, or affection shall not only be the cause either of similar or 
dissimilar action, but both, according to the variety of affections 
and different parts that sympathize. A stimulus in the testicle shall 
produce sickness in the stomach, which shall produce vomiting, 
which is an action; so that a double and different compound sym- 
pathy takes places from the same stimulus. 
Of the simplest Sympathies.-In vegetables we evidently see 
actions taking place in consequence of actions having taken place 
in another part; but how far vegetables have a variety of proper- 
ties and actions is not perfectly known; however, we can hardly 
doubt that they have a great many, for they produce a vast variety 
of effects, all these actions and effects arising from the principle of 
life. So that sympathies of vegetables may be complicated, and 
even dissimilar, but still more simple than the most simple animal. 
The succession of motions in a sensitive plant are no more than a 
succession of sympathies, or a succession of stimuli in consequence 
of those preceding. Here, then, we have an exact similarity in the 
actions of the sympathizers with the part first acted on. 
The most simple sympathy is perhaps to be found in vegetables, 
these being much more simple than the most simple animal. Vege- 
tables have the same properties as animals without brain or stomach. 
Take away, therefore, the sympathies of the stomach writh the 
body, and of the body with the stomach, and those between the 
brain and the body, reducing the sympathies of the animal to the 
simple properties of life, and an animal will be exactly similar to 
a vegetable; and this I know from experiments made on trees. 
The motion of the sensitive plant I have said is produced by a 
succession of simple sympathies: something like this maybe found 
in the more imperfect animals; but no animal can be so simple in 
all its sympathies, though it may in some. I shall at present sup- 
pose that every part of an animal is liable to be affected by the 
stimulus of agreeable or disagreeable sensations, and the more 
simple the animal the more likely it is to be under the same simple 
sympathy. A polypus is the most simple complete animal, and 
therefore must be most similar in its sympathies; but I can con- 
ceive a child in the womb to be still more so, being capable of 
one stimulus only, namely, want in the system; and perhaps it has 
no sympathy even writh this, as it has no demand on any part of 
its body for the supply. This simplicity of stimulus is found not 
only in the simple animals, but in some degree also in the more 
complicated. The similar sympathies may be compared to the 
unison in sounds. 
A polypus, though so simple an animal, is susceptible of four 
different stimuli, disagreeable and agreeable, propagation of the 
species, and want of repletion. In the last the stomach becomes 
115 HUNTER'S PRINCIPLES OF SURGERY. 
116 
the original sympathiser, and produces action in the other parts, so 
that here is a sympathy as in plants, but not so simple, for the 
stomach first sympathises with the whole body when it wants 
repletion, and afterwards by a reflex sympathy the body is called 
into action and its little arms are erected. 
Difference of Sympathies in the Sympathiser arising from differ- 
ence in the mode of Impression.-Difference of affection and action 
of the sympathiser from that of the part affected does not always 
arise from difference in the nature of the two parts, but often from 
difference in the nature of the stimulant, or mode of impression; 
for a stimulant of one kind shall produce a mode of impression of 
its own kind in the part, from which shall arise a peculiar sympa- 
thy, while a stimulus of another kind will produce an impression 
of another kind, which of course will produce a sympathy of 
another kind in the part that sympathises. Thus, when the stomach 
is stimulated in a particular way, the head shall ache, which is 
often the case when something is taken which disagrees with the 
stomach; and if stimulated in another way the headache shall be 
removed, namely, by exciting vomiting.* There will be, therefore, 
a variety in the actions of the sympathiser, arising from varieties 
in the specific modes of action, created by different stimulants, 
which may also produce similar sympathy in dissimilar parts, for 
parts very dissimilar in their natural actions shall be put into 
similar actions by sympathy. When the stomach is stimulated in 
one way, an action shall be brought on in the muscles of respira- 
tion and of the belly for the expulsion of the irritating matter; or 
if stimulated in another way, sweating shall be brought on in the 
skin; or if stimulated in another way, universal debility takes 
place ; a blow on the stomach may even kill. 
Hence it appears, that a stimulus of one kind produces sympathy 
in one part of the body, while a stimulus of another kind applied to 
the same part produces sympathy in another part, each mode of ac- 
tion in a particular part having other parts distinct from each other 
which sympathize with it. 
I should suspect that specific inflammations are not able to give 
to the sympathizer their specific virtues, though they may be liable 
to give them others. In continuous sympathies the affection is simi- 
lar, but not in the remote. A swelled testicle in venereal gonor- 
rhoea does not partake of the specific nature of the original disease. 
In a cancerous breast, the glands in the axilla will often inflame and 
subside again, which they would not do if they were affected with 
cancer. 
Sympathies of the Body arising from Affections of the Mind.-The 
living principle of the body sympathizes with the mind. Strong 
affections of the mind will produce involuntary motions, even of 
those parts commonly at the command of the will. This must be 
* [This illustration is incorrect; the headache is removed, not because another 
mode of stimulation, that of the emetic, takes place, but because the original one 
is removed ; thus spontaneous headaches terminate in sickness, and get well.] OF SYMPATHY. 
117 
by means of the nerves, for the body has no connexion with the 
brain but by the nerves. Fear will produce action of the involun- 
tary parts, as purging, discharge of urine, &c. 
I suspect that particular parts may sympathize more readily with 
the mind than others; therefore in such cases sympathies may be 
called local or remote, but they are, I believe, in most cases uni- 
versal. 
Sympathies of the Mind with the Living Principle.-The third 
principle, mind, is capable of sympathizing with the first, or actions 
depending on the living principle, for I should think that a state of 
the body often forms a state of mind; however, it is not so readily 
affect-ed by w'hat does not produce sensation as by that which does. 
A man in pain not only feels pain as a sensation, but becomes de- 
pressed: or if the actions of life can produce sensation in any part, 
then the mind becomes affected, as when the whole body is in want 
of food the stomach sympathizes strongly with the whole, and the 
sympathy of the stomach causes a sympathizing mind. This is not 
sympathy immediately with the first principle, but sympathy with 
the sympathizer, or second, which, however, arose from the first. 
There are, however, instances where the mind sympathizes with 
the first, or life, for there are many instances where the mind is de- 
pressed without a sensible cause, called hypochondriasis, and also 
where the mind is light or easy without any sensible cause. I sus- 
pect that both these states arise from the living principle being 
eithei' diseased or at rest. 
Sympathy of the mind with the voluntary parts is curious. If 
the voluntary parts are rendered useless, the will has no longer any 
power over them; it produces a state of mind which prevents the 
will putting the parts into action. Thus, when the tendo-Achillis is 
divided, the person cannot put the muscles attached to that tendon 
into action by the will; but as soon as union takes place and grows 
strong, the mind allows the will to take possession of its action over 
the muscles. 
Use of Sympathies.*-Sympathies are designed for very important 
* [To enumerate all the uses of sympathies in an animal body would evidently 
be impossible in the present state of science. Nothing is more certainly ascer- 
tained, however, than that every part of the frame is connected in some myste- 
rious manner with the whole, and the whole with every part, in consequence of 
which a sort of community of feeling is established between all the parts and 
functions of the machine. This is most remarkably exemplified in those organs 
which are associated in some common function, as, for example, in the organs of 
generation, digestion, respiration, &c., which reciprocally act and react upon one 
another on all occasions, in health and in disease. 
Ascending to still higher generalities, as, e. g., to the great centre of organic 
life, the stomach, the brain, and the heart, the same relationship and dependence 
is observed to exist, still more strongly developed ; while these again may be 
regarded as so many primary foci, to which all the impressions of the body tend, 
and from which, by a sort of reflex operation, they radiate to the most remote 
parts of the system. A balance of power and action is thus established which it 
is easy to see must be of the most essential importance to the general economy of 
the animal, whereby the weakness of individual parts is reinforced by the reaction 118 
HUNTER'S PRINCIPLES OF SURGERY. 
ends. They produce a communication between the three principles 
of the animal economy. The use of sympathy is often very evident. 
If there is an uncommon irritation in the lungs or throat, the mus- 
cles of respiration act with uncommon force, and the offending sub- 
stance is thrown up. The irritation is frequently in the lungs, then 
it is transferred to the larynx, the muscles of respiration sympathize 
with the latter, and cough is excited either to get rid of the disease 
or of its consequence, which is increased and morbid secretion. In 
pregnancy the breasts become swollen, preparatory to their secre- 
ting milk in parturition. In labor the uterus is stimulated by the 
child, now become fit for expulsion, and the muscles of the abdomen 
sympathize with the uterus. 
Sympathy in diseases, by becoming the symptom of disease, often 
leads us to the cause, especially when the cause is in a deep-seated 
part, as the pain in the knee when the hip-joint is affected. 
We find that the sympathizer in some cases relieves the part 
irritated or under diseased action, as the testicle relieves the urethra; 
but there appears to be nothing gained by this, as the sympathy is 
the worse disease of the two. 
By the sympathizer often relieving the part diseased, and some- 
times even curing it, it becomes similar to a constitutional affection 
becoming a local one, as in the gout; and, as in the swelled testicle 
from gonorrhoea it often changes sides almost instantaneously, it is 
in this exactly similar to gout. 
of the whole, or, on the other hnnd, the over-action of one organ divided and 
broken by participation with another. Upon this principle it is, also, that one 
disease becomes the cure of another, and that revulsives and counter-irritants 
operate. This consent of parts, or interchange of sympathy, in virtue of which 
the parts of a complex animal body vibrate, as it were, in unison, pre-eminently 
distinguishes an organized being from any work of human art, especially when we 
add to this the further fact that it carries within itself its own resources of repair 
whenever it is injured. The full perception which Hunter had of this extraor- 
dinary co-operation of parts led him to employ a language borrowed from the 
operations of the mind, as if consciousness resided in an animal body, and was 
capable of directing its operations as it were by anticipation. (See pp. 29, 49, 
54, 58, et passim.) 
The prevailing opinion is, that this connexion of function is established by 
means of the great sympathetic nerve, which is supposed to accompany the ar- 
teries in their most remote ramifications. Whether this is so or not is not sus- 
ceptible of proof; we may at least venture to say that our knowledge of this set 
of nerves has hardly kept pace with other branches of physiology, and that in 
fact our actual knowledge of the subject is exceedingly imperfect. In the 
greater number of cases the intervention of the brain or spinal marrow seems to 
be an essential condition to the propagation of sympathy; and probably in those 
cases where this is not necessary, the same condition is fulfilled by the ganglionic 
masses of the sympathetic nerve. Nothing certain, however, can be affirmed on 
this subject. 
Some physiologists have excluded from their definition of sympathy all those 
phenomena which depend on obvious anatomical connexion, functional relation, 
or continuity of structure, restricting the term to those cases only in which no 
functional or mechanical connexion is to be traced. I apprehend, however, that 
this distinction is not tenable, and that these two sets of phenomena will be 
found to depend on the same principle, and insensibly to merge in one another.] OF SYMPATHY. 
119 
Some sympathies are opposite in their action to the original action; 
pain in the liver is depressing, that in the shoulder rousing. Nature 
is incapable of sustaining the former, and sets up the rousing pain in 
the shoulder to continue life. 
Delusion.-A simple sensation in the mind of a local disease in 
the body which does not correspond with the seat of the disease 
itself has, I believe, been always referred to the principle of sympathy. 
Thus, sensation of pain in the shoulder from disease in the liver has 
been always supposed to arise from the shoulder sympathizing with 
the liver. The sensation of the glans penis from a disease or irri- 
tation in the bladder has been referred to the same cause. But I 
believe it is a delusion in the mind ; for the nerves of the part are 
not the seat of the disease, and irritation could not communicate to 
the mind the sensation of pain in the part affected, excepting they 
(the nerves) take on the same action, which they must do when 
they produce the sensation of pain of that part. But if the nerves 
of the part which is the seat of sensation in such cases do not act 
at all, it cannot be called sympathy. 
That there is such a delusive principle in the animal economy 
we see every day, and that it not only exists between mind and 
body, so as to lead us astray from the real subject, but between the 
mind and other bodies with which it has no immediate connexion, 
not even by the common senses. But we must allow that certain 
sensations can form a peculiar state of mind, called a sympathizing 
mind, for we are capable of transferring the sensation of another 
person to ourselves, which is like a dream. A delusion in the mind 
is an object appearing to be. where it is not. 
To account for this delusion in sensation in ourselves may be 
difficult, but we may conceive it to be in this way. We may sup- 
pose that when the seat of sensation in the brain only takes on part 
of the action of sensation in the brain, it may be in this way: 
Suppose E, (Pl. I. f. 3.) the brain; A B, two portions of the brain: 
G H, two nerves; F, communication between these two nerves; C 
D, two different parts of the body. 
The nerve G is inserted into part of the brain A ; the nerve H 
into the other part B. F is a communicating nerve between G and 
H. A and B are the two parts of the brain to which sensation 
from C and D is conducted. C is the disease or part impressed. 
But from the connexion between C and D, by means of the nerves 
G F H, B will become the seat of action of the nerve G as well as 
of the nerve H, and the sensation be in part referred to D as well 
as to C. For if the nerve H is stimulated, in consequence of these 
connexions, to take up part of the action of the nerve G, and B is 
sensible of it as well as A is of the sensation of C, then the sensitive 
principle of the nerves A B is made sensible of both the disease of 
the part of impression as also of the sympathizer D, which become 
the two impressions in the sensorium. If anything stimulates G, 
part of the action is communicated to H; this goes on with the 
action to B, so that both A and B become sensible of the disease 120 
HUNTER'S PRINCIPLES OF SURGERY. 
C. If there is disease in C, the mind is made sensible of it, because 
G always communicates the sense of C to A; but if a small portion 
of it is brought over to H, and this nerve carries on the action to 
B, B becomes sensible of it also, and B refers it not to C, but to D, 
because it is to that point that it has been accustomed to refer all 
its sensations. 
I do not know whether this explanation may be the true one or 
no, but it is one mode of explaining how we may feel both the 
disease and the part of sympathy. But how is it in those cases 
where the sympathizer takes on the whole action, affection, or sen- 
sation ? In this case we must suppose that not only a part but the 
whole of the sensation passes by the communicating nerve F to B, 
and thus the disease appears to be in D only. But it is possible 
that nervous sympathy is not affected by the nerves communi- 
cating with one another in the body, but from their connexions 
in the brain ; as from the point B sympathizing with the point 
A, taking on the whole of its action, and referring its sensation 
to D.* 
Delirium.-It will be very difficult to prove whether delirium is a 
disease of the brain or nerves ; it appears equally easy to prove that 
it is from one as from the other. 
A delirium is a dream arising from disease, whether the dream 
is in the brain itself or in the body; only it is worthy of considera- 
tion, as dreams arise from sleep, and as a delirium is a diseased 
dream arising from what may be called diseased sleep, whether it 
may not be first necessary to give a short definition of sleep. 
Perfect sleep is a cessation of susceptibility of sensation, and of 
course of all its actions; the consequence of which is a cessation 
of consciousness in the animal of its own existence; and also, of 
course, of the consciousness of the relation it bears to itself and 
every other thing. But whether this cessation of the susceptibility 
of impression arises from the brain not then having power to receive 
impressions of the actions of nerves, or whether the nerves are not 
then capable of acting or conveying their action to the brain in the 
state of sleep, is not so easily determined. 
Dreams are actions of the mind in sleep; therefore may be inde- 
* [Thus, if a branch of a nerve be irritated (being in connexion with the spinal 
marrow), it is capable, by a reflective operation, of exciting all those muscles 
supplied by the trunk, although if the spinal marrow be destroyed this effect does 
not take place. 
Sympathies of simple sensation are probably as real as sympathies attended 
with visible action, and to be referred to the same general law. This appears 
from the same cause producing one or both effects, according as the cause is less 
or more intense. Thus toothache and tic-douloureux will occasion pain or in- 
flammation of the face ; diseased hip will produce pain of the knee, and, as I 
have frequently seen, inflammation of that part; gonorrhoea will occasion pain or 
inflammation of the testicle ; disease of the bladder pain or morbid change of 
structure in the kidneys. Many other examples might be adduced to show that 
the same cause is capable of producing simple pain or pain accompanied with 
visible effects : which is evidently inconsistent with the opinion which ascribes 
simple sympathetic pain to a misdirection of the mind.] OF SYMPATHY. 
121 
pendent of any immediate information or impression, but are always 
independent of the relative connexion between body and mind, or 
consciousness of the existence of that relationship between the two. 
For the connexion between the two enables the mind to distinguish 
perfectly what is sensation and what is only thought, without which 
all would be a dream. In a delirium, as in sleep, we find the sus- 
ceptibility of external impression lessened. Whilst sensation is con- 
tinued sleep is kept off; delirium may be also lessened by arousing 
the mind from that particular state by external impressions; so far 
delirium appears similar to dreams, but it widely differs in other 
respects. In natural sleep the more the brain puts on that peculiar 
state the less we have of dreaming; but the more the other state is 
put on the greater the delirium. Dreams often do arise from sensa- 
tions of the body being conveyed to the brain, it being in an imper- 
fect sleep; but the consciousness of the connexion between our own 
body and our own mind being cut off by the state of sleep, the sen- 
sation may or may not be referred to our own body ; it may be 
referred to some other body.* In some cases it is not referred to 
the part of the body where the impression is made: and the same 
thing happens in delirium, where the connexion is cut off; these not 
distinguishing between real sensation and thought, what the mind 
thinks about appears to be real. 
But even where the mind is in full possession of the conscious- 
ness of its connexion and relationship with the body, we have in 
some cases this delusion, as the appearance of the turning round 
of the objects about us whilst they are really fixed, and that in 
consequence of our having turned about quickly; giddiness from 
going to a height, or from riding backwards in a coach. Delusion 
is also an effect of intoxication and disease. Whilst awake and in 
health, impressions produce sensations, which are conveyed to the 
brain, and from these the mind reasons: but suppose the mind to 
* [One of the most remarkable properties of dreams is, that we have no idea 
of time or place, or sometimes of our personal identity ; in consequence of which 
we commit the most ludicrous anachronisms, imagine ourselves dead and alive, 
or in two places, at the same time, or else that our spirits have transmigrated 
into some other bodies. In consequence of the absence of external perception in 
sleep, the ideas and associations of the mind acquire an overpowering vividness 
which leads us to mistake them for realities; while the absence of reason and 
volition permits the imagination to revel in its own creations under the simple 
guidance of association. There are, however, many phenomena respecting 
dreams, delirium, and that variety of the former called somnambulism, which do 
not admit of any plausible explanation : the will, the senses, and voluntary mo- 
tion are still exercised, under certain modifications; whilst it must be in the ex- 
perience of every one that the reasoning faculty is still also capable of exerting 
itself, so as in some rare cases to engage in, and even to accomplish, the analy- 
sis of complicated problems which it could not have achieved during its waking 
state. 
There is one point in which pure delirium and sleep differ from insanity. Per- 
sons may be roused by a strong impression from the former to a right percep- 
tion of their situation, whereas in the insane person truth and error are inextrica- 
bly blended together, so that when seen side by side they are not distinguishable 
by the patient ] 122 
HUNTER'S PRINCIPLES OF SURGERY. 
have lost, or as it were forgot, its former connexion with our body, 
then the above false reference takes place. 
A gentleman came into this country in 17-; his memory was 
imperfect, and a particular kind of delirium began whenever he 
was going to sleep, but afterwards continued whilst wide awake ; and 
for a week before his death he was not quiet from this delirium a 
moment, but whilst his impressions were forced on him by external 
objects. His delirium was of this kind ; he was constantly talking 
of former circumstances of his life, but referring them to the pre- 
sent moment and to some other person. There wras a revival of 
past ideas in his mind, but from a want of connexion between his 
mind and his body, he was not enabled, by his present impressions, 
to infer how little relationship they bore to the present time, or 
to those persons to whom he referred them : at the same time, it 
really appeared more a want of connexion between the mind and 
the body than the mind itself being hurt, for he determined rightly 
what should be done in those circumstances which he supposed 
present, and w'ould express his sentiments in really elegant language. 
That it depended more on want of connexion than on disease of 
the body, appeared, from his being sensible of impressions, and re- 
ferring them to the part where they took place, but supposing that 
to be in any other body than his own. Thus, he would tell his 
nurse or the bystanders that they were hungry or thirsty ; but upon 
offering food or drink, it appeared plainly by his eagerness that the 
idea had arisen from a sensation of hunger in bis own stomach. 
He would show great signs of distress or anxiety, which he would 
say was because his nurse wanted to go to the close stool, but was 
restrained by his presence ; and this from his sensations also. He 
had a violent cough, in which he would sympathize with some by- 
stander, proceeding in his story aftei' the cough, no otherwise dis- 
turbed than by sympathizing with the person whom he thought so 
unfortunate as to have it. The objects about him w7ere more to 
him than his own sensations. 
A gentleman who was fond of his bottle referred all his own 
weaknesses and feeling, as he became intoxicated, to those around 
him; and upon his going home would insist upon undressing all 
his family and putting them to bed, declaring that they w7ere too 
drunk to do it themselves; and this happened not only once, but 
whenever he was intoxicated. I myself once experienced what I 
have since thought must have proceeded from this w7ant of con- 
nexion between the mind and the body. I was reading a remarkable 
case, and reasoning with myself upon it, when I found the letters 
and words made an impression on the retina, but that I was in- 
capable of affixing a meaning to them: this I thought might proceed 
from want of sleep ; but that was not the case: I tried repeatedly, 
but without effect, and at last I went to bed, from which I did not 
move for three weeks, a violent affection of the head following this 
extraordinary circumstance. It may not be amiss to say, that the 
case I w7as reading was that of the late Mr. Foote, who was not OF SYMPATHY. 
123 
able to command his attention to more than one action or circum- 
stance at a time : thus, if he took his snuff-box out of his pocket 
and held it in his hand, it was all very well, until he attempted 
another action, such as taking a pinch of snuff out of it, and then 
the box fell immediately out of his hand : in fact, he was going back 
into a state of second childhood, for a child is not capable of com- 
manding his attention to more than one circumstance or action at 
a time: give him a stick to hold, and call his attention to another 
object, and the stick will be dropped; for it is by habit we become 
capable of attending to several actions at a time. If a person is 
blindfolded and put into a coach, he will think he is riding forwards 
though really moving backwards. An impression from any part, 
either healthy or diseased, may be conveyed, yet there may be no 
consciousness of the mind from which part of the body it was con- 
veyed, the mind having full possession of the impression, and a per- 
fect idea of it, but having nothing to direct it right in its reference 
of it. It must refer it somewhere, and is more likely to refer it to 
another than to itself. Thus, A (Pl. I. fig. 3.) does not refer the 
sensation to C as a cause, nor will B sympathize with A so as to 
refer it to D. 
A gentleman, a medical man, dreamed he had given a patient 
too strong an injection for gonorrhoea, and that it had produced a 
total stoppage of urine : he awoke, and found an erection of the 
penis, and that he could not void a drop of urine. Here was an 
impression without the consciousness, and he referred the impression 
to another person. 
A gentleman, upwards of ninety years old, suddenly lost his 
senses, and in consequence of this there was a reference of all the 
ails which he might be supposed to feel to his wife, who had been 
dead some time, but who he now thought to be alive, and ordering 
the utmost silence to be preserved, lest by noise her illness should 
be increased. The new-born child has probably sensation without 
this consciousness. The contrary takes place when a person 
refers the sensations of others to himself, or when the idea of sen- 
sation is supposed to be sensation itself, as happens in those who are 
affected by animal magnetism. I was asked to go to be magnetized, 
but at first refused, because the spasm on my vital parts was very 
likely to be brought on by a state of mind anxious about any 
event. Thus, at my country box I have bees, which I am very 
fond of, and I once was anxious about their swarming lest it should 
not happen before I set off for town; this brought it on. The cats 
teaze me very much by destroying my tame pheasants, partridges, 
&c., and rooting up my plants. I saw a large cat sitting at the 
root of a tree, and was going into the house for a gun, when I 
became anxious lest she should get away before my return ; this 
likewise brought on the spasm; other states, where my mind is much 
more affected, will not bring it on. Now I feared lest my anxiety for 
the event should bring on the spasm, and that should be imputed to 
animal magnetism. But considering that if any person was affected 
by it it must be by the imagination being worked up by attention 124 
HUNTER'S PRINCIPLES OF SURGERY. 
to the part expected to be affected, and thinking I could counteract 
This, I went; and accordingly, when I went, I was convinced by 
the apparatus that everything was calculated to affect the imagina- 
tion. When the magnetizer began his operations, and informed me 
that I should feel it first at the roots of my nails of that hand nearest 
the apparatus, I fixed my attention on my great toe, where I was 
wishing to have a fit of the gout; and I am confident that I can fix 
my attention to any part until I have a sensation in that part. 
Whenever I found myself attending to his tricks, I fell to work with 
my great toe, working it about, &c., by which means I prevented 
it having any effect on me. 
CHAPTER XL 
OF LOCAL AND CONSTITUTIONAL DISEASES. 
Difficulty of distinguishing between strictly local diseases and local diseasesaris- 
ing from constitutional affection.-Diseases constitutionallocal;-mixed.- 
The first universal, as fever;-or constitutionally local, as gout.-Local dis- 
eases.-Mixed diseases.-Diseases common or specific.-The latter do not 
always depend on a specific cause.-Of diseases peculiar to ages.-Effects of 
climate on diseases ;-of seasons;-of temperature;-of the moon.-Of hu- 
mours, erroneous notions of them ;-effects of substances contained in the 
blood;-experiments of injecting medicines into the blood ;-no specific dis- 
eases produced.-Of diseases supposed to arise from humours.-Of hereditary 
diseases ;-hereditary nature of natural and of acquired properties ;-here- 
ditary dispositions ;-latent hereditary principles ;-similarity of children to 
their parents ;-dispositions hereditary, but not diseasesmore permanent 
than accidental dispositions;-scrofula;-gout;-supposed hereditary.- 
Symptoms of disease local or universal ;-variation of local symptoms ;-> 
universal symptoms affecting the circulation ;-secretions ;-nerves.-Combi- 
nations of symptoms.-Irregular symptoms.-Delusive symptoms. 
It may be difficult in all cases of local diseases to distinguish 
between one truly local and one arising from the constitution ; that 
is, one arising entirely in the part diseased, and one arising entirely 
from the constitution. For as one can and often does affect the 
other, which may be called mixed, it becomes the more uncertain 
where the disease originated.* 
Diseases may be called constitutional, local, and mixed. Diseases 
may be originally constitutional and originally local; that is, dis- 
eases may take place in the same person from constitutional or local 
* [Mr. Abernethy, in speaking of the evil effects arising from the separation of 
medicine from surgery, makes the following observation : " The effects of local 
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 satis- 
factory account of those febrile and nervous affections which local disease pro- 
duces, except that of Mr. Hunter." See his Essay " On the Constitutional 
Origin and Treatment of Local Diseases."} OF LOCAL AND CONSTITUTIONAL DISEASES. 
125 
causes, and be totally independent of each other; but they may 
affect one another. 
The first, or constitutional, is either a universal action of some 
kind, as fever, or where there is a universal susceptibility for an 
action, but the action is local. Therefore they are divisible into two 
kinds, 1st, universally constitutional, and 2d, constitutionally local. 
Universally constitutional is when there is universal action of 
some kind, as fever, where every part of the body is under some 
diseased action, which will be according to the nature of the influ- 
ence which produced the fever, as inflammatory fever, putrid 
fever, &c. 
Those arising from external influence will in some degree reduce 
all constitutions to some one mode of action; and whatever differ- 
ence there is between one and the other must only arise from a 
peculiarity in constitution. 
If an inflammation is produced in any part by violence, it will 
always be as the constitution is. If a man has a fever, a cut will 
partake of the disease, and the inflammation will be erysipelatous,* 
or so on, according to the fever. But if the fever is of some specific 
kind, superadded to the nature of the constitution, as small-pox 
fever, a cut will not partake of the specific quality of that fever, but 
will be exclusive of the specific quality. Nor will a cut on any part 
of a pocky patient be venereal. 
Constitutional diseases are of various classes, which are known 
by their effects. A constitutional disease is a universal diseased 
action, as fever, every part taking on more or less of the diseased 
disposition. Such diseases, I apprehend, have no disposition for 
local action, though it is commonly supposed they have, as where 
fever produces abscess. This I hardly believe, though an abscess 
may form in the time of that fever, and is caused by it, or is an 
effect of that fever; but it is not an act of the constitution, according 
to our third division, therefore does not relieve the constitution of 
that fever. What I call an act of the constitution relieves the con- 
stitution, as gout falling on a part; but in abscess from fever it is 
only that this part has been so disturbed in the time of the fever that 
it has gone into inflammation and suppuration. 
The second of the universal is the constitutionally local, that is, 
when there is universal susceptibility of body to produce peculiar 
local complaints, but not the action, till disturbed ; requiring an im- 
mediate cause, which may at the time be either universally disturb- 
ing, as fever, or in the part only, as an accident. Thus the whole 
constitution may be affected with a gouty disposition, but the dis- 
ease becomes local and is cured. We see constitutional or uni ver- 
* [There are many exceptions to this observation, as, for instance, in several 
cutaneous diseases, gout, rheumatism, &c. These diseases may exist in an 
active state in some parts of the body at the same time that common inflamma- 
tion is produced in other parts by accidental injury. On the other hand, the 
erysipelatous inflammation seems to give way to common phlegmon when in- 
cisions are made into erysipelatous parts.] 126 
HUNTER'S PRINCIPLES OF SURGERY. 
sal diseased affection excite local, as fever exciting scrofula, not as 
a termination of that fever, but because the part affected was par- 
taker of the universal affection, and being disturbed by that univer- 
sal affection or action, it took on the mode of action it was most 
susceptible of. It would do the same thing on being locally dis- 
turbed; therefore, as to its diseased action, it is the same whether 
it is disturbed as part of a whole, or only by itself. The scrofula 
goes no further than a susceptibility for diseased action, until it is 
brought into action by the local injury or constitutional fever. 
Perhaps there is no term so vague or undetermined in the mind 
as the term constitutional. Universal action of every kind may be 
called constitutional, even when arising from some local cause, which 
I have called one of the mixed; or one capable of producing local 
effects, which we have also called one of the mixed. But a true 
constitutional disease is one arising, as it were, spontaneously in the 
constitution, partaking of the nature of the constitution itself. 
Local disease I would consider in two lights; 1st, When it is a 
natural local action, being a kind of violence on a part, there being 
ho constitutional local affection. In this case the disease takes on 
no specific quality of the constitution, either from the constitution 
having none, or the disease not being affected by it, being such as 
either arises from itself in a part from a local cause, and may take 
place in any constitution, or may be produced by accident or vio- 
lence where the constitution was never affected. 2d, Which will 
more properly come under the head of mixed, where the local affec- 
tion either affects or is affected by the constitution. 
The mixed may be said to partake of the first and second, and is 
often the consequence of either, namely, original constitutional pro- 
ducing local, or original local producing constitutional; therefore 
they are often of two kinds, and such as may be called secondary 
actions either of the constitution or part, as universal sympathy with 
local disease, yet not what generally comes under the idea of com- 
mon sympathy, as sympathy of part with part. Of the mixed, the 
first kind is where original constitutional produces local; the second 
where it influences local already produced. Therefore this kind is 
divisible into two species. 
It may be difficult 1o say certainly when a constitutional disease 
really produces a local; but it may be set down generally that there 
will be a distance as to the time of appearance of the two diseases. 
The first of these two species is of various kinds, perhaps belongs 
more to specific diseases than to common, and is where the consti- 
tution from its nature produces a local one, and is necessarily 
relieved by it, by what I have called an act of the constitution. Of 
this kind are small-pox, measles, fevers producing critical abscesses, 
erysipelatous fevers, gout, &c., and on this is founded the doctrine 
of revulsion. 
Local diseases produced by an act of the constitution may be 
illustrated, I think, by the growth of plants. A plant or tree ap- 
pears to have a disposition and power of producing either only a OF LOCAL AND CONSTITUTIONAL DISEASES. 
127 
top shoot, or a number of shoots, called branches, which are 
according to the nature of the plant. If the top is cut off, then a 
new branch sprouts, and it serves as a top ; so that the disposition 
is taken up by some other part most susceptible of action. The 
same thing happens in those plants which grow by branches. So 
that the removal of a part in action gives the disposition of action 
to parts not before disposed to act, but next in order of suscepti- 
bility. 
The second of the mixed is where the original local produces 
constitutional, and which may alter the constitutional disease 
already existing, or cure it. This may be of three kinds. 
1st, The immediate; 2d, Less determined as to time; 3d, The 
remote. Of the first there appear to be two; of the second but 
one, though it may appear in different forms ; of the third probably 
only one. 
Of the immediate we shall reckon that which is called symp- 
tomatic fever. Delirium I shall reckon the second, though it is not 
always the second as to time. The third or remote, is hectic, to 
which may be added symptoms of dissolution, which last stage 
may be the consequence of either of them, or of any other disease. 
The first of these is generally called symptomatic fever, but I 
choose rather to call it sympathetic inflammatory fever. It is 
sympathy of the constitution with the first stages of local disease, 
which is the action of alarm on the constitution, rousing up its 
powers to produce action. 
The second, or delirium, appears to arise from an affection of the 
brain or sensorium, producing sympathy of action of the brain with 
the nerves of the part; not sensation, as headache, but an action 
producing ideas without uniting sensation, which is therefore 
delusive. 
The remote, namely, the hectic, is a sympathy of the constitution 
with local disease, but sympathy of another kind ; it is sympathy 
with the operation of an incurable disease, where the constitution 
is conscious of inability of the part to perform a cure, by which 
means the constitution is at last, as it were, worn out, producing 
dissolution if not removed. 
Dissolution is the last stage and consequence of all, whether local 
or constitutional. 
Diseases are common or specific.-All diseases are either common 
or specific, but it is more than probable that most diseases have 
some specific qualities. A common disease is such as will attack 
every constitution, and perhaps every animal, and rather appears 
to be an increased action, as common inflammation, common 
inflammatory fever, &c. 
Many diseases may be reckoned specific in their mode of action, 
though not in their cause. An ague is a specific action, but its 
causes are various. Gout is a specific action, but its causes vari- 
ous. Cancer is a specific action, though its immediate causes are 
various ; but it is capable itself of becoming a true specific cause, 128 
HUNTER'S PRINCIPLES OF SURGERY. 
by forming a poison. The cause of scrofula varies, though its 
action is specific. The remote cause of all is a greater suscepti- 
bility of such actions. 
A specific is a peculiar mode of action, differing from every 
other mode of action. A true specific disease is one that probably 
cannot arise but from one cause, and which probably belongs only 
to morbid poisons ; for although gout, scrofula, ague, &c., may 
be ranked among the specific, yet they can and do arise from a 
thousand causes. 
There seems a specific susceptibility for those diseases in those 
that have them. But in poisons there must be a specific cause, 
which may be attended at the same time with specific suscepti- 
bility of such, as some have a greater tendency to small-pox than 
others. 
Specific diseases are such as we cannot increase, for they always 
act with the full force of the readiness in which the constitution is 
at the time. If the constitution can be made more susceptible of 
action, the action will be increased. 
Every specific disease has two modes of action-namely, the 
common and the specific,-joined to it. There are specific inflam- 
mations, specific suppurations ; or, in other words, there are inflam- 
mations and suppurations with specific properties, or which have 
specific properties superadded ; thus, in small-pox there is common 
inflammation, with the specific qualities superadded. Specific 
diseases may be either universal or local; universal, as fevers of 
particular kinds ; local, as scrofula ; others are mixed, as agues, 
rheumatism ; and these admit of cure from a variety of medicines. 
A circumstance worthy of notice takes place with respect to 
local specific diseases ; parts appear susceptible of them as to take 
on their action so readily, that were it not for anothei' very curious 
circumstance we might soon expect them to spread over the whole 
body; but the favourable circumstance I refer to is where the 
disease is spreading very fast, affecting parts which the disease has 
not yet touched, whilst in the centre this diseased action no longer 
takes place. Those parts which have already suffered this action 
appear to have lost their susceptibility of it, whilst the surrounding 
parts are contaminated by sympathy with those parts already 
affected : this property belongs to many, as erysipelas, herpes, &c. 
I have seen the same thing take place in ulcerated bubo, spreading 
over the whole belly and thigh, but healing in the centre. Another 
circumstance is to be added to what I have mentioned as hindering 
the disease from extending over the whole body, which is, that the 
constitution itself alters or loses that peculiar susceptibility before 
such an event takes place. 
Different parts differ very much in their power of resisting dis- 
eases, as well as in the power of curing themselves, or getting rid 
of the diseased action and putting on a curative one: this seems to 
be according to the strength of the circulation in the part; where 
this is less the power is less; thus, there is greater power of resis- OF LOCAL AND CONSTITUTIONAL DISEASES. 
129 
tance in a muscle than in a tendon. But in specific diseases I 
should suppose there is little difference in this respect, in conse- 
quence of a difference in structure, although we know that specific 
diseases affect some parts more than others, as the small-pox affects 
the skin; the measles, the skin and surface of the lungs: hooping- 
cough and hydrophobia, the throat; &c. 
Diseases peculiar to Ages.-Particular ages have their particular 
diseases. These diseases peculiar to age are perhaps more of the 
specific than of the common kind; and age is little more than a 
natural or remote cause, there being some immediate cause acting 
so as to produce the disease, as in scrofula. But this is not the case 
with all of them, e.g. cancer, for this appears often to arise without 
any peculiar immediate cause. How far particular ages are more 
or less susceptible of particular poisons we do not know. 
The age of man may be divided into three parts: 1st, The age 
of growth; 2d, The stationary age; 3d, The age of decline. The 
first and last are absolute, but the second is not so easily ascertained, 
it not being very easy to say where the first ends and the last 
begins. The young subject and old are more susceptible of many 
diseases than the full-grown, or stationary, but they are not subject 
to the same diseases. The young are more susceptible of sympa- 
thy, both universal and local; more susceptible of scrofula than 
the middle-aged, but particularly more than the old: and this scro- 
fula may produce consumption, which we know is peculiar to youth. 
Children are more disposed to have affections of the bowels, and 
worms, perhaps, from a peculiarity in their way of life. They are 
also more subject to watei' in the head than those who are older. 
The young have few affections of the mind, excepting those arising 
from natural passions, or immediate sensations of the body. 
The middle age would appear to have but few diseases peculiar 
to it, excepting nervous affections and hypochondriasis, &c. The 
middle age gets into an imaginary region, a region of romance, 
which produces diseases of the mind, and also affects the body. 
However, it is, as it were, accidentally affected with the diseases 
both of youth and age, with which it is gradually intermixed. The 
foundations for the diseases of old age are often laid by intemper- 
ance during the middle age. 
In the old we have perhaps as great a variety of diseases as in 
the young. In the old the power and necessary action are not well 
proportioned, even in health, much less, therefore, in disease. This 
produces a degree of irritability often increasing inflammation, and 
terminating frequently in mortification. In the old we have the 
gout, which seldom takes places in the young. Cancer is peculiar 
to the latter part of the middle age, and still more to the old. Gall- 
stones are to be found chiefly in the middle-aged and old. Ossifi- 
cations of arteries are rarely found in young persons. The blad- 
der becomes less disposed to stretch, and more irritable; hence old 
people make water oftener than young. The prostate gland is 
more subject to indurations. The mind gradually becomes more 130 
HUNTER'S PRINCIPLES OF SURGERY. 
attached to [Quaere, detached from ?] this world and the things that 
are in it the nearer it approaches to a separation from it. 
Effects of Climate on Disease.-Climate in general only becomes 
the immediate cause of disease; however, it is sometimes sufficient 
to produce the whole disease. Climates are of three kinds: hot, 
cold, and temperate. Hot climates carry on the natural operations 
both of animals and vegetables with much more rapidity than either 
of the others. 
It is almost impossible to rear young animals in cold weather; 
therefore most animals bring forth their young in spring and sum- 
mer. Animals of the same species do not grow to the same size in 
cold climates as in warm. It is almost impossible to fatten an 
animal while it is kept in the cold. 
Warmth produces action beyond its power of generating strength. 
Parts more readily yield to any power in summer than in winter. 
Mr. Jones, the inventor of the machine for correcting distorted 
spines, observes that they produce more effect in summer than in 
winter. 
Hot climates produce diseases in the liver, but these diseases are 
more frequent in the West Indian islands than on the continent of 
South America or India.* They also produce violent vomitings and 
other disorders in the stomach; also violent affections of the 
bowels: and fevers and diseased actions, like the natural, are much 
more rapid than in temperate climates, it being no unusual circum- 
stance for diseases to run through all their stages in a few hours, 
ending in death, which is speedily followed by putrefaction. Heat 
produces indolence in the voluntary actions, which is injurious to 
health, but generally increases the involuntary action or actions of 
life, which is always hurtful. Cold climates retard many actions, 
both of vegetables and animals; but cold, when only in a certain 
degree, and continued for a certain length of time, excites action; 
but that is the action of strength, the action of resistance or de- 
fence, not the action of luxury or ease. Cold climates produce 
their diseases, though it would appear that they have not equal effects 
with warm, nor are capable of producing such variety. Whatever 
diseases are produced by cold are not so rapid as those produced 
by heat; and after death putrefaction does not take place so rapid- 
ly. We may observe a curious gradation in this process; in cold 
climates, after visible death, absolute life will remain for some time; 
the muscles will retain their power of contraction, and the blood be 
kept from coagulating. But in hot climates death is as rapid as dis- 
ease; for it is action that consumes life. In cold the action is less: 
in heat it is so great that the body can hardly support it, and death 
comes on. Cold climates lead to voluntary actions, which generate 
heat, and this is much more healthful than heat derived from exter- 
nal sources. 
In temperate climates there is perhaps a greater variety of 
* [The very reverse of this observation is, I believe, the fact; see p. 86.] OF LOCAL AND CONSTITUTIONAL DISEASES. 
131 
diseases than in either the hot or the cold; for the temperate is a 
very irregular medium, sometimes very hot, sometimes very cold, 
and often in the middle state ; and these changes are not at regular 
periods. This irregularity produces some irregularity in the wet- 
ness or dryness, so that in such climates we have a great mixture. 
These changes] in temperate climates give rise to scrofula, colds, 
&c., which are the forerunners of a thousand diseases. Agues are 
also much more frequent in temperate climates. 
Seasons.-Seasons which arise from the variations of heat in a 
climate, produce diseases which will be in some degree similar to 
those both of hot and cold, and also temperate climates ; for seasons 
are, as it wrere, a change from one climate to another. Seasons 
have besides, diseases peculiar to themselves ; they produce an 
increase of old diseases, arising simply from the change, and call 
forth those diseases which only want an immediate cause to pro- 
duce them. The spring and autumn are two of the most unhealthy 
seasons in the year: the spring the most so, although from reason- 
ing alone, without observation, it is supposed to be the most healthy, 
and therefore people do in the spring whatever will allow of a 
choice of time, as inoculating, &c. This idea probably took its 
rise from observing vegetation, that at this time the plants appear 
to come into life and action. But, even in vegetables, this season 
is the most unhealthy; blights much more frequently take place in 
spring than in summer. Of every disease that can be called consti- 
tutional, that is, where there is a strong susceptibility for such 
disease, we find spring becomes the immediate cause, exciting it to 
action; thus, scrofula shows itself, or increases in spring; the same 
with rheumatism and scurvy; hence spring is said to set the 
humours afloat by those who are favourers of the humoral pathology. 
I should doubt much whether there is any diurnal influence on oui' 
body, further than that which the habitual modes of acting produces; 
consequently, I doubt if daylight or darkness produces any effect. 
It is, however, certain that the increase of action which commonly 
takes place in the day, increases diseased action, producing 
exacerbations in continuous diseases. It is probable, therefore, 
that it may bring on the paroxysms of those diseases which are 
periodical, and may bring on the first fit of a disease for the same 
reason. 
Effects of the Moon.-The moon has certainly considerable effects 
on the human body. We find it often become the immediate cause 
of diseased actions, especially those of the mind. Mad people are 
certainly more affected at particular periods of the moon than at 
other times. The full of the moon has the greatest effect: it not 
only affects those who have a natural predisposition, but also some 
who have had injuries done to the brain by external violence. 
A lamp-lighter, by a fall, injured his head: upon examination I 
found a fracture which appeared to run through the foramen mag- 
num of his occiput; he recovered, but he was seized every spring 132 
HUNTER'S PRINCIPLES OF SURGERY. 
with a phrenzy at stated intervals, and this was found to be at the 
full of the moon. 
A gentleman had an anchylosed knee and ankle-joint from scro- 
fula, and he is always deaf at the full of the moon, except in 
autumn, when his sores discharge plentifully. 
This effect of the moon is increased at certain seasons ; in spring 
it is greatest often. Intermitting and remitting fevers often arise, 
recur, or become exasperated about the time of the full or new 
moon, more especially in climates fitted for giving rise to such 
diseases.* 
Of Humours.-The term humour has been applied to the animal 
body, especially the human, both literally and metaphorically. 
When literally, it is used in two senses, either as expressive of an 
extraneous substance existing in the blood, or as meaning the blood 
itself. When used metaphorically it is applied only to the mind, 
and is therefore more applicable to the human than any other 
animal. 
Nothing can be more vague, nothing more unphilosophical, nothing 
more misleading in science, than to employ the same term to ex- 
press two or more different meanings. In whatever sense the term 
is used, however, whether as applied to the mind or the body, it 
always is meant to express the cause of an unnatural or uncommon 
action or effect. 
At present we shall' only consider humours in their literal sense, 
in order to ascertain how far the notion is just or imaginary. I have 
just said that the word is used in two senses, either as something in 
the blood, but foreign to it, or else as implying a vitiation, of the 
whole mass of the blood itself. Among physical people we find 
such expressions in common use as " the humours are afloat in the 
blood;" "sharp humours in the blood;" "the whole humours being 
in a bad state;" "the whole blood must be altered or corrected;" 
and a variety of such expressions without meaning. They even go 
so far as to have hereditary humours, as gout, scrofula, &c., and 
make us the parents of our own humours, saying that we breed bad 
humours. Accidents, or even the application of poultices, have been 
supposed to bring bad humours to a part, because the part in which 
the accident happened, or to which the poultice was applied, would 
not readily heal. Humours are even supposed to gravitate to the 
legs slowly; and, in short, the whole theory of disease has been 
built upon the supposition of humours in the blood, or of the blood 
itself being changed. I cannot conceive what is meant, unless it be 
that a strong susceptibility to a specific disease exists; as small-pox 
may bring on scrofula, or a strain the gout; if in these cases by 
humoui' is meant a susceptibility of either of the diseases, I can con- 
ceive that any kind of accident may bring it on. The small-pox 
introduced may excite action, and so bring on the scrofula. 
* [Dr. F. Balfour has fully confirmed this observation as to the effects of sol- 
lunar influence on the bilious remittent fevers of hot climates.] OF LOCAL AND CONSTITUTIONAL DISEASES. 
133 
I shall now consider the notion of humours afloat in the blood. 
If I have a just idea of the meaning of this expression, it signifies 
something extraneous or foreign, something that does not belong to 
the blood itself. That foreign matter is received into the blood- 
vessels is certain, and that so received it produces disease is also 
certain ; but sjmply foreign matter being introduced into the blood, 
either' produces no effect or no permanent and specific disease ; the 
constitution, or some part, can be disturbed only as the constitution 
or part would be disturbed from any accident. Medicines, applied 
either externally or internally, is a proof of this, for all enter the cir- 
culation more or less, therefore are in the state of something extra- 
neous, or of humours in the blood. Indeed, chemical analysis of 
the blood shows the existence of foreign matter, for it discovers 
substances that form no part of the animal, as sea-salt, iron, earths, 
&c.; yet these substances produce no ill effects by their presence. 
The following experiments show the effects of foreign substances 
in the blood: 
Experiment 1. I injected into the crural vein of a dog, towards 
the heart, a weak solution of sea-salt, which produced no effect. I 
then made as strong a one as possible and threw that in also, but ho 
effect was produced. The quantity of salt thrown in might be about 
two teaspoonfuls. 
Experiment 2. I threw a strong solution of Glauber's salts into 
the vein of a dog-about two drachms of salt. It produced no effect. 
The dog ate and drank and had his stools as before. 
Experiment 3. Two ounces of a saturated solution of salt of 
tartar thrown into the vein of a dog had no effect. 
Experiments 4, 5. Two drachms of sal polychrest in solution 
produced no effect. 
Experiment 6. An ounce of water, in which a scruple of borax 
was dissolved, was thrown into the veins without effect. 
Experiment 7. An ounce of vinegar and water, in equal pro- 
portions, was thrown into the veins of a bitch half gone with pup. 
This brought on an immediate disposition for miscarriage, which 
took place in about six or eight hours. 
Experiment 8. Water, rendered about as acid as the vinegar 
and water, with vitriolic acid, was thrown into the veins, and pro- 
duced little or no effect. 
Experiments 9 and 10. The same experiment was made with 
nitric and muriatic acids with the same result. 
From the above experiments it is evident that substances of con- 
siderable power may exist in the blood and produce little or no effects 
of any kind. We shall, find from other experiments, that there are 
many substances which have considerable effects when thrown into 
the blood; still, none of them produce any particular disease,though 
by repeating them, and increasing the quantities, a man may destroy 
his health, or even his life, by destroying the natural actions of the 
body. 
But all this is not producing any specific disease; it is reducible 134 
HUNTER'S PRINCIPLES OF SURGERY. 
to the effects of local applications, which is similar to an accident, 
producing no specific or permanent disease but what an accident 
would do, nor lasting any longer than the application lasted. 
Experiment 11. I threw about two teaspoonfuls of a strong 
solution of opium, two parts water with one of opium, into the crural 
vein of a dog. The dog seemed to be very sensible of it at first, for 
he was extremely uneasy, and soon became convulsed, but did not 
lose sensation, for when touched he started and seemed frightened, 
and drew back his face when a hand was presented to it; so that 
irritability was rather increased. I then threw in as much more, 
which made him still more quiet, and in great measure produced 
loss of the use of his limbs, so that he could not stand; his breathing 
became slow and laborious, but his pulse very quick; when he at- 
tempted to get up he reeled, and came down as if asleep or drunk. 
Experiment 12. I threw into the veins of a dog two teaspoonfuls 
of common gin. He showed no sense of uneasiness, but became 
soon vastly quiet, and not in the least irritable, showing no signs of 
fear when touched, He seemed wholly relaxed; his breathing was 
easy, and his pulse slow. He continued above an hour in this way 
and then began to recover. 
Experiment 13. I threw about two teaspoonfuls of laurel water 
into the veins of a dog. The pulsation in the vessels became 
tremulous; he seemed very ill, and could hardly raise his head, but 
he recovered. 
From these last experiments it appears obvious that many sub- 
stances, having peculiar modes of stimulus, will, when taken into 
the blood, produce their effects there; but this effect will last no 
longer than the presence of the stimulus; and we shall find in general 
that their effects in this way are similar to what they are when 
taken into the stomach. We find also, by the above experiments, 
that many substances thrown into the constitution by the veins pro- 
duce the same local specific effects on the intestines with those 
produced by the substance when taken in by the mouth. 
Experiment 14. I threw into the veins of a dog an ounce of 
infusion of ipecacuan, made with five grains of the powder to two 
ounces of water. The dog immediately became very sick, and 
was retching before I could untie the mouth, and as soon as it was 
untied he threw up all that was in his stomach. He continued 
sick for some time, and gradually recovered. I can hardly suppose 
that the injection had gone beyond the heart, or even to it, when it 
began to act. 
Experiment 15. An ounce of infusion of jalap, made with twenty 
grains of jalap to two ounces of water, and steeped for twelve 
hours, was thrown into the veins of a dog. In less than a minute 
he vomited a little and then seemed well. Thinking that no more 
effect would be produced, I threw in the remaining ounce. This 
did not produce any vomiting, nor did he at first seem much 
affected; but at last he grew weak on his legs, lay down at times, 
and then rose again. About two hours after the infusion was OF LOCAL AND CONSTITUTIONAL DISEASES. 
135 
thrown in he had a stool, and after this another, which was loose. 
He remained sensible the whole time and then got well. 
Experiment 16. In a similar experiment the dog vomited, had 
some loose stools, and in a few hours got well. 
Although many substances do produce similar effects on the 
stomach and intestines when thrown into the blood as when taken 
by the mouth, as appears from the above experiment, yet this is not 
the case with all. In the second experiment, for instance, we find 
that Glauber's salt had no such effect when thrown into the blood 
as when taken into the stomach. In like manner, 
Experiment 17. An infusion of rhubarb, thrown into the veins 
of a dog, produced no effect but that of increasing the urine, which 
it did plentifully, 
Many substances thrown into the blood produce much more 
violent effects in this way than when taken into the stomach, and 
even cause immediate death. 
Experiment 18. I threw into the veins of a dog a little sether, 
and he died immediately. On opening the body the thorax had a 
strong smell of aether. However, this effect may depend on the 
strength of the medicine, as we shall see by the following experi- 
ments that the reason why death did not take place in experiments 
6, 7, 8, 9, was the weakness of the solution. 
Experiment 19. I threw some common vinegar into the veins 
of a dog, towards the heart. He died before I supposed it could 
have got to the heart. Now vinegar, when diluted, as we found 
before, had no such sudden effect. In the same manner, nitrous 
and vitriolic acid, diluted, to about the strength of vinegar, pro- 
duced almost immediate death. 
Air killed immediately. We should therefore be very careful in 
making experiments, when we inject substances into the veins, that 
air does not enter with the substances, and cause the death which 
we impute to the latter.* The Abbe Fontana committed many 
errors in this way : in short, before any man pretends to determine 
what will kill, he ought to have killed at least a thousand animals. 
A poor devil t was lately hanged at Warwick upon no other testi- 
mony than that of physical men whose first experiments were 
made on this occasion. 
Experiment 20. I threw into the veins of a bitch half gone with 
pup a quantity of serum, taken from the blister of a person who was 
ill of a putrid fever, and soon after died. It made her instan- 
taneously sick, and she vomited. She soon miscarried, but in two 
or three days recovered perfectly. 
From all these experiments we may, I think, at least draw, as a 
probable conclusion, that extraneous matters taken into the consti- 
tution do not produce any specific or permanent disease, that they 
* [Air in small quantities, introduced at once, or even in large quantities 
gradually admitted, is not generally fatal. See Treatise on the Blood, &c.] 
t [Captain Donellan. For an account of this transaction, and of Hunter's 
evidence on the trial, see Life, and the Appendix to the Life.] HUNTER'S PRINCIPLES OF SURGERY. 
136 
operate as direct stimuli, producing immediate effects, and that 
when these are violent they arise from too great a quantity of the 
stimulating or irritating substance being thrown in. 
Poisons come nearest to the idea of humours, but still are not 
what is meant by humours, nor have evei' had this term applied to 
them. Natural poisons will act somewhat as the substances used 
in the foregoing experiments did, that is, either stimulate the whole, 
or part, to increased natural action; or irritate the whole, or part, 
into some unnatural action, but which will last no longer than the 
poison is present. The sting of a bee affecting some more than 
others demonstrates that there is a greater susceptibility in some 
for such actions than in others, and that it cannot be imputed to 
humours in the blood, unless we could suppose a humour similar 
to the poison of a bee, which then might act without that cause. 
I suppose that bugs bite everybody, but some they do not affect 
and others they do. 
This is not so readily demonstrable in the poisons that enter the 
constitution, though even they cannot be said to be assisted by 
any humours in the blood. Other poisons, which we call morbid, 
produce a specific disease similar to the original; but all this does 
not come up to the idea of humours. A humour is something 
which is supposed to go on teazing the constitution if not extracted, 
and is even supposed to be capable of leaving one part and going 
to another. 
What comes nearest this idea of a humour, but only so in its 
effects, is a surfeit; yet though its effects may resemble those which 
are entertained of humours, we know from the mode of their origin 
that they are not caused by a humour. It is a mode of action 
taking place in the skin from a stimulus or irritation being applied 
to the stomach. Drinking cold water when a person is hot will 
produce it. In a similar case, I have seen inflammation come on 
in the heart and lungs; but they being less able to bear the action 
than the skin, it proved fatal. 
The method of cure of those diseases supposed to arise from 
humours gives us no idea of the disease having arisen from extraneous 
matter in the blood-vessels. Can we form any idea how bark 
should extract humours, when it rather stops all evacuations? And 
yet it cures many diseases. Would bathing in the sea cure those 
eruptions of the skin which are supposed to arise from humours if 
they were really caused by them ? Can we suppose that electricity 
extracts any humours, when it cures an ague ? 
It is not easy to account for the blood having been supposed to 
be the cause of disease, excepting from it appearing in a bad state 
after bleeding, and this is always a secondary symptom. Sometimes, 
when this diseased state has not been very great, medicines have 
been given to sweeten the blood.* 
* [In connexion with this subject, it may not be uninteresting to mention the 
following facts, which prove that the blood is capable of being greatly vitiated, OF LOCAL AND CONSTITUTIONAL DISEASES. 
137 
On Hereditary Diseases.-Hereditary, in the animal economy, is 
applied to properties or peculiarities communicated from the parent 
to the child. 
This principle, according to the common notions, may be divided 
either by the actions of the body or by foreign substances being introduced 
into it. 
An animal body may be divided into those parts which form and those which 
consume the blood. The former consist of those organs which minister to diges- 
tion, sanguification, &c. ; the latter, of those structures which perform the offices 
of nutrition. Increased action also (although perhaps always attended with in- 
creased nutrition,) rapidly induces an alteration in the qualities of the blood, and 
renders a more frequent renewal of it necessary. Whatever, therefore, influences 
the regularity of those processes upon which the formation and consumption of 
the blood depend, so as to destroy their just balance, must necessarily influence 
the constitution of this fluid. The following observations, drawn from disease, 
serve to confirm this view of the subject. 
In the first place, then, the varieties in the aspect and sensible qualities of the 
blood prove that the condition of this fluid varies remarkably under different cir- 
cumstances, being either buffy, firm, soft, diffluent, tarlike, or wholly incoagula- 
ble. It is of various colours and odours ; it requires different times for its coagu- 
lation ; it putrefies sooner or later in one case than it does in another; and the 
relative proportion of its constituents is very different in different cases. 
There are, however, other changes to which this fluid is subject which are not 
equally obvious to the senses, but which are rendered evident by their effects on 
the body or by chemical investigation. Thus, urea has been detected in the 
blood in cholera, in certain cases of dropsy in which the urine is albuminous, in 
considerable abundance in cases of suppression of urine, and in dogs in which 
the ureters have been tied or the kidneys extirpated ; sugar in cases of diabetes ; 
and cerebriform, and melanoid matters in persons suffering from these diseases. 
The injection of putrid or ill-conditioned pus into the blood, is found to give rise 
to a train of symptoms resembling those which are produced by inflammation of 
the veins, so as to render it highly probable that pus is taken into the blood in 
the latter cases; but as this is an important point, I shall offer the following con- 
siderations in proof of the fact. 
1st, Pus is frequently formed in the cavities of inflamed veins and lymphatics 
at the same time that these vessels are perfectly open towards the heart. 2d, 
Pus is frequently found in the lactealsin ulceration of the intestines. 3d, Large 
abscesses are sometimes observed to disappear suddenly, which could not hap- 
pen except the pus were taken up by the absorbents and carried into the circula- 
tion. 4th, In inflamed veins, small-pox, and secondary inflammations, there is 
reason for believing that pus is taken up and deposited in distant organs, as if 
by metastasis. 5th, Immediate relief of the constitutional symptoms ensues 
when ill-conditioned abscesses are laid open. 6th, M. Gendrin has observed a 
mucous sediment (couche muqueuse) in two cases at the bottom of the vessel con- 
taining serum, in the first of which the patient was affected with empyema, and 
in the second with a large abscess of the thigh. 7th, MM. Duploy, Andral and 
Rostan have noticed other cases in which the blood, throughout the whole venous 
system, appeared to have undergone spontaneous purulent decomposition, to 
which head may also be referred those cases of polypoid concretions in the ves- 
sels in which a purulent fluid is found in the centre, generally occurring at the 
same time with suppurative inflammation in some other part of the system. 8th, 
The physiological fact, that the actions of absorption and deposition antagonize 
each other, and are continually taking place in all the shut sacs of the body, 
which is proved by the rapid disappearance of injected matters. 
M. Lecanu has detected the colouring-matter of the bile in the blood in cases of 
jaundice, which is well known to tinge the structures and secretions of the body 
of a yellow colour, and to give rise to drowsiness and other symptoms. M, An- HUNTER'S PRINCIPLES OF SURGERY. 
138 
into two kinds: the transmission of natural properties, and the trans- 
mission of diseased, or what I shall call acquired or accidental pro- 
perties. The last is not hereditary in all its causes, for it always 
requires an immediate cause before the action will take place; 
dral has referred to cases in which the principles of the bile were found to be 
accumulated in the form of depositions in several organs of the body. Many 
cases are related of vicarious discharges, especially of the urine, and menstrual 
discharge, when the organs which afford these secretions have been obstructed. 
In cases of obstructed lactation, M. Dance observed symptoms referrible to the 
absorption of the milk, of which sort is a case described by Professor Graaf, in 
which a substance exactly resembling caseum was found in the fluid of an 
ascites, brought on by suppressed lactation, although in a subsequent tapping six 
weeks afterwards no caseum wras discoverable. Milky serum, depending on the 
presence of oleaginous matters, apparently diffused through it in the form of an 
emulsion, is not uncommon, while Blumenbach considers it as not improbable 
that the ferocity of animals during the rut, as well as man's superior courage, 
greatly depend upon the reabsorption of secreted semen into the circulation. 
Besides these instances, there are others of a still more obscure nature, which 
have chiefly been insisted on by the humourists. Gout and rheumatism, for ex- 
ample, used generally to be referred to a vitiated condition of the blood; an 
opinion which is certainly favoured by the constitutional and, above all, the me- 
tastatic nature of these diseases. In the former there is a disposition to secrete 
uric acid in superabundance, both in the urine and in the neighbourhood of the 
joints; a highly azotized principle, corresponding to the highly azotized nutri- 
ment which is known to predispose to the arthritic diathesis. In the latter the 
cutaneous discharges are known to manifest a peculiar acidity. The formation 
of calculi, the tendency to ossific depositions, and the disease called scurvy ap- 
pear to depend upon the superabundance of particular salts in the blood. Du- 
hamel has related cases of the most violent effects, followed by gangrene and 
death, depending upon inoculation with the blood of overdriven animals or of per- 
sons labouring under putrid forms of fever. M. Gendrin inoculated a cat, and on 
another occasion a dog, with the blood of a patient labouring under a putrid fever 
with eruption of gangrenous pustules, both of these animals soon after dying 
with analogous symptoms. Dupuy and Leuret have recorded many similar 
instances in regard to the horse. The following case was related to me by Pro- 
fessor Coleman, and is an interesting proof of the manner in which disease may 
be communicated through the medium of the blood. One of his pupils having 
accidentally inoculated himself whilst dissecting a glandered horse, was taken 
ill, with a set of anomalous symptoms, for which he was bled. The blood which 
was drawn was injected into the veins of a healthy ass, and produced the same 
disease in it as in the horse, notwithstanding that every precaution was used to 
obviate the possibility of any source of error. Mr. Hunter has related a case in 
which a child was born with the variolous eruption, and I have myself known a 
case in which a woman had seven children in succession (six of whom died) 
affected with venereal blotches on the nates a few weeks after birth, although she 
herself had been married upwards of ten years, and during that period had never 
been affected w'ith any syphilitic symptom, although she admitted that she had 
had the disease previously. These and similar facts incontestibly prove that 
the blood is capable of being vitiated by the actions of the economy, in conse- 
quence of which it is rendered capable of propagating disease to others as well 
as of perpetuating it in regard to its own self. The following are some further 
instances calculated to show the influence of the nervous system in producing 
these effects. 
Dupuytren found that the change from venous to arterial blood was not effect- 
ed in the lungs when the eighth pair of nerves was divided ; Dupuy, that the 
fibrin was relatively diminished by the same operation, at the same time that the 
blood was so much altered in quality as to give rise to dangerous symptoms 
when injected into, the- veins of other animals j Mayer, that the fibrin and hsema- OF LOCAL AND CONSTITUTIONAL DISEASES. 
therefore its cause is not similar to the first. To produce an exact 
hereditary effect, there must be an hereditary cause or causes; and 
as in all animals of distinct sexes, in their propagation, there are 
two causes acting to produce a third, the first and second causes 
139 
tosin had a disposition to separate under the same circumstances, and the blood 
in the whole pulmonary system to coagulate. The coagulation of the blood in 
mortified limbs, the stagnation of the circulation in inflamed capillaries, the in- 
coagulability of the blood in cases of sudden death, and the spontaneous concre- 
tions which sometimes take place in the living veins, are also to be regarded as 
proofs of the influence of the nervous system. 
But the blood may be vitiated by extraneous matters. The existence of many 
of these substances in the blood is inferred from their effects, but we have dis- 
tinct chemical demonstration of the presence of others. Among the former we 
may reckon madder, which tinges the bones of a pink colour; the alkalies and 
acids, which correct the opposite states of the urine; ergot, which produces gan- 
grene; salt provisions, or the long-continued use of the alkaline carbonates, 
which produce the sea scurvy ; mercury, which excites ptyalism ; arsenic, which 
inflames the stomach; turpentine and asparagus, which communicate their odour, 
and rhubarb and many other substances their colour, to the urine. Alcoholic 
liquors pass off by the pulmonary exhalation; garlic and many other substances 
become sensible by the same means. Carbazotic acid and nitrate of silver dye 
the tissues, the former of a yellow, the latter of a purple colour. Dr. Graves 
has noticed a case in which sixty leeches, successively applied to a female who 
had lately taken hydrocyanic acid, all immediately perished ; and Dr. Christison 
has related a similar case, occurring six hours after a dose of oxalic acid. Ver- 
niere poisoned an animal with nux vomica, and afterwards a second animal with 
the blood of the first. These examples afford the highest presumption that medi- 
cines actually enter the circulation before they produce their effects on the con- 
stitution ; a conclusion which is further confirmed by observing that they equally 
produce their specific effects, whether administered by the mouth, applied to the 
skin, inhaled by the lungs, or injected into the veins. The following are de- 
monstrative proofs of the correctness of this conclusion : 
Iodine has been detected in the blood, saliva, sweat, urine, and milk ; mercury, 
in the blood, crassamentum, saliva, and urine; lead, in the liver, spinal cord, 
and muscles ; copper, in the liver and perspiration ; camphor, sugar of lead, sal 
ammoniac, verdigris,.and hydrocyanic acid, in the blood; sulphur, in the skin, 
&c. The authorities for these and many similar facts maybe seen in Dr. Chris- 
tison's admirable work " On Poisons." 
That medicines should enter the circulation, and thereby produce their effects 
upon the constitution, is what we should expect; the extraordinary effects how- 
ever, of certain poisonous substances excite our astonishment. Sir William 
Herschel has shown in regard to common matter that a power 50,000 times the 
power of gravity is generated by alloying mercury with yo Part °f sodium. 
The same or greater effects follow the introduction into the blood of certain in- 
finitesimal atoms of organic matters. Thus, the Woorara and Ticunas poisons ; 
the poisons received in dissection of recently dead bodies; of hydrophobia, 
syphilis, and small-pox; of vipers and other venomous animals; and that pro- 
ceeding from exhalations from the surface of the earth or from objects of disease, 
produce effects which, in reference to their causes, seem infinite. As we are not 
able to point out the distinguishing characters of these substances when they are 
presented to us in a concentrated state, it cannot be demanded that we should 
adduce direct proofs of their existence in the blood. Reason and analogy irre- 
sistibly conduct to this conclusion, as well as the fact that the blood, in most of 
these cases, is altered in its sensible qualities, is not disposed to coagulate after 
death, and speedily putrefies after extravasation. The following are additional 
impediments to the discovery of extraneous matters in the blood. 
1st, The rapidity with which they pass off by the secretions; 2d, Their diffu- HUNTER'S PRINCIPLES OF SURGERY. 
140 
ought to be exactly similar in all their dispositions and powers of 
action, or else the hereditary effect must be a mixture of both, either 
in equal proportions, or one side may preponderate more than the 
other. And this we find to be the case. A true and perfect heredi- 
tary cause is such as will produce its effects under all circumstances 
of life, not requiring the influence of any external circumstances 
whatever. It is hereditary for every animal to produce its own 
species, which may be reckoned the first hereditary principle. It 
is hereditary for every animal to produce the proper sexes, whether 
hermaphrodite or of distinct sexes. Of these distinct hereditary 
species we have varieties ; and if the varieties, whether original or 
accidental, are such as can be communicated to the young, they are 
then hereditary qualities. Of this kind we may reckon shape, both 
of the whole body or of parts, the varieties of which come nearest to 
the original hereditary principle of shape. Size is a similar princi- 
ple, as we see it is common for tall or short persons to have children 
of their own stature. Colour is another of these varieties, for we 
find this may become part of the principle of propagation, though 
not so permanent as some others. This property belongs to the 
epidermis, with all its appendages, as hair, nails, &c., which is sub- 
ject to greater varieties perhaps than any other part: and those 
hereditary susceptibilities for certain dispositions and actions of the 
mind are perhaps as much hereditary as any other property in an 
animal. 
These are what we may call permanent hereditary principles, 
becoming part of the constitution, and as subject to be pro- 
duced in the offspring as any effect in nature. They are such as 
will take place under every external influence, as season, climate, 
&c. It is from these varieties being hereditary that we have a 
continuance of them from parent to child. When both parents 
sion through 15 or 20 lbs. of blood ; 3d, Their disposition to locate themselves in 
particular organs; and, 4th, Their actual chemical union with the elements of the 
blood. Mr. Hunter indeed doubted of the possibility of this latter circumstance 
taking place; but, not to mention the presumption which arises from other cir- 
cumstances, the following experiment by Dr. Christison puts the matter beyond 
doubt. He injected eight grains and a half of oxalic acid into the veins of a dog, 
which was sufficient to kill the animal in 30 seconds ; but although the blood 
was immediately tested after death, no traces of the oxalic acid could be disco- 
vered. 
Whatever may be thought of these facts as proofs of the humoral doctrines, 
they plainly establish the fact that the blood is capable of considerable vitiations. 
In general, I believe, these vitiations ought to be regarded as effects, and not as 
causes, of disease. I conceive, however, in many cases the real cause of disease 
primarily exists in the blood, and is in that sense truly constitutional; and 
although we should regard these vitiations of the blood in other cases as merely 
secondary effects, yet we must admit that they will react on the original disease, 
and in this point of view be well deserving of the consideration of the practi- 
tioner. It is not unreasonable to expect that modern chemistry will throw con- 
siderable light on this subject, and discover some general principle by which the 
scattered facts which now exist relating to the blood will be connected and 
explained. In the present actual state of science these facts are practically 
useless.] OF LOCAL AND CONSTITUTIONAL DISEASES. 
141 
are constitutionally alike, they will produce children like one 
another, and also like themselves, though this is not absolutely 
certain, for a less marked hereditary principle may arise so as to 
produce children very unlike the parents. But if the disposition to 
produce similarity in the children to the parents be different in the 
two parents, it is impossible to say what the produce may be like. 
Hereditary varieties will often last foi' some generations, and 
then become extinct, seeming, as it were, worn out. A large nose 
shall be continued in a family for several generations, and then 
cease. A peculiar gait, the turning in of one or both feet, shall in 
the same way continue hereditary for some generations; and it is 
very possible that if such children were to intermarry with one 
another, the hereditary disposition would never be lost. 
There are latent hereditary dispositions, which pass over one or 
two generations, and start up again in the second or third. 
Children are generally more like one another than like either 
parent, because they have the united principles of the parents, which 
are dissimilar, but united will produce the same results. 
Parents may not be at all times disposed to form children alike. 
This difference seems to be owing in some degree to time between 
the births of the children; for we may observe that twins are more 
like each other than like those born a year or two apart, and these 
latter more alike than those born at the distance of several years. 
If the varieties, as white, black, &c., are not original, they must 
be monstrosities; and then we may say that the disposition to pro- 
duce monsters continues and becomes hereditary. The white 
negress, who may be called a monster of the black variety, being 
supposed to be born of black parents, and being herself white, 
with woolly hair, is a remarkable instance of the different disposi- 
tions of parents at different times. This woman married to a 
white man, and had three children, one quite black and the others 
tawny. 
A gentleman had two children, both born with a disposition to 
exostosis; the son showed it earliest, and had exostosis on each 
thigh-bone, and indeed an increase of every bone in his body. 
The girl was little better off. Neither of the parents had any 
disease of the kind, but gave the disposition to their children by 
joint operations. 
Of the acquired Hereditary Principle.-In these cases the princi- 
ple is such as to require accident, or some external cause, to pro- 
duce the disposition in such as have the susceptibility. In this case 
the susceptibility only is hereditary; but the disposition and action 
require the application of external influence before they will appear, 
and are therefore accidental. The action in this case is generally 
some disease. 
As the susceptibility is in some degree hereditary, the immediate 
cause has been in some degree overlooked, and the disease has 
been called an hereditary disease; but it is impossible for a disease 
to be hereditary when one of its causes cannot be hereditary. It 142 
HUNTER'S PRINCIPLES OF SURGERY. 
may be hereditary for a man to be irritable, one man'may be more 
readily put in a passion than another, but no man goes spontane- 
ously into a passion, there must be some violence committed on 
the mind; and so various are our minds, that some shall be put 
into a violent passion at a circumstance which would only slightly 
or perhaps not at all, excite another. 
The natural susceptibility for diseased action is so strong in 
some as to require only a slight secondary cause to put it into 
action; in others so weak, that it requires great violence as an 
immediate cause to bring on the effects. 
All hereditary dispositions must be more prominent than those 
that are acquired or accidental; therefore people who have an 
hereditary susceptibility for any diseased mode of action will in 
general have it constantly, at least it will not vary so much as some 
others. It will not be of that kind which has a great tendency to 
disease at one time and not at another; such fluctuating disposi- 
tions cannot be hereditary. 
Scrofula is one of those diseases which is supposed to be here- 
ditary; but it is only the readiness to fall into this peculiar action, 
when properly irritated, that is hereditary: and when such a cause 
does not exist we find no scrofula. 
Gout is another disease which is supposed to be hereditary, and 
there is often great reason in appearance for supposing that it is so. 
This is a diseased action which perhaps every one is susceptible 
of; but some fall into it much more readily than others, and this 
readiness may be hereditary. But this readiness never takes on 
action of itself; it must have the immediate cause to excite it, 
which is a stimulus of a particular kind. We find gout attacking 
people whose parents for many generations have not had it, and 
often never. We see it starting up in countries where luxury is 
introduced, where it was never known before. However, there 
are many instances where it would appear to be hereditary, as in 
the case of young men of fifteen, the sons of gouty men. But I 
suspect that this does not arise simply from the father's having had 
the gout, but from the circumstance that most people who have 
had the gout severely have deserved it, and that children have in- 
herited the disposition for the way of living as well as the suscepti- 
bility for the disease, and will therefore be more liable to fall into 
the disease than children at large. 
On this principle of the hereditary nature of diseases, if it be 
just, every disease under the sun will be hereditary: but many 
diseases having a stronger visible cause has made the hereditary 
susceptibility in them to be overlooked. Thus, the small-pox is as 
much hereditary as scrofula or gout, but from its arising in all 
cases from poison communicated, and evidently not in a sponta- 
neous manner, is the reason why the hereditary susceptibility has 
been overlooked. But on our principle the small-pox is as heredi- 
tary as any other, only requiring the immediate cause to act to 
produce it as in any other disease. We may make the same OF LOCAL AND CONSTITUTIONAL DISEASES. 
143 
observation with regard to the venereal disease, for we see some 
persons much more susceptible of this disease than others are, and 
suffering more severely from it when they get it. 
I do not know that we have an instance of observation which 
proves that the circumstance of a person's having had the disease 
renders him more liable to communicate that susceptibility to his 
offspring than if he had only the susceptibility for the disease, 
without the action having taken place. If it was a fact that the 
parents having simply had the disease, in some degree entitled their 
offspring to it, the human species would soon become extinct in 
those places where such diseases arose: and if the parents having 
had the disease increased the susceptibility in the offspring, both 
small-pox and lues would have become incurable by this time. 
So that the immediate cause, whatever this may have been, does 
not in consequence of its having had its full effect either give or 
even add to the disposition for such action. 
The only difficulty I find, in stating this as a universal doctrine, is 
in the case of madness. This is allowed to be hereditary, and is I 
believe as much so as many, yet I cannot find the immediate cause 
in many cases. It would appear that the disposition to produce 
action is so strong as to go into action without the application of an 
exciting cause. It would be worth while to see whether people in 
a state of nature ever go mad : if they do not, then the state of mind 
in the civilized state is the immediate cause. 
A gentleman informed me that he had paid particular attention to 
the diseases of Indians, and that he never heard of an Indian going 
mad. 
On the Effects of Mind on Diseases.-When on the animal econo- 
my, I observed that the mind was formed by the senses, as also the 
will; that the will produced the voluntary actions, but that the mind 
produced actions both of the voluntary and involuntary parts, which 
actions are often very irregular and undetermined. On the state of 
the mind, therefore, the latter will depend, or at least they will 
change with it, and even the former may be affected by it; indeed 
there is not a natural action in the body, whether involuntary or vo- 
luntary, that may not be influenced by the peculiar state of the mind 
at the time, and every particular mode of the mind has some parts 
that are more readily influenced by it than others. The skin is 
affected by the feeling of shame; the secretion or even the non- 
secretion of the testicles takes place under certain states of the mind. 
Palpitations of the heart and quick respirations are brought on by 
some states; purging and increased secretions of the urine by 
others. 
In voluntary parts we can also perceive the influence of the mind. 
It often produces actions independently of the will, especially when 
these actions are begun by the will, and when the mind is affected 
by a recollection of them; or even contrary to the will. Thus, fear 
produces a vibratory contraction of all the voluntary muscles, while 
the will is doing all it can to stop it. Since the mind has such 144 
HUNTER'S PRINCIPLES OF SURGERY. 
power over the natural actions of the body, we might suppose it 
■would have considerable effect in disease ; and this we actually find 
it has, especially in those who have a strong susceptibility for such 
actions as the mind can most easily affect. We should naturally 
expect that it would be [diseases principally connected with the 
nerves that the mind would most affect, though we do find that there 
are other diseases, with which they appear to have little connexion, 
that are much affected by the state of the mind; and I believe that 
it is principally those diseases in which the alteration is in the action 
of parts, notintheir structure. 
Minds which are particularly irritable are most subject to such 
diseases, having the acting parts more under the control of the mind, 
and less under that of the will; also the involuntary powers are 
more under the influence of the state of mind, as the heart, &c. 
These diseases are called nervous, and more peculiarly belong to 
women, who being less acquainted with the real properties of natu- 
ral things, are more apt to imagine preternatural ones; and their 
reasoning powers not being so strong, they indulge the actions of 
the mind more, and allow it to take possession of the body; for the 
mind can often prevent diseases of such a nature as are contrary to 
health, and depend on voluntary actions, of which take the following 
instance. A woman, aged forty-six, of a good-natured disposition, 
had been troubled for some years with a drawing of the neck to one 
side, by the contraction of one of the mastoid muscles : this it was 
always in hei' power to prevent, by contracting the opposite muscle, 
when she sufficiently recollected herself. The right muscle, the 
one affected, did not contract of itself, unless by some accident she 
of her own accord contracted it a little, after which it continued 
contracting till it produced its full effect. When her mind was 
agreeably engaged she seldom felt it, or when conversing with an 
intimate friend or reading; but fear and every other unpleasant state 
always produced it. If she expected to see any stranger before 
whom she was particularly anxious to hide her defect, she had it 
always more violently than usual. This circumstance of the mind's 
continuing action when it has once taken it up, is remarkable in 
hiccup, which is often produced by laughing; thus hiccuping, which 
is an involuntary action, is produced by laughing, which is a volun- 
tary one. But as the state of the mind is thus capable of producing 
a disease, another state of it may effect a cure: so the hiccup may 
be cured by producing fear. There are other diseases which a state 
of the mind may cure, though they have not been brought on by it, 
as agues have been cured by charms which have been used with a 
thorough conviction of their being a sovereign remedy. I am apt 
to suppose that a spider's web, when taken for an ague, cures in the 
same way, at least in one case; for on giving it without the patient's 
knowledge, it had not the slightest effect; but by persuading the 
patient that it was a spider, the effect was produced, at least the disease 
did not return. Even tumours have yielded to the stroke of a dead 
man's hand. OF LOCAL AND CONSTITUTIONAL DISEASES. 
145 
It often happens that there is a suspension of some actions in an 
animal body, and those actions return again. Thus we have epi- 
lepsy, which is a suspension of the sensitive principle's actions: 
sometimes we have suspension of the heart's actions. It is perhaps 
impossible to know the cause of these suspensions, and equally so 
the cause of their return. I am apt to suspect that suspension of 
natural action becomes the stimulus to the powers to put themselves 
in action again; or, in other words, the suspension becomes by its 
continuance a force imposed on parts to act, and they act to relieve 
themselves. Thus, by stopping respiration we have such a stimulus 
raised in consequence that we can no longer live without the action, 
and the action takes place. 
I suspect that opium often produces a struggle between the 
necessity of action and the consciousness of the preternatural 
suspension, which rather rouses. Death, which is the ultimate 
suspension of all actions, seems to explain that, as a person seldom 
dies without a struggle or convulsion. Convulsion appears to me 
to be an action arising from a consciousness of debility ; as if there 
was an endeavoui' to act to preserve life, but not being able to pre- 
serve it, they give up the contest. 
Of Symptoms.-A symptom is a sensible effect of a diseased 
action. The first mode of sensation is when the disease is shown 
directly, without the medium of any other reference, and is known 
only to the patient; of this kind is pain. The second is where it is 
given by a reference to some other sense, as that of touch, smell, &c., 
and is common to the patient and others; of this kind is the swelling 
of tumours, the redness of inflammation, &c. The third arises 
from a deficiency of sensation, and can be known only to the 
patient himself. It is by description and the second set of symptoms 
that the practitioner receives his information. Local disease may 
produce only the first mode of intelligence, as pain ; or it may pro- 
ceed to the second, as inflammation ; or the second may be produced 
without the first, as indolent tumour, not known till felt by the 
hand. 
Pain is a simple sensation which is common to many diseases, 
and is divided into several kinds, as sharp, sore, numbing, heavy, &c. 
The sharp pain is that produced by cutting with a knife ; the sore, 
from inflammation and ulcers; the heavy, that which takes place in 
rheumatism ; the numbing, from pressure on a nerve. The sharp 
and sore depend on what I shall call vibration of pain, particularly 
the latter. The heavy seems to be a continual pain, or where the 
repetitions are so quick as to appear continued ; but probably all 
of them are owing to a succession of actions of the nerves. We refer 
all the sensations we can to those senses which give us the greatest 
intelligence. We call them sharp pains from their giving the sensa- 
tions of any thing that bites, or stings, as bees, or acids on the tongue ; 
heavy, from their giving us the sensation of bearing a weight on 
the part. A gentleman who had a hemiplegia, said his sensation 146 
HUNTER'S PRINCIPLES OF SURGERY. 
was similar to an acid on the part, that is, to that feeling on the 
tongue. 
We have often a bad taste in the mouth, or a bad smell; this is 
not always a sign that the saliva or mucus is altered in its qualities, 
as it is in salivation from mercury, which appears to be from the 
taste and smell of the mercury, but it is sometimes produced by a 
morbid action of the nerves. We have these symptoms, together 
with ringing in the ears, commonly in the beginning of diseases, and 
probably they arise from the actions of the disease in the nerves of 
the part. 
Neither susceptibility nor disposition for diseased action can pro- 
duce a symptom; it must be preceded by action; though I believe 
that there will sometimes be an unnatural feel in a part before 
action has taken place, as before a fit of the gout attacking the foot 
an indescribable sensation is sometimes felt, and when the action 
takes place the constitution is relieved. 
Symptoms are either local or universal. Local, as chancre, 
cancer, &c.; universal, when they accompany universal diseases, 
as fever. Local symptoms may produce universal ones, which is 
a means either of increasing the local symptoms or of curing the 
disease. Local symptoms will vary according to the nature of the 
disease ; its violence or its situation, as inflammation, will produce 
different sensations in different parts. Universal diseases will pro- 
duce some of the following symptoms: affection of the pulse, which 
arises from the heart's sympathizing and partaking of the disease; 
the alterations are very various, as full, strong, weak, small, &c. 
The secretions are altered, as in fever; the tongue becomes covered 
with its own secretion, at first white, afterwards brown, or some- 
times black, which last colour arises from blood being mixed with 
the secretion. The tongue also contracts in size, and we have often 
thirst without its being dry, and sometimes, as in low fevers, very 
dry without thirst, which last is owing to a diminution of sensation 
in the nerves, and is an unfavourable symptom. The urine is high- 
coloured, without sediment, owing to its being retained long in the 
bladder, from debility of that organ or from blood being mixed with 
it. The respiration fails, from debility in the lungs. The heat of 
the skin is altered from too great or too little action of the vessels.' 
The colour of the skin in some diseases changes, as from white to 
yellow in a very short space of time, not from jaundice, the white 
of the eye not being changed; nor could jaundice be so quick in 
coming and disappearing; it is probably a change in the rete mu- 
cosum of the skin, such as takes place in the chameleon and some 
other lizards; veins of the skin are enlarged by any tumom' seated 
beneath them ; as in hydrocephalus, tumours of the breast or of the 
uterus during gestation, the veins of the head, chest, or belly will 
be found enlarged. 
The feeling of the part is the first mode of intelligence. Suppose 
a stone in the kidney ; it may produce three symptoms : 1st, Pain 
in the part; 2d, Vomiting, which is symptomatic; 3d, Bloody OF LOCAL AND CONSTITUTIONAL DISEASES. 
147 
urine. Now these symptoms may occur in othei' diseases, inde- 
pendently of stone ; if they are combined, they afford a pretty 
certain diagnosis of the presence of stone, but any one or two of 
them leaves it doubtful. These symptoms attend the passing of a 
stone through the ureter, as well as when in the kidney ; and 
when a stone gets from the ureter into the bladder the symptoms 
abate, and a different pain is felt, and this change occurring con- 
firms us in the opinion we had before formed of the existence of a 
stone. 
Anomalous Symptoms.-These are not immediately expressive of 
the disease, but make the diagnosis doubtful. They are very 
numerous, taking in all the symptoms which occur from dentition, 
worms, &c. Many of them are from sympathy, which we men- 
tioned before. 
Delusive Symptoms respecting Sensation.-This delusion of the 
senses makes disease seem where it really is not, from the different 
seat of the symptoms and of the diseased part. Thus, diseases of 
the liver are referred to the shoulder, of the testicles to the back, 
of the hip to the knee, and even in some cases, as was before 
observed, they are referred to some other person. When the 
trunk of the nerve is injured, the pain is referred to the termination 
of it, as, aftex' amputation of the leg, pain is felt in the toes. When 
pressure is made on a large nerve, the most acute sensation will be 
at some distance below the part pressed on. 
A gentleman complained of a pain in the hip, running down the 
outside of the leg and foot. Supposing it rheumatism I gave him 
James's powder, Dover's powder, and volatile tincture of guaiacum, 
but with no good effect, A liniment of opium to the leg and foot 
gave some relief. He at last perceived a tumour by the os ischii, 
just at the posterior edge of the gluteus maximus. This tumour 
increased, and the person, died. The tumour wras found to fill a 
part of the pelvis, and had made its external appearance at the 
foramen magnum ischii, being filled with coagulated blood ; but the 
pain in the limb seemed to have been produced by its pressing on 
a great branch of the nerve, but chiefly perhaps from the great 
ischiatic nerve being stretched very tight over the upper surface of 
the tumour. Here that happened which may often be observed ; 
that is, the impression made on the trunk of the nerve gave a sen- 
sation as if it had been on the extremities of the nerve. The first 
action of a nerve is at its extremity, and the last in the brain; and 
this last in the brain refers the sensation receiving the first impres- 
sion ; and if, after the brain has become accustomed to refex' any 
sensation to the extremities of the nerves, any impression be made 
on the trunk, the brain receives the impression in the same point 
where it was accustomed to receive the impressions made on the 
extremity of that nerve, and therefore the mind refers the sensation 
to the same spot, that is, the extremity of the nerve. This happens 
when the part to which the sensation is referred does not exist, as 148 
HUNTER'S PRINCIPLES OF SURGERY. 
a person, having had an amputated limb, will for a long time refer 
his sensations to the fingers or toes. 
In diseases the general character of the patient should be known, 
which is essentially necessary before we can judge of every symp- 
tom ; for besides what we can know by the symptoms of a disease, 
yet peculiarity of temperament, &c., will occasion great differences 
in the character of the disease. For our being informed by the 
first mode of intelligence, the patient's sensations, the patient must 
be in his right senses, otherwise he may be deluded, and delude us. 
But even where the patient is perfectly sensible, many symptoms 
may appear to the physician which the patient is not sensible of, as 
wild looks, quick pulse, &c. The brain may not be conscious of 
them, and a false conception of their feelings is then present; and 
this may be called half-delirium. A complete delirium is an action 
of the mind directed by no sensation whatever. But we do not 
know how to distinguish between these two deliriums, the former 
being an action of the mind from sensation, but which sensation 
is incapable of directing its influence to the senses, and refers it to 
other parts or other objects. These should be well understood in 
practice, as in half-delirium the patient will have the sensation, but 
will direct it to some one else, or to the wrong part, which if we 
know we may be able to afford them the relief they want. The 
history of every thing relative to a disease should be known, as 
symptoms alone are often not enough to direct us ; we should, 
therefore, get the history of it and of prior diseases, of peculiarity 
of constitution, manner of living, &c. 
7 O7 
CHAPTER XII. 
GENERAL PRINCIPLES OF INFLAMMATION. 
Frequency of inflammation ;-nature of;-enlargement of vessels ;-several spe- 
cies ;-simple or compound ;-three results from inflammation in a healthy 
constitution :-adhesion,-suppuration,-ulceration.-Adhesion ;-nature of 
the uniting medium ;-partakes of the quality of the diseased solids ;-its uses. 
-Suppuration;-differs in degree according to the exciting cause.-Ulceration ; 
-its uses.-Exciting causes of inflammation;-accidental or specific.-Re- 
mote causes of inflammation.-Comparative susceptibility of parts to inflam- 
mation.-Effects of inflammation on the constitution Of the pulse;-varies 
with the states of the constitution ;-varieties of pulse ;-causes of the varie- 
ties.-Effects on the constitution according to the state of the inflammation ;- 
rigors.-State of the blood in inflammation ; colour, heat, coldness, pain of the 
inflamed parts.-Declension of inflammation.-Ecchymosis ;-varieties of;- 
termination of. 
The operation in the body called inflammation is one of the most 
common and most extensive in its effects, and requires our greatest GENERAL PRINCIPLES OF INFLAMMATION. 
149 
attention. It is the cause of many effects, both salutary and diseased, 
producing abscesses, fistulas, diseased bones, &c., and in many 
diseases is the first step towards a cure; so that it becomes a first 
principle in surgery. 
Inflammation would appear to be produced by an increased action 
of the vessels, but it is most probably in the smallest vessels, for it 
may be confined almost to a point where none but the smallest ves- 
sels exist. What the particular action is, or in what it differs from 
the common action of vessels, is not easily ascertained, we being 
more able to judge of the effects than of the immediate cause. 
Inflammation may be considered as a genus, of which there are 
many species. It may be divided into healthy and unhealthy. The 
healthy is that which will always take place in a healthy constitu- 
tion or part, and is rather to be considered as a restorative process 
than a disease. Unhea'thy inflammation is that which takes place 
in an unhealthy constitution or part, and will vary according to the 
kind of unhealthiness of that constitution or part. 
Inflammation is either simple or compound ; simple, when there 
is only one mode of action in the part inflamed, as in the first stage ; 
compound, when there are two or more modes of action. The 
compound produces three great effects, namely, adhesion, suppura- 
tion, and ulceration, which I shall call adhesive, suppurative, and 
ulcerative inflammation. The last is only an effect of inflammation, 
foi' the process takes place in a different set of vessels. 
I shall place the adhesive first in order, though it is not always so, 
for with respect to priority of these effects of inflammation, it de- 
pends principally on the nature of the parts, with the degeee of vio- 
lence of the inflammation. To explain this more fully, I shall con- 
sider inflammation as it affects, 1st, The cellular membrane in 
general, and the circumscribed cavities; 2d, All the outlets of the 
body, i. e., the excretory outlets and ducts of glands, as the mouth, 
nose, tunica conjunctiva, &c., which have been called mucous 
membranes, and which I shall treat of in their propei' order. 
When inflammation takes place in the first order of parts, it is 
commonly the adhesive: but it will be according to circumstances 
whether the suppurative or ulcerative follows first, and probably 
according to the degree of inflammation. But it sometimes happens 
that the suppurative takes place almost immediately, probably from 
two causes, either from the inflammation exciting the suppurative 
almost immediately after the adhesive, or from the inflammation 
having- little or nothing of the adhesive in it. I suspect that the 
erysipelatous has little of the adhesive in its nature, no adhesion 
taking place before suppuration, whilst in phlegmonous inflamma- 
tion of the cellular membrane it does; so that the erysipelatous 
might be called cedematous inflammation. When inflammation 
occurs with violence on the surface of the skin, the ulcerative pro- 
cess takes precedence of the suppurative, although in the cellular 
membrane the reverse of this is the case. In the second order of HUNTER'S PRINCIPLES OF SURGERY. 
150 
parts the suppurative takes place first, and the adhesive does not 
taj<e place, unless the inflammation is carried to a great height. 
When the inflammation is in the first order of parts, the suppura- 
tion and ulceration are so many actions superadded to the first, or 
adhesive, and arising out of the effects produced by that which now 
become new causes, especially of the ulcerative, which is an action 
of the absorbents. All these actions arise from the first irritation 
or cause. 
The adhesive or suppurative, either in the first or second order of 
parts with their varieties, may have a fourth character superadded, 
such, for example, as the scrofulous or venereal disposition, or other 
specific disease. 
These three modes of action, when carried on perfectly, are the 
effects of a good constitution, and constitute what I would be under- 
stood to mean by common inflammation. 
The union of cavities in an animal body is formed by a uniting 
medium, which appears to be the coagulable lymph, which, by the 
inflammatory disposition of the vessels, is separated from other 
parts of the blood and thrown out on these surfaces. That this is 
the case appears from the following observations. In all large 
cavities where we can make our observations with certainty, we 
find when they have been inflamed that a substance similar to the 
coagulable lymph when separated from the serum and red particles, 
is diffused all over the sides or through the cavity. When we cut 
into an inflamed part after death, we find it firm and solid, like the 
section of a lemon, or some oedematous tumour, where we know 
extravasation has taken place ; and this appearance arises from the 
cells of the cellular membrane being loaded with extravasated 
coagulable lymph. 
This mode of separation of coagulable lymph is not peculiar to 
this species of inflammation; it is separated on many other occasions 
to form tumours,* where inflammation does not seem to be the 
leading cause. 
It is probable that the coagulable lymph undergoes some change 
in its passage through the inflamed vessels which obliges it to 
* [As we are not acquainted with the mode in which the process of nutrition 
is accomplished in its natural state, it is not to be expected that we should b& 
able to account for those aberrations from the healthy state which constitute tu- 
mours.. If the formation of tumours depended upon the organization of effused 
blood or lymph, we should expect to see them much more frequently than we do, 
since few persons escape effusions at one time or other; and we should likewise 
expect to see them differ in their incipient and in their advanced stages. Obser- 
vation, however, discloses nothing of this kind ; on the contrary, the peculiar 
structure of tumours is as well characterized at first as when they become more 
fully developed : the blood or lymph which is effused in inflammation or by ac- 
cident is generally absorbed, and in the great majority of tumours we are unable 
to refer to any previous injury or inflammation to account for their origin. See 
Home ( Trans. of a Soc. for the Imp. of Med. and Chir. Knowledge, vol. i.,) and 
Abernethy (Works, vol. ii.), who have advocated the opinion in the text, and 
Lawrence (Med.-Chir. Trans., vol. xvii.), who justly, in my opinion, objects to 
the statements of these gentlemen.] GENERAL PRINCIPLES OF INFLAMMATION. 
151 
coagulate sooner than it otherwise would, for in those cases of in- 
flamed arms, after bleeding, we find that the cavities of the veins 
are in many places furred over, and in others united by coagulable 
lymph, which must have been thrown out by the vasa vasorum, and 
coagulated blood immediately. Hence it is reasonable to suppose 
that in this separation the lymph must have undergone some change, 
arising from the vessels, and that it is not simply such coagulable 
lymph as is circulating in the blood, else it would be carried off by 
the circulating blood passing through the vein. This change I suppose 
to arise from sympathy with the inflamed vein. The lymph seems, 
however, to retain the living principle, and probably in a greater 
degree than under common circumstances, and is, therefore, better 
fitted to become a living solid. It does not seem, however, absolutely 
necessary that coagulable lymph should first undergo this change 
in the extravasating vessels, for, as I have before said, blood ex- 
travasated from ruptured vessels is perhaps equally efficacious in 
this respect.* 
It does not seem necessary for both surfaces that are to be united 
to be in a state of inflammation, but only for one, to throw out the 
coagulable lymph; nor indeed does inflammation of either seem 
necessary, for union by extravasated blood may take place without 
inflammation. 
Extravasated coagulable lymph, which produces either adhesion 
oi' tumours, always partakes of the nature of the diseased solids that 
produced it; if the case is venereal, the new substance is of the 
same nature; if cancerous, cancerous ; for the absorption of this 
effusion from a cancerous breast will produce cancerous axillary 
glands. 
The intention of the adhesive inflammation is in some degree to 
set bounds to or prevent the necessity of its own larger extent. In 
large cavities the inflamed parts adhere, and thereby exclude or 
prevent the other parts from the necessity of falling into the same 
irritation. But the chief intention is to confine the suppuration to 
those parts where it takes place, for where the adhesions are 
perfectly formed the operations of inflammation appear to be com- 
pleted, so that the suppurative process does not spread; it also 
serves to confine the matter to the cavities where it is formed. 
Inflammation often goes no further than adhesion, and then 
subsides and goes off, which is termed resolution. This cannot 
take place in all inflammations, but only in those where the parts 
can be brought into contact, for if the part in which it takes place 
is an open cavity, suppuration will take place. 
When the adhesive inflammation is not capable of resolution, 
suppuration takes place. The immediate effect of this process is 
the production of matter from the inflamed surface, which appears 
under such circumstances to be a leading step to the formation of 
a new substance, called granulations, which granulations are the 
* [See note, p. 34, and Treatise on Inflammation, Part II. Chap. I.] 152 
HUNTER'S PRINCIPLES OF SURGERY. 
second method of restoring the first order of parts to health. But 
on all internal canals suppuration does not necessarily lead to gra- 
nulation. 
In order for spontaneous inflammations to produce suppuration, 
they must be much more violent than those inflammations (suppu- 
ration being equally necessary), arising in consequence of an 
operation or accident: and those inflammations from either opera- 
tions or accidents, if they have not produced death in the part 
operated on, are more violent and of greater extent than those in 
which death of a part has been produced. Thus, the inflammation 
of a boil or bubo is more violent and commonly more extensive, 
than that in consequence of a cut, or even amputation of the leg ; 
and the inflammation arising from these latter will be more violent 
than that from a gunshot wound on the application of caustic. It 
may not be easy to account for all these differences; however, it is 
possible that in spontaneous inflammations the inflammation is 
more necessary for the ultimate effect than the suppuration; as in 
gout, the inflammation is the mode of carrying off the action of the 
disease. It is curious to remark, that in gout nature seems to 
produce all the purposes and effects intended by inflammation, but 
unaccompanied by either adhesion, suppuration, or ulceration; and 
although the inflammations runs much higher here than in many 
other cases, and although it is attended with all the common 
appearances, yet no adhesions are formed here: for the lymph is 
taken up, and chalk (urate of soda) is deposited in its place. In 
spontaneous inflammation, parts are either naturally more suscep- 
tible of the inflammation, or become so by disease. When inflam- 
mation is produced by stimulus of the death of a part, or of effused 
blood, the inflammation is commonly slow ; but that from a bruise 
is often quick and violent, but then the injury has not produced 
death. If caustics do not act with vigour, they will irritate and 
inflame much sooner than if they had immediately killed the part; 
but irritating applications must be continued some time to produce 
inflammation. After operations where inflammation must take 
place for the union of the wounds, suppuration is more necessary 
than inflammation, and we find it is soon produced. 
The ulcerative inflammation is that which takes place in conse- 
quence of suppuration, therefore is not so much the original in- 
flammation as the consequence. It is that inflammation which dis- 
poses parts to absorb themselves, and which brings matter or any 
extraneous substance to the surface to be discharged, the absorbents 
removing all the parts lying between the matter and the surface. 
This process has been erroneously ascribed to the melting down or 
dissolution of living solids with the pus. 
From the foregoing general account of inflammation, it may be said 
to arise in all cases from injury done to the solids, where either the 
natural conformation of parts on which natural actions depend is so 
destroyed that they are not able to support themselves in that state, 
or from the natural actions or functions of a part being materially GENERAL PRINCIPLES OF INFLAMMATION. 
153 
obstructed, the texture not being primarily affected. The first state 
arises from causes that are visible or external, such as the application 
of any irritating matter, as a blister, heat, or even cold, which acts as 
a sedative when applied only in a certain quantity ; but when in too 
great a quantity, the parts, finding that they are losing their action, 
are roused to action beyond that which is natural, in order to destroy 
the irritating cause. Inflammation may also be produced by causes not 
known or suspected, or from a constitutional disposition being deter- 
mined to some part, producing local effects. I need hardly mention 
that fever is thus often a cause of local inflammation. 
Inflammations from the constitution are of two kinds : one may be 
called accidental, as those arising in common fever; the other are de- 
terminate, depending on the species of fever which may be called spe- 
cific, as small-pox, &c. 
These inflammations are thought to be critical, but I very much 
doubt the truth of this opinion. The small-pox and chicken-pox are 
the only diseases that can be brought in proof of it, with perhaps the 
inflammation of measles; but even these pustules or abscesses are, 
perhaps, not necessary, as critical abscesses, to carry off the fever, 
for specific fevers cannot exist beyond a certain time, though no 
eruption appears; which time depends on the nature of the poison, 
and the constitution. And in these diseases we have large abscesses as 
often formed as after any other; and certainly I cannot suppose those 
abscesses to be critical, for they possess nothing of the specific nature 
of the preceding disease, and must therefore be common ; or, where 
the constitution possesses a susceptibility for scrofula, they may be 
scrofulous, but not critical; and as the preceding disease has already 
been followed by pustules or abscesses which, if any deserve to be 
termed so, certainly ought to be termed critical,we shall find that these 
inflammations and abscesses depend on the state of the constitution 
and part at that time, and are an effect of simple fever abstracted 
from every specific peculiarity. Fever is at all times a disturbed 
action, which may have a specific action joined with it or not. The 
inflammatory fever is perhaps, the most simple fever; and the putrid 
fever is, perhaps, only the same fever occurring in a constitu- 
tion predisposed to its peculiar actions. This opinion may be illus- 
trated by what occurs in the small-pox ; two different people having 
this fever from the same infection, the effect in one will be benign 
small-pox, with only simple inflammatory fever ; in the other it will 
be erysipelatous or confluent small-pox, with a tendency to putridity 
or gangrene. This difference cannot depend on the specific poison, 
as this can have but one mode of irritating. Now, since every 
fever is capable of producing inflammation and abscess, and as I have 
shown that in specific diseases they have no right to be termed cri- 
tical, they certainly cannot be supposed critical in common fever. 
Inflammation may arise from one of four causes, which may be 
called remote: 1st, From accidental force applied to a part: 2d, 
From some irritation, which does not destroy the texture of apart, 
but simply the natural actions, as friction, blisters, heat, cold, and 154 
HUNTER'S PRINCIPLES OF SURGERY. 
often fevers of various kinds ; 3d, From some particular disposition 
in the part itself, as boils arising spontaneously; 4th, From the 
general state of the constitution affecting some particular part, as 
gout falling on the toe, or the irritation of fever on the lungs, liver, 
or any other part, producing adhesions or abscesses; but such, I 
suspect, are of the scrofulous kind, and not in the least critical, and 
therefore belonging to the second cause. To these, I think, we 
may add specific causes, as scrofulous, venereal, &c., as a 5th; 
and the stimulus of defect or imperfection of parts, especially 
cavities, as a 6th. 
Obstruction of the blood's motion in the small vessels has been long 
supposed to be a great cause of inflammation, but is, I believe, now 
pretty generally rejected. This was certainly too confined an idea: 
it reduced all inflammations to one species. The only distinctions 
of inflammations must then have arisen from the nature of the con- 
stitution ; but this doctrine never could account for the peculiar ac- 
tion of any specific disease or poison. It was also too mechanical. 
If they had said that any obstruction to the natural actions of the 
parts which could stop the blood's motion in the part became the 
cause of inflammation, they would not have been so much out as to 
a possible cause of inflammation. In such a case the stagnated 
blood would cause irritation of the vessels, and suppuration would be 
produced to get rid of it. The immediate operation of these inflam- 
mations cannot be called disease, though their remote causes may, as 
small-pox, &c.; for they may arise from the part being only disturbed, 
and hardly exceeding the idea we have annexed to that of being 
disturbed. It is the cause producing inflammation, then, which is 
the disease and not the inflammation,* for all inflammations that 
can be called diseases have specific causes ; and, indeed, even these 
can be hardly called diseases, for in small-pox, where the inflamma- 
tion goes on well, it is merely the action of health; if diseased, it 
would be erysipelatous, &c. Sometimes, by amputating a leg, 
more than simple disturbed action is produced, for it is a great loss 
to the constitution ; but yet when the constitution is in a healthy 
state, we generally find a healthy inflammation and digestion of the 
wound take place: it will not go into an inflammation which is 
unhealthy. Specific inflammation as well as simple inflammation 
partake of the nature of the constitution. Some constitutions are 
more disposed to certain specific actions than others, and will fall 
into that specific kind of inflammation, as the erysipelatous, the 
* [That is, inflammation with a specific character is the only inflammation 
which can be denominated disease. The meaning of the author I conceive to be 
simply that pure inflammation is a restorative action, in contradistinction to the 
actions of disease which tend to destroy (pp. 15, 97); and to this general state- 
ment there can be no objection, although it must be borne in mind that the rule 
of judging from final causes cannot be applied absolutely without excluding 
from the list of diseases a great many affections to which it would be absurd to 
deny this title, such as sickness, purging, increased secretions, ulceration, mor- 
tification, &c., the tendency of which on many occasions evidently is salutary, or 
to get rid of some noxious matters : still there is sufficient ground I think for 
the general observation.] GENERAL PRINCIPLES OF INFLAMMATION. 
155 
scrofulous, &c.; and every aggravation is an aggravation of the 
specific nature of the inflammation; thus it happens in scrofula, 
cancer, &c. But some specific irritations bring all constitutions, 
to their own nature, as the plague, jail-fever, &c. Here it is not a 
specific joined with a simple inflammation, but a thorough change 
of constitution, and the patients generally die, all suffering alike. 
The inflammation arising from these causes may be either the 
adhesive or the suppurative. From all which we may conclude 
that irritations either produce inflammation according to the dispo- 
sition of the constitution or of then.' own nature, of which last is 
the plague. 
The specific diseases will change, according as the constitution 
changes; for instance, after receiving the small-pox, if the constitu- 
tion, then healthy, should by any means become disposed to show 
putrid symptoms, the small-pox will have the same appearance ; but 
if the constitution is altered from this tendency, the eruption will 
also alter. Now the knowledge of this fact is very useful in the 
treatment of specific diseases; for example, if with a venereal 
chancre the constitution be erysipelatous, we may have an erysipe- 
latous inflammation in addition to the chancre, which will spread 
over the whole penis. Now, in this case, we must make use of 
mercury against the one, and of bark against the other of these 
specific diseases, until we bring it to the simple ulcerative inflam- 
mation. Again in the small-pox, when simple, the pustules retain 
their specific distances, but if an erysipelatous inflammation be 
joined to it, it becomes of the confluent kind. In the irritable con- 
stitution we find from continuous sympathy the inflammation will 
extend itself very far; but in general we find that considerable in- 
flammations confine themselves very much. 
Some parts are more susceptible of one kind of inflammation than 
of others', some admitting only of one kind, some two, and some all 
three, which difference appears to be according to the situation in 
the body of the inflamed parts, and also according to the nature of 
the parts inflamed. The deeper-seated parts, especially the vital, 
admit very readily of the adhesive inflammation, as is proved by 
dissections, for we hardly ever open a human subject that has not 
had considerable adhesions in the circumscribed cavities; but they do 
not so readily pass into the suppurative, which is fortunate, otherwise 
internal inflammation would oflener kill. But if the inflammation 
comes on at once with great violence, it would appear to pass 
almost at once over the adhesive, and to take up the suppurative 
action, and in this case we may sometimes have the erysipelatous 
added. 
The external parts of the body are more susceptible of the suppu- 
rative inflammation than the interna], but they always begin with 
the adhesive. This greater susceptibility of the superficial parts 
to suppuration is shown in the passage of pins, bullets, and other 
extraneous bodies to the surface : if deep-seated, they will remain 
a long time inactive, inclosed in a cyst, and produce no inconveni- 
ence until they work their way to the skin, when snnnnrati^ 156 
HUNTER'S PRINCIPLES OF SURGERY. 
be produced. It is very remarkable of the cattle which feed in the 
bleaching-fields, and are always found aftei' death to have a num- 
ber of pins in them. (The stomach of a bull was shown, in which 
several pins were sticking, and which were not known to have 
caused any inconvenience.) Perhaps this does not altogether 
depend on the situation of the part, but also, on the degree of irri- 
tating powei' possessed by the extraneous substance : thus, metals 
and glass seem to produce such a disposition in the part, that it 
becomes satisfied with the adhesive inflammation. A gentleman 
had a piece of glass in his hand for many weeks, which produced 
no pain, except on pressure. This insensibility of deep-seated parts 
to extraneous substances, depends on a sac being formed around 
these substances, possessing a peculiar degree of insensibility. 
Nature acts here with her usual care, preferring the least evil by 
securing the extraneous substance in a part possessing peculiar 
insensibility, rather than calling up the vital powers to produce 
suppuration, which must be considerable to reach the surface, and 
might expose parts which would be attended with considerable 
danger; but when they become external, then she chooses the 
other, to get rid of them as soon as possible. 
In my division of parts, as regards inflammation, into two orders, 
I have made a distinction between the cellular membrane and 
circumscribed cavities on the one hand, and the ducts, canals, and 
outlets which are lined with what has been called a mucous mem- 
brane on the other. In the first order of parts, inflammation pro- 
ceeds in this order; adhesive, suppurative, ulcerative; but in the 
second order of parts, the order of inflammation seems to be 
inverted as regards the two first, as may be seen in internal canals. 
In these, if the inflammation is but slight, the suppurative takes 
place almost immediately, not being retarded by the adhesive going 
before ; as we see in gonorrhoea, catarrh, &c. It has been said 
that these discharges are not purulent, but in my opinion they 
certainly are ; the purulent matter being only a change in the 
natural secretion, and its thickness or thinness depending on the 
degree of the inflammation. If the erysipelatous inflammation 
should come on in these parts, then the movement takes place from 
the suppurative to the ulcerative. In the mucous membrane ulcer- 
ation will take place, probably from the violence of the inflamma- 
tion having produced coagulable lymph, which acts as a stimulus, 
and the parts having been weakened, are unable to support them- 
selves : this is sometimes the case in the mouth, from salivation ; 
in the tongue, &c., in scurvy ; in the intestines, in dysentery, &c. 
Mr. Hunter endeavoured to produce adhesive inflammation in the 
vagina of an ass. He first, by moderate stimulus, could only 
produce suppuration, but by a very active stimulus, as a solution of 
corrosive sublimate, he produced the adhesive, causing coagulable 
lymph to be effused, which afterwards became membranous and 
inseparable, as was seen in the preparation of the parts which he 
exhibited. 
Strength and weakness of the constitution, or of the part affected, GENERAL PRINCIPLES OF INFLAMMATION. 
157 
■will produce very different effects in inflammation. Strength pro* 
duces good effects, and renders the disease more manageable, for 
it lessens irritability. Inflammation is most manageable in parts 
in the following order: muscles, cellular membrane, and skin, and 
the more so the nearer the source of circulation. In other parts, 
as bones, cartilages, ligaments, &c., which have but little power in 
themselves, it is less manageable, though the constitution be good, 
for the constitution feels conscious of the weakness of these parts, 
by which affection of the constitution they become further weak- 
ened. In vital parts, inflammation also is very unmanageable, 
though these have power in themselves; but in consequence of 
their being affected, the universal health is destroyed, and hence 
the disease is less manageable. If the stomach is inflamed, no 
operation of the body can go on well, the powers of restoration 
becoming weaker than ever; hence the greatest danger is to be 
apprehended. 
Strength of the constitution and parts affected, when under inflam- 
mation, produces the following effects : viz., a more ready and 
quick termination, whatever it be. Thus, a wound in a healthy 
constitution unites more readily by the first intention ; adhesive 
inflammation more readily terminates by resolution. If inflamma- 
tion have got beyond the first stage, it passes sooner on to the 
suppurative inflammation; nature going through her operations 
with greater facility and despatch in such a state of constitution. 
Weakness of the Constitution and Parts.-When a wound is made 
in a person of a weak habit, the union is more difficult, and the 
inflammation is more likely to continue ; and this not from there 
being a greatei' disposition to inflammation, but from want of a 
power and disposition to heal, nature needing greater and longer 
exertions to produce the intended effect. 
In this state of the constitution and parts we often find that parts 
seem hardly capable of taking on either adhesive or suppurative 
inflammation : and in some of these habits inflammation will hardly 
even follow a solution of continuity. As in dropsy, I have observed 
that the puncture made by tapping or scarifications will hardly 
heal; a degree of inflammation does take place, but not sufficient to 
procure a healing of the wounds or suppuration, but mortification 
soon comes on. If in such a constitution a wound is made, the 
blood not coagulating sufficiently to heal it by the first intention, 
dies, and becomes an extraneous substance, causing irritation : sup- 
purative inflammation succeeds, and often mortification, which 
mostly proves fatal. 
Effects of Inflammation on the Constitution.-The sympathy of 
the constitution upon an act of violence to the parts, is probably the 
most simple act of a constitution. But this will vary in different 
constitutions, because all constitutions do not sympathize equally. 
It will vary according to the stage of the inflammation, and accord- 
ing to the disposition of the parts inflamed. 
We find the effects of inflammation on the constitution as various 158 
HUNTER'S PRINCIPLES OF SURGERY. 
as any other circumstances, which appear to arise from the follow- 
ing causes ; first, from the nature of the constitution ; secondly, from 
the nature of the inflammation, whether common or specific; if 
common, according to the stage of the inflammation, whether adhe- 
sive, suppurative, or ulcerative ; if specific, according to the kind, 
although I believe specific irritations do not produce much variety 
in the constitution, except the plague, which entirely changes it, and 
such as by their long continuance weaken the constitution, as lues, 
when of long standing; but this will be similar to any lasting 
disease, for at first it certainly does not affect the constitution so as 
to alter the disposition of a wound made on any part: thirdly, from 
the nature of the part inflamed, whether vital or otherwise : and, 
fourthly, from the different situation of similar parts, as of the muscles 
or cellular membrane in the legs or arms, &c. 
In inflammation we have seldom more than the continuous or the 
universal sympathy, but sometimes the remote. The continuous 
causes the inflammation to spread. The general is when the con- 
stitution becomes affected. The remote is seen in pain of the 
shoulder, from inflammation of the liver. 
As the effects which inflammation has on the constitution are by 
sympathy, they will be in proportion to the readiness it has to go 
into that action; and this is much greater in some constitutions than 
in others; moreover, every constitution sympathizes more readily 
with some parts than others. The kind of constitution least affected 
is generally the most healthy where sympathy hardly takes place, 
the surrounding parts even seeming hardly to feel what is going on 
in those nearest them. 
The nature of the inflammation produces, I believe, but little varia- 
tion in these effects : for, of whatever kind, the sympathy will be in 
proportion to the violence of the inflammation, and its rapidity. 
Hence as the inflammation which produces healthy suppuration is 
more rapid, it generally produces more violent effects on the con- 
stitution than any other. 
The effects which inflammation has on the vascular system, and 
which are chiefly discoverable by the pulse, are very remarkable. 
In considering the peculiarities of the pulse, it is always necessary 
to remark that there are two powers acting to produce it, viz., the 
heart and the arteries. That one part of the pulse belongs to the 
heart, another to the arteries, and a third is a compound of both. 
The stroke, which is the pulse, (as regards the number of strokes 
in a given time, the regularity or irregularity as to time, and the 
quickness of these strokes,) belongs to the heart. The vibratory 
pulse and slowness of the systole, with the fulness and smallness 
of the pulse, belong to the arteries. 
As the pulse arises from the actions of the solids on the machine, 
it is of course according to the nature of the machine at the 
time; therefore is capable of being in one of two states, natural or 
diseased. 
In most diseases of the constitution, whether original or arising GENERAL PRINCIPLES OF INFLAMMATION. 
159 
in consequence of diseases of parts in which the constitution 
becomes affected by sympathy, the pulse is altered from the 
natural to the diseased state which is accordin'? to those affec- 
tions. 
The varieties of which the pulse admits are numerous. It may 
be increased or diminished in the number of strokes: regular or 
irregular as to time; quick in its stroke, or diastole, and slow in its 
systole ; or it may be hard in its diastole. In all cases probably, 
when the constitution is in a state of irritation, the pulse will be 
quick and frequent in its number of strokes in a given time, and 
the artery being hard, from the constant contraction of its muscular 
coats, will give a feeling of hardness to the touch: besides which 
the diastole of the artery is not uniformly and regularly the same, 
but there are a vast number of stops or intermissions, which are so 
quick as to give the feeling of vibration, or what we call thrill. 
In such a disposition the pulse may be either full or small. These 
two opposite effects do not seem to arise from the difference in the 
quantity of blood, as might at first be supposed; but arise, I rather 
suspect, from the difference in the degree of strength and quantity 
of irritability that the patient possesses at the time, which when 
joined, give an antidiastolic disposition to the arteries, so that when 
the arteries have a full power of contraction and are in a state of 
irritation at the same time this effect will always take place. 
It is certain that arteries in such a state of constitution do not 
dilate so fully and freely as at other times; and as this varies quickly 
as the state of the constitution varies quickly, it is more reasonable 
to suppose that the effect is immediately from the arteries than from 
an increase or decrease in the quantity of blood. If this is really 
the case, we should naturally suppose that the motion of the blood 
in the arteries would be increased in proportion to their diminished 
size, unless we should also suppose that the systole of the heart 
should be diminished in the same proportion, which I think is pro- 
bably the case/as we find the blood forsakes the surface of the body 
in such a state of constitution, which must therefore be collected in 
the larger veins about the heart. But if the heart were to throw out 
its whole contents at each systole, the velocity of the blood in the 
arteries would be immense, and must be then forced into the small 
vessels on the surface of the body, which it certainly is not. A 
quick hard vibratory pulse is generally attendant on inflammation. 
The fulness or emptiness of the pulse depend greatly on the 
parts that are affected, which either increase or decrease the irri- 
tability. 
Different Parts produce different states of the Pulse.-In inflam- 
mation of common parts, as the skin, cellular membrane, muscles, 
&c., the pulse will be full and strong, and the symptoms acute, 
especially if near the heart. Ligaments, cartilages, tendons, and bony 
parts produce symptoms which are less acute; the pulse is not so 
full, but quicker, there being in these cases a greater degree of irri- 
tability. In the vital parts of the second order, as the brain, the 160 
HUNTER'S PRINCIPLES OF SURGERY. 
pulse is soft and slow; but in the stomach and parts with which it 
sympathizes greatly, as the testicles, upper part of the intestines, &c., 
the pulse is small, quick, and contracted. 
Of the sensations arising from inflammation in different parts.- 
When the injury is in the head, the pain is often dull and attended 
with sickness; when in the heart and lungs, the pain is more violent. 
When in the stomach or upper part of the intestines, it is a heavy 
depressing pain, and attended with more or less of sickness. When 
in the colon it is more acute, but attended with less sickness. When 
the liver, ligaments, or bony parts are affected, the pain is much the 
same as when the stomach is affected, that is, heavy and depressing : 
the pain is acute and rousing when the skin, cellular membrane, or 
muscles are inflamed. 
Inflammations in vital parts do not all produce the same effects 
on the constitution, which would seem to arise from their greater or 
less sympathy with the stomach; but it is certain that a given 
quantity of inflammation in a vital part or its sympathizer will pro- 
duce much more considerable effects than a greater quantity in 
another part, and the blood will be more sizy. When the heart is 
inflamed, its actions are irregular; if the lungs only are inflamed, 
the heart still seems to sympathize, and is irregular in its actions, 
as well as weak. If the stomach is inflamed, the patient feels a de- 
pression and a defective action in the heart as well as in every part; 
simple animal life, or the living principle, seems then to be depressed, 
as the sensitive from inflammation in the brain, and the pulse is low 
and weak. In inflammation of the uterus the pain is very acute, 
and the pulse quick and low, the stomach sick, &c. When inflam- 
mation occurs in these parts the symptoms come on very quickly; 
and if it proves fatal, it runs through its stage very fast; debility 
beginning very early. All this may depend on the stomach being, 
as it were, the central seat of sympathy, whence the actions of life 
are interfered with. However, universal sympathy soon takes 
place here, and the sympathy being similar to the first action, a 
fever of a depressing kind is produced, and death soon succeeds. 
Inflammation of parts not vital, of such violence as to affect the 
actions of life by general sympathy, render the pulse full and strong. 
The constitution in this case is strong and not irritable; for when 
weak and irritable, the pulse is quick, hard, and small in the begin- 
ning, as it is in inflammation of vital parts, and the blood though 
sizy is loose in its texture. 
Difference from different nerves.-One cause of the difference in 
the inflammation of vital parts seems to be the different systems of 
nerves by which they are supplied. In all those parts supplied by 
the par vagum, inflammation affects the patient writh lowness from 
the first, these nerves supplying the parts of involuntary motion, and 
therefore possessing the living principle in the highest degree ; 
whence an inflammation of these parts becomes peculiarly depressing. 
Situation of the blood in the commencement of diseases.-In some 
diseases the blood at first forsakes the skin, extremities, and lips, and GENERAL PRINCIPLES OF INFLAMMATION. 
161 
the parts shrink and diminish in bulk; this is particularly evident in 
the eye, and arises from want of power in the constitution, all the 
powers being called to the citadel, or source of power, and the 
outworks left. This happens in fainting, agues, hectic, &c., and does 
not seem to arise from debility at first, but from a novelty of action, 
and a consequent inability to perform it. In putrid fevers the 
external parts first loose their living power from having a less re- 
sisting power. 
Of the Effects on the Constitution from different stages of Inf ani- 
mation.-The constitutional effects arising from inflammation, inde- 
pendent of the difference of parts, situation, nerves, &c., are more 
or less according to the stage of the disease. When inflammation 
is in the adhesive stage, it has but little effect on the whole system, 
and that effect is generally an increase of animal actions. This 
stage is the one which should be considered as truly inflammatory, 
as in it the constitution appears to be more regular, more deter- 
mined, and more at ease, for it is more steady, more capable of 
continuing the time of action than in any other, hardly any varie- 
ties taking place in the time of this stage of the disease. When 
the suppurative stage comes on, the effects on the constitution are 
much more considerable and more various. Cold fits or rigors are 
generally felt on the commencement of suppuration ; but they are 
not lasting, and arc often succeeded by hot fits, both being more or 
less according to the greatness of the present inflammation and the 
suppuration that is likely to follow, as indeed with the nature of the 
parts, and their situation, whether vital or not, &c. 
Cold fits show plainly the commencement of some new action, 
as the beginning of fever, the absorption of poison, or even from 
simple irritation, as pricking the finger with a clean needle. They 
may also be produced by disagreeable sensations and disagreeable 
states of the mind. These rigors are probably dependent on the 
stomach, which being the seat of simple animal life and the seat 
of sympathy, takes part in every constitutional alteration, and we 
observe how much this viscus is affected by loss of blood, disa- 
greeable sights, &c. What nature intends to effect by this sym- 
pathy with the rest of the body it is hard to say, but it is worthy- 
inquiry whether she may not intend to relieve herself by rousing 
the actions of life by means of vomiting. Rigors seem to be the 
effect of any new action in the constitution, and not at the com- 
mencement of a disease only, for even at the close, changing from 
a diseased action to a healthy one will cause rigors to take place. 
In a strong constitution, where rigors occur in consequence of a 
well-formed fever, the consequent actions of a hot fit and sweating 
go on regularly; but in a weak constitution there is much loss of 
power by each rigor, and they will not be followed by a hot fit, 
but only perhaps by a little sweating. 
A boy was attacked with rigor, followed by sweating, and he 
afterwards continued getting sensibly worse and worse: pulse 
quick and full, blood sizy, tongue white. He was worse every 162 
HUNTER'S PRINCIPLES OF SURGERY. 
other day. After being ill a fortnight, he was again attacked with 
rigor, hot fit, and sweating, which, contrary to my expectation, 
who supposed these would be repeated, carried off the disease with 
that single fit. I think I have seen other cases where Nature has 
attempted something like this, but has failed. 
In many cases the rigor is the first apparent symptom, and is 
followed by a hot fit, and then sweating, and when these whole 
actions of the disease have taken place the patient becomes well; 
but this is not the case where, from weakness, &c., the whole 
regular actions do not take place, but, as at the commencement of 
the boy's case above related, the hot fit does not succeed the rigor, 
and he continued ill afterwards until Nature again took on the 
rigor, and he was able to go through the stages regularly, and one 
fit carried off the disease. The boy above mentioned was also a 
striking instance of the crisis of a disease being like its commence- 
ment. 
Rigors from a local affection are seldom followed by a hot and 
sweating stage, and the bark in such cases can be of little service. 
The ulcerative stage seldom affects the whole system; but that 
rigors take place on the commencement of ulceration is, I think, 
certain, although it cannot be well perceived in all cases, for ulcera- 
tion will follow so close on suppuration in most cases that it will 
be difficult to distinguish which was the cause of the rigors. But 
when suppuration has taken place, and the abscess been opened, 
(so that the act of suppuration is finished,) yet not so opened as to 
afford a ready outlet to the matter, the pressure of the matter 
against the most depending part of the abscess will cause ulcera- 
tion, and thereby rigors will take place ; but these rigors will not 
take place for some time after the first opening, for the first opening 
will for a time remove the disposition for ulceration all over the 
surface of the abscess ; but when it finds this opening not sufficient 
to take off the pressure, it then sets to work to make another, and 
the rigors return. Many have supposed from these rigors that new 
matter was forming. 
Exacerbations are other symptoms, which have a great affinity 
to the foregoing, and are common to most constitutional diseases, 
and to some local ones. They are repetitions of the first attack, 
but seldom so strong as the first. These have been supposed to be 
owing to the disease acting on the constitution at stated times ; but 
we must search for some principle in the animal economy to 
account for this, for we cannot suppose an increase and decrease 
in the cause of disease to account for it. Agues exist in the con- 
stitution as much between the fits as in them. If the constitution 
is strong, the exacerbations are regular; if weak, irregular. These 
may be partly owing to the fact that an animal cannot exist for 
long together in the same state ; life cannot always be affected in 
the same way. 
Of the state of the blood in hflammation.-It is reasonable to sup- 
pose that the blood is affected in the same manner with the con- GENERAL PRINCIPLES OF INFLAMMATION. 
163 
stitution, and that disease has nearly the same effect on it that it 
has on the body, because the same living principle runs through the 
whole. We find this to be really the case; for till the disease has 
affected the constitution the blood continues the same as before; 
but as the constitution becomes affected the blood also becomes 
affected, and undergoes changes which are probably owing to con- 
tiguous sympathy between the vessels and the blood. So that we 
shall find that the changes in the blood are often as expressive of 
disease as in any other part of the body. When the action of 
the solids is of the inflammatory kind, or what is perhaps the 
same thing, when there is too great action of the solids, the blood 
under such a disease more readily admits of a separation of its com- 
ponent parts (see p. 32, note) ; the red particles subside more to 
the bottom of the coagulum, and the coagulation of the lymph, 
though more slow, is firmer; the upper part of the coagulum being 
of an opake white, in which state the blood is said to be sizy. It 
is not easy to say whether this change in the blood is not the first 
produced, and that the constitutional is not an effect of the change. 
I have before said that I can conceive the death of the blood to 
take place independently of the solids, and it appears to me that the 
diseased state of the blood is capable of coming on as suddenly as 
the corresponding state of the solids. 
A man received a stab in the abdomen. I saw him a little time 
after the accident, when there was no degree of fever or constitu- 
tional affection, but he complained of considerable pain; I therefore 
took away some blood from him, which was entirely in the natural 
state : in about a quarter of an hour constitutional disturbance came 
on, and the blood appeared very sizy. 
Whether the disposition for inflammation and the change produced 
in the blood arise from a real increase of animal life, or whether it 
is only an increase of the disposition to act with the power that 
the machine is already in possession of, is not easily determined: 
but it appears certain that it is either the one or the other. How- 
ever, some circumstances incline me to suspect that it is the last, 
because we often have inflammation when the powers are but weak, 
where there appears to be only an exertion of very weak powers, 
arising from some irritation produced. This appears to be equally 
the case in local inflammation and inflammatory fever, or the 
symptomatic fever. On the other hand, there are some reasons 
for thinking it may be a real increase of animal life, for women 
who are breeding, and who are in perfect health, have yet sizy 
blood: and this is the case with all animals in a similar situation. 
Now it would appear necessary for an animal, when put into a 
situation where greater powers are wanted, that these powers 
should be increased. In breeding females there is a process going 
on which, though natural, is uncommon, and which requires a 
greater quantity of power than usual; therefore we have greater 
powers produced. 164 
HUNTER'S PRINCIPLES OF SURGERY. 
If these observations are just, the blood should not be inflamma- 
tory blood, but blood whose powers of life are increased. 
On the other hand, where there is great debility in the solids, 
where the powers of preservation are less, and therefore action 
weak, where the body must therefore have a tendency to dissolution, 
we find the very reverse of the former appearance in the blood; there 
is no distinct separation, but the whole mass continues mixed. This 
effect takes place in those who die instantaneously, and I suspect 
that the blood dies first, and instantaneously. 
When the pulse is quick and hard, and has a kind of vibratory 
thrill, we generally have sizy blood. This may arise from fever, 
or such inflammation, &c., as affects the constitution or the vital 
parts, these being diseased, so as to keep up a constitutional irrita- 
tion, which will always be an attending symptom. 
But when we have neither a quick nor hard pulse, but rather 
small, no visible fever nor inflammation, but perhaps some strange 
and undetermined symptom, such as pain, which is moveable, 
sometimes in one place and sometimes in another, yet seeming to 
impede no natural function, we shall nevertheless, on bleeding, find 
the blood sizy, as happened in a gentleman who had severe pain 
shifting about, with a small slowr pulse : he was blooded, and the 
blood found sizy. After the bleeding the blood became fuller and 
harder, and did so after every bleeding, which, on account of this 
circumstance and the continuance of the pains, was repeated several 
times. Something like this is observable when an oppressed pulse 
becomes liberated by bleeding ; but what was remarkable here was 
its increasing in hardness. We may even have the blood contract, 
so strongly in these cases as to cup. So that the pulse and the 
appearance of the blood do not always agree with one another. 
The manner in which inflammation begins is generally from a 
point. It afterwards spreads from this in proportion to the violence 
and the disposition of the surrounding parts. This is the case in 
accidents; the accident is limited, but the inflammation arising 
from it is not; it is most violent in the first point and gets weaker 
and weaker as it spreads from this until it is lost insensibly in the 
surrounding parts. This extension is owing to sympathy; and 
hence, according to the susceptibility of sympathy will be the 
spreading; and from the difference of disposition to sympathy will 
result great differences as to the diffusion of inflammation ; the more 
healthy the less the sympathy. 
Swelling of the parts in inflammation, like the inflammation itself, 
is greatest in tho middle, and gradually lessens from that till it is 
lost in the surrounding parts. It is owing to the extravasation of 
coagulable lymph and some serum being squeezed out as the coagu- 
lable lymph thickens, and is deposited around the inflamed part, 
causing oedema, which is less in proportion as the parts are healthy. 
Of the colour of inflamed parts.-The colour of an inflamed part 
is visibly changed from the natural hue, whatever it was, to red. 
This red is of various hues, according to the nature of the inflam- GENERAL PRINCIPLES OF INFLAMMATION. 
165 
mation; if healthy, of a pure scarlet red; if less healthy, the 
colour is rather more of a purple, and so on till it shall be of a 
bluish purple. 
This increase of red would appear to arise from two causes; 
first, dilatation of the vessels, by which a greater quantity of blood 
is sent into those vessels which naturally admit only serum or lymph 
(an example of which we have in the conjunctiva of the eye when 
inflamed) ; and secondly, the formation of new vessels in the extra- 
vasated uniting coagulable lymph. From which circumstances 
there is a greater quantity of blood in the part than in a natural 
state, according to that law of the animal economy, that where a 
part has more to do than to support itself, red blood is thrown into 
it in larger quantities. 
The true inflammatory colour is scarlet, that coloui' which the 
blood has in the arteries ; hence we should suppose that the arteries 
were chiefly dilated, or if the veins are equally distended, that the 
blood undergoes no change in such an inflammation in the passage 
from the arteries into the veins, which last I think most probably 
the case. 
Heat of the inflamed part.-The inflamed part is hotter than 
common; but this is most obvious in the skin, from its being a part 
most disposed to carry these sensations to the brain. Heat, I 
imagine, is a sign of strength and power in the constitution, though 
it may often arise from increased action in weak constitutions or 
weakened parts. Jt is an immediate action, while cold is the 
reverse, and often arises from a diminished action of strong parts. 
It has not been considered whether an animal has this power 
equally in every part of his body, though from what is generally 
advanced on this subject, it is probable that it exists in every part. 
Nevertheless, I am inclined to suspect that there is a principal 
source of heat, though I do not think with many that this source 
is in the blood, but rather that this is affected by the source of the 
blood being near to the source of heat. 
That this principle resides in the stomach is probable; at least of 
this I am certain, that affections of the stomach will produce either 
heat or cold. Eructations often give a sensation of heat, but 
whethei' this is increased heat, or only a sensation, it is difficult to 
say. Certain substances taken into the stomach produce a glow. 
Certain affections of the mind also produce a glow. This would 
appear to contradict my opinion, but I suspect that the stomach 
sympathizes with the mind. 
We find that inflamed parts become hotter; but let us see how 
far the increase goes. From all the observations I have made, I 
do not find that a local inflammation can produce local heat above 
that which is natural to the animal; and when in parts whose 
natural heat is inferior to that which is at the source of the circula- 
tion, it does not rise so high. A man had the tunica vaginalis laid 
open for the cure of hydrocele; I introduced a thermometer into 
the wound, and placed it in contact with the testicle, and it stood 166 
HUNTER'S PRINCIPLES OF SURGERY. 
at 92°; by night it had risen to 98i°, a rise of 62°: but this is not 
greater than the heat of the blood at the source of the circulation. 
A wound was made in the belly of a dog, and the bulb of the ther- 
mometer immediately applied to the diaphragm, which gave 101°, 
and did not increase above that. Another dog's rectum gave 102°, 
and when inflamed very much, which it was by injecting a solution 
of corrosive sublimate, the heat was not increased a degree. The 
rectum of an ass, 98°, was injected with a strong infusion of 
mustard and ginger several times repeated, but without increasing 
the heat at all, nor did a strong solution of corrosive sublimate 
have this effect: at last a much stronger one was injected, which 
brought on a very violent inflammation, but the heat was only 
increased to 100°. A similar experiment was made with nearly 
the same result on the vagina of the same ass. Also a wound was 
made deep in the gluteus muscle of the same ass, and in no stage 
of this wound did it raise the thermometer above 100°. A wound 
was made in the belly of the same ass, and an injection of a strong 
solution of common salt thrown into the belly, which produced 
violent inflammation, and even symptomatic fever; yet the heat of 
the part was very little altered. From all which observations and 
experiments I do not find that a local inflammation can increase 
local heat above the natural heat of the animal; and when in parts 
where the natural heat is inferior to that at the source of the circu- 
lation, it does not rise even so high. Yet, that in some instances 
the heat of the parts may be increased beyond its natural degree 
in those parts which have the greatest natural heat, is certain from 
the following experiment; the bulb of the thermometer being held 
in the stream flowing from the abdomen of a man tapped for dropsy 
raised the mercury to 104°. In most of the above experiments 
there seemed a difference of 1° between the heat at night and in 
the morning, and this difference seems to exist in the natural state 
of the body. 
I suspect that the blood has an ultimate standard of heat in itseIf 
when in health, and that nothing can increase that heat but some 
universal or constitutional affection, and that the whole power of 
local inflammation is only to increase it a little in the part, but 
cannot bring it above the standard heat of the constitution, nor 
even to it in parts far from the source. 
Of Cold.-The production of cold certainly is an operation 
which the more perfect animals have a power of performing. (See 
p. 82, note.) 
I suspect that coldness in disease arises from weakness of the 
whole constitution, joined with a peculiar mode of action at the 
time. That universal or constitutional cold arises from the stomach 
is evident, for whenever we are made sick universal coldness takes 
place. This is best proved by producing sickness in animals that 
we can kill while under the influence of the affection of the stomach. 
I threw three grains of emetic tartar into the stomach of a bitch, 
and repeated the experiment with a grain more: she vomited and GENERAL PRINCIPLES OF INFLAMMATION. 
167 
strained very hard, and brought off a good deal of froth, that is 
mucus, from the stomach, mixed with air in coming up. I opened 
her body, and, contrary to what we generally observe, I found the 
intestines, liver, and heart not warm. I have known people who 
had affection of the stomach say that they had plainly a feeling of 
coldness in their belly. I knew a gentleman who said, whenever 
he threw wind off his stomach it felt cold even to his hand. 
Affections of the mind also produce general coldness, but such 
effects arise from the sympathy of the stomach with the mind, 
producing there such a sensation as we mean by the expression 
" turning the stomach with sicknessthe sensation proceeds to 
the shoulders, which, with the rest of the body, are put into motion 
by what we term shuddering. 
Of Pain in Inflamed Parts.-The immediate cause of sensation 
is an alteration in the natural position of the solids, arising either 
from violent action or mechanical or chemical effects,* joined 
with its being produced in a given time; for this alteration may be 
produced so slowly as not to keep pace with sensation, as in many 
* [It must be confessed that we are very much in the dark respecting the 
proximate cause of pain ; for being ignorant of the ultimate distribution of the 
nerves, as well as of their mode of action, we cannot say in what manner they 
may be affected; indeed, we cannot positively say that pain depends on the 
nerves at all, for those parts which are most painful when inflamed have the 
fewest nerves, and these do not enlarge in consequence of inflammation in the 
same manner that the vessels do. 
Pressure is a well-known cause of pain, and therefore has been assigned as the 
cause of pain in inflammation, for not only are the minute vessels distended 
from within and pressed upon without, but the natural sensibility of the parts is 
exalted by the increased vascularity. This is further confirmed by the exquisite 
pain occasioned by inflammation when it occurs in any unyielding texture, as the 
teeth, the bones, the periosteum, the serous and fibrous membranes, &c., as well 
as by the relief which is afforded by such means as tend to diminish the tension 
of the inflamed parts, as bleeding, scarifications, fomentations, &c. It may, 
however, be urged on the other side, that the pain is not proportioned to the 
quantity of nerves, as in fibrous membranes, bone, teeth, &c.; nor to the quantity 
of effusion and consequent swelling, as in serous membranes ; nor to the quantity 
of inflammation present, as in gout, rheumatism, &c.: that the difference in the 
quality of the pain is inconsistent with any mechanical explanation, which would 
occasion differences in degree but not in kind ; that it is irreconcileable with the 
sudden transition of pain from one part to another, as in metastasis ; that chemical 
substances cannot be supposed to act in this way ; and finally, that pain often 
occurs without its being possible to assign any probable source of pressure as a 
cause, as in colic, tic-douloureux, tooth-ache, and many other forms of nervous 
disorders. 
It seems, therefore, most probable that pain depends on some peculiar action 
of the nerves with which we are unacquainted, but to which pressure stands in 
the relation of an exciting cause. 
Pain is the most general symptom of inflammation. What other purpose does 
it answer besides that of inducing the patient to repose the inflamed part 1 Does 
it answer any direct purpose in the economy 1 Intense pain occasions increased 
vascularity of the affected part, and if continued, excites inflammation. This is 
seen in tooth-ache and tic-douloureux, which inflame the face, and in disease of 
the hip, which occasions inflammation of the knee; on the other hand, whatever 
diminishes the pain diminishes the inflammation also.] 168 
HUNTER'S PRINCIPLES OF SURGERY. 
indolent tumours; or, on the other hand, this alteration in the 
natural position of the parts may be so quick as to exceed sensation. 
(See p. 56.) 
Pain is not the same in all the stages of inflammation. In the 
adhesive stage it is generally but inconsiderable, especially if it is 
to go no further, and is perhaps more a heavy than an acute pain. 
But when the inflammation is passing from the adhesive to the 
suppurative, the parts are undergoing greater change, and the 
pain gets more and more acute until it becomes very considerable 
and becomes pulsatory, being increased during the dilatation of the 
arteries. The nerves, too, acquire a degree of irritability which 
renders them much more susceptible of impression than in a natural 
state. When suppuration has taken place, the pain in some degree 
subsides; however, as ulceration begins, it in some degree keeps up 
the pain, and this more or less according to the quickness of the 
ulceration. The pain attending ulceration gives more the feeling 
of soreness. 
Of the Subsidence of Inflammation.-Whatever' disposition it is 
which produces inflammation, and whatever the actions are which 
are produced by this disposition, yet when the disposition arises 
either from the constitution or part, it can be removed, and of 
course the actions raised in consequence of it cease. 
If the disposition for inflammation has taken place, and the vessels, 
which are the active parts, should have dilated thoroughly, they will 
allow the blood to enter them, so that the part shall look red; but no 
hardness or fulness shall be observed, and the whole will subside 
before adhesions have taken place: or if inflammation is gone so 
far as to produce swelling, which is the adhesive state of the disease, 
yet by certain methods it can be assuaged, and suppuration be pre- 
vented from taking place, and then the parts will fall back into their 
natural state, which is called resolution. And as the first symptom 
of inflammation is pain, the first symptom of resolution is the 
cessation of pain. 
Why an inflammation of any kind should cease after it is once 
begun is very difficult to explain, or even to form an idea of, unless 
it is on the principle of what I call custom that the parts adapt them- 
selves in time to their present situation ; and therefore, in order to 
keep up inflammation, it is necessary that the cause should increase 
in proportion as the parts become reconciled to their present circum- 
stances. But this will not account for their returning to their 
original state when this increased irritation ceases. We may sup- 
pose that the removal of the original cause is sufficient to stop the 
progress of inflammation; and when stopped, the parts cannot 
easily remain in the inflamed state, but by their own efforts begin to 
restore themselves to health, like a spring which is bent by a weight, 
but the moment the weight is removed the spring returns to its former 
state. 
Restoration of injured parts.-All alterations in the animal frame 
arise from a disposition to act, and these preternatural actions, in 
consequence of injuries, may be caused,-1st, by a disposition to GENERAL PRINCIPLES OF INFLAMMATION. 
169 
restoration, in consequence of injuries, which is the most simple ; 2d, 
by a disposition of necessity, as thickening of parts, ulceration, &c., 
which is rather more compounded: 3d, by disease, which is the 
most complicated (p. 97.) There are a great many cases requiring 
the assistance of a surgeon but which cannot be strictly called 
disease, but are injuries done to the body. In disease there 
is a disposition to wrong action, which goes on until the disposition 
is worn out, or is put a stop to by remedies ; but the actions in con- 
sequence of accident are widely different, for here, by reason of the 
stimulus of imperfection in the injured part, a disposition to restora- 
tion is excited, and action, different from the former comes on. In 
disease the restoration to health is produced by a prevention of the 
continuance of diseased action; in injuries, or alteration of structure 
by violence, something is required different from the ordinary and 
natural actions, which will differ in some respects according to the 
nature of the violence and of the part; and this alteration is of the 
most simple nature, being the action in consequence of a disposition 
to restoration, and consequently if it requires any assistance from 
art, it is of the most simple kind. The affections from accidents 
may be divided into two kinds, those which take place in sound 
parts, and those in parts before diseased. The first I shall only 
treat of now. Accidents, then, may be divided into two kinds ; first, 
those which do not communicate externally, as bruises, sprains, rup- 
tured tendons, simple fractures, &c.; secondly, those which have 
also an external communication, as compound fractures, wounds, 
&c.; yet these may be, and often are, brought under the first head. 
Bruises, which have destroyed the life of a part, might be con- 
sidered as forming a third head. The first class, when in a simple 
state, requires a most simple treatment; but they may be so com- 
plicated as to require our utmost exertion. The most simple of these 
is the bruise, when the continuity of parts is not broken through; 
here the parts have nothing to do but recover themselves. The 
rupture of a small vessel is next, the blood being effused into the 
cellular membrane ; but the vessel must not be in a part of any con- 
sequence to life, or the extravasation may kill, as in the arteries of 
the brain. The cure in this case will be next in simplicity, the 
vessel being closed by the contraction of its muscular coats, and 
the union effected by means of coagulable lymph, and the extrava- 
sated blood being taken up by the absorbents. The differences in 
these cases will arise from the magnitude of the injury and the 
nature of the injured parts. Some accidents of the first class, as 
fractures, will require the aid of a surgeon to restore the parts to 
their natural situation, and then nature falls to work and completes 
the business. Sometimes the quantity of blood extravasated is so 
large as to prevent nature from going through these processes 
directly, and forms a tumour called an ecchymosis. Ecchymosis 
may be said to be of two kinds ; one is where the blood coagulates; 
the other where it does not. That which coagulates commonly 
subsides gradually, from the blood being absorbed, and gives but 170 
HUNTER'S PRINCIPLES OF SURGERY. 
little trouble, which is likewise the case sometimes with those in which 
the blood does not coagulate, though not generally. I have seen where 
a small wound has led to the cavity containing the coagulum, which 
not being meddled with, the sides of the cavity have gradually con- 
tracted, and have as gradually squeezed out the coagulum. 
A woman fell with the labium pudendi on the edge of a pail. I 
found a very considerable tumour, which I thought was of blood ; 
there was evidently a fluctuation. I bled her, and ordered a poul- 
tice, but did not open it, as I thought the presence of the extrava- 
sated blood might serve to stop the orifice of the vessel. In a little 
time the tumour burst, with a small opening, and on examining with 
a probe I found the coagulum filling a space the size of a goose's 
egg. The cavity grew less and less, but always kept exactly filled 
with coagulated blood ; and thus it continued diminishing until the 
orifice healed. Thus the blood being allowed to remain in the cavity, 
and not acting there as an extraneous body, nor even allowing the 
stimulus of an imperfect cavity or inflamed surface to take place, 
the cavity continued to contract all round the blood until the whole 
had disappeared. Now what wrould have been the consequence if 
I had followed the old method of laying open the tumour, scooping 
out the blood and dressing the internal surface with turpentine ? I 
should have had a sore of the whole extent of the tumour, and given 
considerably more trouble both to the patient and to myself. 
The second species of ecchymosis, or that where the blood does 
not coagulate, does not always terminate so well as the former. 
It has often the appearance of an encysted tumour, but from being 
the immediate consequence of some accident to the part its nature 
is understood. The cause of this blood not coagulating must arise, 
I conceive, from some peculiar mode of action of the vessels arising 
from the injury, for I apprehend that in such cases the blood dies 
as it is extravasated, or in the act of extravasation, like the menses. 
This species of ecchymosis happens very commonly to children in 
birth under the scalp. In such cases nothing should be done but 
to wait with patience, and the whole will be absorbed. In many 
cases the accident has been so violent as to deaden the cellulai' 
membrane under the skin, or as to produce inflammation in the 
surrounding parts ; these sometimes resolve, but they are seldom 
allowed to do so ; for surgeons are led to open them early, from 
seeing the inflammation and feeling fluctuation, two strong entice- 
ments to use the lancet when all circumstances are not well at- 
tended to. But in such cases I should wait until I saw the signs of 
suppuration, viz., thinning of the skin over the matter and pointing 
of the contents, which are the only true marks of the formation of 
matter and of its approaching the skin. 
Sometimes ecchymoses are removed by pressure, which without 
this would remain. Parts cannot bear pressure, so that the extra- 
vasated blood being pressed against the sides of the cavity, the 
absorbent vessels are under the necessityof absorbing it. 
When ecchymoses are not absorbed, but suppurate, abscesses 
are formed, which must be treated as abscesses in common, only GENERAL PRINCIPLES OF INFLAMMATION. 
171 
waiting with a little more patience than when wholly the conse- 
quence of inflammation. In many of those cases of accident not 
only the skin shall be deadened, in consequence of which it will 
slough and leave a sore, but often the skin shall preserve its living 
powers, and only the cellular membrane underneath shall be dead- 
ened and slough, and produce an abscess, which was not at first 
expected. In cases where the skin in one part is killed by a blow, 
and the cellular membrane in another part, while the skin over it 
will remain sound, the deadened skin will come off, granulate, and 
heal kindly ; but then inflammation shall take place, perhaps, an 
inch or two from it, where the cellular membrane was deadened, 
and an abscess shall be produced. 
If these injuries are not very great, little effect will be produced 
on the sensitive principle, no sympathy or irritation taking place ; 
but sometimes the accident will, by its irritation, produce another 
action of the parts, causing inflammation, the end of which is either 
adhesion of the divided parts or suppuration for getting rid of the 
substances become extraneous. The most simple accident may be 
attended with such circumstances as will prevent the more simple 
process of nature from taking place ; such, for instance, as the 
magnitude of the vessel ruptured, or a fractured rib wounding the 
lungs, &c. 
The second division I made was where wounds communicate exter- 
nally.-These are subject to greater variety than the former, yet 
often admit of the same mode of cure. A wound may be either 
simple or compound. The simple, which is what I mean to speak 
of now, is a solution of continuity in a part, which must be made 
with a cutting instrument. In such cases a number of vessels are 
always divided, blood is effused, and the cells of the cellular mem- 
brane exposed, as well as other internal parts. The former class 
required only rest, but in these there is a necessity for replacing 
the divided parts. The present class admit of both a natural and 
an artificial cure. By the natural is meant union by the first inten- 
tion ; when this cannot be obtained, a new bond of union takes 
place-adhesive inflammation ;* and if this is lost, a third mode- 
granulation. In that by art we have to imitate the natural, we are 
to bring the divided surfaces into contact; the living extravasated 
blood being then retained and coagulating, unites them ; the mouths 
of the vessels shut, and the remaining blood is absorbed: the red 
globules are indeed absorbed, and only the coagulable lymph 
remaining becomes the bond of union.t This is an imitation of 
* [Union by the first intention and adhesive inflammation are in the present 
day generally considered to be synonymous.] 
j- [It has been before observed that the blood does not become vascular, but 
only the coagulable lymph which is subsequently effused. The blood at first 
serves the useful purpose of uniting the divided parts ; but beyond this it unques- 
tionably is an impediment to union by the first intention. Wherever, therefore, 
union by the first intention is desired, the incised surfaces should first be cleansed 
of adhering blood previously to their being put into apposition. This rule of 
practice is universal.] 172 
HUNTER'S PRINCIPLES OF SURGERY. 
nature ; but surfaces cannot always be brought to unite in this 
manner, and the blood in some parts loses its living principle, and 
then it becomes a source of irritation, exciting inflammation, which 
is the case sometimes in simple fractures, and which I shall call, 
for distinction's sake, simple compound fractures. 
The best time of replacing the divided parts is perhaps during 
the time that the extravasation continues, but it may also be done 
when the discharge of coagulable lymph in the adhesive or first 
stage of inflammation takes place. Sometimes the inflammation 
runs so high as to get into the suppurative stage; the extravasated 
fluids may lose their living principle, and become a stimulus exciting 
inflammation. 
By adhesive inflammation different parts of the body may be 
united to another by coming into contact; but the most extraordi- 
nary union is that of removing parts from one body and uniting 
them to another. Here is the testicle of a cock, separated from 
that animal, and put through a wound made for that purpose, into 
the belly of a hen; which mode of turning hens into cocks is much 
such an improvement for its utility as that of Dean Swift when he 
proposed to obtain a breed of sheep without wool. The hen was 
afterwards killed, and the testicle was found adhering to the intes- 
tines, as may be seen in this preparation, where the parts are pre- 
served. Here is another preparation, in which the spur of a cock 
has been inserted into the comb of another; and here a human 
tooth, inserted into the same part, and united by means of vessels, 
which you see injected, from one to the other. These living bodies 
thus applied to each other produce adhesive, not suppurative inflam- 
mation. In the same manner, the eggs of one animal laid in the 
flesh of another do not excite suppurative inflammation. This 
would not be the case if the inserted body did not contain the prin- 
ciple of life, for the part would run into suppurative inflammation, 
as would be the case with a pea so introduced. While the guinea- 
worm is endowed with the living principle it gives but little trou- 
ble; yet if killed it gives the stimulus of an extraneous body, which 
produces suppuration through its whole length. 
In this preparation you see a maggot deposited, just below the 
skin, on the back of a reindeei': here the first stage of inflamma- 
mation took place only; coagulable lymph was poured out, which 
has formed a chamber in which the insect resided. A similar power 
is observable in vegetables. Here is an oak leaf, which I picked 
up in my garden; you observe on it seven or eight protuberances, 
exactly circular and uniform. These have been formed by the in- 
sertion of the eggs of an insect into the leaf; and I cannot but 
think the process would have been different if any substance not pos- 
sessed of the vital principle had been inserted. It is on this princi- 
ple of union by the first intention that the union of parts by suture 
has been recommended, which has been found the best practice 
where it can be done. The dry suture in superficial wounds 
answer very well, the quilled is sometimes useful, and the inter- OF ADHESIVE INFLAMMATION. 
173 
rupted is very often useful. The two last are properly called 
sutures. In many cases it is improper to keep the surfaces together, 
as when the wound has been attended with considerable contusion, 
which generally occasions sloughing of the parts. When much 
blood is extravasated, suppuration becomes necessary, in conse- 
quence of the blood acting like any other extraneous body; but 
when laceration only is present, union by the first intention may 
take place, especially when on the head and over other superficial 
bones, as Mr. Cline has observed. The machine is not at all dis- 
turbed by this most simple operation; there being perhaps even no 
local action except the contraction of the vessels, the union being 
performed by the blood only. 
CHAPTER XIII. 
OF ADHESIVE INFLAMMATION. 
Natural tendency of inflammation.-Definition of inflammation.-Seat of inflam- 
mation.-Adhesive inflammation ;-why limited, and how ;-its tendency ;- 
arising more easily in some parts than others;-lymph affected by the state of 
the parts secreting it;-appearances of inflammation ;-redness ;-swelling;- 
pain.-Adhesive inflammation; its use, in large cavities;-in the cellular 
membrane;-in the lungs;-compared with erysipelatous inflammation ;- 
sometimes imperfect;-consequences of this imperfection;-constitutional 
effects of this inflammation.-Of resolution ;-cases in which it is supposed 
to be improper ;-modes of by constitutional means ;-by weakening ;- 
by temporary weakness ;-by lessening irritability.-Venesection;-medi- 
cines ;-local applications.--Treatment of adhesive when about to end in sup- 
purative inflammation. 
Although inflammation is an action produced for the restoration of 
the most simple injury in sound parts that exceeds union by the 
first intention, we must still look upon it as one of the most simple 
operations of nature. It is to be considered only as a disturbed 
state of parts, which require a new but salutary mode of action to 
restore parts to that state in which the natural mode of action will 
be necessary. But this same operation can and does vary, and is 
often carried much further than union, according to circumstances: 
and is often attended with disease, and that of various kinds, by 
which means it becomes more and more complicated. It becomes 
therefore necessary to begin by describing it in its most simple 
form, and with its most general effect, and to particularize further 
as we go on. 
I shall call everything inflammation that produces the following 
local effects, viz., pain, swelling, and redness, all depending on one 
cause, and occurring at the same time. Out of inflammation arise 
many other local effects, which may be called secondary; such as 174 
HUNTER'S PRINCIPLES OF SURGERY. 
adhesions, suppuration, ulceration, and even death or mortification 
in the part, and universal affection, such as sympathetic fever, and 
universal death. 
The act of inflammation is, as I have said, most probably in the 
smaller vessels. What the action is, or in what it differs from the 
common action of these vessels, is not easily ascertained; for we are 
better able to judge of the immediate effects than of the immediate 
cause. 
Hitherto I have only shown that this inflammation takes its rise, 
and is capable of uniting parts, when preternaturally divided, but 
we shall find that it is capable of arising from very different causes, 
and that it is capable of producing adhesions in whole parts, or in 
natural separations, such as common cellular membrane, large 
circumscribed cavities, joints, &c., and these effects will be found to 
answer very important purposes. 
As the adhesive inflammation precedes the suppurative in every 
part excepting the outlets, and the suppurative the ulcerative, the 
propriety of following this order of nature in treating of them will 
appear evident. 
Adhesive Inflammation.-If the actions of adhesive inflammation 
were allowed to extend themselves, it would prove more hurtful 
than any good that could arise from it; hence there are natural 
obstructions to its extending, which we shall first consider. 
Natural Causes of the limiting of Adhesive Inflammation.-I have 
already observed that exposure of internal surfaces becomes the 
immediate cause of inflammation; that when it extends further than 
the exposed surface it is by continuous sympathy ; and that when a 
whole cavity is wholly exposed, the whole would take on inflamma- 
tion. We may now observe, that whenever a cavity is opened, 
the simple contact of its sides, or even the simple contact of these 
with any other living part, will set bounds to the immediate cause, 
which is the exposure. 
To explain this further, we may observe that there is no such 
thing in an animal as an empty space in any of the circumscribed 
cavities of the animal body, exclusive of the outlets or reservoirs, 
which are imperfect, not being circumscribed. Every other part 
of an animal is either connected by the cohesion of one part with 
another, or by simple contact. This holds good too in the cellular 
membrane as well as the circumscribed cavities : for if a wound is 
made into either, we find that the surfaces of both, beyond the cut 
edges, are entire, and generally in contact with one another. 
To explain this position, let me instance a case. If we make a 
wound into the cavity of the belly, in a sound state of those parts 
we shall find every viscus is in contact with some other viscus, and 
that the whole inside of the peritoneum is in contact with the viscera, 
so that no space is unfilled. If this wound is not allow'ed to heal by 
the first intention, still we find that no inflammation will take place, 
or extend further than the attachment of those parts to the cut OF ADHESIVE INFLAMMATION. 
175 
edges, excepting what is owing to continuous sympathy. If this 
were not the case, every part of the cavity must inflame, because 
every part would be equally exposed; and if the contact were 
removed at the time of receiving the wound, or at any time after- 
wards, the whole cavity must inflame, every part being in the same 
predicament as regards exposure. 
The same thing would happen in the cellular membrane, if those 
cells were not in a natural state in contact, and inflammation would 
as readily extend over the surface of each cell as air does when 
blown into part. 
Inflammation, then, takes place at the edges of the exposed parts 
in order to preserve this contact, as well as to serve as a basis for 
future operations : and in cases of spontaneous inflammation of cir- 
cumscribed cavities, we find that where this contact is completest 
the inflammation and its consequences are the least; as in the belly, 
in cases of peritoneal inflammation, the inflammation is greatest 
in the angles between the viscera, where the parts are not so well in 
contact. 
The effect of simple contact, in excluding the irritation from 
extending, was well illustrated in a woman who had the Caesarian 
operation performed. After the child was extracted, the wound 
could not be brought together well, therefore so far gave rise to 
peritoneal inflammation; but the belly closing and falling in on its 
contents, the whole came in contact as before. The woman lived 
twenty-six hours, which gave time for the inflammation to take place. 
After death it was found that the intestines were united to the peri- 
toneum all round the wound, for above half an inch in breadth, and 
the surface of the intestines, which lay unattached at the bottom of 
the wound, was inflamed, while every other viscus, as also the 
peritoneum beyond the adhesions, were free from inflammation. 
The adhesive inflammation seems to be nearly of the same nature, 
whether it arises from the constitution, from a particular disposition 
of the part, or from some violence inflicted on the part; the final 
intention being nearly the same in all these cases, for in all it is an 
effect that has a tendency to repaii' an injury, as is evidently shown 
in many cases of violence, though it may not in all. Its utility is 
most obvious in those cases which arise from the constitution, or 
from disease in a part. When the adhesive inflammation arises 
from the constitution, it may be from some disease of that con- 
stitution ; and, if so, it may be supposed to be of service to it, 
especially if it should be supposed to be the termination of an uni- 
versal irritation in a local one, and by that means relieving the 
constitution of the former, as in gout. But where it is only a simple 
adhesive inflammation, I am rather apt to think that it is more a part 
of the disease than an act of the constitution, or termination of the 
disease. When it proceeds from a disposition in a part, it must be 
considered to arise from a disease of that part. 
Although in all cases and in all parts the adhesive inflammation is 
not absolutely necessary and preparatory for the suppurative inflam- HUNTER'S PRINCIPLES OF SURGERY. 
176 
mation, yet if it is in the cellular membrane or a circumscribed cavity, 
then its effects will prove salutary. It may indeed be considered 
absolutely necessary to prevent greater mischiefs, for very bad 
consequences would arise without it. The object of it in these parts 
is to unite the parts together for their future benefit by means of the 
coagulable lymph and serum thrown out, by which the extension of 
the suppuration will be limited. 
It would appear from observation that some surfaces of the body 
have a much stronger disposition to throw out coagulable lymph 
than others; or we may view this effect in another light, that some 
surfaces of the body do not so readily unite by exudation of the 
coagulable lymph as others do, and therefore on such surfaces there 
is commonly a much larger quantity thrown out than probably 
would have been if union would have readily taken place. Thus 
we see in inflammations of the heart that the coagulable lymph is 
thrown out on the external surface in vast quantities, while at the 
same time the heart shall not adhere to the pericardium. This 
extravasated matter is always of the same nature with that of the 
parts which produced it, which is a curious fact. If the disposition 
of the part is cancerous, the extravasated coagulable lymph is a 
poison, for on being absorbed it contaminates the absorbent glands, 
producing cancer; and probably the same takes place in every 
poison that is capable of irritating to inflammation and extra- 
vasation. 
Appearances of Adhesive Infammation.-The part inflamed be- 
comes redder than common, and redder and redder as it advances; 
the red being of a scarlet hue when the inflammation is healthy. The 
part becomes apparently more vascular than in a natural state, and 
most probably is really so, both from new vessels being set up in the 
old parts, and from the adventitious uniting substance becoming 
vascular. These new vessels become of use both in the state of 
adhesion and of suppuration; in the first to give powers of action to 
this new substance which assist in preventing suppuration, in the 
second to form a basis for the future granulations. In consequence 
of this extravasation the parts swell, which is generally in pro- 
portion to the inflammation, the swelling being probably most where 
the inflammation is greatest, that is, at the point of irritation, and 
it is gradually lost in the surrounding parts. The whole swelling 
appears like a part of the body a little changed, without containing 
any extraneous matter, and indeed is simply formed by extra- 
vasation of fluids, without their having undergone any material 
visible change. 
Such inflammations as approach to the skin often produce vesica- 
tions, which are filled with serum and often coagulable lymph, both 
which are sometimes tinged with red blood. This arises from the 
violence of the inflammation producing an apparent degree of 
weakness, approaching to a death, in the connexions between the 
cuticle and cutis, the life being in this part very "weak, for in the 
beginning of mortification and of the putrefaction of dead bodies it OF ADHESIVE INFLAMMATION. 
177 
is produced. This connexion of the cuticle is more or less des- 
troyed in every inflammation of the skin. We seldom see an 
inflammation attack the skin but the cuticle comes off sooner or 
later. We generally observe it peeling off in flakes after the in- 
flammation has subsided. 
The pain attending inflammation would not appear to be in all 
cases very acute, for many have very visible inflammations which 
do not give very much pain. However, this will vary according 
to the violence of the inflammation, or rather according to the 
quickness of its progress and its approach to suppuration ; for when 
there is a quick dilatation of the vessels, and rapid extravasation 
of the juices, the sensations arising from such will be increased ; 
but in cases where its progress is slow, as from indolent tumours, 
the mind is hardly sensible of its progress. That it must sometimes 
be very trifling is shown by the fact that on opening dead bodies 
we often find strong adhesions where the friends of these persons 
had never heard during life of a single complaint. We also see 
cases in which this inflammation arises from violence, where it 
gives very little pain. A man shall be shot through the abdomen, 
and, if none of the contained parts are materially hurt, the adhesive 
inflammation shall take place in all the internal parts contiguous to 
the wound, yet no degree of pain is felt from this process. In many 
bruises and in simple fractures the pain from the inflammation is 
very trifling, although there may be much laceration of the parts.* 
Of the Uses of Adhesive Inflammation.-This inflammation may 
be said to arise in all cases from a state of the parts which they 
cannot remain in; therefore an irritation of imperfection takes 
place. It may be looked on as the effect of wise counsels proceed- 
ing from a consciousness of imperfection: nature is taking all the 
defensive precautions possible, for in all cases we shall evidently 
see it answer wise purposes, such as checking the suppurative 
inflammation, by making parts adhere which must otherwise fall 
into that state; and where this effect does not fully take place, it 
acts as a check to the extent of it, as we see in circumscribed cavities. 
In the tunica vaginalis, after the operation for hydrocele, the parts 
often collapse and unite to other parts of the same sac by adhesive 
inflammation, which prevents the suppuration extending over the 
* [Redness, heat, pain, and swelling may each of them exist independently of 
inflammation ; and when they arise from inflammation, they may exist in every 
possible relative proportion among themselves. In judging, therefore, of the 
presence or degree of inflammation, it is necessary to look at the whole symp- 
toms collectively. The redness and heat are generally in proportion to the origi- 
nal vascularity of the part conjoined with the momentum of the circulation ; the 
pain is greater in proportion to the denseness and inextensibility of the inflamed 
part, added to the acuteness of the attack and the quantity of nervous supply; 
the swelling is generally greatest where the reverse of these circumstances ex- 
ists. Structure, however, is not the only circumstance which modifies these 
symptoms ; they depend greatly on the specific nature of the inflammation : the 
sting of a wasp produces infinitely more pain and swelling than an attack of ery- 
sipelas.] 178 
HUNTER'S PRINCIPLES OF SURGERY. 
sac, so that partial collections of water again take place.* In still 
larger cavities, as the abdomen, where partial inflammations often 
take place, as after child-bearing or wounds of this cavity, we find 
this adhesion takes place, which either prevents suppuration altogether 
or unites the parts around it, and as the abscess enlarges the ad- 
hesive inflammation spreads, and thus excludes the general cavity. 
The same thing happens in inflammation of the pleura or surface 
of the lung. The cellular membrane everywhere in the body is 
united exactly in the same manner; the sides of the cells, as it were, 
sweat out the uniting matter, which, coming into contact with the 
opposite surfaces, joins them into one mass. 
The lungs are subject to two modes of action in inflammation ; 
being so circumstanced as to partake of the character of both 
orders of parts, the circumscribed cavity, and the secreting surface 
or outlet. The cellular membrane of the lungs readily admits of 
adhesive inflammation, like the cellular tissue elsewhere; but the 
inner surface of the air-cells, like the urethra, passes directly into 
the suppurative inflammation, and the matter which is thus formed 
is obliged to be coughed up. It is, perhaps, impossible to produce 
inflammation of the one without the other, which is, perhaps, the 
reason why inflammation of these parts is treated with such bad 
success. 
We cannot give a better illustration of the use of the adhesions 
arising in consequence of this inflammation than to contrast it with 
the erysipelatous. How far this disease is to be ranked amongst 
inflammations I will not at present say; but it has some of the 
characters, as swelling, redness, pain, &c. The swelling arises, 
not from extravasation of coagulable lymph, but from serum: and 
it has other peculiarities, as being generally superficial, and spread- 
ing along the surface with an abrupt edge, which is, perhaps, owing 
to its specific character being always confined to the part affected. 
It has nothing of the adhesive character attending it which was not 
necessary ; because this inflammation, being confined to the skin, 
seldom produces suppuration. But it sometimes happens, when 
erysipelatous inflammation attacks deeper-seated parts, that it sup- 
purates ; and when it does so, it appears often to be a forerunner 
of mortification. 
A man was attacked with an inflammation on each side of the 
anus. It had such an appearance as might have been expected 
from the suppurative and erysipelatous inflammations joined ; it had 
an oedematous appearance. He was bled, and the blood appeared 
very sizy: he took physic, and was fomented. The next day the 
inflammation had reached the scrotum, where a fluctuation, with a 
gurgling of air, was felt. I now made an opening near the rectum, 
and in the scrotum, and let out a quantity of dirty-coloured matter. 
It continued to spread over the loins, scrotum, bottom of the abdo- 
* [The old operation is here referred to, in which the tunica vaginalis was ex- 
posed by incision, and suffered to suppurate.] OF ADHESIVE INFLAMMATION. 
179 
men, &c., where I made openings, and out of which the cellular 
membrane hung like wet tow. In this case, the suppuration was 
diffused for want of the adhesive process preceding or accompany- 
ing it, by which means it would have been limited. 
Adhesive Inflammation sometimes imperfect.-Sometimes it hap- 
pens that the adhesive inflammation is so imperfect that it cannot 
set bounds to itself, and still less to the suppurative. This may be 
owing to two causes; first, the violence of the inflammation and 
quickness with which suppuration ensues, that is, before the parts 
have sufficiently united; secondly, the inflammation may be, as I 
suspect it is, of the erysipelatous kind, especially when there is a 
tendency from the beginning to mortification. This mixture of the 
suppurative with the adhesive, or hurrying on of the suppurative, I 
have often seen in the abdomen of women who have been attacked 
with peritoneal inflammation after child-birth; and when these cir- 
cumstances become the cause of death, we find matter mixed with 
coagulable lymph, as if formed together. 
The adhesive inflammation also takes place in cases where it is 
impossible it should produce the same good effects; as in wounds 
which are not allowed to heal by the first intention, as a stump after 
amputation, and many other parts. But it is one of those fixed and 
invariable principles of the animal machine, that, on all such irrita- 
tions, the uniting process should be produced, although, like many 
other principles in the same machine, it cannot always produce the 
same salutary effects. So that although the wound is not allowed 
to, or cannot, heal by the adhesive inflammation, yet the parts go 
through the common actions consequent upon being wounded; first, 
they throw out blood, as if to unite the parts by the first intention; 
and then, the vessels contracting themselves, coagulable lymph, with 
serum, is thrown out, which has the effect, even in such wounds, of 
preventing a great extension of the inflammation, wThile the con- 
traction of the vessels prevents the inflammation from running along 
their inner surfaces.* 
Effects of Adhesive Inflammation on the Constitution.-These 
effects are very slight, even when the inflammation arises from vio- 
lence ; but the effects of those inflammations which are indolent in 
their progress are still more trifling in the constitution. This arises 
from the slowness of the alteration produced in the part, as it 
were, insensibly stealing on the constitution. 
We know that one effect of adhesive inflammation is the uniting 
of parts not intended by nature to be united, and which must thus 
* [One of the most remarkable good effects of the adhesive inflammation con- 
sists in the gluing of parts together previously to the discharge of hurtful matters 
from the body, as gall-stones, faeces, urine, &c., which are frequently discharged 
in this way; the ulcerative and adhesive processes proceeding pari passu to 
effect the discharge, at the same time that the latter always keeps a little ahead 
of the former. If it were not for this beautiful provision of Nature, the great 
cavities of the body would frequently be exposed to fatal inflammation from such 
causes.] 180 
HUNTER'S PRINCIPLES OF SURGERY. 
be made less moveable on one another: in fact, they must at first 
have little or no motion on one another, as occurs in the cellular 
membrane and circumscribed cavities: but it happens that motion 
is again obtained after a time by the elongation of the connecting 
part, which is effected by the repeated endeavours for motion. 
These uniting media are seen to become vascular. They are per- 
haps often the cause of many indescribable sensations, which cannot 
be called pain. In the heart they are the cause of palpitation, &c. 
On the Resolution of Inf animation.-Since an animal body can be 
made to act improperly by impression, we can see no reason why, 
when acting improperly according to such impressions, it should 
not be made to act properly by the same mode, namely, by impres- 
sion. 
The cure of inflammation is resolution, and an attempt towards 
it, when in the adhesive state (for this is intended to prevent sup- 
puration taking place), must be in general made only under the 
following circumstances, namely, when inflammation arises consti- 
tutionally, or from disease of the part. In cases of accident where 
there is no exposure, as also where there is, but that exposure is 
removed in time by bringing the parts into contact, and where the 
life of the parts has not been destroyed, in all such cases we find 
that resolution will readily take place. 
It is commonly supposed that there are a great many local in- 
flammations which should not be resolved. An inflammation 
arising from a preceding indisposition in the constitution, commonly 
called critical, has always been classed amongst those which are 
not to be resolved ; it has been insisted on that the inflammation 
should rather be encouraged, and suppuration produced. But in 
such treatment it is always under the idea that the inflammation 
is in such parts as will readily admit of cure when suppuration takes 
place; for if the disease is otherwise situated, the cure of the con- 
stitution by suppuration will be a mode of cure which will reflect back 
another disease on the constitution, under which it will sink; there- 
fore resolution in such situations should, if possible, be brought 
about. Many deep-seated inflammations, if allowed to suppurate, 
will, of themselves, most certainly kill: gout also, in the head or 
stomach, should always be resolved, and left to settle in some other 
part less connected with life. If inflammation is really a concentra- 
tion of the constitutional complaint, and if, by not allowing it to 
rest there, the same disposition would really be diffused over the 
whole animal again, and would be liable to affect some other more 
important part, it would certainly be better to encourage it when 
in a proper part. Still it does not appear necessary that it should 
suppurate, for suppuration is only a consequence of inflammation; 
not an immediate effect of the original constitutional disease, but a 
secondary one. As suppuration, therefore, is only a thing super- 
added, and as we shall generally find that inflammation subsides as 
suppuration comes on, I see no reason why inflammation should 
not in the present case as well subside by resolution as by suppura- OF ADHESIVE INFLAMMATION. 
181 
tion. It may, however, be supposed, that as this suppuration is not 
a natural or immediate effect of the disease, yet as it is a continued 
local action, that it is capable of diverting the disease to the part. 
I hardly know an instance where inflammation from violence may 
not with propriety be resolved, and prevented from going into sup- 
puration, except where it relieves the constitution from any prior 
disease. Thus, Mr. Foote was cured of a violent pain in his head 
by amputation of his leg; but he afterwards died with a different 
complaint in his head. Might not the first diseased action in the head 
be altered in this case, and an action of a different kind induced, 
which proceeded to the degree of effecting his death ? 
Of the Resolution of Inf animation by Constitutional means.-If 
the inflammation is of the true adhesive kind, the only thing to be 
done is to lessen everything that has a tendency to keep it up, 
because we know of no method that will entirely quiet or remove 
the inflammatory disposition, or mode of action ;* there is no specific 
against inflammation that we are acquainted with. Whatever will 
lessen the power or disposition will lessen the effect. 
There appeal' to be three methods which tend to remove inflam- 
mation : first, by weakening; secondly, by producing temporary 
weakness ; thirdly, by lessening or soothing the irritability. 
That which absolutely weakens is bleeding, purging, quietude, 
and low diet. The temporary weakness is produced by sickness 
at the stomach, faintness, &c. The soothing effect may be produced 
by sedatives, antispasmodics, &c., such as many sudorifics, ano- 
dynes, &c. The first will have the greatest, most immediate, and 
most lasting effects; the second and third act as auxiliaries; 
the second probably will come nearest to lessening the cause 
•while the other will assist so far as irritation is a cause; they 
should go hand in hand, for wherever we lessen the power we 
should at the same time lessen the disposition for action. But nei- 
ther bleeding, sickness, nor purging can possibly lessen the original 
inflammatory disposition by lessening the power of action of any 
disposition you only lessen or protract the effects, which, however, 
will be of singular service, as less mischief will be done, and will often 
give the disposition time to wear itself out. 
Bleeding, then, at first may be necessary; but this must be done 
with some restriction. If inflammation arises from real powers, 
then bleeding freely is absolutely necessary; but if from too great 
action of weak parts, bleeding should be no more than what will 
just lessen the violence of the blood's motion, or remove the feeling 
* [Mercury and colchicum are perhaps exceptions to this observation ; at least 
they certainly subdue inflammatory action with extraordinary rapidity in many 
cases.} 
f [In this instance the author has allowed reasoning' and hypothesis to usurp 
the place of observation and fact. It is certainly not uncommon to witness the 
almost complete destruction of an inflammatory attack by a single copious vene- 
section.] 182 
HUNTER'S PRINCIPLES OF SURGERY. 
in the part inflamed of too much to do. The quantity, therefore, 
must be according to the symptoms and other circumstances, that 
is, according to the visible indications. The indication for bleeding 
is, first, according to the violence of the inflammation, joined with 
the strength of the constitution : secondly, according to the disposi- 
tion to form blood ; thirdly, whether the disease is in a vital part: 
fourthly, its situation, whether near the heart or not; fifthly, ac- 
cording to the duration and the extent to which it has affected the 
constitution.* 
With respect to the first kind, in which the constitution is strong 
and the inflammation is violent, bleeding largely is proper, and in 
many cases bleeding near the part will answer better than from 
the general habit; less may be taken away in this way with an 
equal effect on the part inflamed, and of course with less effect on 
the constitution, as bleeding from the temporal artery, or the jugular 
vein, for complaints of the brain, or cupping or applying leeches 
near the part, as, for example, to the temples in inflammation of the 
eyes. 
The same mode of practice is to be followed with regard to the 
second, third, fourth, and fifth. It seldom happens that one bleed- 
ing will be sufficient in a considerable inflammation. The first 
blood taken affords a symptom of the disease; if it is buffy, thick, 
and considerably cupped, future bleedings may be used with less 
caution. On the other hand, there may be indications for bleeding 
sparingly; first, from there being too much action with weakened 
power; secondly, from a disposition to form little blood; thirdly, 
from the part being far from the source of the circulation. 
A gentleman had a violent inflammation of the eye ; the blood 
was sizy, but though sizy the coat was exceedingly tender, and so 
slight as not to bear its own weight when raised up. He was 
blooded plentifully several times without any good. Here was not, 
then, much power, the blood putting on the sizy appearance in 
consequence of there being increased action in the vessels of this 
part of the body. 
* [The propriety of blood-letting is indicated by many other circumstances 
besides those pointed out in the text. I shall only mention three of these at pre- 
sent : the first arises from the structure of the part affected. Thus, serous and 
fibrous membranes require and bear venesection to an extent which would be 
perfectly unwarrantable in regard to mucous membranes. The second arises 
from the probable demands which will be made on the constitution during the 
future progress of the case. It would be extremely imprudent, for example, to 
bleed a patient with a severe compound fracture to the same extent which would 
be perfectly justifiable in inflammation of the eye. The third is derived from 
the act of venesection itself, as whether the blood flows freely and the state of 
syncope is easily induced ; for it has been justly remarked that those inflamma- 
tions which most require venesection support the constitution under considerable 
losses of blood, and enable it to bear them much more easily than it could have 
done in a state of health. In most cases of acute inflammation it is advisable to 
take such quantities of blood at first as shall make a decided impression on the 
constitution ; one effectual bleeding being of infinitely more service in checking 
the disease than a number of successive bleedings to a smaller amount, at the 
same time that the powers of the general system are much less reduced.] OF ADHESIVE INFLAMMATION. 
183 
A lady with inflammation of the tonsils was blooded ; the blood 
was sizy, but loose; and after three bleedings the blood became so 
loose that the bark was given, which did service. The disorder 
returned again, and the same mode was used; the blood was sizy 
only in the first bleeding; the bark was obliged to be again given. 
In such cases bleeding is very seldom necessary. Where it is 
necessary, it should be as near the part as possible, in order that it 
may have the greatest effect on the part with the least damage to 
the constitution. If local bleeding be used, leeches will answer 
best, because but little inflammation follows their bite;* however, 
this can only be put in practice in inflammations which are pretty 
much external. In many cases we cannot take it immediately from 
the part, and must be content to go as near as we can, as in bleed- 
ing from the temporal artery or jugular vein, in affections of the 
head. Sometimes of course even this will be impossible, as in 
inflammations of the liver and stomach. 
Too much action with small powers may often, if not always, 
be classed with the irritable, and bleeding here should be performed 
with very great caution. When inflammation is far from the 
source of the circulation the same precaution is hardly necessary, 
as in general it can be taken away from the part. 
We cannot depend on sizy blood alone as a proof of the pro- 
priety of repeating the bleeding; we must take into consideration 
also the strength of action. 
The pulse is a great indication for bleeding in inflammation, but 
is not always to be relied on. In inflammations that are visible, 
the knowledge of the kind of inflammation is in some degree 
ascertained, in which cases it has been supposed that we go on 
surer grounds in our indications for bleeding. But all inflammations 
are not visible: therefore we require some other criterion. If we 
could ascertain the pulse peculiar to certain appearances in visible 
inflammations, and were sure that universally the same pulse 
attended such appearances, we should then suppose we had the 
true indicative criterion to go by, and be able to apply it to invisible 
inflammations, and judge of these by the pulse. But when we 
consider that the same kind of inflammations in every part of the 
body will not produce the same kind of pulse, but very different 
pulses not according to the inflammation, but according to the 
nature of the parts inflamed, and many of these parts are invisible, 
we see that we at once lose the criterion of the pulse as a guide. 
There may be every symptom of inflammation and the pulse be 
soft, and not quicker than usual, and yet the blood when taken 
away will be sizy and cupped. 
A lady had this kind of pulse (soft and not quick), and at the 
same time had a violent cough, with tightness of the chest and 
stitches in the side; bleeding was ordered, when the blood was 
found sizy, &c.; nor did the illness subside till the sixth bleeding. 
A hard quick pulse is generally an indication for bleeding, being 
* [Cupping will generally be found more effectual where it is practicable, on 
account of the blood being more rapidly removed.] 184 
HUNTER'S PRINCIPLES OF SURGERY. 
frequently accompanied with sizy blood ; but even these signs are 
not always to be depended on as furnishing a criterion. The kind 
of blood is of consequence to be known, for although it should be 
sizy, if it is not firm in its texture, but lies squat in the dish, bleed- 
ing must be performed very sparingly. 
As the pulse simply, independently of all other considerations, is 
not an absolute criterion to go by, and as a sizy and strong coagu- 
lum is only an afterproof, let us see if there are any collateral 
circumstances that can throw some light on this subject, so as to 
enable us to judge, ci priori, whether it is right to bleed where the 
pulse does not of itself indicate it. 
When speaking of inflammation of various parts, I took notice 
of the pulse peculiar to each part, which I may now be allowed to 
repeat. First, I observed in inflammation of parts not vital, or such 
as the stomach did not sympathize with, that if there was great 
power and not much irritability, the pulse was full, frequent, and 
hard. Secondly, on the contrary, in inflammations of the same 
parts, if the constitution was weak, irritable, &c., that then the 
pulse was small, frequent and hard, although, perhaps, not so much 
so as when, thirdly, the inflammation is in a vital part, as the 
stomach or intestines, or some part with which the stomach readily 
sympathizes ; then the pulse is quick, small, and hard. 
Now in the first of these dispositions bleeding is absolutely 
necessary; but in the second, where the pulse is small and frequent, 
bleeding should be performed with great caution : though the per- 
son may be of strong constitution, yet in inflammations of these 
parts the constitution appears to be more irritable, and to have a 
greater sense of weakness. We should bleed to two or three 
ounces by way of trial, which could do no harm. 
The urine will throw some light on the disease; if high-coloured, 
and not much in quantity, it may be presumed, with the other 
symptoms, that bleeding will be of singular service ; but if pale 
and copious, though the other indications may be strong for bleed- 
ing, it may be necessary to do it with caution. 
Bleeding, however, is a remedy of so much importance that it 
should be employed in all cases with great caution ; yet not more 
than appears really necessary. 
I cannot perceive why bleeding should have such an effect on 
inflammation as it often has. We cannot account for it simply on 
the mechanical principle of lessening the quantity of blood, because 
this can never remove the cause of inflammation. 
Medicines.-Medicines which have the power of producing sick- 
ness lessen the powers of life universally, because every part of the 
body sympathizes with the stomach ; and when they are intended 
to produce this effect they should not be given in doses sufficient 
to produce anything more than sickness, for the act of vomiting is 
rather a counteraction to that effect, and I believe has rather the 
effect of rousing, as few are so weak as not to be able to bear sick- 
ness. Purges have been much recommended, under the idea that 
there were humours to be carried off; such practice answers best OF ADHESIVE INFLAMMATION. 
185 
in the cases in which bleeding is useful. In irritable habits, where 
inflammation becomes more diffused, greater caution is necessary, 
as nothing tends to weaken the habit more. A single purge has 
been known to produce death in dropsy. In such cases bark may 
be required to bring the constitution into a proper state, either for 
resolution or suppuration, by increasing the powers and diminishing 
the action; and thebaica may be a good assistant as a soother or 
sedative with the bark. 
Modes of Resolution by external applications-Whether we have 
any external applications which have really a tendency to resolve 
an inflammatory disposition, is not well ascertained. We are in 
possession of many that can weaken, so as to lessen the powers 
(most of which appear to be of the soothing kind), and thus lessen 
the action, though the cause may still exist; by which means the 
effects are lessened, and the inflammation is either cured or pro- 
tracted, until the disposition wears itself out. Perhaps cold is one 
of the greatest weakeners, but it should not be used too freely, as it 
may produce a worse disease, which is indolence. Lead is sup- 
posed to have considerable effects in this way ; but I believe much 
more is ascribed to it than it deserves. Its properties appear to be 
to lessen the powers, and therefore it should not be used except 
when the powers are too strong. Applications to weaken should 
not be applied to irritable parts ; on the contrary, the parts should 
be strengthened, which can only be done through the constitution. 
Whatever power external applications possess, they must act in 
one of four ways: first, which is the immediate or truly local; 
second, by repulsion ; third, by revulsion and derivation ; fourth, 
by sympathy, which is probably the same principle in the animal 
economy as revulsion and derivation. 
The first, or local effect, may be of two kinds : 1st, simply such 
as is an antidote to the action of the part, as cold, sedatives ; 2d, 
such as destroys the first irritation, by exciting a second. This is 
most applicable to specific diseases, as the action of mercury in a 
venereal sore : but all specific diseases will not allow of it; a 
gonorrhoea in a scrofulous habit is an instance of this. In some 
cutaneous affections this mode of cure is very useful. Sedatives 
are less useful as local applications than counter-irritants, but both 
of them may have another effect, viz., repulsion or derivation, which 
must be from a constitutional affection, such as I have called an 
act of the constitution, as in gout. If the constitution is determined 
to have a local complaint, by which she throws off a constitutional 
disposition, then these revulsions do not rid the constitution of the 
disposition. It is difficult to say what will merely repel and what 
will cure. Repulsion, however, is a cure of the part, whatever 
effect it may have on the constitution. Surgeons were formerly 
greatly afraid respecting repulsion. They were even afraid of 
curing a gonorrhoea, lest they should drive it back into the consti- 
tution and produce a pox ; but they did not consider that it does 
not arise from the constitution, and has nothing to do with it. 186 
HUNTER'S PRINCIPLES OF SURGERY. 
Revulsion and derivation appear to me to depend on the same 
principle in the constitution as sympathy, and, like the latter, have 
the greatest effect in habits which are irritable or nervous, and in 
diseases which are nervous, as cramp ; not in such as change the 
structure of parts. I knew a nervous girl cured of pain in one 
arm by rubbing the other. These terms were used under the idea 
of removing humours by inviting them from other parts, as making 
an issue to remove eruptions. They probably act by causing an 
irritation in one part to cease when an irritation in another is 
excited; and this latter may be made greater than the original one 
though in a part less dangerous, and where it can be more easily 
cured, as burning the ear cures the tooth-ache; vomiting, the 
swelled testicle; blisters, pleurisy, &c. In some of these, as the 
vomiting to cure the testicle, no new disease ^s excited, but only 
the action of the part. The cures performed by these modes are 
in many cases preferable to those by means of local applications, 
and they will succeed where the others fail; thus vomiting will cure 
hernia humoralis, when othei' applications have had no effect. The 
cure by revulsion, or sympathy, is in some respects the reverse of 
that by derivation, yet it is probably from the same consent of 
parts, but from a different action. In these a remedy is applied 
to a sound part to cure a diseased, which is either contiguous, 
continuous, or remote, and the action is either similar or dissimilar. 
The cure of continuous parts by similar sympathy is by the applica- 
tion of such remedies as we suppose would cure if applied to the 
part. That of remote parts by dissimilar modes of action, is by 
stimulating a part in such a way as that the sympathy shall act in 
the same way, and yet the action in the diseased part be not at all 
similar to that in the sound part: suppose, for instance, a part in 
any mode of action, a medicine applied to it would increase that 
action, but by applying it to another part it will remove the first. 
The contiguous is different from the two former, and can only be 
applied to surfaces, as a blister to the scalp to remove headache. 
These may be either stimulating or soothing, or specific. 
Treatment of adhesive Inflammation when Suppuration must take 
place.-The treatment must, in some measure, be the same as in 
the foregoing in accidents where the powers are very great, and 
the inflammation violent, namely, bleeding, purging, sickness, &c.; 
but when the constitution is irritable, bark, &c., as before directed. 
In cases where there is considerable sympathy, sudorifics, as Dover's 
powder, seem desirable, as they tend to keep up the harmony 
between the skin and the stomach. Opium in peculiar constitutions 
increases irritability; but in others, where there is not this peculiarity, 
it is highly useful in soothing and diminishing irritability- 
Different applications have been made to the inflamed parts, as 
fomentation, washes, poultices, &c. The mode of applying heat 
and moisture by fomentation appears more efficacious than in the 
form of a fluid ; it certainly gives ease at the time of the application, 
but the symptoms generally recur between the times of using it, 
and with nearly the same violence. How far the application of a OF SUPPURATIVE INFLAMMATION, ETC. 
187 
medicine for fifteen minutes out of the twenty-four hours does good 
I hardly know. 
Washes are fluid applications, and are more commonly used to 
inflamed internal surfaces than to the common integuments. I am 
afraid we are not much acquainted with their true specific virtues, 
the use of them being very vague. For inflammation of the eyes 
we use astringents, as alum, vitriol, &c. For inflammations of the 
throat we gargle with port wine, vinegar, &c.; yet how absurd it 
would be, in the opinion of any surgeon, to use the latter applica- 
tions to the eyes; and yet if the two inflammations are the same I 
do not see why we should not use the same remedies to both parts. 
These, like the former, have only temporary effects. 
Poultices are constant applications, and may be either simple or 
medicated; their effect is greatest locally, but it extends likewise 
to surrounding parts, by sympathy. They may be medicated with 
lead, opium, &c. Simple poultices are the best application where 
we have no particular object in view. 
CHAPTER XIV. 
OF SUPPURATIVE AND ULCERATIVE INFLAMMATION J GRANULATION, 
SKINNING, HECTIC FEVER, AND DISSOLUTION. 
Suppurative inflammation ;-difficulty of tracing the chain of causes leading to 
it;-not arising from the access of air;-nor from external violence;-occurs 
most readily in canals.-Peculiar pain attending it;-rigor;-diminution of 
the inflammation.-Cure of suppurated parts ;-abstraction of matter by ab- 
sorption, or by external opening ;-granulation ;-cicatrization.-Of pus ;-its 
formation ;-gradual changes from lymph to pus ;-breach of substance not 
necessary to its existence ;-erroneous notions of its formation and uses.-Of 
absorption of the whole or parts of the body, in consequence of disease.-In- 
terstitial and progressive absorption.-Interstitial of two kinds ;-1st, wasting; 
-2d, complete removal.-Importance of the latter;-and of progressive ab- 
sorption.-The two sometimes mixed.-New parts most subject to be removed. 
-Causes which render parts liable to absorption.-Relaxing process of the 
skin over an abscess.-Absorption with or without suppuration ;-Ulceration ; 
-progressive and interstitial absorption combined ;-almost always accompa- 
nied by inflammation ;-(Seldom affects the constitution.-Whitlow.-Granu- 
lation ;-not always attended with suppuration ;-does not appear till abscess 
has been opened ;-arises on one surface ;-nature and structure of granula- 
tions ;-colour an index of the state of the parts and constitution ;-contrac- 
tion of granulations ;-followed by cicatrization ;-an assistance to this 
process.-Of skinning.-New skin generally arising from old skin ;-economy 
of nature in forming new skin.-Hectic;-when arising; causes numerous; 
-symptoms ;-erroneous notion of cause.-Treatment;-incurable ;-when 
from local disease in removeable parts, they are to be removed.-Dissolution, 
definition of the term;-when occurring;-symptoms;-incurable. 
When an inflammation exceeds the adhesive state, and has got 
beyond the power of resolution, and when the adhesive has set 188 
HUNTER'S PRINCIPLES OF SURGERY. 
bounds to the suppurative inflammation, the suppurative begins; or 
in internal surfaces, where the adhesive cannot take place, the 
suppurative begins. The irritation which is the immediate cause of 
suppuration is the same, from whatever cause it may have been 
produced: it is a similar process, going through the same stages, 
whether it takes its rise from external violence, or from the consti- 
tution, or from disposition for disease in a part, if all other circum- 
stances are equal. It is very difficult to give a true and clear idea 
of the whole chain of causes which lead to suppuration. Irritation 
simply is not always sufficient; it often only brings on the adhesive 
inflammation. Violence done to a part is one of the great causes of 
suppuration, but this alone is not sufficient: it must be with a pre- 
vention of union by the first intention, or by adhesive inflammation; 
it must be attended with death in the part, as in bruises. The appli- 
cation of air to internal surfaces has generally been assigned as a 
cause of inflammation, when it happened in consequence of destruc- 
tion of a part; but air has certainly no such effect, for a stimulus 
wrnuld arise from a wound were it even contained in a vacuum ; 
nor does it get to the parts forming circumscribed abscesses, which 
yet suppurate, in consequence of inflammation, as readily as exposed 
surfaces. In many cases of emphysema, where the air is diffused 
over the whole body, we have no such effect, excepting there is 
produced an exposure of some internal surface for the air to make 
its escape by, and then the wound inflames. In birds we find the 
cells in their* bones communicating with the lungs, so that they have 
at all times more or less air in them, although they never inflame ; 
but if these are exposed by a wound, the stimulus of imperfection is 
given, and inflammation begins, and suppuration may succeed. The 
same observation is applicable to a wound made in the abdomen 
of a fowl, for* there the wround inflames and unites the intestines, 
to make the cavity perfect again ; but if the union is not allowed, 
to take place, more or less of the abdomen will inflame and 
suppurate. How should we account also for suppuration taking 
place in the nose during catarrh, since it is not more exposed to 
air then than at other times ? Air, therefore, is not the cause of 
suppuration. 
We are at a loss to say, with regard to spontaneous inflammation, 
whether it is a disease in which the constitution will be injured, or 
whether it is a salutary process in which nature is endeavouring to 
relieve herself; and it is evident that the same action may arise 
from different causes. 
Suppuration does not depend on the violence of the inflammation ; 
for that circumstance, simply considered, rather tends to produce 
mortification; and we see that in gout, which does not suppurate, 
there often is more violent inflammation than in many other cases 
that do : and in true scrofula we have suppuration without any visible 
inflammation : so that this does not seem essential to suppuration. 
Although we find that inflammation and suppuration from injury 
are very violent, yet that which occurs spontaneously generally OF SUPPURATIVE INFLAMMATION, ETC. 
189 
exceeds it in violence. In inflammations of the breasts in women 
and of the testicles in men, the quicker the inflammation proceeds 
the better; for where it is slow it gives the idea of specific inflam- 
mation, as this generally proceeds slower than simple inflammation. 
Suppuration takes place more readily from the surface of canals 
than in either the cellular or investing membranes ; the same degree 
of inflammation which will produce suppurative in the first men- 
tioned parts will only produce adhesive in the latter. If a bougie 
be introduced into the urethra, it may produce suppuration; but if 
introduced into the tunica vaginalis or abdomen, it will only give a 
disposition for adhesions. 
Symptoms of suppurative inflammation.-The sensations arising 
from a disease generally convey some idea of its nature. Some 
diseases give what is called a heavy, a dull, or a gnawing pain,&c.: 
but the suppurative inflammation gives as much as possible the idea 
of simple pain, without having relation to any other mode of sensa- 
tion ; this pain is increased at the time of the dilatation of the 
arteries with the sensation called throbbing. The part now becomes 
more swelled by the greater dilatation of the vessels and a greater 
quantity of extra vasated fluid being poured out, and the scarlet colour 
increases from the admission of red globules into vessels, not natu- 
rally conveying them, and the formation of new vessels, and an 
oedematous appearance, like that in erysipelas, takes place. One, 
two, or three parts of the inflammation lose the power of resolution, 
and take on exactly the same disposition with that of exposed sur- 
faces, or a surface in contact with an extraneous body. If it is in 
the cellulai' membrane that this disposition takes place, or in the 
investing membrane of circumscribed cavities, the vessels now begin 
to alter their disposition and mode of action, and continue changing 
till they bring themselves to that state which fits them to form 
matter. But as this change does not take place all at once, some 
parts may for some time continue to discharge coagulable lymph, 
as in the adhesive state, whilst those parts which have taken on the 
suppurative action poui' out matter: and hence, if the tumour be 
now opened, it will be found to contain both matter and coagulable 
lymph: in which state it has always been imagined that the matter 
had not arrived at a state of ripeness by those who supposed its 
purulence to depend on its confinement and stay. It would appear, 
from matter forming from the investing membranes of internal cavi- 
ties and from mucous surfaces, that matter may be formed without 
any breach of surface. 
There is a certain period in inflammation when suppuration 
begins, and which is discovered by new symptoms, as shivering, 
&c.; and though the change is pretty quick, time must be allowed 
foi' the vessels to be fitted for the suppurative state. The effect of 
inflammation seems to be the producing the suppurative disposition, 
or that state of parts which disposes them to secrete pus: in doing 
this, inflammation seems to be carried to such a length as to destroy 
that state of parts on which itself depends; the consequence of which 
is that they lose the inflammatory and come into that disposition 190 
HUNTER'S PRINCIPLES OF SURGERY. 
which fits them for throwing out matter. That the suppurative is 
very different from the adhesive inflammation is plain from this, 
that if a wound in a suppurative state, yielding good matter, has by 
irritation of any kind the adhesive inflammation produced in it to 
any degree, the discharge lessens, and ihe wound puts on appear- 
ances very different from what it had before. It seems a fixed and 
useful law in the animal economy, that when inflammation has gone 
to the length of destroying the natural functions of parts, so as to 
prevent their returning by a retrograde motion to that state from 
which they set out, suppuration should come on to give them a dis- 
position for a second mode of cure. 
Treatment of Suppuration.-Suppuration may sometimes be re- 
moved by producing action in other parts: thus, I have seen a 
bubo cured by a vomit, and similar effects are producible on scro- 
fulous tumours. When suppuration cannot be stopped or resolved, 
in most cases it is to be hurried on towards the skin, which generally 
is the first step taken by surgeons. How far suppuration can be 
increased by medicines or applications I do not know, but attempts 
are generally made ; hence we have, I think, in the pharmacopoeia, 
(though I do not read many books,) suppurating cataplasms, matu- 
rating, &c., but I doubt if they have considerable effect in this way, 
for the same applications applied to a sore would hardly increase 
the discharge of that sore. However, in cases where the parts are 
indolent, and hardly admit of suppuration, by stimulating the skin 
more salutary inflammation may be produced, and of course 
quicker suppuration; but with true suppuration, preceded by 
inflammation, it is I believe hardly necessary to do anything with 
respect to the suppuration itself. Nevertheless it has perhaps been 
found by experience that these applications tend to bring matter 
fastei' to the skin, even in the rapid suppurations; only, however, 
in those cases where the inner surface of the abscess is within the 
influence of the skin. This effect, too, may arise from another mode 
of action being produced than that of quicker suppuration, which is 
the hastening of an ulceration. Poultices of bread and milk are 
commonly used to inflamed parts when suppuration is known to 
have taken place: this application can have no effect, except that 
of lessening the inflammation, or rather making the skin easy.* 
Of suppuration without inflammation.-I have hinted that thickening 
of parts took place sometimes without inflammation, and also that 
the suppurative inflammation might take place without being pre- 
ceded by the adhesive. Many indolent tumours, slow swellings of 
the joints, swellings in the lymphatic glands, tubercles in the lungs, 
and swellings in many parts of the body, are of the first kind, 
namely, thickening without visible inflammation ; and the contents 
* [The immediate effects of poultices and fomentations to inflamed parts are, 
1st, to soothe the pain and irritation ; 2d, to augment the local perspiration ; 
and, 3d, to diminish the tension. The addition of sedatives and narcotics cer- 
tainly increases their soothing effects, and their continued application certainly 
promotes the suppurative process.] OF SUPPURATIVE INFLAMMATION, ETC. 
191 
of some kind of encysted tumours, the matter of many scrofulous 
suppurations, as in the lymphatic glands, and in the joints of the foot 
and hand, for instance, and in the hip-joint, called hip-cases, of the 
loins, called lumbar abscess, the suppuration of tubercles in the 
lungs and in many other parts of the body, all exhibit the formation 
of matter without any previous visible inflammation. They come 
on insensibly, the first symptom being a swelling in consequence of 
the thickening, (which is not the case in inflammation, for there 
sensation is the first symptom,) and this swelling is increased by the 
formation of matter.* 
The nature of the matter is another distinguishing mark between 
suppuration in consequence of inflammation and that without it, the 
latter being generally composed of a curdly substance mixed with 
matter. The curdly matter is, we may suppose, the coagulable 
lymph deprived of serum, the thinner part is true pus, having the 
globules and specific properties of pus, and is often as thick as the 
common pus formed in consequence of inflammation. 
All parts which form pus of any kind, whether in consequence of 
inflammation or otherwise, must go through similar processes to 
produce the ultimate effect or cure. The first step, in either case, 
is the evacuation of this matter, for till that is effected nature cannot 
take means towards a cure; the second step is granulation; the 
third, cicatrization. 
There are three modes of doing the first; one is the absorption of 
matter, which is very common in the scrofulous kind, but not in 
those suppurations which are the consequences of inflammation, and 
which produces no alteration of the part except the gradually 
creeping into a sound state; the other modes of discharging this 
matter are, either opening the abscess, to allow it to pass out, or 
allowing ulceration to take place on the inside to produce its escape; 
which process, in the present case, having peculiarities different 
from those arising from inflammation, it is necessary to explain 
still further. 
Ulceration in consequence of suppuration arising from inflam 
mation, is very rapid, especially if the suppuration is very rapid; 
but ulceration in consequence of suppuration not the effect of 
inflammation, is extremely slow: it may remain months or even 
years before the parts give way. 
When an abscess in consequence of inflammation is opened, it 
immediately proceeds towards a cure, and perhaps may have gone 
* [Those singular deposits of purulent matter which occur in the joints, the 
serous cavities, the viscera, and the cellular membrane, during the progress of 
phlebitis and secondary inflammations, are examples of the same kind. I have, 
on several occasions, found all the principal joints of the body filled with an ap- 
parently healthy pus, although during life there were no symptoms of inflamma- 
tion, nor after death any indications of increased vascularity. 
The question, therefore arises. Does suppuration ever occur independently of 
inflammation 1 I think it does. The formation of cartilage antecedently to that 
of bone is a parallel case, and yet instances every now and then occur in which 
ossific depositions are formed independently of this condition.] 192 
HUNTER'S PRINCIPLES OF SURGERY. 
some steps towards a cure before the opening. As inflammation 
lessens, suppuration becomes still more perfect, granulations begin 
to form, &c. But when an abscess not preceded by the common 
inflammation is opened, a very different process is first to take place; 
the consequence is, that inflammation now takes place over the 
whole cavity of the abscess, which afterwards produces perfect 
matter, like that produced when inflammation is the original disease. 
However, it sometimes happens that they inflame before they are 
opened, in consequence of the matter distending the cavity acting 
like an extraneous body, not in consequence of the cause of suppu- 
ration. I have seen white swellings of the knee inflame before 
they were opened, then ulceration took place, and the pus was 
brought soon to the skin, though before it had been for months 
without producing the least tendency to ulceration, and of course 
none to inflammation; but the confinement of matter became the 
cause of inflammation. The inflammation and new suppuration 
taking place in consequence of an opening into these abscesses, is 
exactly similar to those inflammations and suppurations which take 
place in consequence of an opening made into internal cavities; and 
it is extraordinary that often upon opening these swellings, inflam- 
mation, fever, nay death, shall follow, but if suffered to break of 
themselves no such effect is produced. 
Of Pus.-The immediate effect of the modes of action above 
described is the formation of matter commonly termed pus. This 
matter is very different from what was discharged during the ad- 
hesive stage of inflammation, and also very different from the 
common secretion of internal canals : yet when these surfaces form 
pus it is probable they are formed by the same vessels; if so, their 
mode of action must be greatly altered. 
In suppuration of the cellular membrane or of circumscribed cavi- 
ties their vessels are but little changed at the commencement of the 
suppurative disposition, so that they still retain much of the form 
they aqcuired by the first stage. The discharge is at the beginning 
little more than coagulable lymph mixed with some serum ; this is 
scarce different from the discharge in the adhesive stage of the 
inflammations ; but as the inflammatory disposition subsides, a new 
disposition is every instant altering these vessels to the suppurative 
stage; the discharge is also varying constantly from a species of 
extravasation to the new-formed matter peculiar to suppuration. 
The matter removes further and further from the nature of blood, 
losing the yellowish or greenish hue, and becoming white, and more 
viscid and creamy. By the formation of this new substance, the 
coagulable lymph, which was extravasated in the adhesive state, 
and adhered to the sides of the cells, either on cut surfaces, as 
wounds, or on the walls of abscesses, is pushed off, and if there is a 
cavity, is pushed into it, so that we should find in the cavity both 
coagulable lymph and pus; or, if on a cut surface, it is thrown off, 
and is generally removed, along with extravasated blood, &c., with 
the dressings. OF SUPPURATIVE INFLAMMATION, ETC. 
193 
This is the process which takes place in the first formation of pus 
in an abscess, or from the surface of fresh wounds. 
On the internal surface of canals the parts are not obliged to go 
through all these steps; they run into suppuration almost instanta- 
neously. 
Mode of Formation of Pus.-Pus is formed by some change, de- 
composition, or separation which the blood undergoes in its passage 
out of the vessels. To carry on this process, either a new and 
peculiar structure of vessels must be formed, or a new disposition 
or mode of action of the old must take place. This new structure 
of vessels, oi' new disposition of vessels, I shall call glandular, and 
consider pus as a secretion.* 
Dissolution of the living solids of an animal body into pus, and 
that the pus already formed has a power of occasioning their 
further dissolution, is an old opinion, and is still the opinion of 
many. 
But if this idea were just, no sore which discharges matter would 
be exempted from continual dissolution; and I think it must appear 
inconsistent that matter which was probably intended for salutary 
purposes should be a means of destroying the very parts which pro- 
duced it. 
The circumstance of internal circumscribed cavities, as the abdo- 
men, thorax, &c., forming pus, and where they might often have 
seen pints of matter, without any breach in the solids to produce it, 
(which is proved beyond controversy to take place,) should have 
taught them better; and the prevalence of this idea certainly shows 
a barrenness of knowledge and observation. . ISuch an idea might 
be forgiven when it was thought that the discharge in gonorrhoea 
arose from an ulcer; but now that it is known that there is no ulcer 
in the urethra, it can only continue from mere stupidity. 
The moderns have been more ridiculous still: they have put dead 
matter into pus, and have thought that it has been formed into pus, 
and have thence inferred opinions similar with the former. In this 
case they have been putting dead and living animal matter on the 
same footing. But what is still further, they might have seen that 
extraneous matter cannot be formed into pus, by observing that in 
wounds, and in suppuration with extravasation, blood and pus are 
found separately in the same cavity, and that in extravasation of 
blood in sound parts no pus is produced. In abscesses from violence 
and erysipelas they might have seen sloughs of dead cellular mem- 
brane, hanging like wet tow, and not melting down into pus, 
although exposed to the action of matter for a long time. The same 
observation holds good with regard to dead bones, when exposed to 
the action of pus; besides, if, in consequence of the decomposition of 
* [Delpech endeavoured to prove that pus was always secreted by a new mem- 
brane (membrane puogenique') developed by inflammation; an opinion which re- 
ceived some colour of support from the appearance of cysts in old abscesses. 
Nothing, however, is more common than to see suppuration from mucous and 
serous surfaces, where no trace of any such membrane is discoverable.] 194 
HUNTER'S PRINCIPLES OF SURGERY. 
these parts, some of their parts are mixed with pus, it is altered in 
its properties, thereby attaining a very ill smell. But if there is loss 
of substance in a dead piece of bone, for instance, it is produced 
by absorption; in proof of which we see that the loss is on that side 
where it unites to the sound parts, and where alone the absorbents 
can act. 
The chemists found no difficulty in explaining the formation of 
pus, and this they supposed took place by fermentation. But fer- 
mentation necessarily implies that there should be-something to 
ferment; and, according to this idea, there are three effects wThich 
contradict the notion of fermentation flatly. First, internal canals, 
where mucus only was formed, take on the formation of pus with- 
out previous loss of substance or previous fermentation, and they 
leave off the action in the same way. Secondly, internal cavities 
take it on without loss of substance. Thirdly, abscesses already 
formed leave it off. If fermentation was the cause in the first, 
what solids enter into the matter discharged 1 for the whole penis 
could not afford matter enough to form the matter discharged in a 
gonorrhoea. And how or by what power was the fermentation 
commenced ? and how should it ever cease? for there is the same 
surface secreting its mucus whenever the fermentation of pus 
ceases ? In the second case, what solids were destroyed when fer- 
mentation began? by what power is the first particle of this fluid 
formed in an abscess or sore, before anything exists capable of 
dissolving solids ? And according to the third, an abscess shall 
form matter, become stationary, perhaps for months, and at last be 
absorbed; and what becomes of the ferment during the time it 
remained stationary ? 
We may safely, then, discard these notions, and say that pus is 
formed from the fluids alone, by the action of the living solids. 
Pus appears to consist, when examined by the microscope, of 
globular bodies, such as compose cream;* these maybe white, or not 
so, as we find glass appears white when powdered, though not really 
so. The globules swim in serum, or a fluid like serum, and most 
probably there is a little coagulable lymph mixed with it. The propor- 
tion that those white globules bear to the other parts depends on the 
health of the parts which form it; and when in larger proportion, the 
matter is thicker and whiter, and is called good pus, that is, the 
* [These bodies were found by Dr. Hodgkin to be irregular in size and figure, 
and to have no resemblance to those of the blood; from which Dr. Babington 
has inferred the probability that pus consists merely of lymph, in a minute state 
of division, suspended in serum. The existence of globules gives to this fluid 
an iridescent appearance when viewed between two plates of glass, which was 
proposed by the late Dr. Young as a test of the presence of this matter in doubt- 
ful cases, and is still considered the best which we possess. Another test, 
derived from the facility with which pus is diffused through water, and after- 
wards subsides, is applicable to a great many cases, and is much to be preferred 
to any of those which depend on the reaction of chemical agents. The fact 
however is, that pus and mucus insensibly merge in one another, which renders 
the distinction between them in transitu, impossible.] OF SUPPURATIVE INFLAMMATION, ETC. 
195 
solids that produced it are in health, for these appearances in matter 
are no more than the consequences of certain salutary processes, 
which are going on in the solids, the effect of which is to produce 
a disposition on which both suppuration and granulation depend. 
Pus has a sweetish mawkish taste, as is known when it is formed 
in the mouth, and it coagulates by heat. This is the same, whether 
from an irritated natural surface, as the membrane of the nose and 
other outlets and canals, or from an ulcerated surface. 
These discharges from canals or outlets have been termed mucus, 
and not pus; and the surfaces yielding these discharges have been 
termed mucous membranes. A test has been recommended for 
distinguishing these when their appearances have been so exactly 
similar as to afford no visible difference, and when, as I observe, 
they are in fact one and the same fluid. This test was the chem- 
ical solution of the fluid in menstrua, and its precipitation there- 
from, a proposal which was unphilosophical on the very face of it, 
and which I treated from the first as absurd. I did conceive that 
all animal substances when in solution, either in acids or alkalies, 
were in the same state, and that the precipitation from them would 
be the same. But as it was so strongly asserted, and supported by 
experiments said to have been made, I, to satisfy myself, made 
several experiments with animal matter, both solid and fluid ; these 
I dissolved in different acids, vitriolic, muriatic, &c., and made 
precipitates with several alkalies, both fixed and volatile, but all 
these precipitates appeared the same, even when examined with 
the microscope, exhibiting universally a flaky appearance. 
The quality of the matter always depends on the nature of the 
part secreting it: whatever specific quality the part is affected with, 
the pus will possess the same; hence we have venereal matter from 
venereal sores, cancerous matter from cancerous sores, &c.; but 
though it takes on these qualities when the part yielding it is so 
affected, yet it does not derive these qualities from the constitution 
if it is so affected, unless that part is also affected. A circumstance 
which serves to show that the part which yields it is of the same 
nature with the matter produced, is that it does not prove an 
irritator to the surface yielding it, though it may to another; hence 
no suppurating surface can be kept up by its own matter. The gonor- 
rhoea, small-pox, &c., curing themselves is a proof of this, for 
were not this the case we should have constant pain from the 
irritation and much more difficulty in the cure. We do, indeed, 
sometimes find that pus will irritate its own surface; but this may 
be the effect of some extraneous matter, as blood, &c., in the pus; 
the intestines will sometimes produce a discharge which stimulates 
them very considerably; but this may be secreted by the diseased 
surface, and prove an irritator to the sound part of the canal only. 
What I have hitherto said refers to natural pus only; but when 
a specific nature is added, then the secretion is altered. The first 
alteration is a greater quantity of serum and salts, producing a 
thinner discharge, called sanies; this discharge has sometimes 196 
HUNTER'S PRINCIPLES OF SURGERY. 
appeared to affect the solids, and has thence been called corrosive, 
a property which it does not possess,* the parts only receding 
from the irritation ; and where this is the case, perhaps, the decom- 
position and new combination necessary to the formation of pus is 
not perfect, in consequence of the vessels having lost that structure 
which is proper for the secretion of pus; and this is probably the 
case, as healthy granulations are not produced when such matter 
is secreted. By what particular organization matter is produced 
we can no more determine than we can the nature of any other 
glandular organization. 
Pus appears to have a greater tendency to putrescency than the 
other secretions have, but I do not think this is in the degree that 
has been supposed. It is brought into a putrescent state by circum- 
stances independently of the pus itself. If the air is admitted to it 
by a small opening in an abscess, or it is placed near the intestinal 
fasces, or some parts of the solids which have sloughed, then it will 
be fetid; or if any dead blood, as in recent sores, is mixed with it, 
it is fetid ; but if perfectly confined in an abscess it is always sweet, 
and will be a long time in putrefying. In erysipelatous inflamma- 
tion, however, where there is an internal inflammation, there will 
be putrefaction; but this is probably from the solids themselves first 
putrefying. Hence wre find, in most cases of specific disease, that 
the pus is offensive, because blood is mixed with it. Where there is 
dead bone also pus becomes very offensive. 
The final intention of this secretion of matter is not, I believe, yet 
understood. Some say it is carrying off humours from the consti- 
tution, or that it is a constitutional disease changed into a local one, 
and so discharged, or thrown out of the body, either in the form of 
pus, or with it, as in those cases called critical abscess. Or it is 
presumed to carry off local complaints from other parts, by wray of 
derivation or revulsion; hence sores or issues are made in sound 
parts to allow other sores to be dried up. But I am apt to 
believe that we are not yet well, or at all, perhaps, acquainted with 
its uses. We might naturally suspect that it was on the surfaces of 
sores to keep them moist, but this will not account for its formation 
on internal surfaces. 
Absorption of whole parts in consequence of Disease.-The imme- 
diate effects of absorption of the body in consequence of disease 
may be said to be of two kinds. The first is only a wasting of a 
part, or the whole, without any breach in the structure or form, and 
* [Pus very often corrodes the external parts. There seems also the greatest 
reason for believing that the presence of pus is highly deleterious in several 
forms of inflammation, as carbuncle, diffuse cellular inflammation, erysipelas 
aedematodes, inflammation arising from the bite of vipers, &c. Unless free and 
early openings are made in these cases, the inflammation or gangrene extends, 
apparently from the infiltration of pus, or that diseased secretion which precedes 
the formation of pus into the unadherent cellular membrane. That the pus, 
under such circumstances, acquires a highly poisonous quality, is proved by the 
effects which it produces on the constitution when injected into the veins. 
(See p. 136, note.)j OF SUPPURATIVE INFLAMMATION, ETC. 
197 
this I call the interstitial absorption; the second consists of the total 
removal of a part, as if by art, and this is the progressive absorp- 
tion. The interstitial absorption may be considered in two lights; 
1st, where it leaves the part affected still a whole, though wasted; 
3d, where it entirely removes it, which latter resembles the natural 
process by which useless parts are removed, as the thymus gland, 
the membrana pupillaris, &c. 
The process of removing entire parts of the body, either by the 
second interstitial or the progressive absorption, answers very ma- 
terial purposes in the machine. It is by means of the progressive 
that bones exfoliate and sloughs separate, that pus is brought to the 
skin, and that while new bones are formed old ones are removed ; 
and although in these cases the process arises from disease, yet it 
is somewhat similar to the modelling process in the natural forma- 
tion of bone. It is this last that removes useless parts, as the 
alveolar processes w'hen the teeth drop out, or when children are 
shedding teeth, which allows these to drop out; and it is by these 
means that ulcers are formed. It is in many cases a substitute for 
mortification (which is another mode of loss of substance), for it 
is a degree of strength or vigour superior to that where mortification 
takes place; and in many cases it finishes what mortification has 
begun, by separating the mortified part. 
The progressive is that absorption which begins at one side of a 
part to be removed, and goes on until the whole is removed, as in 
spreading ulcers. 
These two modes, the interstitial and progressive, are generally 
going on at once, which may be called the mixed. This operation 
of absorption, like many other processes arising from disease, would 
often appear to be doing mischief, by destroying parts which are of 
service, and where no visible good appears to arise from it, as in 
those cases where the external covering is destroyed by ulcers or 
sores; but in all cases it must be reduced to necessity, for we may 
depend upon it that those parts have not the power of support, and 
it becomes a substitute for mortification. In many cases we shall 
see both ulceration and mortification going on, ulceration removing 
those parts which have power to resist death. 
New-formed parts, or such as cannot be said to form a part of 
the original animal, admit more readily of removal than those parts 
originally formed : probably this arises from the principle of weak- 
ness. It is on this principle that all adventitious new matter is more 
readily absorbed than that matter which forms the substance of old 
tumours. 
Remote Causes of Absorption.-The remote causes of absorption are 
various. The most simple appears to arise from a part's becoming 
useless, as the thymus gland, the ductus arteriosus, the alveoli after 
the teeth drop out, the crystalline lens after couching, the fat of 
the body in fever, either inflammatory or hectic, all which are 
removed by the absorbents as useless parts. Another cause is want 
of power in the part to support itself under certain irritations, which 198 
HUNTER'S PRINCIPLES OF SURGERY. 
may be considered as the basis of every cause of removal of whole 
parts, as calluses, cicatrices; also of parts pressed on. From all 
which it would appear that parts are liable to be absorbed from 
five causes: first, parts pressed on ; second, parts considerably 
irritated by an irritating substance ; third, parts weakened ; fourth, 
parts rendered useless ; fifth, parts become dead. The two first 
appear to me to produce the same irritation ; the third, an irritation 
of its own kind ; and the fourth and fifth may be somewhat similar. 
Immediate Causes of Absorption.-The immediate causes of absorp- 
tion of the body itself must be of two kinds respecting the parts, one 
passive, the other active. The first of these is a consciousness in 
the parts to be absorbed of the unfitness or impossibility of remaining 
under such circumstances, the action excited by the irritation being 
incompatible with the natural actions and existence of the parts, 
whatever these are ; therefore they become ready for removal, 
or accept of it with ease. The second is a consciousness in 
the absorbents of such a state of part; and both concurring to do 
the same thing, they fall to work. When the part to be absorbed 
is a dead part, or extraneous matter, the whole disposition is in the 
absorbents. Pressure from without rather stimulates than irritates, 
for we find it produces thickening of parts; but if it exceeds the 
stimulus of thickening, it becomes an irritator. If pressure is from 
within, parts rather appear to give wzay, and absorption takes 
place. 
Interstitial Absorption.-This is of two kinds with respect to the 
effects, or, rather, has two states. The first, where it takes place 
only in part, as in the wasting of a limb, where disease of the 
joint has rendered it useless; in a broken tendon ; a divided nerve 
going to a voluntary part; or when it takes place in the whole 
body in consequence of disease, as atrophy, fever, &c. The 
second, wThen entire absorption takes place, and no vestige is left; 
and this would seem to be of two kinds, one where it takes place 
only in consequence of another disease, and is a necessary and 
useful effect of that disease, assisting iAbringing parts to the surface, 
&c.; but the other appears to arise from disease in the part itself, 
as a total decay of the- alveoli without any disease in the teeth or 
gums, as also the wasting of the testicle. The first of our second 
division of absorption of entire parts is taking place in a thousand 
instances; it is gradually taking place in that part of the body between 
many encysted tumours and the surface, and is generally slow in its 
progress. 
Progressive Absorption.-The removal of those surfaces imme- 
diately contiguous to the irritating cause, which is an absorption 
of necessity, is effected by progressive absorption. Absorption 
from pressure is the removal of the part pressed, which may 
either be the surface of an abscess in contact with pus, or of 
that part of the surface of the body in contact with some body 
constantly pressing, as the buttocks or hips of those who lie long 
on their backs. OF SUPPURATIVE INFLAMMATION, ETC. 
199 
Of the Relaxing Process.- Besides the modes of removing parts 
above mentioned, there is another process, called the relaxing or 
elongating process, carried on between the abscess and skin. It is 
possible that this process may arise in some degree from the 
absorption of interior parts; but there is certainly some other 
cause, for the skin which covers an abscess is certainly looser 
than it would be from mere stretching ; and it is very beautiful to 
observe how nature goes on in her own way to produce an effect. 
In consequence of the pressure of pus in an abscess, Nature sets 
up three processes to let it out; first, progressive absorption; 
secondly, interstitial, by which the progressive is assisted j thirdly,, 
the relaxing process, making the parts yield to distension. In 
women, the relaxation of parts is very considerable before the 
birth of a child: and the old women in the country know when a 
hen is going to lay, by the relaxation and softness of those parts. 
The following cases exemplify those processes of absorption. 
A lady, after inflammation of some of the abdominal viscera, 
had the belly swell; some time after, a kind of pointing was 
observed in various parts of the belly, and on opening the largest a 
very considerable quantity of fluid (matter, I think,) was discharged; 
this opening was near the sternum, and the ends of the recti 
muscles were quite ragged. The patient died. Here was an 
instance of the effects of absorption, by which an exit was obtained 
for the matter. Suppose an abscess to go on for a long time with 
a smooth surface, yet if any part takes on the absorbing process 
the matter will be very rapid in arriving at the skin, although this 
process may have taken place in the thickest part. This process 
may be induced by an irritation in any part of the surface; thus, 
after opening an abscess, if matter is permitted to collect at the most 
depending part, it may bring on this process, whence a fresh opening 
will be made. 
This preparation [showing one'] represents the front of a chest, 
which contained an aneurism of the aorta; and here on the right 
side you see an instance of the elongating process, the cartilages 
being bent outwards, or elongated, to adapt themselves to its 
figure. 
This is another preparation (see Pl. III. f. 1.),-an aneurism of 
the aorta. A A, ends of the aorta; B, the first sac, which contracted 
at C, and having proceeded to d, where it met with resistance from 
the sternum DD, it became again contracted; but having produced 
absorption of the sternum d> E, by which an opening is made 
externally, the sac is again expanded. Here are two other prepa- 
rations, exhibiting similar appearances. 
Ulceration. 
Before I enter on this subject I shall make a few more general 
observations on absorption. 200 
HUNTER'S PRINCIPLES OF SURGERY. 
Some parts of our solids are more susceptible of being absorbed, 
especially by ulceration, than others under the same or similar cir- 
cumstances. This is particularly the case with cellular and adipose 
membrane, as we often find muscles, tendons, and ligaments deprived 
of their connecting membrane by ulceration, as maybe observed in 
the opening of large abscesses. The skin itself, if affected by 
pressure from without, is less easily absorbed than the cellular 
membrane; hence we may observe, that in continued pressure 
from without the skin w'ill remain whole, although the parts beneath 
are wasted by the absorption of the cellular membrane; but some- 
times the skin is more susceptible of absorption than the cellular 
membrane; this may proceed from the skin acting with so much 
more vigour, either in opposing any injury or in taking on salutary 
action. Although in abscesses, in tumours, and in the case of ex- 
traneous bodies, the parts all round are equally pressed, yet we find 
that the progressive absorption takes place only on that side near- 
est the skin, and arrives at the skin only on that side: a very slight 
degree of pressure from within will produce this effect, so slight as 
would from without have produced only a thickening of parts. 
Bones are susceptible of a similar process. Absorption may be 
of two kinds,-without suppuration, or with it. The first, I believe, 
is universally the case with the interstitial absorption when it takes 
place alone, as in the absorption of callus, of the alveoli of the 
teeth, &c.; but the second may precede or produce suppuration 
where there was none before, as in old sores breaking out anew. 
To distinguish the second from all other modes of absorption of 
whole parts, I shall call that absorption ulceration which is either 
preceded, accompanied, or succeeded by suppuration. Absorption 
may be a consequence of pressure under two circumstances,- 
where the pressure is from diseased parts, or from extraneous sub- 
stances. Of the first is that from tumours, &c.; thus, in a case of 
aneurism, where the coats of the artery press against the bones, 
the rib for instance, its coats begin to be absorbed, and, after they 
are absorbed, that absorption goes on in the bone, the adhesive 
inflammation takes place at the same time round it, and unites the 
circumference of the absorbed parts: another instance is where 
tumours make their way to the skin, without any suppuration taking 
place. Of this I once saw a very remarkable instance in a soldier 
in the Dutch service: a tumour had formed between the pia mater 
and dura mater, which gradually increased to a very considerable 
size, and had shown itself externally some time before the man 
died. Upon examination after death I discovered that the pia mater 
was absorbed underneath it; but the chief absorption had taken 
place on the side next the skin, for on this side the skull was absorbed, 
and the absorption had begun in the integuments of the scalp, which 
it would soon have probably ulcerated had not the man died before 
Nature had finished her operations; and in this case no matter 
was found either on the brain, skull, or in the integuments, 
owing, perhaps, to the pressure being made by a living part. This OF SUPPURATIVE INFLAMMATION, ETC. 
201 
species of absorption is attended with very little or no pain, and its 
effects are as trifling on the constitution, although it may be an 
effect of an alteration in the constitution, as the absorption of calluses 
in scurvy, &c. 
Ulceration.-I shall now take notice of that action of the absorbent 
system which I call ulceration, and which is the second species of 
our first division, being connected with the formation of pus, either 
as a consequence or as a cause; and it is this kind which always 
constitutes an ulcer. 
This process of ulceration or absorption with suppuration, is 
almost constantly attended with inflammation, which led me to 
call it ulcerative inflammation. Ulceration is generally attended 
with considerable pain, which is called soreness; but this does not 
attend all ulcerations, for there are some which are of the specific 
kind, which give little or no pain, as scrofula ; but even in this 
disease, where ulceration proceeds pretty fast, it often gives con- 
siderable pain, wherefore the pain may be in some degree in pro- 
portion to the quickness of its operation. Tn those cases where 
ulceration is set up to separate dead parts, as sloughs, it is seldom 
attended with pain, and it is not easy to assign the cause of this. 
It seldom or never affects the constitution much, although the 
process is affected by the constitution. 
What I have hitherto said of ulceration I shall illustrate by 
noticing what occurs in an inflammation of the peritoneal coat of 
an intestine. The first inflammation produced is the adhesive, 
which occasions an adhesion between the inflamed part of an in- 
testine and the peritoneum lining the cavity, which remains, although 
the inflammation should stop here ; but if it does not stop here, 
then the suppurative takes place, and an abscess is produced, the 
matter of which is collected into a regular cavity in these adhesions, 
and is prevented from diffusion through the cavity of the abdomen 
by the effects on the surrounding parts, by the preceding adhesive 
inflammation, as well as of that which accompanies it. This matter, 
by its pressure, irritates, and absorption takes place in consequence; 
but as none of the parts, except those between the matter and the 
skin, are hardly, if at all, susceptible of this irritation, no parts are 
absorbed but such as are so situated: hence the abdominal muscles, 
cellular membrane, fat, and skin are removed in preference to the 
coat of the intestine. If the suppuration had at first begun in different 
points, the parts between are absorbed until it becomes one abscess; 
and when it reaches the skin we have the ulcerative inflammation. 
It is in the same manner that Nature acts in all abscesses of cir- 
cumscribed cavities, as in common abscess, inflammation of the 
lung of the side next the pleura, of the pleura itself, gall-bladder, 
liver, &c.; also in the case of lumbar abscesses. In the substance 
of the lungs we sometimes find abscesses go on in a different man- 
ner, and open into the cells, and this because the adhesive inflam- 
mation finds it difficult to connect the air-cells together; and that 
the air-cells do not take on the adhesive inflammation is evident 202 
HUNTER'S PRINCIPLES OF SURGERY. 
from many observations. Whilst a part is under the ulcerative 
inflammation, irritation will increase the absorption on any part of 
its surface. Thus, if a large abscess forms on the thigh, opposite 
the great trochanter, we shall find that, from the pressure of the 
trochanter on the part opposite to it, ulceration will take place 
there likewise. An irritation we have of the same kind in milk 
abscesses, from the irritation of the matter in a depending part of 
the abscess, which shows how very easily, from the slight pressure 
of matter, the ulcerative process may be produced. Ulceration is, 
therefore, no more than a process by which parts are removed out 
of the way of pressure. The ulcerative process has no effect on 
the cuticle; but in general this is so thin as not to give any trouble, 
as it easily bursts. But on the fingers and hands of working people 
it becomes so thickened as to cause excessive pain and trouble in 
whitloes; and as from this cause we have so considerable a sepa- 
ration between the cuticle and the skin, these abscesses should be 
opened early. Poultices in these cases are more useful than in any 
other, for their moisture is absorbed by the cuticle as by a sponge, 
and the cuticle is rendered more dilateable. After these have been 
opened, or have opened of themselves, by a small orifice, the soft 
parts lying under are apt to push through the opening, and appear 
like a fungus, occasioning great pain, which is owing to the cuticle 
around the granulations underneath. To this escharotics have 
been applied ; but it would appear that there is no necessity for 
them, -as it would disappear of itself when the thickening of the 
parts in consequence of inflammation has gone off. But besides 
ulceration, the consequence of previous suppuration, which we have 
been hitherto describing, we have ulceration taking place where no 
reason can be assigned for it, except perhaps weakness be the 
-cause, the parts not being able to support themselves. New parts 
are more susceptible of it than old, as cicatrices, stumps, calluses, 
&c. This arises from the new parts being less firm than the old 
original ones, as in Anson's voyage, when there was a general 
debility from the change of climate, &c. The appearances of 
ulceration are different at different times, according as the process 
is going on, at a stand, or the parts healing. The ulceration in the 
small-pox is attended with death in the parts, hence loss of sub- 
stance and pitting. 
Restoration of Parts.-We are now to trace the operations of 
Nature to bring parts back as near to their original formation as 
possible. These operations cannot be looked on as morbid, as they 
are for a salutary purpose. 
Granulations.-These have, I believe, in general been supposed 
to be a consequence of, or an attendant on, suppuration ; but the 
formation of granulations is not confined to a breach of the solids 
allowed to suppurate, as from accident, or a breach of the solids, 
produced in consequence of suppuration, as in abscesses ; but it 
takes place under other circumstances, and when the first and 
second bond of union have failed, as in simple fractures. OF SUPPURATIVE INFLAMMATION, ETC. 
203 
I believe no internal canal can granulate in consequence of 
suppuration, except there have been a breach of continuity. And 
here I may observe, that when granulation does take place in 
such a canal, it is not on the proper coat of the canal, but on the 
surrounding cellular membrane. Few surfaces of abscesses gra- 
nulate until opened, either of themselves or by art; therefore in 
abscesses of very long standing we seldom or never find granula- 
tions. 
In most abscesses, if not in all, after they are opened, there is 
one surface more disposed to granulate than the others, which is 
the surface next to the centre of the body in which suppuration 
takes place, the surface next to the skin hardly ever having the 
disposition to granulate ; on the contrary, it is sometimes ulcera- 
ting when the bottom of an abscess is granulating. Exposure is 
so far necessary for granulations, even in cases where there is an 
opening, that if the opening is only a small one, and the abscess is 
deeply seated, the latter will not so readily granulate, which often 
becomes the consequence of deep-seated abscesses not healing. 
I have said that granulations are not confined to a breach of the 
solids attended with suppuration ; for parts are capable of making 
new matter internally in cases where union by the first intention 
ought to have occurred. A case in St. George's Hospital first 
gave me this idea. 
I was called to a man with a fractured thigh, and made use of 
the usual means, but without success, for no union of the fractured 
parts was formed in the usual time; and about the end of four 
weeks the man died with another complaint. Upon examination 
of the parts, I found that the upper end of the bone rose consider- 
ably over the under, and consequently there was a great cavity in 
the soft, parts, the parietes of which were thickened by the adhesive 
inflammation, though not so much as if the parts had been better 
disposed for the adhesive inflammation. There was no extrava- 
sated blood, nor matter, nor coagulable lymph to be found, except 
a few threads, which were probably the remains of extravasated 
blood. Here the parts had lost two chances of being united, the 
one by the extravasated blood, the other by the coagulable lymph 
thrown out by the adhesive inflammation; and Nature had begun 
a third, which was that of forming granulations of new animal 
matter on the ends of the bone and the surface of the surrounding 
cavity; and adhesions, you see, had taken place between the bones 
and soft parts, by which the bones would have been united by a 
bony case. Hence we find that granulation may take place with- 
out the parts being exposed, and without suppuration.* 
This mode of union by granulation is, I believe, much more 
* [The effusion of callus in this case does not seem to differ essentially from 
the effusion of callus in other cases. It certainly cannot be regarded as a con- 
clusive proof of the existence of granulations without suppuration and exposure, 
although these do sometimes continue to form after cicatrization, as in burns and 
some other cases.] 204 
HUNTER'S PRINCIPLES OF SURGERY. 
extensive than has been imagined; this third bond of union taking 
place where the parts have missed the first and second, as just men- 
tioned. In the exposure of cavities of abscesses we have granula- 
tions going hand in hand with, and following suppuration. As the 
suppurative inflammation follows injuries with exposure, it seems 
that this inflammation is in general necessary to granulation in these 
cases. 
Granulations are an accretion of new animal substance on the 
surface of a wound, or a newly-formed surface composed of coag- 
ulable lymph exuded from the vessels, into which new substance 
the old vessels probably extend, and entirely new ones are formed, 
so that the granulations come to be very vascular, more so indeed 
than any other particular animal substance. The vessels pass from 
the original parts to the base of the granulations, and from thence 
to their outer surface. The surface of this new formation continues 
to have the same disposition for the secretion of pus as the parts on 
which they are formed had; therefore it is easier to suppose that 
the nature of these vessels does not alter by forming granulations, 
but they are completely changed for this purpose before granula- 
tions are begun to be formed, and that these granulations are the 
consequence of the change. They always also are of the same 
nature with the parts on which they are formed : if a diseased part, 
they are diseased; if the disease be of any specific kind, they are 
of the same kind and produce similar matter. The surface of the 
granulations is convex, being just the reverse of an ulcerating sur- 
face, which is thus, as it were, shagreened by a great many points 
or small eminences: the smaller these points are, the more healthy 
the granulations. The colour of healthy granulations is a florid red, 
which would make us suspect that it is principally owing to arterial 
blood; when they are of a livid red they are most commonly un- 
healthy, and have a languid circulation in them ; however, this 
appearance frequently is owing to the particular position of the 
parts. I knew an instance of this in a young man who had a gran- 
ulating wound on his leg. I was surprised to see it on some days 
of a healthy scarlet, and on others quite livid; but the cause of this 
he explained to me, by showing that if he kept it in a recumbent 
posture for a short time, its surface was then of a bright scarlet, 
but if he stood for a few minutes it would become quite livid. This 
appearance must have arisen from the stagnation of blood in the 
newly-formed vessels, and from their not possessing sufficient strength 
to resist the superincumbent column of blood, which sufficiently 
accounts for the difficulty of healing sore legs when patients are 
allowed to stand or walk much. 
Granulations not only show the state of the part on which they 
are formed, but also how far the constitution is affected in many cases. 
The chief of those which affect granulations are the irritable and 
indolent habits, and, still more, fevers, which must be of such a 
nature as to produce universal irritation in the constitution. 
Granulations have a disposition to unite with one another, which OF SUPPURATIVE INFLAMMATION, ETC. 
205 
is absolutely necessary to healing; and this is done, I suppose, in 
the following manner : when two granulations meet, the mouths of 
the opposing vessels are irritated, which causes them to embrace 
each other; this junction perhaps being aided by the attraction of 
cohesion, or they may throw out coagulable lymph, and unite in that 
way. I have seen granulations from the dura mater and scalp unite 
so closely in twenty-four hours as to be with difficulty separated, 
and then to bleed very freely, which shows their great disposition 
to unite. When the parts, and consequently the granulations, are 
not sound, there is not this disposition to unite, and a smooth surface 
is formed, which continues to secrete pus. I conceive the internal 
surface of a fistulous sore to be of this nature, and somewhat similar 
to the urethra in gleet. Ulcers of this kind are cured by exciting 
inflammation in them. 
Granulations have less powers and shorter lives than originally 
formed parts. Different animals have different periods of life, and 
so have granulations, and sometimes they seem to be formed with 
a short period of existence. They often die and slough off without 
any visible cause, and, coming down to the original parts, a fresh 
crop of granulations is formed, which in a certain time will again 
slough off without any apparent change in the constitution. 
Many small wounds would perhaps do much better without any 
dressing. The blood, coagulating and drying, forms itself into a 
scab, which falls off and shows that Nature has completed her 
work undei' it; the same will often happen when small suppurating 
sores are suffered to dry. This is a circumstance not attended to, 
perhaps, as much as it ought: even compound fractures with a small 
opening, if suffered to proceed in this manner, will often give but 
little trouble. In blisters, where the cuticle is not removed, the 
process is exactly similar. It would be a great advantage to us 
to ascertain what sores require dressing, and what do not. I be- 
lieve all cutaneous sores do best without dressing ; excoriations 
and little pimples had best be left to themselves, for often when ap- 
plications are made to any of these, a hundred little pimples will 
sprout up: when this is the case, I make it a general rule to desist 
from any application. 
A young gentleman had a small pimple on his leg, to which a 
little ointment was applied, and in a day or two the surrounding 
parts were covered with similai' pimples : these, being treated with 
similar applications, spread, until the whole leg was covered with 
them. When I was consulted, and asked what was to be done 
-" Nothing." " How is that ?" " Can anything be easier ?" I 
said ; " do nothing to the leg." 11 Then the stocking will stick to 
it." 11 Let no stocking be worn: put the boy on a pair of trousers." 
The advice was taken, and the leg dried up and healed directly. 
Cicatrization.-Immediately on the formation of granulations, 
cicatrization would seem to be in view; contraction is going on in 
every part, but principally from the edges to the centre, so that the 
sore becomes very small, without much new skin. This contrac- HUNTER'S PRINCIPLES OF SURGERY. 
206 
tion is easiest effected on loose parts, but with difficulty when over 
bones, as on the scalp, shin-bone, &c., where the granulations can- 
not contract much. This observation should direct us, in opera- 
tions on such parts, to leave as much skin as possible. This con- 
traction continues until the whole is skinned over ; but their greatest 
power, or at least their greatest effect, is at first. This contraction 
can be assisted by art, which shows there is a resistance; this is 
done by bandages, but these should be avoided at first, while there 
is inflammation, and until granulations are formed, otherwise they 
might prevent the granulations rising. Besides the contractile power 
of the granulations, there is a similar power in the surrounding edge 
of the cicatrized skin, which assists the power of the granulations, 
and is often greater than that of the granulations; this may be seen 
in sugar-loaf stumps, where the skin grows round and embraces 
the granulations like a ring, appearing to squeeze them out; but it 
is only in the new skin, the old being loose all round. This con- 
tractile power prevents the necessity for so much new skin, the 
surrounding old skin being drawn over the parts. The advantage 
of this is very evident, the original skin being more fit to live than 
the new, and less liable to ulceration. As the granulations contract, 
the old surrounding skin is stretched, and is probably elongated. 
If it is elongated, it must be so by the interstitial deposition of new 
matter. 
Of Skinning.-When a sore begins to heal, the old skin, which 
had been inflamed, then becomes whitish, and especially near the 
edge : this is one of the first appearances of healing. The new 
skin is a very different substance with respect to texture from the 
granulations on which it is formed; but whether it is an addition 
of new matter, or a change in the surface of the granulations them- 
selves, is not easily determined. We find new skin generally taking 
its rise from the surrounding old skin, as if elongated from it; but 
that is not always the case, for in very large old ulcers, where the 
edges of the old skin have but little tendency to contract, new skin 
forms in different parts of the ulcer, standing on the surface of the 
granulations like little islands. These little specks show that the 
ulcer is healing slowly, and it seldom or never takes place the first 
time a part is ulcerated ; but the old surrounding skin assists by 
shooting towards the new. The granulations may perhaps acquire 
a disposition to skin from their being in the neighbourhood of the 
old skin, but it is plain they can take on this disposition without that 
assistance. 
Skinning is a process in which Nature is always a great econo* 
mist. We never find that newT-formed skin is so large as the sore 
was on which it wras formed. This is brought about by the con- 
traction of the granulations, which in some measure is in proportion 
to the quantity of the surrounding old skin. If a sore be in a part 
where the surrounding skin is loose, as the scrotum, the contractile 
power of the granulations being not at all prevented, very little new OF SUPPURATIVE INFLAMMATION, ETC. 
207 
skin is formed ; whereas if the sore is on a part where the skin is 
tight, as the scalp, the new skin is nearly as large as the sore. 
Nature of the newly-formed Cutis. - When granulations are 
formed near a bone, the skin is at first fixed ; but it gradually be- 
comes loose, from elongation, by continued attempts at motion. 
Motion given to the part so affected must be mechanical, but it 
becomes a stimulus by which the parts become conscious of their 
not being able to exist as they are, therefore the lymphatics set to 
work to absorb all the adventitious substances which prevent their 
motion. Medicine has not as much power as we could wish in 
assisting this process ; however, mercury seems to have nearly the 
same effect as motion, especially when combined with camphor, 
and should be used. When everything else fails, electricity may 
be tried, for it has restored the motion of parts after they have been 
fixed from inflammations after strains. 
The newly-formed skin has no indentations, or lozenge-shaped, 
marks, on it, like the old, nor has it the living principle so strong. 
The new cutis is at first very vascular, but afterwards becomes 
less so, the vessels perhaps being obliterated, or converted into 
absorbents, and so becoming white. 
Cuticle.-That formed on the new cutis is at first horny, but 
afterwards shining. It is sooner restored than the cutis, and is 
formed at once from every part of the cutis. 
Rete Mucosum.-This is much longer in forming than the cuticle, 
and sometimes is never recovered, as we see in wounds, blisters, 
&c., in blacks, their skin in that part remaining white for ever. 
Effects on the Constitution.-I have divided diseases into 
local and constitutional; and when on local, I observed that they, 
and especially inflammation, had secondary or sympathetic affec- 
tions, which were immediate or remote. The immediate were 
considered when on inflammation, namely, the sympathetic fever. 
The remote are now to be treated of. 
One would suppose that the suppurative would only so far affect 
the constitution as by the preceding inflammation which produces 
it; but the contrary is sometimes the case, and the suppurative 
will produce worse symptoms than the inflammation itself. The 
condition which the constitution takes on after suppuration is some- 
times productive of those diseases termed nervous, as locked-jaw, 
hysteria, spasm on the muscles of respiration, restlessness, debility, 
&c., all of which seem to arise from the suppurative action, and 
are not salutary effects, but harass the constitution and even pro- 
duce death. The locked-jaw I shall defer for the present, and 
consider hectic or sympathetic fever. 
Hectic fever is a remote constitutional sympathetic affection, and 
appears to have a very different origin from the other remote 
sympathizing effects, though in general the consequence of a local 
disease. It is the constitution affected by a local disease, or irri- 
tation, which it is conscious it cannot cure; for while the inflam- 208 
HUNTER'S PRINCIPLES OF SURGERY. 
mation lasts, which is only preparatory to an immediate effect of 
most injuries, in those parts at least which can most affect the con- 
stitution and call up her powers, there can be no hectic. 
It takes its rise from a variety of causes, which I shall divide 
into two: 1st, From an affection of vital parts; 2d, From an 
affection of parts not vital. The only differences between these is 
in the time of the hectic's coming on, and its rapidity and violence 
when it does come on. In vital parts, hectic will be produced by 
many complaints which will not produce it in other parts, as 
scirrhus of the stomach or mesenteric glands, also diseases of the 
lungs or liver. These also produce other symptoms, according to 
the nature of the part injured and of the injury; as coughs, when 
in the lungs; sickness and vomitings, when in the stomach; drop- 
sies and jaundice, when in the liver. 
When the hectic arises from disease in a part not vital, it is 
generally in parts where such a quantity of mischief can take place 
as to make the constitution sensible of it, as the large joints. In 
small joints, although the same local effect takes place as in large 
ones, yet the constitution is not made sensible of it, so that we find, 
scrofulous joints of the toes, &c., not affecting the constitution with 
hectic, and the ankle, elbow, and shoulder are much longer in 
affecting the constitution than the knee or hip. 
Although hectic commonly arises from some incurable local 
disease of a vital part, or of a common part of some magnitude, 
yet it may be an original disease of the constitution; the consti- 
tution may fall into the same action without any local disease 
whatever. 
Hectic may be said to be a slow mode of dissolution; the general 
symptoms are those of a low or slow fever, attended with weak- 
ness; but more the action of weakness than real weakness, for on 
the removal of the part causing the hectic there is immediately 
the action of strength produced. The particular symptoms are: 
debility; small, quick, sharp pulse; the blood forsakes the skin; there 
is loss of appetite; often vomiting ; wasting; tendency to sweating, 
especially when in bed; constitutional purging; urine clear at one 
time, and at another depositing a branny brick-dust sediment; 
dissolution. This disease has been supposed to arise from absorp- 
tion of pus; but I have long thought that the blame has been 
improperly laid to the absorption of pus, and the following facts 
will make this evident. First, hectic takes place where there is 
disease, and no suppuration in vital parts; also in many inflamma- 
tions before actual suppuration has taken place, as in many of the 
large joints, called white swellings, while the same kind and quantity 
of inflammation and suppuration in any of the fleshy parts, and 
especially such of them as are near the source of the circulation, 
have in general no such effect. Therefore in such cases it is only 
an effect on the constitution, produced by a local complaint having 
a particular property. 
I have said that with all diseases of vital parts the constitution OF SUPPURATIVE INFLAMMATION, ETC. 
209 
sympathizes more readily than with many other parts; and also 
all diseases of vital parts are more difficult of cure than those not 
vital; as also diseases of bones, ligaments, tendons, affect the con- 
stitution more readily than of muscles, skin, cellular membrane, 
&c.; and we find these general principles hold good in universal 
remote sympathy with local disease of those parts and structures. 
When a disease is in the vital parts, and is such as does not kill 
from the first constitutional effects, then the constitution becomes 
teazed with the complaint, which is destroying the necessary actions 
of health which are vital. In diseased joints there is not a proper 
power, or rather, perhaps, disposition to produce salutary inflam- 
mation and suppuration for their recovery; therefore the constitution 
is irritated with an incurable disease. 
If absorption of pus always produced such symptoms, I do not 
see how any patient who has a large sore could escape this disease, 
because we have as yet no reason to suppose that any one sore has 
more power of absorption than another. If in those cases where 
there is hectic the absorption of pus is really greater than when the 
habit is healthy, it would be difficult to determine whether the 
increase of absorption is a cause or effect. If it is a cause, it must 
arise from a particular disposition of the sore to absorb more at one 
time than at another, even while in a healthy state. What reason 
we have to suppose that a sore in a healthy constitution has power 
to absorb more at one time than at another, I do not see. If this 
increase of absorption does not depend on the nature of the sore, it 
must take its rise from the constitution; if so, there is a peculiarity 
of the constitution ; therefore the whole of the symptoms cannot arise 
from the absorption of pus, and the cause must be a peculiar con- 
stitution and absorption combined. 
If the absorption of matter produced such violent effects as are 
ascribed, which are never of the inflammatory kind, but of the hectic, 
why does not venereal matter produce the same effects? We often 
know that absorption is going on by buboes taking place, yet no 
symptoms appear until the mattei' appears to produce its specific 
effects, and these symptoms are not very similar to those called 
hectic, though from reasoning we should expect that venereal matter 
would act with more violence than common matter from a healthy 
sore. 
Again, as matter is often formed on the inside of veins in inflam- 
mation of those cavities, and this matter enters directly into the 
circulation, why have we not the hectic symptoms in these cases1 
We have the inflammatory, and sometimes death. We also find 
the matter of large abscesses which have been produced without 
visible inflammation, such as many of the scrofulous kind, wholly 
absorbed, and that in a very short time, yet no bad symptoms 
follow. 
From all these facts and reasonings we may conclude that the 
absorption of pus from a sore cannot be the cause of so much mis- 
chief as has been generally supposed. If it was owing to matter in 210 
HUNTER'S PRINCIPLES OF SURGERY. 
the system, I do not see how the symptoms could ever stop until 
suppuration ceased; yet we often do find that they get well before 
suppuration ceases, even when no medicine was given; and in the 
case of inflammation of the veins, there is reason to believe that 
after all the bad symptoms are gone suppuration is still going on, so 
that though matter is still passing into the constitution from the vein, 
hectic is not produced, which it must be if it was caused by matter 
getting into the circulation. 
But I much doubt the fact of absorption going on more in one 
sore than another. In large abscesses hectic seldom comes on till 
they are opened, though they have been forming matter for months. 
In such cases the disposition often comes on soon after opening the 
abscess: in others very late; but till the stimulus for restoring the 
parts is given no such effect can take place. If the parts were dis- 
posed to heal, no such hectic disposition would come on. In diseased 
joints also, if the parts are capable of taking on salutary inflam- 
mation we shall have only the first sympathetic inflammatory fever; 
but as they seldom do this, the constitution is teazed by the complaint 
not taking on immediate and salutary steps towards a cure. Hectic, 
therefore, would appear in some measure to depend on the parts 
being stimulated to produce an effect beyond their powers, and this 
stimulus is sooner or later in taking place. 
Treatment of Hectic.-We have as yet, lam afraid, no cure for 
this. I believe the cure consists in the removal of the cause, viz.: 
the local disease. Strengtheners and antiseptics are recommended. 
Strengtheners are proposed on account of the debility, which has 
evidently taken place; and antiseptics, from the idea of absorbed 
pus giving the blood a tendency to putrefaction. To prevent both 
these effects taking place the same medicines are recommended, 
namely, bark and wine. Bark will in most cases only assist in sup- 
porting the constitution; I should suppose it could not cure the con- 
stitution of the disease; however it may render it less susceptible of 
it. When hectic comes on from some specific disease, as from 
venereal irritation, the bark will enable it to support it better than 
it otherwise would have done. Wine, I am afraid, rather does harm, 
as it increases the action of the machine without giving strength, a 
thing to be carefully avoided. However, I have not yet made up 
my mind about wine. 
When hectic arises from the disease of such a part as the system 
can bear the loss of, the part should be removed. On removing 
the cause (as by amputation of an extremity,) the pulse, from being 
very quick, returns to its usual state; I have likewise known the 
patient sleep the first night without an opiate, after having had little 
or no sleep for a week before, and the sweats called colliquative 
have been stopped; and I have known purging immediately to stop. 
Perhaps the pain and newly excited action of the constitution may 
assist in the abatement of the symptoms. 
Of Dissolution.-To the hectic I have joined another disease. PRACTICAL ILLUSTRATIONS, ETC. 
211 
arising from suppuration, which I have called dissolution, because 
few recover from it. 
It may arise in long-continued suppurations, which may not be 
incurable in themselves, and in this it differs from hectic. Dissolu- 
tion seems more the effect of the past than of the present, which is 
the reverse of hectic. We never find this take place in consequence 
of small wounds, or such as affect the constitution but little, but 
rather after bad compound fractures, amputations, &c. It appears 
more in hospitals than in private practice; more in large towns 
than in the country. In cases of compound fractures and amputa- 
tions, we find the constitution often capable of going through 
the inflammatory sympathetic fever, producing suppuration and 
granulation, and continuing this for some time, yet sinking under 
them at last, and often without any apparent cause, the effect taking 
place more readily if the patient was in full health before the 
operation, than if he had been for some time accustomed to hectic 
symptoms. 
The first symptoms are generally those of the stomach, shiver- 
ing ; vomiting immediately follows, if it does not accompany it; a 
small quick pulse; perhaps bleeding from the whole surface of the 
sore: often mortification and speedy dissolution. Here is a very 
fatal disease taking place in some almost immediately, and when 
everything appears to be within the powers of the animal. It 
therefore cannot immediately arise from the sore itself: yet the sore 
certainly assists, because we never see the disease take place where 
the sore is healed. 
The removal of the local disease will not prove effectual for the 
cure of this as it does that of hectic, nor do I find anything that has 
any effect. 
CHAPTER XV. 
PRACTICAL ILLUSTRATIONS OF THE PRECEDING SUBJECTS. 
Union of a broken tendon ;-rupture of the tendo-Achillis ;-principles of treat 
merit;-impossibility of causing voluntary contraction of the muscle;- 
management of the injury ;-pain and inflammation trifling;-length of cure. 
-Empyema ;-varieties of contained fluid ;-symptoms differing ;-ultimate 
effects of contained fluid the same;-to be distinguished from disease of the 
heart.-Symptoms of the disease peculiar ;-general;-sympathetic.-Opera- 
tion.-After-treatment.-Pericarditis.-Adhesion;-suppuration fatal.-Em- 
physema from fractured rib ;-operation to be avoided.-Peritonitis ;- 
symptoms;-rapid progress;-true and erysipelatous.-Puerperal, not from 
inflammation of the uterus;-causes;-arising after tapping.->Hernia.-Cesa- 
rian section.-Opening cavities of joints.-Ganglions.-Inflammations of the 
eye-Phlebitis following venesection ;-causes ;-extension;-frequency in 
the horse.-Arteritis. 
Union of a broken Tendon.-The treatment of a broken tendon 
is very similar to the treatment of a fractured patella, because 212 
HUNTER'S PRINCIPLES OF SURGERY. 
their uses, and in some degree their situations, namely, the 
giving way of an intermediate substance between the power (that 
is the muscles,) and the resistance. All come under one general 
principle of cure, though the mode of treatment is somewhat dif- 
ferent. 
These intermediate parts are principally tendons, probably some 
ligaments, and bones. The fracture of a tendon is probably always 
produced by the powei' being in action, and the resistance counter- 
acting at the same time and with great velocity. We might sup- 
pose that every tendon in the body would be liable to such accident, 
but I believe there is only one that stands any chance of such effect 
by the natural exertions of the body; this is the tendo-Achillis.* 
There is also, probably, but one bone in the human body which can 
be broken in the same way, that is the patella; though there may 
be instances of processes of bone being turn off near their insertion, 
which would be somewhat similar. 
The tendo-Achillis seems liable to be broken by the natural actions 
of the body, from having at the same time to sustain the action of 
the power and of the resistance also. When it has only the action 
of the muscles to contend with, there is no danger of its rupture, 
because the tendon is capable of supporting a much stronger power 
than that of the muscles. Though the tendon is continually in this 
state, yet there is little danger, because when the action is voluntary 
all the actions tend to support one another; but in a careless un- 
guarded action the motion is more violent and quick, and the part 
less prepared against it. I believe fracture of this tendon often hap- 
pens when a person is fatigued and off his guard, as after dancing, 
&c., and after the muscles have acted spontaneously, as in the 
cramp; at least it happened to me after dancing, and after a violent 
fit of the cramp. The general principle of cure in parts displaced 
is the replacing them in their natural situations, which is the whole 
cure in some, as dislocations, and the first step to be taken in every 
case wrhere the continuity of parts is broken. 
When the tendon is broken it is seldom attended with pain in the 
parts. It commonly gives a pain, which instantly seizes the calf of 
the leg. The noise or snap which it produces gives no idea of the 
mischief done; but being at the same time attended with pain in 
the calf of the leg, and the patient not being able to walk as usual, 
he conceives that some one has struck him with a hard body on the 
calf, and if he is so situated as not to have been liable to a blow, he 
becomes puzzled to conceive what can have happened. We gen- 
erally find that the muscle is thrown into a state of cramp when the 
tendon gives way, losing the power of relaxation by the will, or of 
itself. As a surgeon is seldom present when such an accident hap- 
* [This is a mistake: the tendons of the patella, triceps extensor cubiti, and 
quadriceps extensor cruris are sometimes ruptured from a sudden and abrupt 
exertion of these muscles. An example of the latter kind is at this moment in 
one of the wards of St. George's Hospital. I may also mention that fractures of 
the collar-bone, from muscular exertion, are not very uncommon.] PRACTICAL ILLUSTRATIONS, ETC. 
213 
pens, it is often allowed to remain some time in that state; but the 
pain often leads to the right mode of cure, the patient squeezing the 
muscle down with his hands, which a surgeon should do if at hand. 
The broken ends will always at first be some distance from each 
other, because they are pulled apart by opposite forces. 
The parts should be allowed to remain nearly in their natural posi- 
tion; no inconvenience will attend a small separation of the broken 
ends of the tendon, namely, half an inch or so; whereas considerable 
disadvantage would arise if we were to push the two broken ends 
together by throwing back the heel (which has been the general 
practice). The only circumstance that would seem to forbid such 
practice, namely, letting the broken tendons remain without a ban- 
dage, is, that the muscle will lose half an inch of its power of con- 
traction, which the motion of the ankle may or may not lose; but 
though this may be lost at first, we know muscles will acquire it 
again afterwards, and therefore no attention need be paid to this 
objection. The advantage of not throwing the heel up, and of 
allowing the tendon to heal nearly in its natural position is, that the 
patient may be enabled to walk from the very beginning of the cure, 
a very desirable circumstance. 
However, it is not necessary to adhere rigidly to either of these 
modes of treatment, but to adopt a medium between the two, which 
will be best. The heel may, therefore, be a little raised during the 
time of walking only, by raising the heel of the shoe. A roller should 
be passed several times round the calf of the leg, and kept constantly 
applied, as we cannot guard against the involuntary actions of the 
muscles; and at night we may apply an apparatus consisting of a 
leathern slipper or sock, with a strap from the heel to be fixed to a 
belt, in order to steady the muscles. 
When the tendo-Achillis is broken, there is but very little inflam- 
mation attendant; but some general fulness comes on about the 
small of the leg and ankle, the skin looks dark from the effusion of 
blood, and the parts have a firm feel, from coagulable lymph being 
thrown out. This firmness of the cellular membrane increases near 
to the fracture laterally, and this assists in keeping the tendon in its 
place. The inflammation hardly requires any particular treatment 
when the foot is in a proper position. 
As I would not restrain the patient from walking almost from the 
very beginning, (the inflammation may prevent it for the first day or 
two,) it is necessary to give him some directions how he is to manage 
the muscles under the cure, as walking cannot be performed in the 
usual way. I have recommended to keep the position of the foot 
nearly at a right angle with the leg, as in standing, but not quite so, 
the heel being a little raised, by some pieces of leather put into the 
shoe, which may be removed one by one. When he walks he must 
turn his toes out, and carry the inside of his foot forwards, without 
attempting to bend the joint of the knee; indeed, the latter precau- 
tion is unnecessary, for this motion is only necessary when the heel 
can be raised from the ground, which he cannot do. This foot will 214 
HUNTER'S PRINCIPLES OF SURGERY. 
be for some time the leading foot in walking, for it will be an easy 
motion to set it forwards before the other, especially if the heel is 
not much raised; but it will be impossible to set the other foot for- 
wards and leave this behind. The patient will be hardly able to 
mend his pace for two months, except it be by getting familiar with 
his present mode of walking. The ankle and foot will swell occa- 
sionally, especially in the evening; and this may continue more or 
less after the tendon is united, but is of no importance. Three or 
four weeks after the accident he may remove the roller from the 
calf of the leg, and about the same time leave off the slipper at night. 
We cannot say when he may use the muscle of this tendon: that 
will depend on the fitness of the tendon to be used, which can 
only be known by the power the patient has of putting it to use. 
About two months after the accident we find him gradually bring- 
ing his toes more and more forwards, until he at last walks as 
usual.* 
It is impossible for a patient with a fracture of the tendo-Achillis 
to act with the gastrocnemius and soleus muscles, if he were to try 
to do so. When the Duke of Queensberry broke his tendo-Achillis 
he was immediately aware of what had happened, and pointed out 
to me the broken ends. He readily submitted to my reasoning: 
walked about his room as well as he could, and found it impracti- 
cable to contract the gastrocnemius muscle. Some surgeons thought 
the tendon could not be broken, because he was walking about his 
room; but in such a case the patient has no more power to contract his 
gastrocnemius and soleus muscles than to jump over St. Paul's. 
Of simple Fractures.-A fracture is the solution of continuity of 
a bone, whereby more or less of a cavity or space is allowed 
between the broken parts. It often, if not always, happens that 
the surrounding soft parts are also torn by the broken ends of the 
bone. On the surface of this broken or torn part are the mouths 
of many ruptured vessels, which immediately fill the cavity with 
blood. This is the first stage of the bond of union. This blood, 
having the living principle in it, unites with the torn surfaces, in 
the same manner as in ingrafting the living parts of animals. An 
inflammation generally comes on, similar to that which produces 
adhesions where there is no ruptured vessel, which is of service in 
this case for the better union of surrounding parts,, where extra va- 
sated blood cannot enter, by which means the callus becomes 
larger than it would otherwise be. Vessels are either continued 
from the old parts into this extravasated blood, or it forms new 
* [The period of perfect recovery is generally protracted several months before 
the ultimate organization of the uniting medium is effected, in consequence of 
the low powers of vitality which tendinous parts possess. Simple incised 
wounds of tendons, as in amputation, are observed to heal without difficulty; 
but the union of ruptured tendons is a much slower process, depending upon the 
slow reproductive powers of these parts. At first the union is by cellular mem- 
brane, which gradually becomes harder and tougher: very often it becomes 
osseous, as in Mr. Hunter's own case; but very frequently it remains a fibro- 
cartilaginous knot, which never assumes the tendinous character.] PRACTICAL ILLUSTRATIONS, ETC. 
215 
vessels in its own substance; this substance then goes through the 
regular stages of ossification, becoming first cartilaginous and then 
bony. Thus 'new parts are formed and old ones united without 
the occurrence of any considerable inflammation, and all owing to 
this circumstance of the extravasated blood being preserved, and 
allow'ed to retain its living powers. All the surgeon has to do in 
such cases is to put the parts as much into their natural situation 
as possible, and to keep them there by art in the easiest way to the 
patient that he can. The same idea and the same practice is 
extended to all unions by the first intention. 
The position of the patients themselves, when the fracture is in 
the lower extremities, (abstracted from the nature of the fracture 
itself,) has been of late a consideration. It has been a question 
whether they should lie on their backs or on their sides. I am in- 
clined to prefer the back; for, from the experience of one patient, 
who had the same thigh-bone broken twice, lying on the back was 
the easiest, though it was the last, method of lying; and I conceive 
that it is a position that can be borne longer than that on the side. 
The pain arising from fracture is but little, only from the bones 
either tearing or wounding the soft parts. The inflammation is of 
course but little, if the parts have not been violently torn. 
Of Compound Fractures.-If the violence of the fracture has con- 
tinued the laceration through the skin, so as to have allowed part 
of the blood to escape, and to have exposed the remainder sufficiently 
long to allow it to lose its living principle, so as to become an 
extraneous body, unfit for the purposes of union, then the suppura- 
tive inflammation must take place, and granulations finish the union 
which the blood was incapable of doing. In this case the granula- 
tions become the origin and seat of formation of the callus, and go 
through the regular changes until they become ossified, as was the 
case with extravasated blood in simple fracture. In these cases 
considerable fever and inflammation, proportioned to the local 
injury, come on. 
There are two cases which partake of the nature both of simple 
and compound fracture. The first is, where the injury was a 
simple fracture at first but afterwards becomes a compound, which 
I shall call the simple compound fracture; the other is when the 
fracture is a compound one at first, but the external wound so 
small, and the soft parts having sustained so little injury, as to 
require very little different treatment from what happens in the 
simple fracture; and this kind I call a compound simple fracture. 
Of the Simple Compound Fracture.-This is owing, in some cases, 
to some part of the extravasated blood losing its living principle, 
and then acting as an extraneous body ; in others it is owing to 
the sharp end of the bone pressing against the inside of the skin and 
causing it to ulcerate. In these cases we see inflammation come 
on, at first, as in simple fracture, with that mildness which generally 
attends such cases; but some days after a stimulus is given by the 
broken pieces of bone, or by the blood which has lost its living 216 
HUNTER'S PRINCIPLES OF SURGERY. 
principle, or from the parts being beyond the power of union by the 
first intention, and the suppurative inflammation comes on. 
The cases which I have seen of this kind have been much less 
dangerous than fractures that were compound from the first. The 
only reason I can assign for this is, that the whole of the blood pro- 
duced from the lacerated parts does not lose the living principle, so 
that a considerable portion becomes so much a part of the living 
solids during the first few days as to be able to keep its ground, 
only a portion of it acting to produce the suppurative inflamma- 
tion, which is therefore less. 
The treatment of the simple compound fracture is very simple: 
the limb may be bound up in general as in a simple fracture, with 
splints and a roller, only leaving a free space for the change of 
dressing and to keep the parts clean. 
Of the Compound Simple Fracture.-The effect of this is similar 
to the foregoing, though the cause is different. There are cases of 
compound fracture where the wound in the skin is but very little at 
first. If the broken ends of the bone have not done much mischief 
to the soft parts, and only made a small wound in the skin, they may 
be treated as simple fractures, which gives us an opportunity of 
retaining the uniting matter. By immediately closing up the wound 
with a bit of sticking-plaster, or a little lint soaked in the blood and 
allowed to dry on it, the greater portion of the wounded parts and 
broken ends of the bone will unite by the first intention, and only 
those parts of the solids which are exposed will suppurate. This 
small suppuration will oblige the surgeon to leave the wound in the 
skin free from bandage, in order to be enabled to look at it occa- 
sionally ; though, from some accounts, it might seem that even this 
was not necessary. This mode of treating it as a simple fracture 
obliges it to heal as such. This practice has been followed even 
when the laceration in the skin was considerable; but I have not 
seen a sufficient number of cases to say how far it may be 
extended. 
Inflammation, Suppuration, and Ulceration of circumscribed Cavi- 
ties.-All circumscribed cavities, as the pleura, peritoneum, &c., 
admit of the three inflammations. They may be formed into true 
and distinct abscesses by adhesions inclosing the matter, as in com- 
mon abscess. If the inflammation does not stop at the adhesive, 
then suppuration follows, and ulceration also becomes necessary for 
the exit of the matter, which is an extraneous substance. A material 
circumstance happens in the inflammation of cavities containing 
vital parts, which is, that very little sympathy exists between the 
surrounding part and the parts contained, whence the inflammation 
of the one is not always continued to the other ; thus, inflammation 
of the peritoneal coat of the abdomen and of the intestine may exist 
without inflammation of the inner coat of the intestine. But this 
does not hold good universally, for inflammation of the tunica vagi- 
nalis spreads through the whole body of the testis. 
Inflammation of the Pleura.-This membrane is more subject to PRACTICAL ILLUSTRATIONS, ETC. 
217 
inflammation than any other investing membrane. Probably this 
does not arise from any difference of structure, but from its situa 
tion, by which it is exposed to the operation of cold air, and fron 
its contact with the lungs. Perhaps there is hardly one in fifty who 
at the age of fifty, is without adhesion of the lungs to the pleura 
We often find the lungs adhering to the whole surface of the pleura 
lining the thorax, and it does not seem necessary that inflammation 
should take place on both surfaces to produce adhesion. Abscesses 
may be formed here, either having the matter inclosed in a parti- 
cular bag or diffused through the whole side, forming one large 
abscess; hence true and false empyema. 
Empyema.-The cavity of the chest is subject to the twro 
diseases of other circumscribed cavities, dropsy, and inflammation 
and suppuration, or empyema. These two kinds of disease will 
have some of theii' symptoms very different, though the symptoms 
arising from the ultimate effect, namely, the collection of fluid in 
the chest, will be nearly the same in both. But as this cavity has 
connexions with parts w'hose symptoms when diseased will be very 
different from those of this cavity simply, and as those parts will 
sympathize with the diseases of this cavity, we shall find that a 
complication of symptoms will often take place which may mislead 
the judgment so much as to make us suspect that the sympathizer 
is the seat of the disease. 
This sympathizer is the heart; and as a disease of this part has 
produced symptoms which have been lately called angina pectoris, 
we find that it requires particular attention to be paid to the 
specific symptoms of empyema, to separate them from those of the 
heart. 
The general cavity of the chest is divided into two distinct cavi- 
ties : therefore whatever disease affects one simply, cannot affect 
the other by its having affected this. 
Water' may collect in the cavity of the chest almost at once, 
without giving much previous notice. It may be the consequence 
of various causes, as cold, fever, &c. The symptoms arising from 
the presence of a fluid are cither peculiar, common, or sympathetic, 
which last may or may not occur. 
The first true specific or peculiar symptom arising from an extra- 
neous fluid, in some considerable quantity, in the cavity of the chest, 
is difficulty of breathing, which is always an attendant, and is dis- 
tinguished from difficulty of breathing from other causes by this, 
that the patient is always able to breathe much better in certain 
positions. This position will vary according to circumstances: if 
water is only on one side, the person can lie on that side, and on 
that side only; if on both sides, he can lie on his back, not hori- 
zontally, but with the chest raised as much as possible. He feels 
the fluctuation of the fluid within the chest whenever he moves, 
especially v.'hen he raises himself up. I have heard patients often 
say that they could hear the fluid move. The fluid is felt pressing 
like a weight on the diaphragm. An anasarcous habit often takes 218 
HUNTER'S PRINCIPLES OF SURGERY. 
place, and sometimes ascites. These two last symptoms would 
seem to arise from a universal irritable debility. 
The second, or common symptoms with other diseases, of those 
parts are difficulty of breathing, and of expanding the chest; great 
lowness and oppression ; a feeling of suffocation or of dissolution. 
The third, or sympathetic, symptoms are often great irregularity 
of the pulse, palpitations, flutterings. 
When the symptoms are known to arise from the presence of a 
fluid in the chest, it should in general be let out by an operation 
called paracentesis thoracis, which is only making an opening into 
the thorax and allowing the fluid to flow out. The wound should 
be made to unite by the first intention. The fluid to be evacuated 
may be of various kinds: as blood from a ruptured vessel, or 
wound made with a ball or cutting instrument; or extravasated 
serum, as in hydrops pectoris ; or pus, the consequence of inflam- 
mation. 
Whatever the fluid is which is to be discharged, I have always 
found suppuration take place in all the operations I have seen per- 
formed ; for when the discharge was nothing at first but serum, 
(as water in ascites), yet afterwards it gradually changed into pus. 
This arose simply from keeping the external wound open. I am 
inclined to think that nothing could have saved these patients but 
resolution of the inflammation, and the parts falling back into their 
natural disposition. This, as I have mentioned, sometimes takes 
place in common abscesses, especially those of a scrofulous kind, 
and in the present cases it might the more readily take place, as 
there is here no change of structure or granulation of the whole 
surface of the pleura or lungs. However, wounds have been made 
into the cavity of the thorax, suppuration has taken place, and yet 
the patient has got well; but how this has been brought about I 
cannot tell.* General Murray, to whom I have often expressed a 
wish to peep into his chest, has been twice wounded in this way. 
I tried the experiment by shooting a dog ; but both Nature and the 
dog cheated me, for I intended to keep open the wound until the 
whole surface of the pleura had taken on suppuration, when I meant 
to let Nature have her way and cure the dog as she pleased, and 
then I intended to kill the dog and see what she had done. But 
the dog would always lie on the wounded side; and when, after 
death, I examined it, I found the lungs had adhered to the wound 
and prevented the inflammation spreading over the surface of the 
lungs. The wound, after the evacuation, therefore, should be 
united as quickly as possible, to prevent the whole pleura from sup- 
* [There cannot be any doubt that the cure is effected in these cases by the 
obliteration of the cavity of the pleura, partly by coagulable lymph which is 
effused at the same time with the serum or pus, and partly by granulation ; the 
cavity of the pleura being precisely under the same conditions as a common 
abscess, and healing by the same methods. In these, cases the patient seldom 
regains the power of complete expansion of that side of the chest, which always 
remains in a more or less contracted and flattened state.] PRACTICAL ILLUSTRATIONS, ETC. 
219 
purating, which would destroy the patient in nineteen cases out of 
twenty. 
Inflammation of the Pericardium.-The cavity of the pericardium 
is not so apt to produce universal adhesions as that of many other 
cavities.* When it goes no further than adhesion the patient lives, 
although this produces many disagreeable symptoms, as palpitation 
of the heart, irregularity of the pulse, great oppression and faintings, 
which in general produce a bad state of health, a great debility, and 
symptoms which have gone by the name of angina pectoris. If the 
inflammation approaches to suppuration, it will certainly kill. 
Emphysema.-It will not be improper here to say something of 
the treatment of patients affected with emphysema arising from a 
wound in the lungs by a fractured rib, for if any surgical operation 
is necessary, great caution is required not to make the wound com- 
municate immediately with the cavity of the thorax, in order to 
avoid the mischief above described. 
If the lungs are wounded by a fractured rib, we know that the 
pleura must be wounded, and that, there must be a communication 
between the cells of the lungs and the cavity of the thorax. There 
is also a communication between this cavity and the common cel- 
lular membrane of the body by the wound in the pleura. The air 
escapes from the lungs into the cavity of the thorax, and in the act 
of respiration is squeezed into the cellular membrane of the body. 
The internal wound does not inflame so quickly as the external, 
because the internal depends on extravasated blood for the renewal 
or adhesion of parts ; and the wound of the lungs, from its being 
in contact with the air, may be considered as an external wound, 
while that of the pleura is an internal one ; the former will therefore 
probably heal sooner than the latter, whereby the air will be con- 
fined in the cavity. 
The operation for the relief of this disease is making a perfora- 
tion into the cavity for the relief of this disease, which operation 
should be religiously avoided, because it will produce the suppura- 
tive inflammation all over the internal cavities, and most probably 
make the wound in the lungs ulcerate. If an external opening is 
necessary, it should be made at some distance from the fractured 
rib, and never on the rib itself. If this is not attended to, it will 
make what was at first a simple a compound fracture, which pro- 
bably would produce the same effect as an incision at once into 
the cavity of the thorax; or if it did not produce this evil, would 
produce adhesive inflammation quickly about the fractured rib, 
* [This may be accounted for by the unintermitting action of the heart, which 
must present the most unfavourable conditions imaginable for the organization 
of the lymph. The opposing surfaces of the pleura or peritoneum may be pre- 
served by the patient in the most perfect state of apposition during the progress 
of inflammation, by breathing only by the chest or diaphragm, according as the 
case may be. But the heart has only one mode of action, which must con- 
tinually tend to disturb the process of union, just in the same manner that the 
continually recurrent action of the sphincter ani prevents the cure of fistulee in 
that situation.] 220 
HUNTER'S PRINCIPLES OF SURGERY. 
which would prevent any future escape of air from the pleura, 
which should be allowed; and for the same reason the patient 
should not have a roller bandage put on, as this would cause an 
impediment to the respiration by the other lung, and, by preventing 
the escape of the air, cause the whole contents of the thorax to be 
pressed to the other side. 
Peritoneal Inflammation.-This inflammation is attended with 
great pain, not of the colicky kind, but a violent soreness or tender- 
ness on external pressure. The fever' or sympathy of the constitu- 
tion, arises much higher than if it arose from the inflammation of 
a common part, and runs through all its stages much sooner than 
another part. When the immediate cause of these constitutional 
symptoms is not known, and the effects are violent, it has been 
called a fever, and the chief attention has been directed to check- 
ing this fever ; but the symptoms are merely the consequence of 
the inflammation in a part by which the constitution is easily 
affected ; so that if it were possible to restore the healing disposition 
to the cavity of the abdomen, the other symptoms would vanish 
and health be restored. A diarrhoea sometimes comes on, but at 
other times there is costiveness, both of which I am inclined to 
think may be considered as sympathetic affections. 
It is perhaps almost impossible at first to say what the inflamma- 
tion is, whether the true inflammation or the erysipelatous, because 
we are only guided by the constitutional symptoms, not by the 
appearances. A person in seemingly tolerable health attacked at 
once with so violent a local disease will be at first roused, which 
will make it appear a truly inflammatory complaint; but if it is 
erysipelatous he soon sinks. Still at first the apparent indication 
would be bleeding, and that largely; but if it is of the erysipelatous 
kind we may be led by those symptoms beyond the quantity 
suitable to the constitution. Yet I do not know what we can do 
better; I should be inclined to reduce the patient to the lowest 
pitch rather than allow suppuration to take place, for that would 
certainly kill. In whatever light we consider an inflammation of 
the peritoneum that is capable of producing suppuration, it is one 
of the most dangerous diseases we can meet with. How far in 
such cases it might appear desirable to make an opening into the 
abdomen, and throw in warm water repeatedly to wash away the 
matter, I will not undertake at present to determine. 
Peritoneal Inflammation after lying-in. - Inflammation often 
attacks some part or the whole of the peritoneum in women some 
days after childbirth, and hence has been called puerperal fever, 
from supposing it to be a fever peculiar to that state, and the 
inflammation of the peritoneum a consequence of this fever, whereas 
the fever is only a sympathetic symptom of the inflammation; but 
as this inflammation is connected with vital parts, the sympathetic 
fever is so much the more violent and dangerous. I believe I am 
the first who formed this idea of this disease. 
Why such a disease should occur after so natural an operation PRACTICAL ILLUSTRATIONS, ETC. 
221 
is not easily explained. It does not arise from an inflammation of 
the substance of the uterus first taking place, as we might at first 
naturally expect; for if the uterus did inflame in consequence of 
delivery, there would be no more necessity for the peritoneum of 
that viscus to inflame than for the peritoneum of an intestine to 
inflame when the intestine is itself inflamed, which it seldom does; 
and if the peritoneum of the uterus inflamed in consequence of 
inflammation of the uterus, that is not a necessary cause why the 
whole peritoneum should inflame, excepting the inflammation was 
carried so far as to produce suppuration on that part of the perito- 
neum. But the substance of the uterus generally appears as sound 
as in those who have no such disease; however, although the 
uterus is to appearance sound, yet it may be in such a state as 
to give the same stimulus of imperfection as if it were entirely 
removed or not existing. To illustrate this we may bring forward 
the circumstance of two cocks' combs that were frozen and thrown 
off as dead sloughs, for I suppose from analogy that the frozen 
parts were still alive, and if so we may see that a living part may 
be so circumstanced as to give the stimulus of death to the parts 
with which it is connected. That the inflammation of the perito- 
neum arises from the stimulus of imperfection is also evident, because 
if a man is wounded in the belly with a sword which has also 
wounded one of the intestines, if the wound in the abdomen is 
closed, and unites by the first intention, the wound in the intestine 
will unite with some part with which it comes in contact, either 
by extravasated blood oi' the adhesive inflammation, and no further 
trouble will ensue, because the stimulus of imperfection has not 
been given. But if a man is wounded in the belly, and there is no 
wound of the viscera, yet if the wound is kept from healing by the 
first intention, the whole peritoneum becomes inflamed immediately, 
not from the spreading of inflammation by the continuity of surface, 
but the consciousness of imperfection in the membrane itself, by 
which the whole is brought into the same action. It is probable 
that the uterus suddenly contracting, the neighbouring parts, 
becoming sensible, as it were, of the loss of a part they have been 
accustomed to, inflame. Sometimes adhesion will take place, and 
a circumscribed abscess will be formed in the lateral and lower 
part of the belly, and probably the inflammation was chiefly in the 
round or broad ligament; first there is hardness and pain, then 
prominence and fluctuation, when it may be safely opened.* 
* [Mr. Hunter has fallen into two errors on this subject: first, in ascribing 
puerperal peritonitis to an ideal cause ; and secondly, in supposing that the con- 
stitutional fever invariably arises from inflammation of the peritoneum. There 
cannot, I should think, be the least hesitation in ascribing the inflammation of 
the peritoneum which ensues on child-birth to the irritation which the uterus has 
suffered during that process, for the inflammation is not only sometimes confined 
to that part of the membrane which covers the uterus, and always is most violent 
there, but it invariably commences from that point. The fact, however, of the 
same cause giving rise to inflammation of the adjacent organs is completely 
subversive of the imaginary cause assigned by Mr. Hunter, arising from the 222 
HUNTER'S PRINCIPLES OF SURGERY. 
Inflammation of Peritoneum after tapping.-A man whom I 
tapped at the hospital died the third day. I said he died of the puer- 
peral fever. This was smiled at in the hospital, and some were 
pleasant in remarking on the curiosity of a man being delivered; 
but a few months afterwards another having the same fate, I con- 
vinced them, by dissection, that he had died of suppuration of the 
peritoneum, which wre must admit to happen in puerperal fever. 
Frequently the inflammation does not go so far as to produce sup- 
puration, and then the patient commonly recovers ; but it often runs 
the whole course and produces death. It seldom attacks those 
parts of the peritoneum that are pretty sound, or where the disease 
is not of long standing; but where the disease has arisen from a 
bad constitution or diseased viscera, it seldom fails of attacking 
them, especially in the second or third tapping. 
Hernia.-The consideration of inflammation of internal cavities 
leads me to make a few remarks on hernia. We might suspect 
that the operation for hernia would often be the cause of universal 
inflammation of the peritoneum, but I believe in bubonocele and 
femoral hernia it is generally prevented by the sides of the skin of 
the abdomen being pressed togethei' after the operation. This 
inflammation is met with after the operation for umbilical hernia, 
because the edges of the wound cannot be brought together. 
In this case we should contrive that a portion of the epiploon 
shall remain at the bottom of the wmund, and if it is not protruded 1 
think it would be the best way to find it if possible; in this way, 
by adhesion taking place round the opening, the general cavity 
would be excluded. 
Ccesarian Operation.-In this operation, and in every othei 
instance where the lips of the wound do not come well together, 
assistance should be had from art to unite them as closely as possi- 
ble. If it should be found necessary to use sutures, care should be 
taken that they do not pass through into the cavity of the abdomen, 
as by this they would produce effects exactly contrary to what was 
"consciousness of imperfection." No such imperfection can be supposed to be 
felt by the veins, the absorbents, or the ovaries, and yet these parts are frequently 
inflamed, independently of the peritoneum. Of forty-five fatal cases of puerperal 
fever which were examined by Dr. Lee at the British Lying-in Hospital, (in all 
of which was found some morbid change, the effect of inflammation,) the perito- 
neum and uterine appendages were found inflamed in thirty-two; in twenty-four 
there was uterine phlebitis; in ten there was inflammation and softening of the 
muscular tissue of the uterus; and in four the absorbents were filled with pus. 
In short, the irritation of parturition may extend to any or all the circumjacent 
parts within the sphere of its influence, and give rise to puerperal fever by exciting 
local inflammation. Local inflammation probably always exists, but the perito- 
neum is not always that part which the inflammation attacks. 
The morbid appearances presented on dissection are extremely various, and 
closely resemble those which arise from inflammation of the peritoneum following 
the great operations of surgery, as lithotomy, hernia, &c., viz., large effusions of 
lymph, turbid serum, or pus separately or blended together in different pro- 
portions. Pus is not an invariable product of this inflammation, as might be 
inferred from the text.] PRACTICAL ILLUSTRATIONS, ETC. 
wished,-that of rendering the cavity perfect; for as these continue, 
suppuration of the wounds made by them will come on, they acting 
as a seton, by which the exposure of the cavity will be greater, 
though perhaps, from the irritation they would occasion, adhesions 
would be formed at the bottom of the wound before they suppurated, 
which might prevent the admission of air. 
In a woman in whom I performed this operation, and who died, 
I found, thirty-six hours after death, that the intestines had adhered 
to the inner edge of the wound of the belly for the breadth of an 
inch: the uterus was entirely within the pelvis; but the edges of 
the wound in the uterus had not closed at all, and a good deal of 
coagulated blood was found in it I should therefore in future wait 
until the bleeding had nearly stopped from the uterus before I 
closed the external wmund. 
Bladder.-It may be said that the bladder being so seldom 
inflamed after the operation for stone, is an objection to my suppo- 
sition that an opening into any circumscribed cavity, by the expo- 
sure and consciousness of imperfection induced in that cavity, is 
almost necessarily productive of inflammation of that cavity; but 
here it must be observed that the internal surface of the bladder 
partakes more of the nature of an outlet than of a circumscribed 
cavity, admitting therefore less of the adhesive inflammation, and 
that it is more accustomed to and less affected by the action of 
extraneous matter, which must render it less susceptible of inflam- 
mation from exposure. 
Ca,vities of Joints.-It is from the disposition that the cavities of 
joints have to fall into the suppurative inflammation when an opening 
is made into them that union by the first intention does not take place. 
The greatest care should be taken to put this in their power if pos- 
sible, for as they do not readily run through the regular stages of in- 
flammation, they give rise to the more violent symptoms. W hen they 
suppurate it is very tedious, and then the parts are apt to die and 
slough, which makes these accidents of such dangerous conse- 
quence. In cases of wounds I should think a simple bandage would 
be best. We should avoid making stitches, because they tend to 
produce inflammation, as was explained under wounds of the abdo- 
men.* 
Sacculi mucosi.-There are other cavities, besides those of the 
joints, which are liable to inflammation from irritation ; these are 
the sacculi mucosi, which are in fact joints formed between tendons 
and tendons, tendons and bones, bones and skin. They are subject 
to disease, causing an increased quantity of fluid in them, not from 
inflammation, but from slight irritation. They are seldom attacked 
223 
* [The lighter and cooler the dressings in this sort of accidents the better. 
Perfect repose of the organ, an easy position, cold lotions, and a little lint dipped 
in blood over the wound, is probably the best, as it is also the simplest mode of 
treatment. If symptoms of inflammation arise, they should be combated at once 
by a copious venesection, which should be repeated, if necessary, until the 
inflammation is subdued.] 224 
HUNTER'S PRINCIPLES OF SURGERY. 
with suppurative inflammation; nor does the absorption of the fluid 
which they contain readily take place. Ganglions have been some- 
times dispersed by soap plasters, and sometimes, although rarely, 
by electricity. A gentleman was cured of a ganglion on the wrist, 
which had returned after being dispersed by a blow, by the Balsa- 
mum Canadense, applied thick and bound on tightly. I would 
advise a blow to rupture the sac; but the fluid is soon reaccumu- 
lated. For a radical cure, an opening should be made, and this pre- 
vented from healing by the first intention, that it may suppurate and 
heal by granulations. As these are connected with joints, weak- 
ness and stiffness may be produced for a time ; but this is overcome 
by motion. 
Inflammation of the Eye.-I shall consider the eye now as a cavity. 
Inflammation of the eye often takes place after extraction of the 
crystalline lens. The lips of the cornea not adhering by the first 
intention, suppuration ensues, which is followed by a shrinking of 
the globe. The same effects are sometimes produced when an 
opening is made to discharge the accumulated aqueous humour, as 
also when the globe has been suffered to burst spontaneously. This 
has sometimes happened from accident, the opening into the anterior 
chamber not closing; but probably these effects only take place 
where either the crystalline lens or the vitreous humour have been 
disturbed or lost in part, but more particularly the latter, as the 
adherence of the crystalline to the processus ciliares would prevent 
the inflammation extending; but when separated, the posterioi' part 
of the eye becomes conscious of this, and suppuration follows. The 
pus may be seen through the cornea, but no fluctuation can be felt. 
It is necessary to distinguish between simple opacity of the cornea 
and the accumulation of pus in the anterior chamber; they may ap- 
pear similar, and both may be present at one time ; the first maybe 
of long standing, the last must be recent: an inflammation must have 
very recently preceded the accumulation of pus. If the progress of 
the opacity can be observed,-but it cannot always, especially in 
children,-we may distinguish them: if in the cornea, a dimness 
may be seen to begin over the whole, and get white by degrees, or 
it may remain in a point, and remain there only; if pus, it will be- 
gin at the bottom of the cornea, and its shape will be semilunar, the 
straight line being uppermost, and as it advances the line will rise 
till it comes to the top, and if first seen in this state it is with difficulty 
distinguished. 
If the disease is an opacity of the cornea, reabsorption is the only 
cure, and no operation is to be performed; in the other case, the 
removal of the pus is the cure. There appear to be two natural 
modes of cure ; one the absorption of the pus into the constitution, 
which I have often seen take place; the other is ulceration of the 
cornea, as in other abscesses, and discharge of the pus. The latter 
is the worst mode of cure, for the pus, by its pressure on the crystal- 
line lens, may disease it, and an irritation will be kept up by the PRACTICAL ILLUSTRATIONS, ETC. 
225 
distention, which should be avoided, as the consequence will be the 
obliteration of the cavity of the eye, as in any other abscess. 
This, then, leads to an artificial cure, which is by removing the 
pus at an early period, when we see it will not be absorbed, by an 
incision like that for removing the lens, by which we avoid the 
second oi' natural cure; but it is not always perfect, as we cannot 
heal the wound by the first intention.* 
Of the Brain.-I have not seen a sufficient number of cases to 
determine how far inflammation attacks the pia mater when it is 
exposed in trepanning, but from the protrusion of brain in such cases 
inflammation may be inferred, as I have mentioned already. I never 
saw a case recover where the dura mater had been punctured,f 
which I attribute to inflammation of the pia mater extending to the 
brain below. 
Inflammation of Veins.-The cavities of veins are subject to 
inflammation, either in consequence of inflammation of surrounding 
parts, or from themselves taking on the inflammatory disposition and 
involving the surrounding parts. 
This inflammation of veins happens sometimes after bleeding, and 
has been attributed to a pricked tendon or nerve by some, and by 
others to a bad constitution; but if we consider this consequence 
arising from bleeding more accurately we shall find that it happens 
after bleeding in veins where no tendon could be wounded, and 
when no nerve is in the way, as often as in the others, and fre- 
quently in constitutions where there is no apparent want of health, 
and also where the wound, on bleeding from another part in the 
same person, probably with a view to cure the former, has healed 
readily. 
The manner in which these inflammations come on shows very 
plainly that they arise from the wound made by the lancet not healing 
by the first intention, and in different arms we have also the different 
degrees of extension of the inflammation. In some, suppuration has 
only spread superficially, the veins and parts below having united, 
and the inflammation only seated between the vein and the skin, 
and then it is of little consequence ; in other cases the skin shall 
appear united, but not close to the vein, so that a small abscess shall 
* [Hypopium, or the accumulation of pus in the anterior chamber of the eye, 
is very oftefi the result of inflammation of the whole internal part of the globe, 
which rarely admits of a cure. When it proceeds from an ulcer situated on the 
internal part of the cornea, a cure may be expected, particularly if mercury is 
employed, which causes the effused pus to be absorbed. Neither of these cir- 
cumstances, however, can justify the surgeon in making an opening into the 
cornea, unless there is at the same time an excessive accumulation of purulent 
fluid, giving rise to great pain and tension of the globe. In which cases relief 
may be afforded by letting out the pus, although little hope of saving the sight 
can be entertained from the operation.] 
f [Wounds of the dura mater undoubtedly very much aggravate the ultimate 
danger arising from other accidents, but are not in themselves universally fatal. 
On the contrary, numerous cases are recorded of extensive penetrating wounds 
of the brain which have recovered without a single untoward symptom.] 226 
HUNTER'S PRINCIPLES OF SURGERY. 
form between the skin and the vein. But when this imperfect union 
of wounded parts is carried on to the cavity of the vein, then more 
mischief ensues; the external wound in most cases festers or 
inflames, then suppurates and ulcerates ; then the vein inflames from 
being an imperfect cavity, the inflammation extending both towards 
the heart and from it; and also, for a considerable way, the 
surrounding parts join in the inflammation. We find in these cases 
all the different degrees of inflammation in different cases ; some- 
times it goes no further than the adhesive inflammation, and suppu- 
ration is prevented by adhesion being allowed to take place in this 
part. The veins in such cases are ever after obliterated, and may 
be felt, after the surrounding inflammation has subsided, like hard 
cords. But these slighter effects are not always all, and suppuration 
will unfortunately too often take place. 
The suppuration has all the degrees of violence and extension. It 
is often so confined as only to form a small abscess near the orifice; 
this arises from adhesions having taken place in the vein a little 
above and below the orifice. In many cases the inflammation and 
suppuration extend further, adhesions not having taken place; some- 
times a very long abscess is formed, and often there is a series of 
abscesses, following one another in the direction of the vein, between 
the orifice and the heart; but not always in this course, for we find 
them sometimes between the wound and the extreme parts. I have 
seen from a wound in the foot the saphena inflame all up the leg 
and thigh, nearly to the groin, and have been obliged to open a 
string of abscesses almost through the whole course. 
I have almost always found that inflammation has taken place in 
the larger veins which pass through a part that has been violently 
inflamed. This disease often happens in horses after bleeding, for 
the operators do not take proper care to close the orifice in these 
animals. This has sometimes proved fatal; but whether from the 
inflammation extending to the heart, or from the matter that is 
secreted in the veins passing in considerable quantity into the cir- 
culation, I cannot say. 
The method of preventing these ill effects is to bring the edges of 
the wound carefully together, when the bleeding is finished, that 
they may unite by the first intention. I would recommend a com- 
press of linen in preference to plaster; for I imagine that the blood 
itself being applied over the orifice is a kind of bond of union which 
is more natural than any other application. I have seen more sore 
arms after bleeding where a plaster has been applied than in any 
other cases. I have also seen it several times where the orifice 
has opened a second time and bled again, and has not been properly 
closed. 
Treatment.-If inflammation has just come on and not arrived 
to suppuration, a compress should be applied to produce adhesion 
of the sides of the vein, whereby the inflammation may be prevented 
from reaching the suppurative stage. If the suppuration is come OF HYDROCELE. 
227 
on, let pressure be applied immediately above, to prevent the matter 
from passing to the heart, by producing adhesion there. 
Inflammation of Arteries.-Arteries unite by adhesion when their 
sides are compressed. This we find after the division of the larger 
arteries after amputation. I never have seen arteries suppurate, and 
do not know whether they ever do suppurate, nor what would be 
the consequence. Perhaps it would produce mortification; but I 
am about to determine this by experiment. 
CHAPTER XVI. 
OF HYDROCELE. 
Theory of the cure simple, but in practice the operation often fails.-Description 
of the disease;-distinguished from others.-Encysted hydrocele;-its 
nature;-common to all ages and constitutions ;-disappears spontaneously in 
children;-rarely in adults;-symptoms;-state of the testicle to be ascer- 
tained ;-hydatid ;-scirrhus ;-false membrane covering testes ;-adhesion of 
testis to cicatrix after puncture ;-former cicatrix to be avoided.-Palliative 
treatment;-haematocele ; diffusion of blood into the cellular tissue;-suppu- 
ration following simple puncture.-Radical cure;-various methods recom- 
mended ;-object of all;-adhesive inflammation occasionally occurs;- 
obstacles to its taking place.-Erroneous notions of the mode of cure.- 
Injection ;-tent;-seton ;-caustic ;-laying open sac ;-violence of the latter 
method;-all severe.-Practice of removing testicle when enlarged;- 
doubtful if always required.-Causes of failure of all the above operations,- 
of each in particular.-Mode of operating recommended;-after-treatment, and 
consequent symptoms.-On the actions of medicines.-On diseased disposi- 
tions and actions.-Of the difference of different parts to heal.-Of one disease 
curing another. 
The disease called hydrocele is a very common one ; it consists of 
an undue secretion of the fluid which moistens the tunica vaginalis 
testis, and admits of a cure according to the laws of inflammation, 
suppuration, and granulation, which is the process of a common 
abscess. Although the theory of the cure of a hydrocele is very 
simple, yet no disease affecting the human body, and requiring an 
operation for its cure, has called forth the opinions and pens of 
surgeons so much as this disease.* The reason of this is easily 
accounted for ; for they have gone so far as to find that every mode 
* [This was no doubt the reason which led Mr. Hunter to enter so fully into 
the consideration of the subject. " At the time," Sir Astley Cooper remarks, 
" I was attending Mr. Hunter's lectures, the town was divided in opinion as to 
the best mode of performing the operation for hydrocele; and so great was the 
difference of opinion among the students of the different hospitals, that it was 
quite ridiculous to observe their warmth on this subject. The operation, by injec- 
tion, as recommended by Sir James Earle, was not introduced until a few years 
afterwards, but has since been universally acquiesced in as one of the most 
simple as well as most effectual remedies of surgery.] 228 
HUNTER'S PRINCIPLES OF SURGERY. 
of operating but their own has failed, but have not noticed the cause 
of failure. It was enough for them that they could condemn. 
They rested contented with having recommended a method which 
was to them infallible; nor did the condemnation of this favourite 
method of theirs by others rouse them into an inquiry as to the 
cause of its failure. 
The scrotum in man has two circumscribed serous cavities in 
it, which may become the reservoirs of any part of the blood that 
may be extravasated, but which are generally in these cases dis- 
tended with water, forming an aqueous cyst. Besides this, there 
are other extravasations of water into the scrotum, but they are 
common to every part of the body as well as it. 
Each of these cavities is called tunica vaginalis testis, and when 
either of them is filled with fluid it is called a hydrocele. 
There are other cavities formed in these parts from disease, like 
those formed from similar diseases in other parts, and which may 
be called hydatids. I believe they are more common in these parts 
and in the ovaria in women than in most other parts, probably 
from their being glands of a peculiar kind. 
But every distention of the scrotum with water is called a 
hydrocele: even water collected in the cellular membrane of the 
scrotum in anasarcous habits, where it has only soaked through 
from the parts above, or arises from irritation: this kind might be 
called diffused hydrocele. This collection in the cellular membrane 
is often so great as to be diffused into the cellular membrane of the 
penis, which always produces phymosis, with twisting of the skin 
of the body of the penis, from the frenum not being so extensible 
as the common skin. This often proves very troublesome, by 
confining the urine. The radical cure of this kind of hydrocele 
will be the cure of the disposition, which is commonly more consti- 
tutional than local. But this cannot always be done; and we may 
then give a temporary relief to the parts where the scrotum is 
become considerably enlarged, with much phymosis. It then 
becomes necessary to procure an evacuation of the water, which 
can easily be done by making small punctures with a lancet or 
needle in the most depending part of the scrotum, and also, if 
necessary, at the end of the prepuce. However, some attention 
must be paid to the state of the patient; for, if very weak and 
debilitated, mortification may take place at these orifices; there- 
fore the smaller and fewer the punctures the better. 
Another watery swelling, similar to the above, is described, 
namely, an anasarcous state of the spermatic cord. This disease 
I never saw.* 
* [Pott and Scarpa have both described this disease, which they represent as 
consisting of an enlargement of the cells of the spermatic cord, which in process 
of time, particularly towards the bottom of the tumour, merge in one general 
cavity, divided by a number of septa more or less perfect. Essentially, there- 
fore, it does not differ from encysted hydrocele of the cord, except in the mode 
of its commencement.] OF HYDROCELE. 
229 
The encysted hydrocele is a collection of water in some cyst 
situated in these parts. This species of hydrocele has been divided 
into three kinds, according to the situation of the water: first, 
when it takes place in the tunica vaginalis testis; secondly, when 
it occurs in the body of the testicle: thirdly, when in the spermatic 
cord; and, indeed, by the same mode of multiplying species, I 
could from my own knowledge, make a fourth and fifth, namely, 
hydatids at the back of the testicle, where the vessels enter, and 
hydatids on the body of the testicle,* within the tunica vaginalis 
testis; which last may be complicated with hydrocele of the tunica 
vaginalis, as I have seen. These two last, as also hydrocele of 
the cord, are only hydatids in those parts. The hydrocele in the 
body of the testis must also be classed with hydatids: but this I 
have never seen. Of those on the outside of the testis I have seen 
several cases. All these tumours, however, are properly only 
divisible into two kinds; hydrocele of the tunica vaginalis, and 
hydatids; for it does not alter the disease whether the hydatids be 
in the spermatic cord, cellular membrane, scrotum, or body of the 
penis; it is still hydatid, wherevei' placed. 
As the symptoms arising from the testicle being in a state of 
irritation are different from those of irritation in other parts, so we 
shall find that the symptoms arising from, and the cure of, these 
encysted hydroceles will be different from those arising from 
hydatids in the body of the testicle ; whereas these will be similar 
to those of the tunica vaginalis testis because in both they have 
connexion with the testicle. But the symptoms arising from the 
cure of hydatids not connected with the body of the testicle will 
be similar to common inflammation in all cases of the disease. 
The cause of the anasarcous hydrocele is very evident: it arises 
from a universal disposition to throw out serum: and, from the 
situation of the part, it becomes a universal detainer of the water 
as it is descending from the upper parts. 
In the encysted hydrocele the cause is generally not known, 
especially of the hydatid kind. However, the hydrocele of the 
tunica vaginalis often arises from a disease of the testicle; for I have 
observed that many who are operated on for the radical cure show 
* [According to Sir Benjamin Brodie, these swellings commence between the 
tunica vaginalis and tunica albuginea of the testicle, and not in the proper struc- 
ture of the testicle as has generally been supposed ; they do not therefore essen- 
tially differ from encysted hydrocele of the epididymis, except in being more 
strictly bound down by the tunica vaginalis which will necessarily tend to limit 
their growth, and on this account to obviate the necessity of surgical interference. 
Simple hydatiform cysts in the body of the testicle are referred to by Dr. 
Hodgkin. See Med.-Chir. Trans., vol. xv. p. 289. 
It will scarcely be necessary to remind the reader that the term hydatid is 
employed by Mr. Hunter in the old acceptation. The true hydatid has no con- 
nexion with the surrounding textures, and is probably a parasitical animal, 
endowed with independent vitality and a peculiar mode of propagation. These 
do sometimes occur in the gland of the testicle in association with malignaht 
disease ; but never, I believe, as an original and independent affection.] 230 
HUNTER'S PRINCIPLES OF SURGERY. 
a disease in the testicle ; also I have seen several hydroceles that at 
first were hardly anything but true hydrocele, the testicle hardly 
appearing diseased, yet in time (viz., a year or two) the testicle has 
increased gradually, and the water has been diminished so much, 
that hardly anything was left but a large diseased testicle, and all 
this time giving little or no pain. 
Hydrocele of the tunica vaginalis is common to all ages; it is 
met with in children, in middle-aged and old men. In children 
they arise sometimes before communication between the tunica 
vaginalis and abdomen is completely cut off, so that any fluid from 
the abdomen can pass down and distend the bag. In appearance 
this somewhat resembles a rupture ; for when the water is pressed 
upwards, it makes a swelling close up to the ring, but by squeezing, 
it can be made to pass up into the belly. In these cases a slight 
bandage or truss should be worn for some years. 
Hydroceles are common to every kind of constitution; not more 
common to the dropsical and anasarcous person than to the healthy, 
which is not the case with ascites or hydrops pectoris; therefore 
it is probable they arise from a disease in the part, or are what 
my be called truly local. They are common in all countries; but 
they would appear to be most common in warm climates. 
In general we find them go away of themselves ; in young lads, 
therefore, in such cases, I never recommend any mode of treatment. 
In grown people they seldom or never go away;* I have known 
only two or three cases in which they have disappeared without 
the obliteration of the sac. I have tried several stimulants, as 
mercurials diluted, turpentine, &c., by way of application, but they 
had not the desired effect. However, I once thought the latter, 
namely, turpentine, checked the progress of a hydrocele. Even 
letting out the water simply does not prevent the accumulation 
again taking place, whence the term palliative cure. 
Diagnosis.-The encysted hydrocele consists of a bag filled with 
water placed in the scrotum, sometimes a little higher on the sper- 
matic cord. The principal points to be known or discovered are, 
whether, when a tumour appears in this part, it contains water ; 
and, if possible, the true situation of that water as respects the 
testicle : for there is another disease that will imitate this so as to 
be with great difficulty distinguished from it, which is a diseased 
testicle simply. 
Some ruptures put on an appearance somewhat similar to hydro- 
cele, and when the gut contains a fluid, it often gives an obscure 
* [Many examples are on record in which old hydroceles have disappeared 
spontaneously ; an event which is most likely to happen, according to Sir Astley 
Cooper, when the disease has originated in inflammation; or, according to Sir 
Benjamin Brodie, about once in twenty cases. However, there is no rule on this 
subject. As ruptures of the tunica vaginalis from external injury are not followed 
by a permanent cure, we have no right to suppose that slighter degrees of 
external violence will have this effect; although something of this kind has 
frequently been supposed, when spontaneous cures have taken place.] OF HYDROCELE. 
231 
fluctuation; so that hydrocele is but too often confounded with 
rupture. 
Fluids contained in a circumscribed bag are commonly easily 
made to pass from one side of the bag to another, unless the bag 
is extremely full and thick in its coats, and then there will be only 
a gentle receding of the fluid from the side pressed on. This is 
made plain to the senses by applying our hands or fingers to two 
different parts of the bag, and pressing those two parts alternately; 
this is called fluctuation. But solid bodies also, of a loose texture, 
inclosed in a bag, can be made to recede from pressure, and give 
nearly, if not wholly in many cases, the sensation of a complete 
undulation; a feeling which the testicle sometimes takes on in one 
of its diseases. Therefore, as this body sometimes conveys the 
feeling of fluctuation of a hydrocele, and as the latter often acquires 
a hardness like that of the testicle, the difference we might expect 
to find between the feel of water and of the testicle is in some cases 
wholly lost. 
I think that in general a distinction is to be made in the shape ; 
for I observe that in general when the testicle swells, it flattens on 
each side, having an edge forwards and backwards, and is not, like 
hydrocele, of a pyramidal figure, with the apex upwards, passing 
into the cord towards the ring of the abdominal muscles, and even 
in some cases passing a little way into the ring, with (in many 
cases) a slight contraction at the part where it does pass into the 
cord. But this cannot be set down as an invariable rule, for the 
testicle will vary in shape according to the disease and other cir- 
cumstances ; and hydrocele will also vary in shape according to 
circumstances, and if it be an hydatid, and not within the tunica 
vaginalis, it will have less of the pyramidal form, though even then 
it often retains or acquires that shape; but if flat, it may be suspected 
to be the testicle. It has been recommended that we should put 
a light on the opposite side, and see if the tumour has a degree of 
transparency; but this can only take place where it must be evident 
from other symptoms, where, namely, the skin is not thickened, 
and the fluctuation is therefore perfect.* 
* [There is only one disease of these parts which there is much danger of 
being mistaken for hydrocele, and that is the medullary disease of the testicle, 
which it is often very difficult to distinguish from hydrocele. Besides the points 
of difference which have been noticed in the text, I may observe that the oval 
shape of the testicle in fungus haematodes is generally marked with some degree 
of bulging, which destroys the perfect ovality of the swelling ; that the cord may 
be felt perfectly distinct for a greater extent of its course than in hydroceles of 
equal size ; that the feel, although generally pulpy and elastic, is not uniformly 
so, but softer in some parts than it is in others ; that the weight of the tumour is 
greater than that of hydrocele, and the superficial veins more swollen ; and, finally, 
that the swelling commences uniformly in every part, unlike that of hydrocele, 
which begins at the lower part of the scrotum and gradually ascends. The test 
by the lighted candle ought not to be despised, especially as it conveys useful 
information as to the real situation of the testis, and very often gives immediate 
knowledge of the disease, when, from the tension of the swelling, it is scarcely HUNTER'S PRINCIPLES OF SURGERY. 
232 
But supposing the disease to be well ascertained to be water, we 
are not in all cases properly prepared for an operation until its 
situation with respect to the testicle is exactly ascertained, for the 
situation of the testicle with respect to the general tumour will vary 
according as the water is situated. When the water is in the tunica 
vaginalis, as is most common, or in an hydatid in that bag, the 
testicle will mostly, if not always be placed at the posterior part of 
the tumour, and there is consequently but little danger of doing 
mischief to the testicle by any of the operations, unless adhesions 
between the tunica vaginalis and testicle have previously taken 
place, and then the testicle will be confined to the side on which 
the adhesions are, as well as to the posterior part. If water is 
contained in an exterior hydatid, then it is not at all certain in what 
part of the general tumour the testicle may be. Perhaps it is often 
not possible in such cases to distinguish the situation even by the 
sensations of the patient, and therefore we must always be on our 
guard when the situation is not ascertained. If the testicle is found 
on any side of the scrotum except the posterior, it is more than 
probable that the water is not within the tunica vaginalis, but in 
some cyst or hydatid placed contiguous to the testicle, or that some 
adhesions have taken place between the tunica vaginalis and testicle, 
cases of which I have seen. If an hydatid is within the tunica vagi- 
nalis, and fills up the whole tunic, it will in general be similar to the case 
of water within the bag itself; but it admits of a variety of compli- 
cations, which may lead the surgeon into error even in the time of 
the operation, a case of which I think I have seen. The complication 
appeared to be the following: water both in the hydatid and tunica 
vaginalis, which led the surgeon to remove the whole as a scir- 
rhous testicle ; for on opening the tumour and letting out the water, 
he found another tumour within this, which he naturally took to be 
the testicle itself, and which of course led to the extirpation of it. 
On examining the parts after removal, it was found to be simply 
another cyst of water, with the testicle sound within it, or rather 
behind it.* 
There is another mode of complication which the above case gave 
me an idea of, and which I do conceive I once met with in a patient 
of my own, namely, that inflammation had taken place over the 
whole sac, so as for the sac to have become lined with coagulable 
lymph, similar to what I have seen in othe^r cavities; that this lining 
at last became part of the sac; but that a part of this lining had 
separated from it, and the space between the two had become filled 
with water, as also the general cavity, so that they formed a sort 
possible to discern fluctuation. In doubtful cases, it is always expedient to insert 
a lancet or explorative needle into the tumour previously to the operation of cas- 
tration.] 
* [There is reason to believe that this mistake has frequently occurred. The 
danger, however, of confounding hematocele with disease of the testicle is still 
greater, although the history of the case, and the suddenness with which haema- 
tocele commences, will never fail to point out the difference to the intelligent 
surgeon.] OF HYDROCELE. 
233 
of double hydrocele. This case and the anterior hydatid would, I 
presume, assume the same appearance. 
We should naturally suppose, when the situation of the testicle 
is not immediately known, and where the temporary cure has been 
performed with success, that there could be but little doubt of the 
testicle being at some other part of the tumour than the part where 
the wound was first made ; but this is not always to be trusted to, 
for the operation of the temporary cure often becomes the cause 
of adhesions of this part of the sac to the body of the testicle. This 
very case occurred to me when about to perform the radical cure, 
for after having made the first incision on the cicatrix, and cutting 
through the tunica vaginalis as I thought, I was cutting on the body 
of the testicle. In performing this part of the operation I suspected 
all was not right, but did not in the least expect to find the testicle, 
and therefore cut carefully on till I came to the tubular substance 
of the testicle. I of course desisted, and performed the operation 
in another part, at no great distance from the first, as the testicle is 
not a large body, and I did not require to make a second incision in 
the skin. There did not appear to be any additional symptoms in 
this case, in consequence of the wound in the testicle, which seemed 
to heal as readily as a wound elsewhere would do. When the 
testicle is in the fore part of the tumour, either from the water not 
being in the tunica vaginalis, or from previous adhesions there, and 
its situation is not known or attended to, and the operator makes 
an incision on the fore part where the testicle is, like that in the 
above-mentioned case, and he finds he is cutting on the testicle, and 
determines to shift his ground, I would advise him either to go lower, 
or to ward one side with his future incision; but at all events not 
to go above the testicle, to get into the sac, for there he will most 
probably find the spermatic cord passing along the fore part; and 
by cutting through it he may cut the spermatic artery and castrate 
the patient, or cut the vas deferens, which will in all probability 
render the sore fistulous. A case of this kind I once saw, where 
the spermatic artery being cut, the blood escaped into the cellular 
membrane of the scrotum. This circumstance of the cellular 
membrane of the scrotum being sometimes filled with blood in con- 
sequence of an operation, may at first mislead the surgeon to sup- 
pose it is mortification, if he is not acquainted with the cause.* 
* [Every species of hydrocele, as Mr. Hunter has remarked, is reducible to 
two forms, that of hydrocele of the tunica vaginalis, and encysted hydrocele of 
the cord. The first, or common form of hydrocele, is a true dropsy of the tunica 
vaginalis, and arises from the same causes which produce dropsies in other 
situations. The encysted hydrocele of the cord is an adventitious production, 
which has no existence in the primary structure of the parts, and ought to be 
classed with serous cysts occurring in other parts of the body. 
The varieties of common hydrocele depend on the form or structure of the sac, 
or the nature of its contents. The ordinary situation of the testicle in hydrocele 
is two-thirds of the way down the tumour at the posterior part; but, as Mr. 
Hunter has remarked, the tunica vaginalis is liable to every possible form of 
adhesion, which will necessarily occasion great differences in the position of the 234 
HUNTER'S PRINCIPLES OF SURGERY. 
Of the temporary Cure.-I shall not say much with regard to 
the palliative or rather temporary cure of hydrocele, as it consists 
only of the evacuation of the water in the easiest and shortest way, 
without doing anything to prevent a recurrence of the disease, and 
is hardly so nice an operation as bleeding. The same care is 
testicle and its vessels, as well as of the external configuration of the hydrocele. 
When the testicle has united to the anterior part of the tunica vaginalis, at the 
lower part, the vessels of the cord are generally spread out over the anterior 
surface of the tumour, and become liable to be injured by the trocar. Sometimes 
the tunica vaginalis presents a honeycombed appearance on its internal surface ; 
occasionally it is much thickened, especially in those who have resided in hot 
climates; or converted into cartilage, in which more or less extensive deposi- 
tions of hone have taken place; at other times it is presented under the form of 
an hour-glass contraction, which may be either partial or complete, or may, after 
being partial at first, become complete afterwards. When there are no adhesions, 
and no thickening of the sac, the hydrocele may attain a very considerable mag- 
nitude. I have known several cases in which the apex of the tumour has 
advanced considerably beyond the external abdominal ring, so that no part of the 
spermatic cord could be distinctly identified, and the quantity of fluid exceeded 
from three to four pints; but a case is mentioned by Sir Benjamin Brodie which 
increased till it hung down to the patient's knees. The fluid of this form of 
hydrocele resembles that of ascites, that is, it is of a deep yellow colour, and is 
readily coagulated by heat. It loses its transparency, however, and becomes 
whitish when inflammation has been present, or becomes of a chocolate hue of 
various shades when from any cause the smaller vessels of the sac have been 
ruptured, so as to cause an effusion of blood into the cavity of the cyst: some- 
times it contains a number of micaceous particles, consisting of adipocire ; at 
other times a number of small bodies, looking like melon-seeds ; and occasion- 
ally one or more loose cartilages, which exactly resemble those which are con- 
tained in the joints. 
The serous cysts which are developed in the spermatic cord and epididymis, 
or between the membranes of the testicle, are wholly different from the common 
hydrocele of the tunica vaginalis, and resemble those which are not unfrequently 
met with beneath the common integuments of the body, on the surface of the liver 
and kidneys, in the breast, the ovary, and in other situations. It is possible that 
they may be produced by the distention of one or more of the cells of the cellular 
membrane, which a partial inflammation or some other cause may have shut off 
from their communication with the adjoining cells; but this has not been ascer- 
tained. The secreting cyst is extremely thin and loosely attached ; and the 
fluid, instead of being like that of hydrocele of the tunica vaginalis, is remarkably 
transparent and watery, and does not coagulate by heat. The occurrence of 
these cysts on the body of the testicle, or epididymis, will necessarily give a 
lobulated and very irregular appearance to this organ, and expose it to be mis- 
taken for malignant disease, although this mistake may easily be avoided in 
general, by a careful examination of the part with the fingers, or by a lighted 
candle. When they occur high up, they are liable to be confounded with hernia, 
especially as from their loose connexion with the neighbouring parts, and conse- 
quent great mobility, they may easily be pushed up towards the abdominal ring, 
or even through it, and in that case be protruded again whenever the patient 
coughs. In such cases, however, there is always a visible bulging above the 
situation of the ring, which cannot be entirely dispersed ; besides, hydrocele in 
this situation may always be distinguished by pushing the tumour downwards, 
and then feeling for the spermatic cord above the tumour; under such circum- 
stances, no impulse will be communicated to the finger when the patient coughs. 
Hydrocele of the tunica vaginalis may coexist with encysted hydrocele of the 
spermatic cord, hernia, varicocele, diseases of the testicle, and haematocele. 
These complications may generally be distinguished without much difficulty, 
provided all the circumstances of the case are duly considered.] OF HYDROCELE. 
235 
necessary as above described to ascertain the situation of the 
testicle, lest the operator should puncture the body of the 
testicle, and wounding it, will certainly fail in his intentions with 
regard to the evacuation of the water, and may be led by his 
failure to mistake the disease, and suppose it of more consequence 
than it really is ; not to mention the injury which might be supposed 
to arise from injuring so sensible a part, though I believe this last 
circumstance is not of so much consequence as might be imagined, 
for I know a case where the water was placed in a distinct bag 
on the posterior part of the testicle, so that this body could not be 
distinguished from the general tumour by the surgeon, who there- 
fore supposed it to be a hydrocele of the tunica vaginalis, with the 
testicle in its proper place; and that he might avoid wounding the 
testicle, he pushed his lancet into the fore and lower part, but no 
water came. This he repeated four times, nearly in the same 
place, with the same effect; and on a further knowledge of the 
disease it was found that all those four wounds were in the testicle ; 
yet no bad consequence followed, nor did the patient suffer more 
pain than afterwards, when the lancet went into the cavity of the 
bag where there was only water. 
In such cases the best guides are the feelings of the patient, and 
not that of the surgeon,'-a circumstance to which too little atten- 
tion has been paid, for a great many diseases may be distinguished 
by the sensation of the part when in pain. It is well known that 
the pain felt on squeezing the testicle is very different from that 
arising from other parts; therefore if it is this organ that is swelled, 
the sensation arising from squeezing the tumour will be the same 
in every part, and will be that sensation which is peculiar to the 
testis; but if it is a hydrocele, or any adventitious swelling, the 
sensation will be different in different places, that is, when the part 
pressed is the testicle, the pain will be such as is usually felt on 
squeezing the testicle; and when the watery part of the tumour is 
pressed, the sensation of common pain only will be felt. From 
attending to this circumstance only, I have been able to distinguish 
a hydrocele from a pulpy testicle, when the disease was supposed 
by other surgeons to be the latter. However, there are cases in 
which I have still had my doubts about the situation, from the 
impossibility of pressing on it with sufficient firmness to give the 
true sensation when the coats are much thickened. 
The operation for the temporary cure requires an incision not 
bigger than that made in bleeding ; or it may be done with a small 
trocar. When the water is let out in this way, it sometimes hap- 
pens that a vessel is wounded either in the skin, cellular membrane, 
or sac, which bleeds pretty considerably, and the blood is either 
diffused into the cellular membrane of the scrotum, giving the 
appearance of mortification, or extravasated into the sac, and fills 
it up probably as large as ever. Both these effects from tapping I 
have seen, but never saw any bad consequences arise from them, 
the blood being always absorbed. I could even conceive a good 
consequence to arise from the last, as it might be the means of 236 
HUNTER'S PRINCIPLES OF SURGERY. 
forming a bond of union between the sac and the testicle by the 
first intention, which I have seen take place partially. This is one 
of the diseases called haematocele, described by authors; they have 
also described others of a different kind, but taking place from the 
same accident; and also some cases of haematocele of the spermatic 
cord, which I have not seen. 
A blow has been known sometimes to burst the bag, by which 
means the water has been diffused into the cellular membrane of 
the scrotum, and a temporary cure has been produced in this way. 
The patient, and also the surgeon, have been alarmed sometimes 
with this case; for blood has been diffused with water into the 
cellular membrane, which has given the idea of mortification 
having taken place. 
I would advise that the operation for the palliative cure should 
not be performed but at a time when the patient can lie by, as 
inflammation may come on and produce the radical cure where 
only the temporary was intended. A gentleman who was usually 
tapped every six months begged I would do it for him before he 
went to Paris. I objected, telling him my reasons. He was 
pleased with them, and postponed the operation until his return, 
and fortunately for himself, for it actually happened that inflamma- 
tion succeeded the tapping, which proved the radical cure. 
In cases where such an occurrence takes place, the wound made 
by the lancet or trocar has generally healed up in some measure ; 
but inflammation has taken place in the whole sac, and suppuration 
has come on, and ulceration has led the matter to and through the 
skin. As the orifice has in many cases healed up, the cause of this 
inflammation is not so evident as it would be had the sac remained 
exposed, and the inflammation is therefore not so quick in its ter- 
mination, and in many cases seems to be stationary, as if suspended 
between resolution and suppuration. In other cases resolution will 
take place when the inflammation has been very violent, and when 
we have been every day in expectation that suppuration would 
ensue. In this case I would advise you to open the sac, and com- 
plete the operation by suppuration.* 
Of the radical Citre.-As various methods have been practised 
and recommended to effect a radical cure, it naturally leads me to 
make some observations on those methods, for they cannot be all 
equally proper in all cases; however, I mean not to be very par- 
ticular in my criticisms on those different methods that have been 
proposed, only so far as to point out different cases where they may 
be attended with inconvenience, arising from particular circum- 
stances in them ; nor shall I mention these different methods further 
* [Besides the suppuration of the sac which occasionally follows the pallia- 
tive operation, particularly in West Indian patients, the sac sometimes mortifies 
in old people. Sir Astley Cooper has mentioned two cases of this kind, which 
were followed by death, from which he has judiciously enforced the propriety of 
keeping old persons to their beds whenever this apparently simple operation is 
performed.] OF HYDROCELE. 
237 
than will illustrate my own opinion. I do not even mean at present 
to recommend one method in preference to another, but only to 
show the advantages that each has, although they all proceed on 
the same principle, leaving to the surgeon, and in some measure 
to the patient, to choose for himself after he has thoroughly con- 
sidered all the different circumstances of the case; while at the 
same time I mean to show that more depends on the mode of treat- 
ment after the operation has been performed than on the mode of 
operating. 
The radical cure depends on the obliteration of the cavity which 
contains the water. There are but two natural methods in which 
obliteration of the sac can probably take place, namely, by our two 
inflammations, adhesive and suppurative ; for union by the first 
intention can hardly take place, though I can conceive it possible 
in some cases where the operation for the temporary cure has been 
performed. 
I have observed that this is a disease which never arises from 
the constitution, and seldom or never affects it; nor are the parts 
themselves much affected by the consequence of the disease, namely, 
the accumulation of water, especially if it is occasionally let out. 
It is necessary, therefore, that we should be very particular in our 
method of cure, for whatever danger arises rests in the mode of 
cure alone. We should always make a material distinction between 
an operation which is to cure a person of a disease which will pro- 
bably kill of itself without an operation, and an operation which is 
performed to cure an inconvenience only, and where the danger is 
not in the disease but in the method of cure.* 
The method of cure by adhesive inflammation is union of every 
part of the cavity with itself; and as the testicle makes part of the 
cavity, the tunica vaginalis must also unite with it. However, this 
method is one which I need hardly take notice of, as it is one which 
very rarely occurs in these cases, and as yet we have no certain 
method of procuring it without running a risk of the suppurative 
following it. It is much to be wished that such a method of cure 
could be put in practice with certainty and success. That it is pos- 
sible for such a method to take place I know from experience, and 
also from the dissection of dead bodies, for we very often find the 
cavity of the tunica vaginalis entirely obliterated, and fixed to the 
tunica albuginea; but it is more than probable that in such cases 
there never had been water in the cavity, and therefore adhesions 
the more readily took place, these adhesions being a very common 
* [M. Dupuytren, in his Le^on Orales, used to remark that operations of con- 
venience much more frequently prove fatal than others, such, for instance, as 
amputation of the thigh for old anchylosis of the knee, the removal or discharge 
of large bursae, &c.; so much so that he was accustomed to decline operating in 
such cases. Surgeons occasionally allow themselves to be persuaded, by the 
importunities of a patient, to undertake operations against which their own judg- 
ments loudly declare : surely such conduct ought to be reprobated, as proceeding 
either from culpable weakness or some motive still more reprehensible.] 238 
HUNTER'S PRINCIPLES OF SURGERY. 
consequence of swelled testicle from gonorrhoea. Perhaps letting 
out the water, and only keeping the wound open a short time, 
might just procure the adhesive state, and by allowing it to heal up 
before the suppurative took place the latter might be prevented; 
however, I believe the knowledge of this critical time, if there be 
such, is beyond the power of human sagacity; therefore I believe it 
would not answer in most cases. Indeed I have seen suppuration 
follow simple tapping; and admitting we were masters of the degree 
of inflammation, yet many arguments might be brought against the 
probability of its success, for we might suppose it not possible for 
the adhesive to produce its effects universally: first, because it is 
next to an impossibility to evacuate the whole of the water, and 
that remaining would be sure to keep some parts separate; secondly, 
as the tunica vaginalis is much enlarged in such cases, the collap- 
sing ot the skin might prevent adhesion taking place at all; thirdly, 
the contact could not be so uniform as to bring all parts into appo- 
sition. I know but of two cases where this method occurred suc- 
cessfully. 
Observations on the different methods of radical cure.-I believe 
I am the first who have taught that the radical cure is performed 
by inflammation, suppuration, and granulation; it was the general 
opinion, and I was always taught, that it was by adhesion; but if 
union took place by adhesion, without granulation, then we should 
not have had suppuration. 
The most simple mode recommended for obliterating this cavity 
consists of making a small opening into the sac, and introducing an 
extraneous body to prevent union by the first intention in the wound, 
by which means universal inflammation should take place over the 
whole surface of the sac. This probably was not thought sufficient 
to raise an inflammation, therefore it was recommended to throw 
into the cavity by this orifice stimulating liquors, so as to increase 
the inflammation; they had not an idea of an imperfect cavity pro- 
ducing inflammation of itself. In very old cases, where suppura- 
ation is but slowr in its progress, this mode may be of considerable 
service. 
Another method was by seton, which was no more than a double 
tent, or two wounds instead of one. 
The ideas annexed to these modes of practice were, that they 
produced adhesions of the sides of the sac to each other, and also 
to the testicle, by the first method of union. Great pains have been 
taken in a treatise published by Mr. Douglas to show the impossi- 
bility of the sac collapsing so readily as to unite in every part of its 
extent. But this is neither the effect one might naturally expect to 
ensue from the methods put in practice, nor what really takes place 
in the very cases where they were tried, as is easily known from 
the symptoms described by the operators themselves, which were 
plainly those of the suppurative inflammation, though they did not 
see it in that light. 
So far was this disease treated to procure adhesions of the tunica OF HYDROCELE. 
239 
vaginalis to obliterate the sac, and perhaps it was on the same 
principle that a small caustic was at first applied, and which has 
been used with success; but in a late publication (Else's) it is 
recommended on principles very different from the foregoing,' for it 
is there supposed that the whole tunica vaginalis sloughs off and 
passes out through the opening. But that the whole tunica vaginalis 
should slough away by this treatment more than when the whole 
cavity is laid open, is not to be conceived. It is, however, a well- 
known fact that the tunica vaginalis often throws off partial sloughs, 
and in some very old cases may slough wholly away; but it is 
not to be expected as a general effect. When it does slough, this 
is owing entirely to the diseased state in which the sac is at the 
time, and not to any particular virtue in the method of cure. I sus- 
pect that after caustic, more than after other methods of cure, there is 
an appearance very much like sloughing, so much so as very readily to 
deceive; this appearance is the coagulable lymph thrown into the 
cavity among the water from the internal surface of the sac in the 
time of the adhesive inflammation. 
From the ignorance of the true principles of cure, and the uncer- 
tainty of success from the former methods, practitioners were led 
naturally into the method of opening the whole sac or bag; but most 
probably they were led to this practice by imitating what may be 
called the natural cure, in cases where the sac had burst, and a 
radical cure ensued. It is most likely that the bursting of the sac never 
happened from mere distention, but from preceding inflammation 
and suppuration, which might arise from the distention, and in that 
light is only to be considered as an abscess. And here it will be 
proper for me to observe, that such a case might lead a surgeon to 
form an erroneous idea of it; for if he had not been consulted from 
the beginning of the disease, namely, when in the state of hydrocele, 
and also had not made himself master of what the disease now is, 
he might readily suspect it to be a diseased testicle, and might be 
confirmed in the opinion by the inflammation and suppuration, unless 
the appearance of these should cause him to suspect it not to be 
cancerous ; but if it does not, he will be most, likely led to the 
extirpation of the whole mass, unless by first laying open the abscess 
freely he should gain a knowledge of what the disease is. Even 
then, however, he might continue to be deceived, for the inflamma- 
tion having attacked the body of the testicle, he will find it very 
much swelled, and to appearance diseased, especially if the abscess 
should not have been thoroughly opened. A case of this kind I 
once saw, and also the mistake above-mentioned : the abscess was 
opened, and the testis exposed and condemned ; when I saw the 
abscess and the testicle at the bottom, I suspected what the case 
was; the testicle wras not removed, and the patient got rid of his 
hydrocele. 
It is possible that a case of this kind might happen where the 
disease would not show itself so manifestly; for if the water had 
been contained in a hydatid, the testicle would not be exposed by 240 
HUNTER'S PRINCIPLES OF SURGERY. 
opening the abscess, and the whole tumour might appear to be the 
body of the testicle. In a case of this kind the sick heavy pain and 
the pain of the back which attend diseased testicle would not be 
present, nor the pain in the small of the back ; so that if these 
.symptoms were attended to, there might still be a means of saving 
the testicle. 
Although this natural cure might have shown the possibility of a 
cure being effected by inflammation and suppuration over the whole 
sac, and that very probably no more was necessary to produce it 
than making an opening into the sac, and not allowing it to heal 
by the first intention, yet it was certainly not understood, for it was 
thought necessary by some to open the whole sac, and indeed to 
make it still more secure by cutting off' a part of the sac, or even 
the whole, which indeed was all that they could, unless they had 
dissected off the tunica albuginea from the testicle. As this method 
of operating is much more violent than the others, of course its con- 
sequences are more violent; it is, therefore, evidently not to be put 
in practice to its full extent, if a less violent and as sure a one can 
be devised. However, do not suppose that I mean to prefer a 
patient's ease during an operation to his cure. 
In every one of the operations for the radical cure of hydrocele, 
the suppurative inflammation is an effect which is pretty violent, 
and therefore in many cases of thickened sac it produces an inflam- 
mation which is absolutely sufficient to kill some parts which are 
not able to support the actions of life, and which are thrown off' in 
the form of sloughs. 
Incision, it has been said, is to be preferred, because it gives the 
operator an opportunity of seeing the state of the testicle, which has 
been found very much diseased in such cases, so that the operator 
has thought himself obliged to have recourse to extirpation of it. 
This is a case which sometimes happens ; but I suspect that, if the 
symptoms were particularly attended to, we might inform ourselves 
exactly of it before the operation was performed. 
Perhaps in most cases it would be right to perform the temporary 
cure first, which would show the state of the testicle at the time ; 
and as the sac generally fills again pretty fast, there could be no 
danger of the testicle becoming diseased during the time of refilling: 
for in most cases where the testicle is diseased there is an obscurity 
in the feel; it will give the feel of water in some positions, and in 
others of more of a solid substance. However, in any of the opera- 
tions, excepting that by caustic, we might judge, I think, of the 
state of the testicle as soon as the water was wholly or in part 
evacuated ; and if the testicle is found of its natural size, there will 
be no reason for apprehension about it; and if very much thickened, 
then the surgeon is to act accordingly. But I am inclined to 
believe that such diseases of the testicle as are generally attendant 
on dropsy of its coats, and are perhaps the causes of that dropsy, 
seldom do much mischief. 
I cannot say I ever saw a cancerous testicle that began by pro- OF HYDROCELE. 
241 
ducing a common hydrocele, nor can I call to mind any case of 
common hydrocele, where the radical cure has been attempted, in 
which the testicle ever became cancerous afterwards. Yet I have 
known cases where it appeared a true hydrocele at first, and the 
testicle afterwards enlarged, and by degrees the water diminished, 
till at last the whole has been an enlarged testicle, and has been 
obliged to be extirpated. I have often seen the testicle diseased on 
opening the sac, and it has been generally thought proper in such 
cases to remove the whole ; yet I imagine it is seldomer necessary 
than is thought. This disease would appear to be not sufficiently 
distinguished from cancer, to which I believe it has no real affinity; 
however, it is possible that cancer of the testicle may be attended 
with hydrocele. Perhaps this disease may have some connexion 
with scrofula, for I have seen scrofulous testicles, and have even 
extirpated them as cancerous. In some cases this practice is right, 
and it was so in those in which I did it, but it was not intentionally 
right; for although not cancerous, yet they often become so much 
diseased and so large that it is absolutely necessary to extirpate 
them. But still such have an advantage over cancers, as we may be 
pretty certain of the cure from the operation, which is not always 
the case where there is a cancerous disposition. If the case appear 
very dubious, I should recommend an incision, that the state of the 
testicle may be better understood, and the patient will be equally 
sure of a cure. 
I shall now mention the causes of failure common to every method 
of cure, and then the causes of failure peculiar to each. 
The sac containing the water being membranous, it only can be 
distended by the water which it contains, and readily collapses and 
throws itself into folds whenever this distention is taken off; and, as 
every method of cure requires the evacuation of the water, the mem- 
brane will collapse, if not prevented ; and this collapsing I find to be 
the common cause of failure in them all. 
It is a principle in the animal economy, when any natural internal 
cavity is exposed, that if any two parts of the cavity are brought 
togethei' they will unite, but only at the edge next to the exposed 
surface ; beyond this, if any two parts of the surface are in contact, 
they will not unite, being excluded from the necessity of union by 
the union of the edges which are nearest to the exposure. This 
part that does not unite then is formed into a cavity capable of con- 
taining a fluid, and of being hereafter filled in that way ; where the 
sac has been large and not thickened, several such cavities may be 
formed, each capable of carrying on the disease. Until I understood 
the above facts, I could not understand why we have recurrence of 
this disease in the same tunica vaginalis. The first time I saw that, 
a recurrence could take place was in a patient of myown, who died 
of small-pox whilst under the radical cure of the hydrocele. The 
recurrence of the disease will follow every method which docs not 
prevent the two sides of the sac coming into contact with one 
another in the time of inflammation. 242 
HUNTER'S PRINCIPLES OF SURGERY. 
Of the causes of failure common to the Seton, Tent, and Caustic.- 
In either of these three methods of treatment, if the water is eva- 
cuated immediately, or is evacuated soon after the operation, at least 
before suppuration has come on, it often happens that the surface 
of the sac surrounding the orifices shall come in contact with the 
body of the testicle and adhere, which will immediately exclude all 
the other parts of the cavity from the necessity of inflaming, suppu- 
rating, &c., so that no union of the sac is produced but at the part. 
I have known a seton inclosed in this way along its whole course, 
and lying in a canal formed for it, instead of being loose in the 
general cavity. 
I have known the same thing happen to the parts when the caustic 
has been applied: the edges of the sac all round have adhered to 
the testicle, so that when the slough has come away this has formed 
the bottom of the wound, which granulated ; the wound filled up, 
the disease recurred, and required a second operation. I have also 
found sometimes, where the caustic has been used, that Nature has 
covered the inner surface of the eschar with new living matter, by 
which the inner cavity has been made perfect. A patient of mine 
had a hydrocele in each tunica vaginalis. I applied the caustic to 
each ; when the sloughs came out, I observed at the bottom of each 
a bluish white surface, while the edges all round were red and 
granulating. This surface I suspected was the tunica vaginalis not 
affected by the caustic. I endeavoured to complete what the caustic 
had failed in; but was surprised to find that I was obliged to push 
my lancet in half an inch before the water came; when I intro- 
duced a tent to preventits being wholly evacuated. I made a similar 
attempt on the other side ; I introduced my lancet half an inch, 
and no water came, and I then made a puncture through the 
sound skin, and had not to go so deep as when the eschar had fallen 
out. 
I suppose that when a breach or waste or loss of substance is 
produced in the outside of any cavity (and probably in every other 
part) there immediately takes place an irritation suitable to this 
cause, and this irritation produces an extravasation of coagulable 
lymph on the inside, to preserve the cavity or part as entire as pos- 
sible, which it had certainly effected in this case. Probably this is 
the common cause of failure in the immediate effect of caustic, which 
was not before understood. 
We see the same thing take place in joints ; where that part of 
the bone which makes part of the joint becomes dead, we find a 
layer of coagulable lymph laid over the dead part or end of the 
cartilage, which preserves the joint perfect; otherwise the whole 
cavity must suppurate. In these cases of joints, as well as in the 
above, it has puzzled me to know how the layer of coagulable 
lymph was formed. If in either case death in the part did not go 
quite to the cavity, but leave a living surface, (no matter how thin, so 
as it is sufficient to produce a surface by extravasation,) we may then 
conceive how new matter may be laid on this surface and increase OF HYDROCELE. 
243 
to any thickness. If we can provide one layer, we can easily 
make it increase. It is a curious fact, and deserves attention. It 
is as if Nature was making the same opposition as we should do if 
a neighbour was endeavouring to make a way through the wall of 
our house, and, as we could not prevent his endeavours on that side, 
we should barricade further on this side, by raising up another wall. 
To avoid these failures, I have practised and recommended that 
the tent or seton should be as large as the opening made for the 
introduction of it, so as to fill up the whole wound, and to allow 
but little or no water to escape, until inflammation and suppuration 
have come on; and in cases where the caustic has been applied I 
have not cut through the eschar, but allowed it to slough off, by 
which time the necessary inflammation has come on. This mode 
would seem to give the preference to the caustic ; but we find 
Nature taking all the steps she can to frustrate our operations 
whenever they are violent upon her, as described above. 
In some of the cases where the sac has collapsed and united as 
above described, leaving a cavity beyond it loose, it has happened 
that the preceding inflammation has gone too far for those cavities 
to remain in a quiet state, and suppuration has taken place in them 
while under cure, forming there an abscess which either breaks 
through the adhesions and opens into the first sore, or makes a new 
passage through the scrotum, like any other abscess, and a com- 
plete cure has been effected. 
I have reason to believe that from the small opening made by 
these three modes, old hydroceles are sometimes deprived of the 
full effect of exposure; and that, though the parts inflame and 
suppurate, yet when the orifice has become small and taken on the 
closing process, the sac loses the suppurative disposition, (like the 
pleura when suppuration takes place,) the surface never having 
granulated, but simply secreted matter like the inside of a duct; 
and when the exposure ceases, falls back into the natural state, and 
the accumulation of water recurs. 
When the radical cure is to be performed, either by tent, seton, 
or caustic, it is more proper to do it in one part of the tumour than 
another. One might at first suppose that the most depending part 
of the tumour would be the best, as in an abscess; but in fact it is 
the very worst, because here the inflammation is to follow the 
operation, whereas in an abscess the opening follows the inflam- 
mation. Why this should be a reason for performing it in a differ- 
ent part may not at first sight appear: but it is to be considered 
that the tumefaction attendant on the inflammation which is to 
succeed, will not be so great in the part where the operation is 
performed, if the extravasated juices, which are the chief cause of 
the swelling, can be allowed to depend; hence the opening will be 
less liable to close up when made at the upper part of the bag 
than at the lower, where it would be in the centre of the tume- 
faction, and would not allow a free discharge of matter, as we 
really see to be the case on many occasions. To avoid this 244 
HUNTER'S PRINCIPLES OF SURGERY. 
inconvenience, the opening should not be made at the lower part of 
the tumour; nor at the upper, for the following reason, viz., the 
water as it increases commonly pushes up the sac into the sper- 
matic cord; therefore the situation of the upper part of the sac 
is changed immediately on the evacuation of the water; and the 
sac collapsing and contracting in proportion to the evacuation, its 
upper part moves downwards, which of course must alter the 
relative situation of the opening in the sac and in the skin. The 
opening should therefore be made in the middle of the tumour. 
Of the Mode of performing the Operation with the Tent.-When 
the bag is pretty full of water, examine the bag carefully for the 
testicle. The situation of this being ascertained, grasp the bag in 
the hand, and squeeze the water towards that side where the testi- 
cle is not. Push the lancet in until the water comes out by the side 
of it, and then carry it forward, and enlarge the wound to about 
double the breadth of the lancet. Withdraw the lancet, but keep 
the tumour in the same situation, that the orifices in the skin and 
sac may continue opposite each other, or it will be almost impos- 
sible to introduce the tent; but do not press the sac quite so hard, 
or all the water will come out before the tent is introduced. Intro- 
duce the tent with the right hand, and hold it till it swells, when 
there will be less danger of its falling out. Then put on a piece 
of sticking-plaster, to secure the whole. 
The tent may be kept in till the edges of the wound swell, 
which will be in a few days, and then the tent becomes loose, after 
which there will be no danger of the wounds closing up, for by this 
time the alarm will be given to the whole cavity, and the irritation 
of an imperfect part will be sufficient to prevent the wound healing. 
I recommend a sponge tent, as it swrells and keeps the orifice perfectly 
open, and as this swelling is greater at the two ends than between 
the lips of the wound, by which two disagreeable accidents arc 
prevented: the one, the escape of the tent into the cavity of the 
tunica vaginalis; the other, the escape of the tent altogether from 
the wound. 
Of the Seton.-This is to be preferred to the tent, as being more 
easy to perform. The most easy method is with the common 
seton needle : holding the scrotum as above, introduce the needle 
perpendicularly where we know the water is ; lower the end and 
raise the point, and bring it through the skin about half an inch or 
more above the other incision. Take off the needle, and apply a 
piece of sticking-plaster over the wound. 
A lancet and eyed probe, carrying a skein of silk, is sometimes 
used, but it does not answer so well. 
When suppuration is established, the seton may be either left in 
or removed, according to circumstances. 
Of the Caustic.-A small caustic applied to the tumour is com- 
monly sufficient to produce the effect, if it acts quite through the 
sac. In applying it, we should attend to the feelings of the patient, 
to judge when the sac is deadened by the action of the caustic. OF HYDROCELE. 
The uncertainty of its acting through all the coverings of the sac 
has been an objection to this practice by many; and when it does 
'fail in this way, the finishing what the caustic has not effected 
reduces the operation to the case of a simple puncture. I have 
before shown another objection also. 
If the chance of the caustic not penetrating was the only objec- 
• tion, I should prefer the caustic to all other methods of cure for the 
following reasons: because it removes a small part, which gives a 
freer passage to the water than a simple wound; and we may 
produce the adhesive inflammation in the innei' edge surrounding 
the slough before the watei' is evacuated, which in some degree 
determines the thickness of that part before the general tumefaction 
comes on. This gives it a considerable advantage over the punc- 
ture or seton, for they produce the general inflammation nearly as 
early as the local one, which proves inconvenient in many cases 
by thickening the scrotum at the orifice, which lengthens the pas- 
sage and almost shuts it up. Besides, if the effects of caustic are 
produced quite through into the cavity, they excite the suppurative 
inflammation over the whole cavity before the water is evacuated, 
the presence of which more readily allows it to become universal. 
However, the caustic is not always a certain cure, even when its 
immediate effects are completely gone through, for I once saw a 
case where the seton had been used first, and on the recurrence of 
the disease the caustic was employed, yet after this there remained 
a small sac which required a third operation. The cause of failure 
in both the first was, I believe, that which I have before noticed of 
the edges of the opening collapsing and becoming united to the 
body of the testicle. 
From what has been said it must appear that the great art in 
this operation is the prevention of the possibility of a relapse ; to 
prevent which it is requisite that every part of the sac should be 
obliterated, for which purpose it is necessary that every part should 
be subject to suppuration. 
I have now considered this disease, the precautions necessary 
before the operation, and the different methods of operating, with 
their advantages and disadvantages. I have endeavoured to show 
that every method hitherto recommended has in many instances 
failed, and I have also endeavoured to show the causes of their 
failure. It is proper now to consider of some method which shall 
not be subject to the above mentioned inconveniences. 
I have of late used the following method of cure, with a view to 
producing universal inflammation and suppuration of the sac. 
Make an incision into the sac about three inches in length, and 
let the whole of the water escape ; then fill it as full as possible 
with pretty stiff poultice, occasionally introducing your finger to 
direct the poultice into every corner of the bag; and, lastly, put 
some lint into the wound to keep the poultice in. The poultice 
should be be made of linseed meal, and pretty stiff; if it is made 
into little balls it will be still more convenient. The advantages 
245 HUNTER'S PRINCIPLES OF SURGERY. 
246 
that this method has over the others are, first, that it is simpler than 
exposing the whole; secondly, the parts are kept universally dis- 
tended by an extraneous body, so that the inflammation becomes 
universal; thirdly, the poultice does not become entangled in the 
granulations as dry lint does ; fourthly, as the parts granulate and 
contract, the poultice is gradually squeezed out, and only requires 
superficial dressing during the whole time. With the same intention 
I have sometimes used lint dipped in oil or lard, which prevents its 
becoming entangled in the granulations, which without this precau- 
tion it is liable to do ; so that I have known it retained in the sore 
for six weeks, when it was obliged to be removed to allow the sore 
to heal over.* 
To prevent inflammation coming on too quickly and causing 
unnecessary pain, I believe it is right to apply a piece of linen cloth, 
folded ten or twelve times, and of sufficient breadth to cover the 
scrotum, first dipping it in brandy and squeezing it dry. Over this 
apply a suspensory bandage, which should be wetted as it becomes 
dry. 
The symptoms following the operation are those common to all 
wounds, but as there is also a part in some cases concerned in this 
operation which has symptoms peculiar to itself, it becomes neces- 
sary to describe these; this part is the testicle. The testicle is only 
concerned when the collection of water is in the tunica vaginalis. 
The symptoms peculiar to it are in some measure those of a vital 
part; a dull heavy pain is felt, the stomach is sooner affected, and 
lassitude soone;' produced, than in affections of common parts. 
Besides these, there is one peculiar symptom, that is, the pain in the 
back attending inflammation of the testicle. This is generally sup- 
posed to arise from the nerves of the testicle arising from the nerves 
of the loins. If this is the true solution of the case, we can only 
say this is peculiar to this part; therefore out of the common way 
of symptoms. In less than twenty-four hours the symptoms of the 
operation will begin; for, although the patient should have no pain, 
he will soon feel a lassitude, small short rigors attended with rest- 
lessness, which show that where this operation of inflammation is 
going on in the part, though it may not affect the senses, it is yet capa- 
ble of producing considerable effects on the animal economy, so as 
very much to effect the vital principle. These symptoms increasing, 
the scrotum becomes sore to the touch, a greater degree of heat 
than common arises in the skin, the patient complains of thirst, and 
at last the diseased part becomes painful, swells, and throbs. The 
swelling is often very considerable; and, from the pain, this might 
be supposed to arise from the testicle, but it consists principally of 
the cells of the scrotum, which being composed only of cellular 
membrane, and that very ductile, gives way to the extravasated 
fluid, viz., coagulable lymph and serum. However, the testicle 
* [Mr. Hunter afterwards substituted the use of flour, which he dusted over 
the exposed surfaces.] OF HYDROCELE. 
247 
itself swells and inflames in hydrocele of the tunica vaginalis, espe- 
cially when that body is laid bare, as might be expected, as that 
part, or rather its coats, inflame and suppurate. Besides, we have 
the symptoms which denote affection of the testicle. 
The future treatment is like that of common wounds, only a sus- 
pensory is required, as it relieves the pain in the back. 
After the parts are healed, the testicle, for a considerable time 
appears hard and large, and the skin of the scrotum adheres to it. 
This gradually subsides by the contraction of the granulations, 
which are the chief cause of it, and by the absorption of the adven- 
titious substance deposited by the inflammation. This natural 
process may be much accelerated by the use of the mercurial 
ointment, rubbed on the scrotum, for a month or six weeks.* 
Before I proceed to make any further observations on particular 
diseases and injuries, I shall say a few words on medicines, or 
rather of their action on the human body. 
On the Action of Medicines. 
* [There is one capital objection to all the operations above mentioned, which 
is their severity and danger. Many cases of death occurred, and many more of 
high constitutional irritation which placed the patients' lives in imminent peril. 
The operation which is now almost universally resorted to, and which is only 
cursorily alluded to by Mr. Hunter (p. 238), is free from these inconveniences, at 
the same time that it very rarely indeed fails of curing the disease. It was intro- 
duced by Sir James Earle, and consists in injecting the evacuated sac with 
any mild stimulating liquid, such as a solution of zinc, or equal parts of port 
wine and water, which are allowed to remain in from five to ten minutes, 
according to the feelings of the patient. A moderate inflammation generally fol- 
lows this operation, and in a few days the fluid re-collects : after a short time, 
however, the inflammation subsides, and the fluid is absorbed. The time 
required for the absorption of the fluid varies from one to six months. Occa- 
sionally, but very rarely indeed, the disease returns. 
It was imagined that this operation effected the cure by causing an adhesion 
between the opposite sides of the sac. An effect which is doubtless sometimes 
produced, and probably in all cases to a certain extent, although later observa- 
tions have proved that universal adhesion of the sac is by no means a general 
consequence of the operation, which cures by destroying the morbid action of the 
secreting vessels in some manner which has not been explained. The success 
of this operation is not by any means in proportion to the quantity of inflamma- 
tion produced, although a certain quantity seems necessary for the effect. The 
inflammation arising from injection rarely exceeds the adhesive stage ; although 
this does sometimes occur. Only three cases of this kind are mentioned by Sir 
Benjamin Brodie as having occurred in his experience, and these three were 
West Indians, in whom suppuration took place. Occasionally the scrotum 
sloughs. (See note, p. 236.) 
Where the operation by injection has failed, the operation by incision may be 
had recourse to. In children it is generally advisable to have recourse to the 
seton, using a few threads of silk only, passed by a common curved needle. In 
encysted hydrocele of the cord the same means may be adopted ; or, what is still 
better, the sac may be laid open, and the fore part of it cut away. If it be situated 
on the testicle or epididymis, and of small size, it had better not be meddled 
with, or it may be simply evacuated, provided it is inconvenient to the patient 
from its magnitude. The operation by injection does not succeed in encysted as 
in common hydrocele.] 248 
HUNTER'S PRINCIPLES OF SURGERY. 
The living principle, I before observed, is susceptible of impres- 
sions which may be productive of action, either diseased or healthy, 
i. e., productive of restoration; each of these may be brought on by 
medicine. Whatever affects the animal body otherwise than mechan- 
ically must be in a state of solution. From our juices being chiefly 
watery, the solution of many substances can easily be conceived; 
but they are likewise capable of dissolving earths, metals, &c.; 
nay, there is, I believe, hardly any substance which is not capable 
of being dissolved in the human body. Earth, and even iron, is 
found in animal substances on analysis, which must have been 
dissolved in the fluids, as well as essential oils, which may be 
detected passing off by our excretions. Taste is one proof of the 
power of our fluids to dissolve, for there is hardly any substance 
capable of stimulating but what will give a taste if applied to the 
tongue: thus, almost all metals held in the mouth for a little time 
will give a taste : the same thing most probably takes place with 
substances applied to the organ of smell. The blood, from its 
being so heterogeneous a fluid, may have its powers of solution 
inferred; and as I suppose a necessity of solution of these sub- 
stances to affect the organs of smell and taste, so in like manner 
I suppose the necessity of solution, not only for its introduction, 
but for it to affect the system. Simple water possesses much less 
power of solution than when combined with some other substances ; 
thus, by the addition of fixed air it becomes capable of holding 
earth in solution. From some similar combination perhaps the 
blood and other animal fluids derive their extraordinary powers of 
solution. 
Medicines affect the living principle by their stimulant or sedative 
qualities only, unless they act chemically, as caustics; they have 
the effect of irritating oi' quieting, and these two contrary effects 
are generally to be found in the same substance, the difference 
resulting from the difference of quantity; thus, a small quantity of 
heat relaxes and softens, but a larger quantity will stimulate. A 
stimulus is what either causes a natural action, or increases one 
which has already taken place, or excites an action contrary to one 
present, as by giving an opiate when a patient cannot sleep, &c. 
Medicines may either stimulate or irritate; such as increase the 
natural power of acting are stimulants : such as excite new and 
unnatural actions are irritants. The powers of both will be accord- 
ing to the medicine and the parts combined, for fixed air in the 
stomach increases its action; in the lungs it destroys action.* 
The effects of medicine will be different according to the mode of 
action the parts are in at the time, that is, diseased, natural, or 
restorative. This is well illustrated by many diseases of the consti- 
* [Sir Humphry Davy found that when he attempted to breathe pure carbonic 
acid the glottis spasmodically closed, from the stimulant action of this gas, so as 
to render further inspiration impossible ; on the other hand, Fodere has remarked 
that a too free use of aerated waters will sometimes produce precisely the same 
effects as the inhalation of the dilute acid by the lungs, viz., giddiness and 
intoxication.] OF HYDROCELE. 
249 
tution, as fever, &c., curing diseases in parts which had before been 
incurable; if the part had not been diseased the effect would not 
have taken place, for fever deranges a healthy sore. 
Actions may be, first, of healthy parts ; secondly, action produced 
by stimuli or irritants on healthy parts; thirdly, action of diseased 
parts: fourthly, action of stimuli and irritants on a diseased part. 
Irritants may produce very different effects on a healthy part, or 
whilst disease already exists ; thus, mercury, by its irritation, will 
produce diseased action in a healthy part; the venereal poison, by 
its irritation, will also produce diseased action in a healthy part; 
but from the application of mercury to a part already affected with 
diseased action from venereal irritation, an action results different 
from that which would be produced by the application of it to a healthy 
part; for from the conjoined action of the two, results the action of 
health ; but if carried beyond that it may do harm, producing its 
own specific action. Besides this, it is to be observed that the vene- 
real action, or in fact any other morbid action, may produce a dis- 
position for other increased actions, which may require only the 
absence of the former disease to allow it to come into action. 
These consequences are therefore to be distinguished from the ori- 
ginal disease, otherwise the mode of cure may be continued too long, 
and that which might be curative of the first disease may increase 
the consequent one. 
In a former part of the course I mentioned susceptibility, disposi- 
tion, and action. Can the same medicine have an influence on all 
these? Will mercury, for instance, destroy the susceptibility and 
the disposition for the venereal disease, when formed, as well as the 
action? It will certainly destroy the latter, and we have cases 
which would make us think it will lessen the susceptibility also; but 
as to its having any effect in lessening the disposition I should very 
much doubt; but it may perhaps retard it. 
A gentleman had a chancre, for the cure of which he used a 
large quantity of mercury, both by friction and internally, which 
produced very little soreness of his mouth. The sore at last healed, 
and from the quantity of mercury which had been used it was 
thought that the constitution was preserved ; but in a little time 
discolorations of the skin appeared; for these he drank a quart of 
sarsaparilla daily, without their removal; on the contrary, fresh 
ones appeared. I gave two grains of calomel twice a day, and 
he was cured. Now I suppose that a disposition for this diseased 
action might have existed before the mercury was first used, which 
disposition was by this not lessened, but only retarded, and the cure 
did not take place until the venereal action took place, which was 
then cured by the action of mercury, the first mercury not prevent- 
ing the disposition from forming; and it thus appears that what will 
cure the action will not cure the disposition, hence lues often 
requires repeated courses of mercury. The ultimate effect of 
impressions, I have already shown, are actions; and I also showed 
that diseased actions were thus produced; and here is the place to 250 
HUNTER'S PRINCIPLES OF SURGERY. 
observe, that in the same manner actions may be produced which 
are destructive of that which is diseased. But disease is not always 
the consequence of impression, but sometimes of imperfection of 
parts; thus, there may be a wasting of the body from a want of 
absorption of chyle from the intestines, or mesenteric obstructions. 
There is no impression without a counter-impression ; as if one has 
a pain in the knee from a disease in the hip or loins ; here it would 
be ridiculous to apply a remedy to the knee, as that is only the 
effect; yet this is often done.* 
Medicines have visible and invisible effects. The visible may be 
divided into two, the constitutional and the local, the former pro- 
ducing the latter. The local are vomiting, purging, &c.; as an 
instance of the constitutional, the effects of mercury may be men- 
tioned. Their invisible effects are commonly the specific effects, 
for we find that their curative do not always depend on their visi- 
ble effects; and indeed their specific effects are often greatei' when 
they have no visible effect, as mercury producing salivation in the 
attempt to cure the venereal disease, bark in intermittents : but 
others cure by their visible effects. 
Of Stimulants, Irritants, and Sedatives.-The two former are most 
commonly used by surgeons, because a want of disposition for res- 
toration is more common than excessive wrong action; and a 
backwardness to heal is more apt to excite the idea of sluggishness 
than of excessive or wrong action, though perhaps even the latter 
may be the case. Medicines given slowly and continued long will 
produce effects very different to those produced on their sudden 
application, and thus it is that even stimulants and irritants may 
produce weakness. 
On restoration of Action.-In the restoration of action of the whole 
body, or of diseased parts, attention should be paid to the strength 
of the parts, or of the whole system, for there may be too much 
action and too little strength, or too much strength and too little 
action. Strength and action should be well proportioned to pro- 
duce good effects. When parts have lost their action for some 
time, they become weak, as we see in people recovering after 
drowning. If we do not attend to the degree of strength, we shall 
often produce irritability by hurrying on action too soon in weak 
parts. If a man is weak from loss of blood or from famine, his 
strength should not be tried by too much food, stimulation, &c. 
When strength exceeds action, then there is room for the use of 
* [However unscientific this practice may appear, yet it is often found to 
relieve the pain, probably upon the simple principle of counter-irritation. If (it 
is argued) the knee sympathizes with the hip, why may not the hip sympathize 
with the knee? The principle is not very different upon which leeches are 
applied to the anus, and sinapisms to the feet, in affections of the head; that is, 
certain parts of the body sympathize with each other more readily than with 
other parts, and on this account are thought to afford the most favourable situa- 
tions for counter-irritation ; hence blisters to the knee relieve this part by first 
relieving the hip. The precise meaning of the term " counter-impression" in 
this connexion is not very apparent.] OF HYDROCELE. 
251 
stimulants. If the effects of medicines did not extend beyond the 
point of contact, their effects would be very trifling indeed; but 
their effects are extended much further by sympathy. This sym- 
pathy may be either contiguous, continuous, or remote. Such 
sympathies as are continuous and similar lose their power by dis- 
tance only, and medicines acting thus maybe termed local. But it 
is to be remembered that the remote sympathetic effect of medicines 
is not always the same as their effect on the part to which they 
were first applied. If the continuous sympathy was not similar, 
and if the effect of any medicine on any part thus affected was not 
continued by that same similar continuous sympathy through that 
part, how trifling would be the effect of such applications ; and how 
could any application to the surface affect an inflammation which 
extends to a great depth but by the same sympathy? It is by 
sympathy that ether, applied to the forehead, relieves headache; 
applications to the skin of the abdomen, its contents, &c.; in short, 
if this were not the case no medicine could cure without coming in 
contact with every part of the diseased organ. 
On the effects of external applications.-The commonly-received 
opinion respecting external applications is that they enter into the 
pores of the skin, and so reach the part; and on this idea practice 
was built. Parts were supposed to be relaxed and moistened by 
luhe joint effects of warmth and moisture, and on this idea warm 
baths were used to ruptures and dislocations. In many cases, indeed, 
very salutary effects were derived from their use ; but this cannot 
be from the cause assigned, for the warmth of a living part is not 
thus increased ; and a living part may be immersed for ever in warm 
water without becoming moister, except where the water is in 
contact. The good effects are produced by the external parts 
being soothed, and by sympathy the parts beneath lose their 
irritability, and the natural actions return. In suppression of urine 
the warm bath is often effectual; not surely because it penetrates 
from without, but because relaxation is brought on by sympathy. 
Volatile spirits and vapours have been used with the same idea, but 
it is well known that water will often penetrate where these will 
not. Oils are often used for the purpose of restoring stiff joints, 
perhaps from seeing theii' salutary effects on rusty hinges; but rusty 
hinges have greatly the advantage of the animal body, as oil will 
penetrate into every part of them and wash off the rust, whereas in 
a stiff joint not a particle of the oil will penetrate. The idea of 
their penetration has been carried so far as to lead some to prefer 
animal to vegetable oil, on the supposition that as it had come 
from an animal it would more easily enter an animal. Essential 
oils are used as stimulants in rheumatism, &c., but I suppose their 
effects are only produced by sympathy. 
Although I do not admit of this mechanical penetration of sub- 
stances, I have no doubt of their absorption by the action of the 
proper absorbing vessels: thus, mercury applied to the thigh is 252 
HUNTER'S PRINCIPLES OF SURGERY. 
absorbed and carried through it; but if rubbed on the bubo this 
can only be affected by sympathy with the skin.* 
Pressure and Friction.-The ultimate effect of these seems to be 
similar, namely, stimulating, but from different causes. If pressure 
is used as a stimulant, it must be gentle: if violent, it will irritate, 
and produce vesication, as we see in bedridden people. Pressure 
produces increase of action, by first impeding action, the impedi- 
ment acting as a stimulus on the part. Friction is more powerful, 
more active and immediate than pressure, and may be applied to 
larger surfaces; it does not impede action as pressure does at first, 
but rouses the parts into action, and excites a warmth in them. 
Stimulating or irritating medicines render friction more powerful 
in torpid parts. Fibres, by frequent rubbing, are stretched, and 
lengthen. 
Heat, cold, and electricity produce effects not only at the part to 
which they are applied, but much deeper also. Water as it con- 
ducts quicker, is a better vehicle for the application of heat than 
air. Cold, when applied to the skin, has great and immediate 
effects. We have two opposite effects from cold-bathing, according 
to the mode of application and the state of the constitution at the 
time. By its quick and sudden application the power which the 
body possesses of forming heat is called up and exerted, and a 
glow of heat is soon felt on the surface; this is what takes place 
in a strong constitution; but if it is too often repeated in the same 
day, or the constitution is weak, instead of being refreshed, the 
person is more languid, is chilly through the whole day, the con- 
stitution not having sufficient power to restore the heat so suddenly 
abstracted. 
Heat would seem to be produced in the vital parts; and it is to 
be observed that both birds and beasts have warmer clothing over 
their vital organs than their extremities, which abound more with 
oil, even in the bones. Action from the application of cold may 
be diseased, being sometimes the action of weakness; it may also 
act by sympathy, as cold applied to the back will stop a bleeding 
from the nose. Applied to the skin it will produce pain in the 
intestines, and a relaxation of the bladder. In a sprain it is com- 
mon to pump cold water on the part, as it is supposed to produce 
action in old sprains. I believe it is not so plainly indicated, except 
where the constitution is sluggish. 
Heat pervades all matter: the quality made evident to our senses 
is here meant; for the matter of heat is to be found more in some 
bodies than in others, though theii' sensible heat may be the same. 
Heat may be native or foreign: the latter I mean to consider here. 
Heat may be either stimulant, irritative, or sedative. It tends 
directly to increase action ; cold, to lessen it. A case explaining 
* [Later observations have shown that many of the phenomena of absorption 
are referrible to imbibition.] OF HYDROCELE. 
253 
my idea of the necessity of adapting action to the strength may be 
introduced here. 
A child, with fever of the putrid kind and sloughs in her throat 
was very low and weak; she had taken bark, and had been 
blistered. I was called on account of a large slough appearing 
on the blister, to which I applied poultices, with opium. It was 
proposed to apply stimulating applications, which I objected to, 
on the idea that action had been already beyond the proportion 
which it ought to keep with the powers of the patient. The warm 
bath was likewise proposed, and on the same ground objected to ; 
but it was tried, and my opinion confirmed, by the ill effects it 
produced. In fact, in such a case as this I should be careful of 
not increasing action too far; for as it is spared, so must the 
powers and the strength he preserved. 
Heat is either applied in a dry or moist state; the first can only 
convey absolute heat to the part: water or bran in a bladder are 
the best dry applications. Electricity is the only application, 
perhaps, which can be said to penetrate, and its influence is very 
extensive. 
On Diseased Dispositions and Actions.-I have formerly compared 
the dispositions of the body with the dispositions of the mind, and 
observed that dispositions were cured by actions taking place. 
In some cases the action entirely destroys the disposition; in 
others it destroys it only for a time, but the disposition is renewed; 
in others the whole action never destroys the disposition, or if it 
does, the action goes on without the disposition, as if from habit, 
till stopped by some unnatural power, as medicine. 
In the first case, where the action destroys the disposition, it is 
the action of restoration, as suppuration after inflammation. In 
the second case the disposition is destroyed for a time, or its power 
of continuing the action is destroyed for a time, but recurs again 
because the original cause, whatever it is, continues to exist, and 
is capable of renewing the disposition again, which again renews 
the diseased action. This is the case with all periodical diseases 
as agues, &c., and even some natural actions, as the menses. 
But whenever the constitution or part is capable of forming the 
full action of the disease, then that constitution or part is perfectly 
master of the disease, and it will seldom if ever prove dangerous, 
excepting it should produce some local effects in a vital part, as 
sometimes is the case of the gout. Let us take an ague as an 
example: it consists of three actions, which complete the whole, 
namely, the cold fit, hot fit, and sweat. If it stops in the cold fit, 
debility is either the cause, or it takes place; if it stops at the hot 
fit, strong action takes place which will probably prove a continued 
fever; if it goes through the third, then it is completed. It often 
happens that it is not able to form the hot fit, and, as it were, 
passes over it with sweat, which is cold and clammy, as if the dis- 
charge were not common sweat. But such cases approach to 
dissolution, for the sweat appears not to be the termination of dis- 254 
HUNTER'S PRINCIPLES OF SURGERY. 
eased action, but the termination of all action. Fits of all kinds, 
as epilepsies, are the same ; they are a full action of the disposition ; 
for such people shall be ill for days before the fit comes on, and 
after the fit they shall recover perfectly, only feeling a little weak 
from the exertion. 
Of the third we have an instance in the lues venerea; for it 
appears, from experience, that it goes on increasing, till it is eithei' 
cured or destroys the patient. (See note, p. 90.) Cancel' the 
same, and probably many other diseases. 
Of the first class there are many more diseases than we might 
at first imagine. Vomiting would appear to produce the cure of 
sickness; for sickness is the disposition; and the action, which 
we must suppose to be the ultimate effect, destroys the disease. 
Causes may produce a disposition, and that may bring on action 
at some distance of time, although health may intervene. 
A young man applied a strong solution of corrosive sublimate 
for the cure of an itching of the pubis; by this application a violent 
inflammation was produced. I ordered a wash of lime-water, to 
decompose any part of the sublimate still adhering, and a poultice 
of oatmeal and lime-water to cover the parts, with tinctura 
thebaica sprinkled over it, which gave him much relief. This was 
continued two days, when I ordered him the bark, to diminish 
irritability; but the apothecary chose to give him an emetic first, 
which brought up a great deal of blood from the stomach, for 
which Dr. Heberden, who was called in, ordered tincture of roses; 
but this proved ineffectual. Seeing the patient dying, and well 
knowing the good effects of turpentine in stopping bleeding exter- 
nally, I gave him two spoonfuls every two hours of an emulsion 
made with Chio turpentine ; cold water clysters being also used. 
He continued for some time very low, and had scarcely any pulse, 
having lost so much blood; but he recovered, and got strong and 
fat. He now became dropsical, but recovered from this by the 
use, first of emetics, and then of squills and turpentine. Here the 
loss of blood produced not only debility but a disposition to dropsy, 
which disposition was not at first brought into action, and the 
patient got fat and well; but the disposition being at length brought 
into action he became dropsical. 
It is on the same principle that many acute diseases cure chronic, 
the disposition being removed by a full action taking place. Should 
we not therefore attempt to induce this action for a permanent 
cure ? 
This practice is attempted in some obstructions to the full 
actions of natural operations, as in the menses: the period of attempt 
being when the natural effort is made, which is judicious. In 
intermittents, when there is not full action, perhaps giving a glass 
of brandy in the hot fit, and sudorifics to complete the termination, 
might be proper. At present this is only conjecture; but it shall 
be tried. 
On the greater or less Disposition of different Parts to Heal.- 
Some parts of the body have a stronger disposition to heal in con- OF HYDROCELE. 
255 
sequence of common inflammation than others. Those parts 
which have the greatest powers sympathize most and inflame most, 
as the muscles, skin, and cellular membrane; but we must also 
observe that these parts have different powers in different parts of 
the body. Other parts have but little powers of healing, which 
may be owing to their natural want of powers as tendons, liga- 
ments, bones, &c. These parts often lose their living principle, and 
be sloughed off, which is often salutary. The cellular membrane is 
common to different parts, and partakes of the powei' of such 
parts; thus, that connecting tendon to tendon has much less power 
than that of muscle. The sensation of those parts which are 
backward to heal is very different from that of the muscles and 
skin, as we should find on pricking them. 
There is a difference in the power of healing, according to the age. 
-The diseases peculiar to different ages we have observed, some 
of which are specific. Those diseases which are common to all 
are less difficult to heal in youth than in old age. In youth the 
healing powers are much stronger than when that period is passed: 
and this is still more the case with regard to the powers of resto- 
ration than in the cure of diseases. Ages I divide into growth, 
rest, and decline. The powers of restoration may be ranged in 
the same order, and may be supposed greater in a child of two 
years old than in one which is younger, because it now has strength 
adding to its powers of growth, the increase of strength being in 
proportion to its growth up to a certain period. 
One Disease often cures another.-We have observed that there 
may be universal sympathy with local affection; now this principle 
is capable of being reversed. One local disease often cures 
another, as hernia humoralis a gonorrhoea: and we have a local 
complaint curing a constitutional, but this local complaint is pro- 
bably caused by the constitutional, the whole disease centering in 
one part, as gout, which I have called an act of the constitution. 
It is on this principle that blisters, setons, and issues are ordered ; 
the former are useful, but from the latter two I have seen but little 
advantage. Constitutional diseases may cure local ones; the 
reason is, no part escapes the constitutional disease. I have seen 
fevers cure old ulcers, noli me tangere, &c.; which is done by 
destroying morbid action in the part; the local diseased action and 
the constitutional producing the third act, or health. Constitutional 
diseases sometimes cure themselves without taking on the complete 
action or crisis. When a local disease cures another (which is 
often the case) it must be by contiguous or remote sympathy, as 
headache by blistering the arm, gonorrhoea by swelled testicle, 
&c.; but I have seldom seen the second affection cured by bring- 
ing back the former. Local may be cured by constitutional, but 
may have reflected back on it the same disposition as that from 
which the constitutional action proceeds. 
Of the Mode of Recovery.-As there is no disease but what has a 
peculiar mode of cure of its own, and every particular part a par- 256 
HUNTER'S PRINCIPLES OF SURGERY. 
ticular mode of curing its own diseases, it is necessary to see how 
far in this case Nature imitates natural principles. We shall first 
give the original or natural ones, and then show thatNature is always 
uniform in her operations, and when she deviates is still regular in 
her deviations. We may observe that a disposition is given at first to 
particular parts, and that that disposition continues in restoring their 
own properties, as cartilage grows cartilage, bone bone, &c.; but 
sometimes she changes the disposition, as the parts become adapted 
for different purposes, as where a joint is created at the end of 
an unreduced dislocation. Nature's adherence to her original prin- 
ciple may be exemplified by observing that in the regeneration of 
bone which was originally cartilage, as the long bones, there when 
a fracture takes place she begins by forming cartilage, but in the 
head, where the bone was at first membrane, there membrane is 
formed. 
CHAPTER XVII. 
INJURIES OF THE HEAD.* 
Injuries of the head ;-of four kinds ;-concussion;-compression ;-wounds;- 
want of due support.-Three first to be treated of;-symptoms attending all 
three.-Concussion.-Compression, from internal or external causes.- 
Wounds, and loss of substance.-Want of compression from loss of blood.- 
General remarks on fractures of the skull;-mode of examining them ;-com- 
plications ;-treatment. 
Injuries of the brain may be said to be of two kinds; one where 
the imagination is diseased, as madness, which probably arises from 
many different causes, which we have nothing to do with at present; 
the other, where it has suffered from some external or internal injury, 
which is mechanical. This mode of injury may be of four kinds : 
first, concussion; secondly, compression; thirdly, wounds, and loss 
of substance; fourthly, want of due compression, which last does 
not come within our present subject. To these may be added a 
consequent, namely, inflammation ; but as this may arise from other 
causes, and is not always the consequence, it only requires to be 
mentioned. The first may be simple, that is, existing alone, or it 
may be complicated with one of the others. The first three kinds 
of injury will produce symptoms similar to each other, but very dif- 
ferent from the fourth, as also from what may be called the fifth, or 
inflammation. 
* [It may be observed that the lectures on gun-shot wounds have been omitted, 
in consequence of their great similarity, both in substance and arrangement, to 
Mr. Hnnters's published opinions on the same subject. It was considered 
useless to repeat them under these circumstances, especially as they are less 
perfect in several particulars.] INJURIES OF THE HEAD. 
257 
The symptoms of an injury done to the brain can, I think, be but 
two, viz., an increase of imagination, or a diminution. The first is 
least frequent, and I should suspect arises from a slight cause rather 
than from a violent one, namely, such derangement as takes place 
in common madness, fevers, inflammations of the brain, &c., and 
which may arise from very slight compression. 
The three first injuries will generally give the appearance of too 
much repletion. The muscles about the mouth and throat become 
flaccid, hence laborious respiration; and as respiration must go on, 
a kind of rattling in the throat is produced, which often works up 
the saliva into a froth. But all these symptoms will be in proportion 
to the injury done, and perhaps many other circumstances. The 
fourth will produce an insensibility, attended with restlessness similar 
to convulsions or fainting; and 1 suspect that the fifth produces a 
delirium, if but in a slight degree. In all cases of affection of the 
brain, sympathy takes place in the stomach, which produces vomit- 
ing; but I believe that in order that this symptom should take 
place it is necessary that the senses be not entirely gone, for those 
who are struck perfectly insensible, I believe, do not begin to vomit 
till they begin to recover in some degree their senses. 
Sometimes erysipelatous inflammation of the head arises, and 
then the patient often feels violent headaches, sometimes approaching 
to delirium, rigors, &c. In these I suspect that the brain is in 
some degree affected with the same inflammation, therefore the 
symptoms are not to be attributed to the immediate effect of the 
blow. 
Concussion is always from some considerable violence. It may 
arise from some degree of displacement or alteration of the texture 
of some part of the brain, so as to destroy the arrangement on which 
health, sensation, &c., depend. 
Compression may arise from accident, or from many other dis- 
eases. Those arising from accident may bo either immediate or 
secondary. Immediate, as when a piece of the skull is beaten in 
upon the brain, or a blood-vessel ruptured, producing apoplexy. 
The secondary is from slow extravasation, as from inflammation, or 
the formation of pus. Compressions arising from disease will 
always be the immediate effect of that disease. They may be said 
to arise from eight causes; two of which may be called external, 
the other' six internal. The two externals are, when the brain is 
compressed either by the skull being beaten in, or from the thickening 
of the bone by disease. The six internal causes are : first, distention 
of the ventricles by water; secondly, distention of the blood-vessels 
of the brain; thirdly, inflammation; fourthly, formation of pus; 
fifthly, extravasated blood, as in apoplexy^; sixthly, tumours in the 
substance of or on the brain. 
Wounds or loss of substance are somewhat similar. When the 
substance of the brain is broken in upon, loss of substance may or 
may not be the immediate effect of the violence. It is the imme- 
diate effect, when part of the substance is carried offby the violence ; 258 
HUNTER'S PRINCIPLES OF SURGERY. 
but the consequence, when a part is lost in consequence of an open- 
ing being made to take off any fluid that is pressing. 
The fourth species, where there is want of due compression, 
arises from large bleeding, or where the water is let out which the 
brain has been accustomed to bear, as in hydrocephalus or spina 
bifida, which are rare, and which are out of the power of surgery.* 
Whichever of the three first species of injury takes place, the 
effects are nearly the same, if the degrees are the same; and 
whatever are the causes of compression, the symptoms are the 
same. 
If we only know that symptoms have arisen in consequence of 
violence, then it is necessary to know the date of the violence, that 
we may know whether the symptoms are the immediate or the 
secondary effects, or both; for they are often attendants on one 
another. 
The symptoms of concussion, if slight, are always the immediate 
effect, that is a more or less immediate loss of sense, &c., which is 
proportioned to the violence done. Under certain circumstances, 
the effects of concussion will be more violent than what belongs to 
the injury itself; for a man who is drunk may get a blow on the 
head which, joined with the effects of the liquor, will produce violent 
symptoms, and may lead the surgeon to do more than is necessary. 
Therefore it is better to wait until the drunken state is gone off, and 
the effects of concussion left pure. 
When there is depression of bone or extravasation, the symptoms 
of concussion are lost, though it may be at the bottom of all. If 
the symptoms of concussion have kept up eight or ten days, we 
may expect extravasation has taken place; if three or four weeks, 
suppuration. We may know whether the symptoms are caused by 
blood or pus, by their going off entirely and then re-appearing. If 
they come on soon after, it is blood; if not for a week or so, it is 
probably pus. 
A gentleman for two years after receiving a blow on the skull 
was delirious. I felt a little depression, and applied the trepan, and 
took out a piece of bone which had been depressed all this time, 
part of the internal table of which was absorbed, and pus was lying 
on the dura mater.t 
* [Modem experience has shown that both these diseases are capable of relief 
from surgery. The operation of drawing off the water, when performed under 
favourable circumstances and with proper precautions, holds out a reasonable 
hope of success, and has effected a cure in several cases.] 
f [The great importance of injuries of the brain may justify a few observations 
in this place, for the purpose more especially of pointing out the distinction be- 
tween the symptoms of concussion, compression, and lacerations of the brain, 
which is a part of the subject which has been only slightly adverted to in the 
text. Indeed, Mr. Hunter has said that these "three kinds of injury will pro- 
duce symptoms similar to each other." 
1. Concussion.-When a severe injury is inflicted on the head, the patient is 
instantaneously deprived of volition and the power of voluntary motion ; the 
pulse becomes feeble and intermittent, and the whole system labours under a 
remarkable depression, approaching to a state of syncope. After a few minutes* INJURIES OF THE HEAD. 
259 
General Observations on Fractures of the Skull.-Fractures of the 
skull may be divided into three kinds, and these are sometimes 
or perhaps several hours, the patient recovers his consciousness; the action of 
the heart is re-established ; the sickness, with which he was at first affected, 
passes off, and nothing remains but a severe headache, which may last for several 
days as a solitary symptom, or else recur at different intervals, upon any occa- 
sional excitement. 
These effects of concussion may of course be variously complicated with 
wounds of the scalp and brain, compression of the brain, and fractures of the 
clanium; but very often these complications do not exist; and yet after death 
no perceptible lesion of the affected organ can be detected, except perhaps a sepa- 
ration of the dura mater from the internal table of the skull, or the extravasation 
of blood in minute specks in the substance of the brain. In the severer forms of 
concussion, indeed, the brain is generally lacerated in one or more parts, from 
whence it is reasonable to suppose that disorganization of a less palpable and 
extensive kind is also produced in the slighter forms, although it is not capable 
of being detected by the eye. 
Now it is observable, that although one of the first effects of severe concussion 
is complete insensibility, yet this state is soon followed by one in which the 
sensibility is only impaired, so that it is not difficult to rouse the patient by any 
sudden and strong impression. Upon being roused, his manner is generally 
peevish, obtuse, and incoherent, and he instantly relapses into his former state 
of tranquil lethargy, as soon as he is left undisturbed. There are no indications 
of paralysis: the pupils contract on exposure to light; the pulse, which at first 
was exceedingly feeble, now rallies and rises above the natural standard ; the 
circulation is easily accelerated upon the slightest exertion, and there is very 
generally an intense headache, which becomes proportionably more severe as the 
reaction of the circulation takes place and the sensibility returns. 
The dangers attending this species of injury are twofold. The first arises 
from the state of collapse immediately following the injury, which may be so 
considerable that the constitution is not able to make any effectual effort to rally 
from it. The second arises from the inflammation which may afterwards ensue. 
Cases of the first description are of rare occurrence and only require that the 
surgeon should bear in mind the possibility of such an event, in order to guard 
against it by the administration of cordials whenever the necessities of the case 
seem to demand these aids to reaction. The danger of inflammation is much 
more formidable, and will be in general in proportion to the severity of the first 
symptoms and the rapidity and violence of the reaction. Other circumstances, 
however, will exercise an important influence on this event, as, for example, the 
separation of the dura mater from the cranium ; the existence of disorganization 
or rupture of the minute structure of the brain ; the denudation of the pericranium 
from the bone; or the patient's being in a state of intoxication at the time of the 
accident. These circumstances will greatly increase the dangers of his situa- 
tion, and require a more vigorous adoption of such measures as are calculated to 
avert inflammation. At first, when the reaction of the heart has taken place, the 
patient should lose a considerable quantity of blood, so as completely to subdue 
the force of the circulation; afterwards, for the most part, it is only an occa- 
sional bloodletting which is required, and that to a moderate extent. These 
measures should be assisted by perfect repose of body and mind ; depleting and 
cooling medicines ; cold applications to the head ; a spare diet, and a raised 
position of the head and shoulders, which should be persisted in more or less for 
several weeks, even although all apparent effects of the injury have disappeared. 
It is unnecessary to observe, that the old practice of applying the trephine in 
such cases is in the highest degree pernicious, and cannot possibly answer any 
good object. 
The occurrence of secondary inflammation, at the end of four or five days to as 
many weeks, should be jealously watched for, and instantly combated by the 
most vigorous depletion. Such cases generally terminate unfavourably; but 260 
HUNTER'S PRINCIPLES OF SURGERY. 
complicated with one another: first, when the external table is 
beaten in ; secondly, fissures ; thirdly, when the bone is broken oft' 
happily they are of less frequent occurrence than they were formerly, in conse- 
quence, it may be presumed, of the steady antiphlogistic measures which are 
now almost universally resorted to in the first instance. When, however, these 
symptoms arise, followed by rigors and the evidences of compression, attended 
at the same time with a puffiness in some point of the scalp, or a glassy unhealthy 
state of the wound, if there happens to be one, then the application of the 
trephine, to let out the matter which is collected between the dura materand the 
skull, is justifiable, and ought not to be delayed. Still it must be evident that 
this operation will be unavailing when the matter is effused on the interior of the 
dura mater, which very frequently happens in such cases. 
2. Compression.-The enumeration of the causes of compression by Mr. 
Hunter will probably be found to include every possible variety; yet it is to be 
observed that compression produces different effects, according as it is gradual 
or sudden ; in the substance or on the exterior of the brain ; in one spot or dif- 
fused over a large surface ; or as it is situated at the inferior or superior part of 
this organ. The slow encroachment of a tumour on the brain does not so sud- 
denly rob the patient of his faculties, as a portion of the cranium suddenly 
depressed by accidental violence ; neither is it of common occurrence for san- 
guineous effusions on the surface of the brain to produce hemiplegia, although 
this is one of the most frequent symptoms of apoplexy arising from spontaneous 
effusions into the substance of this organ. " There is reason," Sir Benjamin 
Brodie observes, " to believe that pressure is on the whole more dangerous when 
it affects the lower part of the brain than when it affects the upper part; and it 
has appeared to me that more urgent symptoms are produced by a given quantity 
of blood when it is effused into the cells between the tunica arachnoides and pia 
mater than when it is collected in one mass so as to produce a less general 
pressure." In speaking, therefore, of the effects of compression, I would wish 
to be understood as confining myself to that form of the affection which arises 
from accidental violence. 
It should never be forgotten that the blow which occasions a fracture and 
depression of the cranium or an extravasation of blood is likely to produce con- 
cussion also, although, as Mr. Hunter has remarked, the symptoms of concussion 
in such cases will be proportionally less severe, as the cranium has yielded more 
readily to the cause of fracture. 
The leading symptom of compression of the brain is insensibility, which is 
generally much more complete than that which arises from concussion, and more 
nearly allied to that of apoplexy, with which in other respects the symptoms of 
this accident closely correspond. The pulse is oppressed and slow ; the pupils 
are dilated and immoveable; the respiration is slow and stertorous; and the 
voluntary muscles are paralysed. Sickness and vomiting do not usually occur, 
at least in the worst cases, until the cerebral symptoms have undergone some 
mitigation, and it is observable that the symptoms all disappear the moment the 
compressing cause is removed, which explains why a copious venesection shall 
frequently produce a temporary but fallacious amendment. When these symp- 
toms arise from depression of bone, they show themselves immediately after the 
infliction of the injury; but when they depend on an extravasation of blood, a 
longer or shorter interval elapses before they come on, depending on the rapidity 
of the effusion, which will in general be greater in proportion to the celerity and 
violence of the reaction from the first impression of the accident. Not unfre- 
quently, therefore, the first insensibility is produced by concussion, then the 
patient recovers, and then relapses again upon the effusion taking place. In 
other cases, the insensibility, which was only partial at first, gradually termi- 
nates in complete stupor, corresponding to the gradual manner of the effusion ; 
in other cases, again, the patient does not recover from his insensibility until 
inflammation has set in, and then the two sets of symptoms are confounded 
together. In short, the symptoms of compression not only vary in degree, but as INJURIES OF THE HEAD. 
261 
into a loose piece. I have also been told of a case where the 
symptoms of an injured brain arose, but the skull showed no frac- 
they happen to be complicated with those of other injuries of the brain ; and it is 
worthy of remark that the same amount of compression gives rise to symptoms 
of very different degrees of severity in different cases ; while of two individuals 
in whom the early symptoms appear to be equally urgent, one may die in the 
course of three or four hours, and the other may survive for several days; in one 
the symptoms may wholly subside in the course of a day or two, and in the 
other continue, at least some remains of them, for several months or even years. 
Sir Astley Cooper, for example, has related an extraordinary case, in which a 
total loss of volition and voluntary motion continued for upwards of thirteen 
months, on which Mr. Cline afterwards operated successfully by removing a 
depressed portion of bone, which restored the young man to the perfect posses- 
sion of his intellect in the course of four days. 
But compression may give rise to other symptoms besides those which have 
been mentioned, as, for example, pain in the head, general convulsions, furious 
delirium, partial paralysis of particular muscles or sets of muscles, and various 
states of the pupil. The pupils, as I have already mentioned, generally remain 
permanently dilated ; sometimes, however, they remain permanently contracted, 
or contract and dilate as usual, although in other respects the patient may be in 
a complete state of insensibility. Dr. Hennen has related a case in which the 
admission and withdrawal of light operated differently to what it usually does ; 
and Sir Benjamin Brodie has referred to cases in which the two'pupils were in 
opposite states, or in which they dilated and contracted independently of light 
and darkness. The loss of one entire class of sensations, as of speech, smell, 
taste, hearing, or sight, is not very uncommon; or the affection may be even still 
more partial, as, for example, a ptosis of one eye, a paralysis of one arm or one 
side of the face, the destruction of the sexual powers, or the loss of memory, 
which may be either of recent or of remote events. In some of these cases dis- 
section has disclosed some local cause of pressure, while in others the removal 
of a depressed portion of bone has immediately removed the symptom, so as to 
leave no doubt on the mind as to the real cause which produced it. In many in- 
stances, however, it is only possible to offer a conjecture, derived from general 
analogy and the particular circumstances of the case, guided by the knowledge 
which we possess of the functions of the different parts of the brain, from all 
which it would appear probable that these partial lesions are sometimes due to 
disorganization of, or pressure on, certain districts of the cerebrum, from whence 
the nerves to the paralysed parts are specially derived. However, as Sir Ben- 
jamin Brodie has remarked, " it is difficult to conceive that pressure on the brain 
should exist in so great a degree as completely to destroy a complete class of 
sensations, and at the same time be so partial as not to affect any other function 
of the nervous system. On the other hand, it is also difficult to regard these as 
the effects of concussion of the brain, since it is one of the characteristics of con- 
cussion to produce no more than a diminution of sensibility, and that diminution, 
instead of continuing for months or years, is completely relieved in the course of 
a few days, and probably in a much shorter space of time." 
The most common situation in which blood is effused in accidents of the head 
is between the dura mater and tunica arachnoides, especially towards the base of 
the brain. It may occur, however, between this last-mentioned membrane and 
the pia mater, or between the pia mater and the brain, or in the substance of the 
brain itself. It may also occur between the dura mater and the cranium, when- 
ever the connexion between these parts has been destroyed by the violence of 
the injury. It is, however, to be observed that considerable effusions of blood 
rarely occur in this last situation, except when the cranium has been fractured in 
the direction of the middle meningeal artery, and the artery has been ruptured in 
consequence. 
The treatment of compression arising from depression of bone will be spoken 
of in a future note; but where compression arises from extravasation of blood, 262 
HUNTER'S PRINCIPLES OF SURGERY. 
ture or fissure; and on removing a portion with the trephine, the 
inner table was found beaten in, the external table being perfectly 
the same general principles must be followed as in cases of concussion, both to 
prevent any further effusion and to obviate the danger of inflammation. The 
question however arises, whether any operation can be beneficial for the purpose 
of giving an exit to the effused blood 1 In answer to which it may be replied, 
that as a general rule no operation can be beneficial in these cases, both on ac- 
count of the difficulty of ascertaining the precise seat of the effusion, and the im- 
possibility in the great majority of cases of reaching it when it is discovered. 
When, however, a blow has been inflicted over the meningeal artery, and the 
symptoms of compression are not only not relieved by venesection, but gradually 
become more urgent, it will be extremely proper to give the patient the chance 
of the operation, which will also be proper in other cases where the seat of the 
injury is well marked and the stupor is hourly becoming more alarming. Un- 
questionably it would be unwise and unwarrantable to resort to an operation too 
hastily, but under the circumstances which are supposed an operation will 
scarcely be supposed to add much to the danger of the case, at least the opera- 
tion of dividing the scalp in order to ascertain whether the bone bleeds freely, 
or whether there be any fracture. If the bone does not bleed so freely as it 
ought, or if there be a fracture, these are justifiable grounds for perforating the 
cranium ; and the surgeon will be further justified in puncturing the dura mater 
if he finds an accumulation of blood beneath that membrane pressing on the 
brain. It ought, however, to be remarked, that it will always be expedient to 
remove the cranium extensively whenever the trephine is resorted to for this 
purpose, or for affording an escape to pus, as without this is done only half the 
benefits of the operation will be obtained. 
3. Wounds of the Brain and Membranes.-The peculiar danger of wounds of 
the brain and its membranes arises, in the great majority of instances, not so 
much from the immediate effects of the injury as from the extensive and intract- 
able inflammation which afterwards follows, giving rise to effusions of pus, dis- 
organization of the substance of the brain, and hernia cerebri. When the head 
receives a severe concussion, the brain is liable to be lacerated, particularly to- 
wards the base, in consequence of the inequalities of the cranium at that part; 
and the symptoms in such cases will necessarily be complicated with those of 
concussion as well as with those of compression : but when the brain has been 
simply incised or punctured, very often no symptoms whatever arise to indicate 
that the bodily or mental functions are in the least degree impaired ; indeed this 
absence of symptoms is sometimes very remarkable, and extends to cases in 
which considerable portions of the brain have been lost, or foreign bodies been 
lodged in it. Wounds of the brain, however, are always dangerous, and it is 
not to be supposed that there can be an extensive destruction of apart so import- 
ant as the brain without immediate death, or death in the course of a very few 
hours. A confusion of intellect beyond that which simple concussion usually 
produces, and twitches of the muscles of the extremities, are diagnostic marks 
by which (as Sir Benjamin Brodie has observed) these cases may sometimes 
be distinguished. The same author also observes : " I have not been able to 
discover, among all the works which I have consulted, a single instance of re- 
covery from a wound of the posterior lobes of the cerebrum, of the cerebellum, 
or medulla oblongata ; and in the great majority of cases in which a cure has 
taken place, the injury has been confined to the frontal bone, and that part of the 
brain which is covered and defended by it." 
It is unnecessary to observe that the general principles of treatment which 
have been already pointed out are equally applicable to wounds of the brain, 
and must be persevered in with the most watchful assiduity. The local treatment 
resolves itself into the management of fracture, which will be considered in an 
ensuing note. I shall only, therefore, further observe, that the most judicious 
surgeons of the present day unitedly concur in the wisdom of forbearance, and 
in not attempting to extract foreign bodies, unless this can be done with the most 
perfect facility.] INJURIES OF THE HEAD. 
263 
sound. I have seen several instances 'where the external table was 
beaten in, and the inner table not hurt.* Depression of the external 
table may be complicated with extravasation or concussion, and 
may become the cause of extravasation or of the formation of pus. 
Fracture may be complicated with fissure, that is, fissures often run 
from the fracture a very considerable way along the skull. Where 
the external table only is beaten in, it is owing to the meditullium 
being thick and spongy, and allowing the external plate to sink 
into it. This is generally done by a small instrument with a good 
deal of velocity, as the edge of a horse's shoe. Every violence 
that can produce complete fracture must cause more or less 
depression, though it may not be very visible ; and sometimes, if 
the force has not been very great, the piece may be returned again 
into its position immediately. Besides, the inner piece is always 
broader than the point where the violence has been applied on the 
external. All fractures of the skull may be called compound ; for 
if not so naturally, they are made so by the removal of the scalp. 
They differ widely from fractures in general in other parts, as 
healing the parts is only necessary in fractures of other bones, but 
here we have to prevent the mischief arising from the broken bone 
to parts essential to life. 
Fractures of the skull of themselves produce no symptoms 
respecting the brain, only those of a broken bone ; but when they 
are complicated with other effects, then symptoms arise accord- 
ingly, more or less according as the fracture is greater or less. 
There may be bleeding at the nose and ears when the fractures 
must be running over these parts, but they may occur without a 
fracture of these parts, and there are symptoms of other injury 
besides fracture. When complicated with concussion, the symp- 
toms of this will be less according as the fracture is greater, for it 
is from the bones not giving way easily that the head is violently 
and quickly moved so as to produce concussion. These effects will 
be according to the weight and velocity. When the weight is great 
and the velocity small, we shall have more concussion than with a 
small weight and great velocity: hence from gun-shot wounds we 
seldom have any concussion. 
In cases of fissure only it may admit of a dispute whether we 
are always to trepan. If there is no symptom of an injured brain, 
* [Dr. Hennen has given an account of a case in which the internal table of 
the skull was splintered, and at one part driven more than half an inch into the 
membranes of the brain, although there was not even a fissure of the external 
table. Cases of a similar kind are preserved in almost every museum, and are 
easily accounted for by the greater brittleness of the internal table. Of course 
the same cause will produce similar effects in ordinary cases, so as to render it 
impossible to ascertain the actual amount of pressure which exists in any given 
case from mere inspection of the external fracture. In children the bones generally 
are more tenacious than in adults, in consequence of containing less earthy matter. 
Hence the cranium may be depressed or indented in them without being fractured, 
just as a tough or green bough will yield to a force in a very different manner 
from a dry stick.] 264 
HUNTER'S PRINCIPLES OF SURGERY. 
certainly it will not be necessary. It may not be necessary even 
when attended with symptoms of an injured brain, for the injury 
may only be from the concussion, and we never trepan in a con- 
cussion. However, as we cannot tell for certain at the time whether 
the symptoms arise from concussion, compression, or from extra- 
vasation of blood, it may be more advisable to trepan, as the ope- 
ration can do no harm. In cases of depression of the outer table 
it would also be unnecessary to trepan ; but it will be impossible to 
say that it is certainly a case of this kind: for, though there may 
be no symptoms of an injured brain, there may be depression of the 
inner table, which may do mischief afterwards. In young people 
there may be fracture with depression which may cause no bad 
symptom at the time, but as the patient grows up bad symptoms 
may arise, probably from this cause, that there is not sufficient 
room for the natural growth of the brain. 
In all cases of violence attended with compression, either from 
fracture or not, the trepan is absolutely necessary ; but we cannot 
always promise relief from the operation, nor can we always apply 
it where it is necessary. When compression is by bone, and its 
situation known, and the situation is a proper one for trepanning, 
there is no difficulty; but when the compression is by blood or pus, 
and there are no external marks of violence, then it is more puzzling. 
However, rather than let the person die, one would trepan some- 
where or other; and if this did not answer, one would not stop 
here : for I have seen a collection of matter on the opposite side to 
that on which the blow was inflicted ; yet this is a case where one 
wrnuld promise but little encouragement, there being but little chance 
of success. 
Even when we have external marks of violence to guide us, and 
do trepan, yet this is often not sufficient to free the patient from the 
compression, for these fluids are often formed between the dura 
mater and the brain when none is found between the skull and dura 
mater. The dura mater must not, however, be perforated without 
good grounds; we should be as certain that there is fluid contained 
under the dura mater as wre were certain of the necessity of apply- 
ing the trepan in the first instance. In all cases where 1 have seen 
the dura mater wounded, it was by a crucial incision, and the 
patients have all died. When it is necessary to open the dura 
mater, I would recommend making a simple incision, for this would 
be more likely to heal by the first intention, and we could then 
move the edges to one side, and see if there were any injury below. 
Whenever I have seen the dura mater opened, the brain has worked 
through the opening, and the patients have died.* This was the 
* [As hernia cerebri may occur simply from the support of the cranium being 
removed, it will d fortiori be more likely to occur when the dura mater is removed 
also. I should remark, however, that hernia cerebri does not necessarily ensue 
under these circumstances. 
It may be proper to observe, that the treatment of this disease consists in the INJURIES OF THE HEAD. 
265 
case with a Mr. Cooper, whose dura mater I opened with a crucial 
incision on account of the state of parts beneath: he died, and 
I think it is probable I killed him, by opening the dura mater. 
Patients, under these circumstances, might probably have died, 
independently of the opening, but this I think wrould certainly kill 
them. 
Fractures very rarely run through the base of the skull where 
operations cannot be performed ; but if the bones of the base of the 
skull are only fissured, it will be of sufficient service to trepan on 
the fissure as low as we can follow it. I have trepanned once 
below the insertion of the muscles of the neck, and with success. 
Trepanning on sinuses has been condemned, but it can do neither 
harm nor good if the blood is between the dura mater and pia 
mater; if there is only a depression on them it can only obstruct 
the sinuses, and not affect the brain. 
An incision is sufficient to examine for a fracture if made suffi- 
ciently long ; and if a fracture is found, it is to be followed to its 
full extent: but where it is found necessary to trepan, it will be 
proper to remove the scalp, and do it freely, for an operation 
should have no incumbrance which we can prevent. We should 
scalp carefully, lest there should be some loose pieces of bone 
underneath which we cannot see, by which otherwise we might 
plunge into the "brain ; and yet I own I cannot always call to mind 
this caution at all times when operating.* 
It has been recommended lately, after trepanning, to put the 
scalp down again, and unite it by the first intention ; but I doubt 
whethei' we should be able to bring the angles perfectly together; 
and if not, part of the dura mater must be exposed, and must sup- 
purate. 
A fungus is very apt to arise from the dura mater. Why this 
should be more than from any other part I cannot say. 
A poultice is the best application after either scalping or trepan- 
judicious application of pressure until the fungus is repressed below the level of 
the dura mater, which then heals over it and prevents its reproduction. This 
plan generally succeeds, although the old method, consisting in the removal of 
the surrounding bone, or of the fungus itself, almost invariably failed. 
The danger of hernia cerebri being formed when the cranium is removed may 
justly be urged as an argument for not having recourse to the operation of 
trephine without the most satisfactory reasons, to which may be added, the still 
more alarming risk of inflammation and sloughing of the dura mater from acci- 
dental violence inflicted by the trephine, or from the mere effects of simple 
exposure. The fact also of a portion of the cranium being left undefended after 
the recovery of the patient, should not be neglected in estimating the dangers of 
this operation, which unquestionably are very considerable.] 
* [It is impossible to help being struck with this confession, so characteristic 
of the love of truth and candour which Hunter possessed. Indeed, the same 
remark appears to me to apply to all the preceding observations, in which may 
be traced a hesitation and forbearance of judgment uncommon to the author, as 
if he had not fully approved of the existing rules of treatment, although he had 
not yet gone to the extent of substituting others in their stead.] 266 
HUNTER'S PRINCIPLES OF SURGERY. 
ning, because it always admits of immediate removal, and keeps 
parts in an easy agreeable state.* 
* [No part of surgical treatment (with the exception perhaps of aneurism,) has 
undergone such important amelioration as that which relates to injuries of the 
head. Whoever will look into the writings of the period when these lectures 
were delivered will be astonished at the officiousness of surgeons in counteracting 
the restorative efforts of Nature by their rude interference, and converting into 
complicated wounds what were simple in their origin. Hunter was unques- 
tionably less infected with this evil than most of his contemporaries, but still 
we cannot but observe the influence of this spirit in the directions which he has 
laid down for the treatment of fractures of the cranium, for which reason it will 
be necessary to guard the reader against drawing false conclusions on this im- 
portant subject. 
The propriety of these observations will be apparent from considering the 
cases in which Hunter thought the application of the trephine was justifiable, 
viz. 1, in young children in whom there was depression without symptoms; 
2, in cases of depression of the outer table only; 3, "in cases of fissure only it 
may be more advisable to trepan, as the operation can do no harm;" 4, "in all 
cases of violence attended with compression, either from fracture or not, the 
trepan is absolutely necessary," and if blood is not found on one side, to trepan 
on the other; and lastly, in fractures of the base of the cranium. 
Now it is to be observed that there is as much, if not a much greater, difference 
between simple and compound fractures of the cranium as there is between 
simple and compound fractures of the thigh ; consequently, nothing can be more 
unadvisable and rash than to convert a simple fracture into a compound one, 
unless the urgency of the symptoms is such as imperatively to demand inter- 
ference. 
In regard, therefore, to simple fractures of the cranium, it may be laid down as 
the general rule of practice never to interfere without the strongest reasons for so 
doing, nor even then until a reasonable time has been allowed for the symptoms 
(which may depend on concussion,) to subside, and depleting measures been 
freely employed. Under such treatment the symptoms will often disappear after 
a short time, and the dangers of subsequent inflammation be infinitely lessened. 
Nothing surely can be worse than the attempt to anticipate the symptoms of 
compression by resorting to the trephine. 
And in regard to compound fractures of the cranium the same rule is to be 
observed. If there are no symptoms, the surgeon should desist from any inter- 
ference, and endeavour, to the utmost of his power, to procure union by the first 
intention. If, indeed, the depression is very considerable, it may be advisable 
to elevate it, although there are no symptoms at the time; but if there are 
symptoms, it will be right and proper to do so in all cases. The same principle 
should guide the surgeon in the extraction of splinters of bone and foreign bodies, 
and restrain him from making the attempt unless his object can be accomplished 
without adding to the irritation of the injury. It is scarcely possible to imagine 
a case in which an operation so near the basis of the cranium as the author has 
described can answer any useful object.] OF THE DISEASES OF BONES AND JOINTS, ETC. 
267 
CHAPTER XV1IL 
OF THE DISEASES OF BONES AND JOINTS ; OF FRACTURES, DISLOCA- 
TIONS, ETC. 
Bones liable to all the diseases of soft parts.-Death of bone.-Caries.-Dis- 
eased actions; - ulceration; - induration. - General treatment of diseased 
bones.-Accidents to bones; simple fracture;-principles of treatment;- 
period and mode of union;-false joints.-Inflammation of bones;-treat- 
ment.-Suppuration of bones.-Compound fractures ;-treatment;-communi- 
cating with joints.-Question of amputation.-Fracture of patella, olecra- 
non, and outer ankle.-Suppuration in bones;-spina ventosa;-necrosis;- 
treatment.-Of the contraction of diseased joints.-Sprains ;-treatment.-Dis- 
locations ;-observations on their reduction.-Formation of new joints.-Acci- 
dents andinflammation of joints.-Loose cartilages.-Anchylosis.-Diseases of 
joints.-Wasting of muscles.-Exfoliationsand necrosis;-treatment, by actual 
cautery.-Extraction of sequestra.-Rickets.-Mollities ossium ;-treatment. 
-Exostosis;-treatment.-Exfoliations of cartilage. 
Bones have been very much considered separately from other parts 
in their growth, structure, and diseases. Bones being less subject 
to changes after death than the soft parts, are therefore more 
favourable for the explanation of their diseases after death, such as 
ulceration, tumours, &c.; and diseased bones of all kinds may be 
picked up in church-yards. 
The bones, in their causes of disease, in many of their diseases, 
in the terminations of these, and in theii' restoration, are similar to 
the soft parts. They are susceptible of the different inflammations 
and their consequences, but they are more backward to heal, form- 
ing fistulas; in their specific diseases also they resemble the soft 
parts. But, unluckily for bones, they can hardly swell; nor can 
their coverings swell without its being immediately suspected as 
venereal, so that mercury is often given to the detriment of the 
patient. Nor can they require a different treatment, as regards 
their vital power, from the soft parts, though they may in the 
mechanical part; but it will be found that they require a different 
mechanical treatment only in consequence of theii' solidity. The 
hardest bones are most liable to venereal affections; the softer to 
scrofula ; but the surrounding parts very often partake of their 
diseases for very wise purposes. Their diseases do not so readily 
recover as those of soft parts, as the restoring powers are much 
more weak and tedious in their operations. This slowness is pro- 
bably owing to an indolent disposition and weak powers. This 
may, in some measure, arise from the earth in them being a part 
not possessed of the living principle; yet we find that the hardest 
bones are cured the soonest; but this is when there is exfoliation, 
which shows they are more ready to die, and, consequently, to 
exfoliate. HUNTER'S PRINCIPLES OF SURGERY. 
268 
Their diseases are often very serious, in consequence of our 
ignorance of the extent of disease, as well as of its nature; for 
though, from an increase of size or a fistulous opening, we may 
know the bone to be diseased, still we obtain very little information 
as to its nature. 
Death of Bone.-Bones often lose their life from becoming de- 
tached, and their surface being either exposed to the air, or to 
matter surrounding it. The reason of this is, that bones receive 
most of their nourishment from the surrounding parts, as from the 
periosteum; therefore it is natural to suppose that the surface at 
least will become dead when this part is removed. This may be 
observed on the projecting end of a stump. The harder the bone, 
the more ready it is to lose its vital principle by exposure. Some- 
times the external surface dies easier on being laid bare than the 
internal: this is the case in the skull; the external will often ex- 
foliate without the internal.* 
Caries.-Death of the exposed surface makes a material differ- 
ence in the appearance of ulcers of the bone, and they have been 
classed accordingly. In one case surgeons found the surface of 
the bone dry; in others moist, and covered with matter ; hence the 
distinction of dry and moist caries ; but this arose from ignorance 
of the disease. When the bone is entirely dead, then there is dry 
caries; but in the moist the bone is inflamed and ulcerated, and 
furnishes a discharge, not being dead. When it was perceived that 
the dry caries only exfoliated, the actual cautery used to be applied 
on the idea of drying the moist caries; but this was done without 
knowing the principle on which it was done, viz. that of entirely 
destroying the life of the bone. By caries I should understand a 
rotten bone, and by a rotten bone a dead bone. But the distinction 
between a diseased bone and a dead bone has not been sufficiently 
attended to, for the term caries has been commonly applied to a 
bone in the state of an ulcer, and also to a dead bone. Now a 
disease must always be in a living part, whether soft or hard; but 
the same term applied to the two different states of bones can give 
no just ideas of the disease which it is intended to designate, for 
that which is commonly called caries is, strictly speaking, an ulcei' 
in the bones ; but ulcers of the bones are as different from the death 
of these parts as ulcers in soft parts are different from common 
mortification. 
Diseased Actions of Bone.-Bones are very susceptible of diseased 
actions and dispositions, and sometimes a very slight accident will 
convert a disposition into an action, as in scrofula; and this may 
again be increased by the part of the bone which is injured ; thus, 
in the case just related the effect is most considerable when it hap- 
pens at the end of a bone forming part of a joint. The situation, 
with respect to the body, is also a cause of retardation in healing, 
as it is in the soft parts. 
* [The reason of this is that these two layers are nourished by two different 
sets of vessels.] OF THE DISEASES OF BONES AND JOINTS, ETC. 
Ulceration.-Ulcers of a bone are exactly the same in their im- 
mediate causes as those of a soft part, and in some of their effects 
also, the difference not being that of the disease but of the structure. 
Bones admit of every mode of absorption that the soft parts do. 
The most common cause of absorption in them is pressure ; what- 
ever makes an unnatural pressure gives a stimulus for the removal 
of the bone. Bones admit of being absorbed from debility, or want 
of power to support themselves; but this I believe only takes place 
in newly-formed bones. 
Induration.-It does not appear that ossific inflammation takes 
place in the parts pressed, so as to make them firmer and harder, 
as in the soft parts. If bones were rendered harder they would 
have less power, and therefore would be more liable to death. 
However, there is often a thickening or running up of the bone all 
round, as in old dislocations, so that a new joint will be formed. 
Diseased bones communicate their disease to contiguous parts; 
most commonly to the nearest, as the periosteum ; when near to 
the joints, to the ligaments or cartilages. 
General treatment of diseased Bones.-This I shall refer, as much 
as possible, to the treatment required in soft parts, which is very 
similar, though the slow action in bones renders it more tedious, 
and requires a somewhat different method of cure. 
If an abscess is seated in the soft parts, and also in the bones, 
that in soft parts will readily be recognised, from the difference in 
its appearance and feel from any of the surrounding parts; and it 
will in general approach the skin very soon, which, however, will 
depend very much on the nature of the disease and of the soft parts. 
The abscess in the soft parts will generally make a passage for 
itself, without the necessity of an artificial opening. But this is not 
so in bone ; if a spontaneous opening takes place, it is not sufficient 
for a cure ; therefore the trephine is often necessary; or it maybe 
necessary to destroy the living principle in the bone, and then the 
actual cautery will be necessary. To kill the soft parts the caustic 
is sufficient; but the actual cautery is required foi' bones. 
Of accidents to Bones.-The effects of accidents which hurt a 
sound bone are never to be reckoned as disease while it retains the 
actions of restoration natural to the animal body. 
Injuries done to bones are of two kinds: one, simple injury without 
exposure; the other, injury with exposure. One simple injury is a 
bruise; another simple injury is a loss of continuity, as in a simple 
fracture. The union of the bone in simple fracture is exactly similar 
to the healing of a wound in the soft parts by the first intention; 
but here adhesive inflammation is unnecessary, though it generally 
happens from the irritation, and then adhesive inflammation is sub- 
stituted for union by the first intention. 
Simple fractures.-A simple fracture is a solution of continuity, 
generally with laceration of the surrounding parts, attended often 
with splinters of bone attached to the soft parts, or loose. The 
space between the broken surfaces of the bone and other parts are 
269 270 
HUNTER'S PRINCIPLES OF SURGERY. 
first filled with extravasated blood from the ruptured vessels. This 
blood coagulates, and in time becomes vascular, as in the same 
mode of union in soft parts, forming a callus.* Then the arteries 
and absorbents, by their action, model the part, and form it into a 
cellular substance, in which the arteries deposit calcareous earth. 
It is first formed into cartilage, and then into bone. Adhesion of the 
detached splinters also takes place, interstitial absorption making 
them softer, and less pointed; and this takes place not only in those 
which are attached to the soft parts, but even in such as are entirely 
loose. (This was shown in a thigh-bone, in which one of the splin- 
ters had been turned quite round on its axis, and adhered by its outer 
surface to the bone.) Therefore these pieces must retain the living 
principle, and probably only this, while those that remain attached 
have more. I never examined a compound fracture without finding 
some of these loose pieces, which shows they must be common. 
Their union must be similar to that in the transplanting of teeth. 
Callus.-The modelling of the callus to the parts in the neigh- 
bourhood is very evident in ribs that have been fractured, foi' on 
that side next the lungs the inequality is very inconsiderable. 
Whether the modelling in these cases is purely from the mechanical 
pressure of the lungs, or whether it is from absorption in conse- 
quence of that pressure, I cannot pretend to say: probably both 
* [I have already observed, when speaking of the mode of union by adhesion 
in soft parts, that this is always accomplished by the effusion of coagulable 
lymph, which afterwards becomes vascular, and not by the organization of 
coagulated blood. The only difference in regard to bone consists in the time 
required for the ultimate organization of the new-formed structure. It is pro- 
bable that there is no difference in the quality of the lymph (as it is first poured 
out,) from any of the structures of the living animal body, because the organic 
elements w'hich enter into the composition of these structures are essentially 
the same, whether of bone or any other parts, viz. cellular membrane, nerves, 
blood-vessels, and absorbents. When a bone is fractured, the periosteum and 
surrounding cellular membrane concur with the broken surfaces and lining 
membrane of the bone to pour out a mass of lymph (callus'), which gradually 
undergoes successive transformations of structure, until the new-formed part 
closely assimilates in all respects to the old structure. For the first week or 
ten days it is observed to consist of a soft vascular granular-looking mass, which 
gradually assumes, toward the twentieth day, a white and cartilaginous aspect, 
and at the same time diminishes in bulk : from this period to the fortieth or 
fiftieth day the diminution of the callus still proceeds, and the process of ossi- 
fication is now observed to have converted the greater part of it into true bone, 
although towards the centre of the mass a portion may still remain, which is 
not fully converted into bone before the expiration of the fourth or sixth month. 
If at the end of this period the bone be examined, it will be found to be thick 
and irregular at the point of fracture ; the medullary cavity will be found to be 
obliterated, and the new bone to possess the hardness of ivory. Ulterior changes, 
therefore, still go on for two or three years, which at last end in the complete 
restoration of the external form of the bone, as well as of the internal medullary 
cavity and reticulated structure. Dupuytren has called the external callus, 
which embraces the broken extremities of the bone like a bulky ferrule until the 
union is consolidated, the cal provisioned There is not, however, as it appears 
to me, anything peculiar in this process to require the application of a new name, 
for the surrounding induration which attends the union of soft parts is precisely 
a similar phenomenon.] OF THE DISEASES OF BONES AND JOINTS, ETC. 
271 
may act. The increased solidity of the new substance is either 
from the deposit of new matter, mixed with the first, or from 
absorption of the first, and deposit of new matter instead. I think 
the last the most likely. 
Ossification of the Callus.-The ossific substance is first deposited 
at the extremity of the bones themselves, and then extends to the 
callus; at the same time several points in the callus are forming 
ossific matter. Young people seem to have a greater disposition 
to form ossific matter than old, but there is a difference even in 
those of the same age. This new substance is similar to the original 
bone, and on this account probably is stronger than that from gran- 
ulation ; however, it is not so durable as the original bones are. 
This process must necessarily be more tedious than in the soft parts, 
in consequence of the second process which is required; sometimes 
no union takes place for a length of time after the accident, and the 
variety of callus is great. 
Treatment in simple fractures.-Parts to be united by the first 
intention are first to be placed in their habitual position; but this 
cannot possibly be effected in all cases, nor is it always necessary 
in soft parts and when there is no external wound. In those parts 
which are for the support of the body, the fractured parts must if 
possible be brought into their original and natural position, before 
they are retained by bandage, &c.; but in some of these it is impos- 
sible, as in the ribs, clavicle, neck of the femur, &c., especially in 
fat lusty people. In such it is very difficult to say what the case is, 
or how the parts are situated. In the extremities there is more 
room for the exercise of art, but not in all equally. 
Simple fractures seldom affect the constitution except the soft 
parts are much lacerated ; then there is generally constitutional 
affection in proportion to the degree of inflammation. Rest of the 
part is necessary : in most cases, therefore, splints and bandages are 
used ; and when there is much inflammation expected, a folded 
compress, moistened with some cooling lotion, is applied until the 
inflammation subsides, and then rollers and splints are applied, which 
should be tightened as the limb subsides. Spasms often arise from 
the splinters pricking the soft parts ; I should think that a solution 
of opium would be the best application to remove this symptom. 
The position for the patient to lie in was formerly on the back ; but 
the side is now generally adopted. However, 1 think its whole 
advantage is that it has the appearance of novelty, and is not a real 
improvement; but time will establish the truth. I prefer the back 
position, with the knee bent, as the patient will support this for the 
greatest length of time, and it is always the position of debility. In 
this position the limb will be kept more steady, and will be less liable 
to be moved by moving the body.* 
* [The use of fracture-boxes, consisting of two inclined planes, the angle of 
which is regulated by a rack-work, has led to the almost universal adoption of 
the position on the back in fractures of the lower extremities. These boxes are 
of various construction, but most of them combine the double advantage, first, of 212 
HUNTER'S PRINCIPLES OF SURGERY. 
Period of Union, and manner in which this effect takes place.- 
The time in which the bone will be united will depend on circum- 
stances. In the soft parts union will often take place in forty-eight 
hours : but it will require a much longer time in bones. In the first 
place they cannot be brought so closely into contact, therefore a 
larger quantity of new matter must become vascular; secondly, 
there is the second or ossific process to be effected ; thirdly, there 
is laceration of the soft parts ; fourthly, the state of the constitution 
and restorative powers may be weakened; fifthly, age. The situa- 
tion too of the bone will cause a variation; the lower requiring a 
longer time than the upper extremities. In the middle-aged, and of 
a good constitution, union will take place in three weeks, so as not 
to admit of perceptible motion. If much longer in uniting, it will 
be very uncertain at what time this will take place: I have 
known it months, and yet unite at last. This slowness seems to be 
from imperfection in the two first bonds of union, the adhesive and 
the cartilaginous ; sometimes from a want of disposition to ossifi- 
cation.* 
These two, union by the first intention and that by adhesion, con- 
stitute the two first modes of union of bone; the third is where 
these two have failed, and here the union is effected by means of 
granulations from the broken ends of the bone and from the soft 
parts, which granulations become converted into bone (see note, 
p. 203). It is difficult to account for the failure of the first two: often 
it depends neither on the constitution nor the part; for the constitu- 
tion has often been good, as is seen by it bringing on new inflam- 
mation on exposure. 
I have seen a simple fracture where the two first processes, 
an easy position, resulting from the semi-relaxed posture of the principal mus- 
cles, and, secondly, of admitting of the application of fresh bandages and 
dressings without being required to disturb the fractured member. Mr. Earle 
and Mr. Amesbury have contrived beds on the same principle, which effectually 
combine these advantages, and must be considered as most important acquisi- 
tions in the treatment of compound fractures.] 
* [It may be observed that this want of disposition is particularly manifested 
during the periods of pregnancy and lactation, which would seem to divert the 
powers of the constitution from the reparation of the injury to the more important 
object of nourishing the offspring. The same effect will be produced by exces- 
sive depletion, or constant motion of the fractured extremities of the bones. By 
the former the naturally weak reproductive powers of bone are still further 
reduced, and by the latter the ossific process is arrested, and a new disposition 
created for the formation of a bursal structure, similar to what takes place in 
other parts of the body when friction is employed. It should be observed that 
constant motion of a fractured bone will inevitably lead to the formation of a 
false joint; but this will be differently formed in different cases. If the process 
of union has been interrupted from the commencement, the broken extremities 
will be found rounded off and covered with hard enamelled surfaces, inclosed by 
an adventitious synovial bursa; but if the interruption has taken place during 
the ossification of the callus, then the extremities of the bone will be united by 
a cellular or fibro-ligamentous structure. I am not aware that true cartilage is 
ever reproduced when removed from the surfaces of joints by ulceration, or ever 
found as a new formation on the extremities of bones forming a false joint.] OF THE DISEASES OF BONES AND JOINTS, ETC. 
273 
namely, the conversion of the blood into a vascular substance and 
the deposition of cartilage, had taken place, and the third had 
failed; and then, on allowing the parts a little motion, they got 
firmer, and at last perfectly strong. 
False Joints.-Sometimes simple fractures will not unite at all. 
This is a worse consequence than any of the foregoing, there being 
no soft union even, or, if there ever was, that being absorbed. 
Here the surrounding parts thicken and form a kind of capsular 
ligament, and the extremities of the bone rub against each other at 
each motion of the limb, by which stimulus the broken parts are 
absorbed, and the extremities become smooth, and in time are 
covered with something similar to cartilage, and at length the 
cavity between them becomes filled with a fluid very much resem- 
bling synovia. In this case it is necessary to lay open the new 
cavity and irritate the ends of the bones, and then, by keeping 
them in position, bony union will often take place. It has been 
recommended to saw off the ends of the bones; but all that seems 
necessary is to irritate them sufficiently to excite a fresh inflamma- 
tion.* 
Inflammation of Bones.-Bones are subject to the adhesive, 
suppurative, and ulcerative inflammation, as the soft parts are. 
The adhesive inflammation of bones is attended with this peculiar 
circumstance, namely, the formation of new bony matter in the 
inflamed parts, and therefore may be called ossific inflammation. 
Soft bones and the soft parts of hard bones are the most liable to 
inflammation and suppuration. Whether this arises from the struc- 
ture of the bones or from some other cause, I cannot say. 
The suppurative and ulcerative inflammation is the same in 
the bones as in soft parts, as is also the granulation and. cica- 
trization. 
When an injury is done to a bone sufficient to cause inflammation, 
or if inflammation arises spontaneously in a bone, then, some time 
after, there appears a swelling. This state is similar to the adhesive 
inflammation in soft parts. But pain appears to be the first symptom 
of inflammation in bones, and to precede the swelling a considerable 
time, whilst in soft parts they appear together. From this slowness 
in swelling it would appear to be a different operation, and it is 
* [It has not been found that any plan uniformly succeeds. Among the least 
severe methods adopted in these cases may be mentioned blisters over the seat 
of fracture, or lateral or longitudinal pressure (according to the circumstances of 
the case) of the broken ends of the bone, so as to excite inflammation. Thus, 
Sir Everard Home procured a fractured femur to unite by encircling the limb 
with a stiff leathern belt, and making the patient walk. A seton passed between 
the ends of the bones has succeeded in a few cases ; but the excision of the 
fractured extremities is much more effectual, although it is attended with the 
great inconvenience of shortening the limb. Mr. Hunter's is certainly a less 
severe method, and may be applicable to those cases, such as fractures of the 
tibia, where the bursal sac can easily be exposed ; although I should mention 
that it has lately failed in two cases in St. George's Hospital. I believe, how- 
ever, that time and a well-adjusted apparatus will succeed in the great majority 
of cases, without having recourse to any other method.] 274 
HUNTER'S PRINCIPLES OP SURGERY. 
difficult to understand how a bone can swell from extra vasated 
lymph or calcareous matter, yet it is impossible to conceive that it 
is from any other causes. A swelled bone is true bone, and nearly 
as hard as any other bone ;* it is easily distinguished from the 
sound bone and from swelling of the surrounding parts. A cylin- 
drical bone seems most liable and ready to swell at its extremity 
or softest part, which is the last formed part; and this is agreeable 
to what I have before said, that the latest formed parts are weakest 
and least able to resist disease. But in the bones of the skull the 
swelling is generally in the centre. 
Pain in inflammation of bones is more violent than in other parts. 
Whether this arises from the nerves being more compressed, or 
from the nature of the nerves themselves, is not easy to determine. 
This is rather a heavy depressing pain than an acute one, and is 
similar to that of rheumatism, generally more violent at night when 
warm in bed. This symptom is common to all inflammations of the 
bones and periosteum, though it has been supposed to be peculiar to 
venereal affections. 
In this stage the constitution is not much affected, except from 
the long-continued pain, which may be so continued and violent that 
the patient may in the end become considerably affected by it. 
We cannot divide the bones, like the soft parts, into vital and non- 
vital; therefore we have not two species of symptoms. We have 
oftener, however, hectic from inflammation of the bones than from 
that of the soft parts. 
The parts surrounding the bone generally, if not always, sym- 
pathize with the ossific inflammation; first producing simply adhesive 
inflammation of the periosteum, then of the muscles and cellular mem- 
brane. When considerable, this adds much to the swelling: the 
periosteum becomes fixed to the bone itself, so that this seems more 
swelled than in reality it is. 
The soft parts contiguous to the bone, besides sympathizing with 
the inflammation, receive the ossific disposition. The cells which 
contain the marrow are subject to be affected, so that the cavity is 
filled up, and the bone increased in size. The ossific disposition 
takes place in the surrounding parts much oftener than either the 
swelling of the bone or the ossific disposition of the cavity ; therefore 
it seems an easier operation to nature. This ossific disposition in 
the soft parts assists in the union of fractures and in the formation 
of anchylosis. 
Here are bones [exhibiting them] where the ossific or adhesive 
inflammation had taken place in the substance of the bone, pro- 
ducing thickening of that substance; others where inflammation 
has taken place on the surface of the bone; and here, similar to the 
exudation of coagulable lymph on the soft parts, a coat of adventitious 
* [There is great difference in this respect in different cases. Bones, in ge- 
neral, become spongy and light from inflammation ; but there are other cases in 
which they acquire a hardness and denseness of structure little inferior to that 
of ivory.] OF THE DISEASES OF BONES AND JOINTS, ETC. 
275 
bony matter is laid on the surface of the bones by ossific inflam- 
mation. This in some, you may perceive, is laid on so close and so 
thin as to appear like ossification of the periosteum ; in others it is 
loose and capable of being shelled off. In this bone of a lion it is 
laid on in places nearly half an inch thick, adhering closely to the 
bone; and in this it appears, from the little connexion it had with 
the bone, that the bony matter had grown from the surrounding soft 
parts. 
From this preparation of one of the bones of the lion, which had 
been injected and steeped in acid, it appears that this newly-added 
bone was vascular, and had only lost its earth by this steeping, its 
form still remaining; it therefore must be as much an animal sub- 
stance as the original bone. This appearance on the surface of 
bones, some years ago, before I gave these lectures, would have 
been supposed to have arisen from caries. If a bone is bent, broken, 
or hurt, &c., the consequent inflammation produces an addition of 
adventitious matter, which will strengthen the part even beyond 
what it originally was. In disease of the bone, when the ossific 
disposition does not exist, we may observe that the periosteum is 
very slightly attached to the bone, being as easily raised from it as 
the cuticle may from the skin. 
Treatment.-The swelling of a bone, if of no specific nature, 
requires little chirurgical treatment, but will most probably require 
internal and external medicines before it can be reduced to its 
original size. 
If a bone be only in a state of adhesive inflammation, every 
method is to be used that is used in inflammation of other parts, as 
bleeding, rest, &c.; and if in the lower extremities, a horizontal 
position will add greatly to the cure. Fomentations will give ease, 
especially when near the skin. However, this treatment is some- 
times ineffectual, and suppuration comes on. 
Suppuration, however, is not always the consequence; for in 
some cases the bone becomes indolent, and remains swelled for 
years. I believe bones are more likely to take on the indolent habit 
than other parts. The adventitious bone may always be considered 
as in a weak state, not being an originally-formed part, and as it 
is often in parts where it becomes an incumbrance, must be consi- 
dered as a disease ; and if it could be removed it would be of ser- 
vice ; but in most cases this could not be done without producing 
worse effects. 
When bones take on this indolent habit, it will be necessary to 
rouse the diseased part to action. For this purpose mercury may 
be used internally, and pursued for a considerable time in a middle 
dose between what would be used in a venereal affection and what 
would be given as an alterative. 
Mezereon has been much recommended in indolent swellings. 
The decoction recommended by Dr. Russell is to be made as fol- 
lows. Fresh mezereon root one ounce, pure water a gallon and a 
half. Boil it in a copper vessel tinned, over a moderate fire down 276 
HUNTER'S PRINCIPLES OF SURGERY. 
to a gallon. Towards the end of the boiling, add an ounce of 
liquorice-root, sliced. Half a pint is to be taken three times a day, 
which is more than most can drink. This does not increase any 
of the secretions, except being a laxative in a very few cases. 
It has been tried with double the quantity of mezereon, but was 
then too pungent for the stomach. Patients using this decoction 
are not confined to any regimen. The medicine has been strongly 
recommended in the Medical Observations by Dr. Russell. The 
cases he has described I should not call venereal, though they were 
treated as such, but scrofulous; therefore we may find mezereon a 
good remedy in scrofula. It cannot be considered as a specific in 
syphilis, as it is only useful when the bones are affected. 
Of the Suppurative Inflammation in Bones.-When the ossific 
inflammation is not cured, suppuration takes place. There is no 
visible difference between suppuration in bones and in the soft 
parts; for as bones are composed of animal matter with calcareous 
earth, there is no reason why they should not go through the same 
process. Suppuration does not indeed take place so readily in 
bones, the inflammation often not reaching so far. Whether this 
proceeds from an indolent disposition stamped on them from the 
first, or from their structure, I do not know; but whenever suppu- 
ration takes place in them it is a serious piece of business. The 
periosteum and surrounding parts are more ready to take on suppu- 
ration than the bone itself, yet it may originate in the substance of 
the bone. The consequence of suppuration is ulceration, which 
may also originate from pressure, or blood lying on the bone. 
There is, I believe, no difference between the ulceration of soft 
parts and of bone, the adhesive going on with the suppurative in 
the soft parts; so in the bone we have the ossific going on with 
the suppurative. To repair the loss that has been made, Nature 
sets herself to work to repair the loss with granulations. The 
intention of these is, to fill up abscesses; to repair compound frac- 
tures ; to restore the part lost by trepanning, &c. Nature sets about 
to repair these injuries of bones by the same original principles by 
which bone was first formed: thus, if a cylindrical bone is to be 
restored which was originally formed on cartilage, the first step to 
its reproduction will be the formation of cartilage ; if a bone in the 
skull, it will be of membrane. But we sometimes have too great 
a disposition to ossification in the granulations, so as to make the 
new part bulky and inconvenient. A difference is observable in 
the newly-formed substance which arises from ossific inflammation 
and that which is formed from granulations in consequence of 
ulceration. The former has a smooth fibrous appearance, very 
different from the latter, the surface of which is granulated, as if 
the bone had grown from the centre to the circumference, the grain 
being of a sandy texture. 
Compound Fractures.-These differ from simple fractures in the 
first and second modes of union being lost; and therefore the third, 
by granulation, takes place. The granulations between the ends of OF THE DISEASES OF BONES AND JOINTS, ETC. 
277 
the bone and on the lacerated surfaces take on an ossific disposi- 
tion, and the suppuration is always more or less surrounded by the 
adhesive inflammation, so that it extends pretty far, and conse- 
quently the callus is large. Hence these fractures are so tedious 
and dangerous, especially when in the lower extremity, which is 
their usual situation. There are no bounds to the mischief done by 
a compound fracture : the loss of the uniting substance by the 
wound, and the loss of the living principle to what remains by the 
exposure, are causes of the failure of the first process ; and, besides, 
the ends of the bones are sometimes so locked together as to require 
to be sawed off, or so denuded of their investing membrane as to 
lose their living principle and to exfoliate, as the dead part must be 
thrown off before the wound can heal. This sometimes takes six 
or eight months, and is so extensive as to be very dangerous. The 
inflammation, too, which follows the accident is commonly very 
considerable, and may proceed to mortification. 
Treatment.-The only peculiarity in compound fracture by which 
it differs from other lacerated wounds is the breach of continuity 
of the bone, which admits of motion in the part where none was 
intended. This singularity it is which requires a peculiarity in the 
treatment, as this motion and the operations of nature are in contra- 
diction to each other. A variety of inventions have been employed 
to prevent this motion ; but the dressing of the wound every day 
counteracts the effect of every invention that has been thought of, 
and it is perhaps impossible to dress the sore without motion (see 
note, p. 271). At first the part is generally put into a poultice, but 
changing this must give considerable movement. Instead of a 
poultice, I would lay the leg or arm in cloths, doubled several 
times, and wetted with goulard, and lap them over so as to come 
into contact. These should be wetted occasionally, and continued 
until the inflammation is over and the suppuration takes place. 
When the wound is on the back of the leg we shall be obliged to 
raise the leg every day to apply the cloths. A bit of oil-cloth should 
be put under the leg, and wiped clean every day. 
The time of union of a compound fracture is necessarily much 
longer than that of a simple fracture, from the processes they have 
to go through, and is very uncertain ; but the union of the bones is 
generally effected long before the external wound is healed up, for 
whatever retards the cure of the bone retards also the cure of the 
sore. When granulations have been formed and bony union is 
late in taking place, and the wound is healed up or nearly so, it 
should be treated like a simple fracture in the same circumstances, 
and gentle pressure is of use, as walking, with a machine to take 
off the weight of the body: here necessity acts as a stimulus for 
bony union to form. 
Compound fractures do not always take on the bony union: but 
there is never a want of soft union, as there is at times in simple 
fractures; and therefore new joints are never formed, as they are 278 
HUNTER'S PRINCIPLES OF SURGERY. 
sometimes when simple fractures do not unite by the first or second 
modes of union. 
Compound Fractures communicating with Joints.-Joints do not 
so readily go through the suppurative and granulating inflammation 
when wounded as other parts ; and it would be improper for them 
to do so, as it would produce anchylosis. If, in a compound frac- 
ture, the fracture extends to a joint, the question arises, What shall 
we do ? The injury may be viewed in one of three lights : first, 
as a compound fracture; secondly, as a laceration of a joint: 
thirdly, as a compound of both. If it is such a fracture as seems 
impossible to recover, it is not necessary to consider the joint at all, 
but amputation must be performed. If the laceration into the joint 
be such that, although the fracture may not be considerable, inflam- 
mation and suppuration of the whole joint must come on, then it is 
probable that amputation must also be its fate. But if the fracture 
appears to be such as may unite, and the laceration in the joint be 
such as can unite by the first intention ; if the fracture be such a 
one as we think would do well when restored to its situation, if not 
complicated with a wound in the joint, it becomes dubious what 
ought to be done. If the wound in the joint will admit of being 
kept from exposure, then we may consider the case as one of com- 
pound fracture only. This sort of injury most often happens at the 
ankle joint, this tibia being very liable to fracture at its lower extre- 
mity. All wounds of the joints should be healed by the first inten- 
tion, if possible.* 
Of Fracture of the Patella, Olecranon, and outer Ankle.-The 
peculiarity attending these fractures is, that they make the lateral 
part of a joint so exposed that the fracture communicates with the 
cavity of the joint w'hich gives an exit to the immediate bond of 
union. The treatment of the patella and the olecranon will be very 
similar, because they not only make the lateral parts of joints, but 
they have inserted into them the tendons of considerable muscles. 
Hence the fractured ends are separated from each other, instead of 
riding over one another as in common fracture, and a different 
treatment is consequently necessary. 
As the fractured patella is commonly produced by a contraction 
of its muscles, especially when opposed by a resistance of other 
* [The question of amputation in cases of compound fractures, is one which 
depends on many circumstances: as, for example, the implication of the great 
joints ; the degree in which the soft parts are bruised and injured and the bone 
comminuted ; the injury of the principal vessels or nerves of the fractured limb, 
as well as the age, previous habits, and present conveniences of the patient. 
Without, however, going into the subject further, it maybe sufficient to mention 
that surgeons are now more in the habit of trusting to the efforts of Nature than 
used formerly to be the case; so that cases which would certainly have been 
condemned by Pott and Hunter are frequently saved in the present day. Where 
youth and a sound constitution exist, the surgeon should be especially careful 
not hastily to condemn a fractured limb because the joint happens to be impli- 
cated, or on account of any other simple circumstance ; but should reflect how 
extensive the resources of Nature are, and that an attempt to save the limb in 
the first instance will not necessarily preclude his having recourse to the remedy 
cf amputation in a later period of the case.] OF THE DISEASES OF BONES AND JOINTS, ETC. 
279 
muscles, the fracture is then transverse, and then the muscles are 
at liberty to contract to their full extent, and consequently the 
broken part of the bone above is drawn up the thigh with them, 
for the rectus muscle has more than a simple power of extending 
the leg, namely that of bending the thigh on the pelvis. 
Treatment.-When the ends of the fractured bones are pretty 
soon brought tolerably close together, I can conceive that union 
may take place as in simple fracture. Before the year 1750 it was 
the practice to endeavour to bring the broken ends of the bones as 
near together as possible, with little or no motion allowed; but 
after that a fashion arose (for we have fashions in surgery as in 
everything else, arising perhaps from a person happening to do 
well who had not been treated in the old way,) of letting the parts 
separate, and of not forbidding motion so strictly; but now caprice 
has I believe had its day, and we are taught by reason and experi- 
ence that the parts should be, when cured, as nearly as possible 
in their natural situation. To effect this, the upper portion of the 
patella should be brought down as much as we can, and the com- 
mon bandage be applied. It may be imagined that in the treat- 
ment it is not only necessary to extend the leg, but to lay the 
thigh at right angles with the body; but from a complete knowledge 
of all the circumstances, it will appear that this practice is not at 
all necessary; for as the rectus has a greater power of contraction 
than extending the leg, so it must also be granted that it has a 
greater power of relaxation; therefore it is not necessary to place 
the leg at right angles with the body. 
Fracture of the patella seems to be cured by Nature, in the 
manner of the simple fracture, by granulation, because the first 
and second bonds of union have escaped into the cavity of the 
joint and have been absorbed. But, perhaps, if the ends were 
brought together earlier, they might be united by the same means 
as the common simple fracture, especially as we sometimes see a 
luxuriance round their edges, which is probably owing to the 
ossific disposition having taken place in the coagulum. But if the 
first and second modes fail, I conceive the third, by granulation 
takes place: the ends of the bone and ligaments exuding coagu- 
lating lymph, which coagulates immediately, and, taking vessels as 
in other granulations, becomes not bone, but a kind of tendinous 
or ligamentous substance; which seems a wise provision of Nature, 
because if they were united by bone, this might be of such a length 
as would prevent the motion of the joint, except with the leg at 
right angles with the femur. 
When union is formed it would be proper to give some passive 
motion; but voluntary motion is always better, because the will is 
always sensible how far the powers of a part extend, and will 
attempt no more; but if force is used to extend a part, all the 
muscles of which have not their due power, it may be thrown into 
such a situation as to give an impropei' action to a weak muscle: 
the will alone is proper to perform those actions she has determined 
on herself. 280 
HUNTER'S PRINCIPLES OF SURGERY. 
The method of cure by ligament only is very tedious; but there 
are other things to be done after this union has taken place. First, 
the accommodation of the muscles to their new situation, where 
less length is necessary, from the patella having become longer; 
secondly, the new contraction in this new situation; thirdly, 
acquiring sufficient strength in it. 
We have reason to believe that the greatest contraction in a 
muscle is somewhat greater than the joint will allow of; for we 
find them firm when the limb is stretched as if the power was 
greater; and when the part is depri ved of this firm band we find 
the muscles draw the bone up higher than they should. Thus the 
upper' part of the patella is always drawn up when the bone is 
broken. While the union is taking place, the muscles are accom- 
modating themselves to the great length of the bones. After this 
it will be necessary to bend the limb and keep it so, in order that 
the muscles may be thus enabled to admit of an elongation equal to the 
flexure of the limb, by which means the patient will be enabled easily 
to bend the limb. Extension will not be so easy ; but still by perse- 
verance it may be acquired, as the following case will show. 
I called with a friend to pass a day or two with a family in the 
country. The lady of the house had had her knee fractured, and 
had been treated according to the maxims the surgeon had learned 
while attending the London hospitals, which at that time were to 
leave the whole unconfined, and take no measures to bring the 
portions of bone together. She recovered from the accident, but 
was totally unable to use the limb, and had Jo be wheeled about in 
a chair. Her leg was made to swing backwards and forwards 
as she sat on a high table or chair, but still she had no power of 
contracting the rectus muscle, and as soon as the force that gave 
the motion ceased, the motion ceased with it. It was not until 
several years after the accident that I saw her; and, having spent 
a whole night in considering the probable cause of her loss of 
power, it appeared to me that the space between the two attach- 
ments of the rectus being much shortened, while the muscle con- 
tinued of the same length, the utmost degree of its contraction 
would scarcely be able to straighten itself, much less move the 
patella and leg also. I advised hei' to sit as before, but instead of 
having hex' leg moved, to move it herself. This she could not in 
the least effect at first. I considered, however, that the power of 
contraction which the muscles possess beyond that necessary for 
the mere purpose of extending and flexing the limb, as mentioned 
above, is probably obtained by the mind's influence on the muscle; 
and that, in this case, if the influence of the mind was frequently 
exerted on the muscle, it would gain this power of contraction, in 
which it would probably be aided by the interstitial absorption 
taking place, and actually shortening the muscle and suiting its 
length to the office it was to perform. I therefore advised her 
ladyship to repeat her exercise, as often as she could, every day 
for a month, assuring her that if at the end of the month she had 
obtained the least power of motion, I had not a doubt that she would OF THE DISEASES OF BONES AND JOINTS, ETC. 
281 
again be enabled to walk by a regular exercise of the muscle. 
The event proved as fortunate as I could wish: the lady, at the 
end of three or four months, being able to walk, although she had 
not walked for years. 
Fracture of the Olecranon.-The olecranon may be considered as 
a fixed patella, the inserting-point of a considerable muscle, and 
when broken is drawn up as the patella. The immediate treatment 
is the same; but the consequences are often different, as it should 
always be united by bony union. The arm should be extended, and 
kept so ; and the upper portion brought down, if up, and retained 
by a bandage, which will be somewhat similar to those used after 
bleeding. When soft union has taken place, and. bony is beginning, 
passive motion of the joint should be made. As the union gets 
stronger, the motion should be increased, but should not be very 
great till bony union is completed, as before this it will bend the 
olecranon over the lower end of the os humeri, and occasion it to 
make a smaller curve than it should do, even an angle; by which 
the full extension will be prevented. This, by proper attention, 
may be avoided. 
Fracture of the Ankle Bones.-It is possible for these to unite in 
general, like simple fractures, as the displacement can hardly be 
very considerable, unless great injury has been done, here being no 
muscle fixed to them, the contraction of which would draw up the 
parts ; so that the extravasated blood and juices may be sufficient 
to unite them by the first intention. 
Suppuration in Bones.-I shall first consider that on the surface 
of bones, or on the periosteum ; secondly, in the substance ; thirdly, 
in the medullary parts ; fourthly, may be reckoned that in the joints, 
which is similar to that of a bone; but, as it is attended with 
consequences peculiar to the nature of the part, I shall treat of them 
after. 
When inflammation attacks the surface of a bone, the first effects 
are adhesive ; and when suppuration takes place, the periosteum is 
separated as far as the suppuration extends, making underneath a 
cavity for the matter. As the adhesive state takes place some way 
round the abscess, there is in many cases a circle of adventitious 
bone formed in the periosteum round the abscess. This will be 
more or less, according to the rapidity of the suppuration: if it 
takes place soon, there will not be time for theossific inflammation; 
if slowly, a ridge will be formed, as is often the case in the cranium 
giving the appearance of bone being wanting under the muscles. 
As soon as ever it is known that suppuration has taken place, it 
should be freely opened, to prevent as much as possible the separa- 
tion of periosteum;* granulations will form, and in proportion to 
* [The propriety of this direction cannot be questioned as regards those cases 
where collections of matter between the periosteum and bone give considerable 
pain, or where, suppuration not yet having taken place, the suffering from the 
periosteal inflammation cannot be subdued by the ordinary antiphlogistic and 
mercurial treatment. It should be recollected, however, that considerable col- 282 
HUNTER'S PRINCIPLES OF SURGERY. 
them will the ossific disposition follow, which ossific disposition is 
often not confined to the granulations, but exists in the surrounding 
cellular membrane, &c.; so that, around the bone, ossific matter is 
deposited which increases it very much in thickness : this is seldom 
the case when the granulations are healthy, but almost always when 
unhealthy. The oftener bones have undergone inflammation and ul- 
ceration the thicker they become, and also much more subject to it, as 
we evidently see in working-people's legs, &c. Often, from the sepa- 
ration of the periosteum, part of the bone dies, and must exfoliate. 
The second Species.-This is of greater consequence, as more of 
the bone becomes diseased. When inflammation attacks the sub- 
stance of the bone, it is seldom that the whole diameter of the bone 
swells, generally only on one side, where the suppuration is. This must 
at first be much confined, from the solid parts around, and ulcera- 
tive inflammation is obliged to take place early; and accordingly, 
as in common abscesses, the ulceration goes on towards the soft 
parts, and until it arrives there it is impossible to tell whether there 
is abscess in the bone or not.* It will burst, as usual in abscesses; 
but this probably does not so quickly take place here as in soft 
parts. When neai' the external surface, and so near the periosteum 
as to give it the stimulus of adhesion, then the adventitious substance 
is formed on the external part of the bone, while its substance is 
gradually lessening internally by absorption; but the addition ex- 
ternally is not in proportion to the internal loss, and therefore it 
bursts externally. [Preparations of this were shown where suppura- 
tion and ulceration had taken place in cylindrical hones, as in the 
tibia, #c.] This used to be called spina ventosa. 
The third Species.-Inflammation in the medullary part is still 
more serious in its consequence than the last. The body of the 
bone thickens from the adhesive disposition, and also the ossific dis- 
position takes place in some degree in the periosteum all round, so 
that the external parts are much increased in bulk; this only takes 
place in the bones of the extremities, where strength is necessary, 
and never in the scalp, &c. The ossific disposition in the medullary 
parts takes place at all points of the abscess; and by this the other 
part of the marrow is saved. When suppuration takes place, there 
being no vent obliges the ulcerative inflammation to take place: on 
all sides and on the outside additional matter is deposited. Nature 
intending to keep up the strength which it is losing internally; the 
lections of pus, arising from a venereal cause, are frequently dispersed by an 
appropriate treatment directed to the cure of the original disease; especially 
when such collections are situated on the frontal bone.] 
* [Notwithstanding the great obscurity which involves the early existence of 
these cases, yet it is not always impossible to discover their true nature. In the 
clinical lectures delivered by Sir Benjamin Brodie, that gentleman has related 
several cases in which he has detected and given exit to circumscribed abscesses 
in the heads of bones entering into the composition of the large joints. Such 
cases are marked by a fixed deep-seated pain in some determinate spot, unat- 
tended by any considerable swelling of the parts, or disease of the neighbouring 
joints.] OF THE DISEASES OF BONES AND JOINTS, ETC. 
283 
newly-formed bone is itself disposed to the ossific inflammation, by 
which it in many parts becomes much thickened, so that the 
remaining shell is often entirely new. Where the two opposite pro- 
cesses do not bear a proportion to each, the bone becomes often so 
very thick as to resemble a compound fracture. In the two last 
mentioned we have often exfoliations, as well as in the first; 
they are less favourable, from their situation being different, 
and are called internal exfoliations. The head of the tibia is 
more subject to abscess than any bone in the body. The medullary 
arteries and membrane, which furnish nourishment for the internal 
laminae of the bones and marrow, is the seat of the inflammation 
producing it. [A preparation was shown where it was very large, but 
only a mere shell remaining.'] 
Treatment.-When the adhesive or ossific inflammation does not 
stop, but goes on to suppuration, it must be treated as inflammation 
in soft parts. When the suppuration is superficial, so that the bone 
only makes one of the sides of the abscess, the matter will come 
immediately to the surface. 
All the soft parts are to be laid freely open, or entirely removed. 
This is necessary in all wounds, where healing does not take place 
from the bottom, to expose them and bring on inflammation; and 
when there is exfoliation, the opening is more necessary, as it cannot 
heal until this is removed, and it will sooner be removed and healed 
by exposure. It will often be necessary to remove a part; but when 
the skin and bone are very near, then it must be only a simple open- 
ing, without removing the skin, as in such cases the skin is fixed 
very much to the bone, and should not be lost; and again, here the 
granulations have less power to contract than in deeper and more 
fleshy parts, and there is less danger of sinuses or fistulous openings; 
but when deep-seated, simple and free openings are insufficient, and 
some parts must be removed, otherwise the external opening will 
close, and fistulous openings will remain till the bone has recovered* 
Bones are very apt to fall into an indolent inactive state, which 
should be discovered, and stimulating dressings applied. Oily dres- 
sings have been objected to; but oil has neither a power of pro- 
moting nor retarding granulations, though the former has been 
imagined to be the case. By this means they are often cured, but 
are afterwards very liable to new inflammation; and this is generally 
attended with ulceration, which begins in the skin. This is owing 
to weakness in the part, and is most frequent in the lower extrem- 
ities. 
In some cases it will be necessary to apply the actual or potential 
cautery to the bone. 
The treatment of these cases is various, and the cure is generally 
very difficult. They are seldom understood: at first they may 
appear as a common abscess, and are often opened and dressed as 
such, which, proving generally ineffectual, leads the surgeon to a 
more particular examination, and he easily discovers a diseased 
bone, if the opening has been free. As the bone cannot be dilated 
by a cutting instrument, it must be killed either by the potential or 284 
HUNTER'S PRINCIPLES OF SURGERY. 
actual cautery, or sometimes the trepan will be useful. After exfo- 
liation is finished, the same dressing as in caries is required ; but in 
many cases it will be necessary to do something more. The cavity 
of the abscess in some requires to be exposed, by removing sur- 
rounding parts, as is sometimes done in abscesses of the soft parts 
before they will heal. 
Of the Matter in Diseased Bone.-The matter discharged from a 
sore where there is diseased bone is seldom good matter, especially 
if it become fistulous. The diseased bone that is bare is often pro- 
ducing mechanical effects, such as rubbing the soft granulations, so 
that there is a small quantity of blood mixed with the matter, which 
gives it a bad colour. Such matter generally blackens or in part 
corrodes silver probes. This probably arises from the hepatic air 
(sulphuretted hydrogen gas) which Mr. Kirwan has discovered to 
be produced by the putrefaction of animal matter. 
Of the Shortening of Muscles of Diseased. Joints.-Joints when dis- 
eased naturally get into a middle state between flexion and extension; 
and, as the joints are passive, this must be performed by the muscles, 
and either by their voluntary or involuntary action. This stiffness 
of the joint depends on the involuntary contraction of the muscles, 
and is in consequence of the muscles sympathizing with the joint. 
But this involuntary contraction is not like tetanus; the muscles in 
this state feel like strong cords, and, if straightening the joint be 
attempted it seems to the patient as if these cords were breaking. 
As the joint loses its power of motion by the disease, in that pro- 
portion the muscles are altered; they adapting themselves to the 
quantity of motion the joint will admit. 
In the artificial extension of a joint which has been contracted, 
the muscles which are contracted should never be called into action, 
because the parts which ought to lengthen will thus be shortened. 
To illustrate this, let us suppose the gastrocnemius and soleus 
muscles to be contracted, and to draw up the heel, so that the 
patient rests on his toes, his foot being in a line with his leg: in 
walking he will involuntarily use these muscles to give firmness to 
his leg. In this case we should give support to the heel in a 
degree. By this means the patient, convinced of his ability to bring 
his heel as low as the support requires, will cease voluntarily to 
contract the gastrocnemius and soleus muscles, and they by 
degrees will acquire the property of relaxing themselves; which, 
if the heel was entirely supported at first, they would have no 
occasion for, and while altogether unsupported they never could. 
Of Sprains.-In sprains the ligaments are probably often torn ; 
for in most sprains there is a considerable extravasation in the sur- 
rounding cellular membrane. 
Considerable pain is felt, at the time of the accident, of the heavy 
dull kind, which often produces sickness, and the blood leaves the 
skin of the body generally. Considerable swelling takes place, and 
this is almost instantaneous. The swelling arises from two causes; 
the surrounding cellular membrane being loaded, and the increased OF THE DISEASES OF BONES AND JOINTS, ETC. 
285 
secretion of synovia into the joint. This will be more visible in 
the joints where the capsular ligament is loose, as in the joint of 
the knee above the patella. 
These symptoms are succeeded by inflammation, which pro- 
duces great pain and sensibility on motion. These parts are very 
insensible in a sound gtate, but they easily move from a state of 
insensibility to one of sensibility. Nature does not seem to have 
bestowed so much pains on these parts as on others, for they 
have very weak powers of restoration, which produces tediousness 
of cure. 
Treatment.-In the first place, rest should be employed, with 
topical bleeding. Pumping on, or long immersion in cold water, 
and friction with vinegar, lees of wine, spirits of wine, &c. on the 
part have been recommended. Whether these last remedies serve 
any useful purpose oi' not I am undetermined: but we know' that 
sprains are at least seldom perfectly cured. I have known the 
effects of a strain continue through life (above fifty years), always 
swelling and becoming painful on the least violence. Where there 
is a perfect cure obtained, I suspect the ligaments only have been 
injured, and not the cartilage, which is extremely slow to restora- 
tion. Though the mechanical strength is recovered, yet a weak- 
ness is often found to remain, which may sometimes be removed by 
some application which has not been before applied, as a pitch- 
plaster, opodeldoc, &c., which gets the credit and the name of a 
specific: but these often fail. The same applications are often 
recommended in the second stage as in the first, but to use it in the 
same way must be improper. In the second stage cold water 
should be applied no longer than to excite heat. Sprains often 
remain very painful after the original symptoms have been removed; 
this pain is often removed by giving the part motion, as if some 
part was moved into its place by that motion; but it is most pro- 
bably by the motion's giving the parts an opportunity of adapting 
themselves to each other's action. 
On Dislocation.-This term generally is applied to bones, and 
probably might also be applied to cartilages, when any two bones 
forming a joint are displaced. Probably the articulating substance 
or ligament is torn; but this circumstance is not yet well ascer- 
tained. In many joints a lateral motion must be applied to produce 
it, the muscles being at right angles with the bone that they move, 
&c. When the head of the bone has moved beyond a certain 
point, then the antagonist muscle is unable to bring it back, and 
then it requires some passive motion to bring the bone so far back 
that the antagonist muscle can replace it. A lady had the tibia 
brought too much below the os femoris, by too great flexion: the 
surgeon attempted to replace it, by bringing the foot forward, and 
so to replace it by the extensor muscles: but I thought the tibia 
was got beyond the centre of motion; therefore I conceived that 
the above means would make it worse : he then, by my direction, 
raised the head of the tibia a little upwards, by placing the hand 286 
HUNTER'S PRINCIPLES OF SURGERY. 
in the ham, and the reduction of it was then finished by the extensor 
muscles. 
General observations on the Reduction of Dislocations.-As joints 
are composed of two parts, one more moveable and the other more 
fixed, the more fixed might be called the reactor, and the moveable 
part the actor. When a violence has been applied to the actor there 
is a deformity occasioned, as if this was out of its place, yet both 
are equally so. In dislocations the powers are generally applied to 
the actor, and though in most cases the reactor does its office spon- 
taneously yet it often requires assistance. In most joints of the 
body the reactor can be made more fixed, as, e. g., the body in 
dislocated hip, but in the shoulder there wants a counter resistance, 
or reactor, the scapula being so verv moveable, and hardly to be 
fixed by art: hence extension is obliged to be more on the muscles, 
as the latissimus dorsi, pectoralis, &c., than on the ligament where 
it should be; therefore, to reduce it, it is necessary to make the 
scapula a fixed point, to do which often requires much labour and 
some art. When you stretch the shoulder as far as it can, the sca- 
pula is brought forwards as much as possible, but the latissimus 
dorsi and pectoralis major prevent the os humeri from being extended 
on the scapula beyond a certain point, which is much against you 
in the reduction. 
In reducing a dislocation the bone should be returned exactly in 
a retrograde motion, overcoming that effect first which was pro- 
duced last, and then a lateral motion is to be made in a contrary 
direction to that motion which occasioned the dislocation ; in doing 
this the most immoveable part is to be the fixed point if possible, 
and the moveable is that which is to be extended. This is to be 
done as soon as possible after the dislocation, as afterwards the 
parts will become adapted to their new situations, and render the 
reduction more difficult, and sometimes impracticable. 
New Joints produced in consequence of Dislocations.-We have 
sometimes new joints produced in consequence of dislocations when 
the bones are not reduced, which brings the parts into somewhat 
of the condition of simple fracture ; and there is the same disposi- 
tion between the two surfaces in contact as in simple fractures 
which do not unite by the soft continuity of parts. But this can 
only be when the dislocated bone comes in contact with another 
bone, as the thigh-bone with the ilium. When the two bones rub 
and press on one another absorption of the external surface takes 
place, the adhesive ossific inflammation goes on around the edges, 
a fluid is secreted in the cavity, and thus we have the new joint. 
These joints of necessity oftenest take place in the thigh-bone than 
elsewhere, but sometimes between the os humeri and the scapula. 
The effects of Accidents and Infammation of Joints.-They being 
circumscribed cavities, are subject to the same diseases as other 
circumscribed cavities, as inflammation, &c., but their peculiar 
structure sometimes renders their consequences different. Nature 
is very little disposed to take on the adhesive inflammation, because OF THE DISEASES OF BONES AND JOINTS, ETC. 
287 
the necessary consequence would be loss of motion in a part 
originally intended for motion. This makes inflammation in joints 
so much worse than in any other circumscribed cavities, for, as 
before observed, if adhesive inflammation does not come on, the 
inflammation and consequent suppuration must spread through the 
whole cavity. 
The joints are mechanically strong; yet this is not that sort of 
power which resists disease; but they have sometimes a greater 
disposition than other parts to disease ; and sometimes they become 
diseased from the violence of accidents. They are slower of cure 
from their composition, than other circumscribed cavities are; 
besides, they are also subject to specific diseases, from the materials 
which they are composed of, and more backward in their cure. 
Inflammation in joints is generally of more serious consequence 
than in other parts; even when resolved it is disagreeable; yet 
this is always to be wished for. Inflammation from accidents often 
does well without any adhesion, but not when it arises from other 
causes. In all inflammations of joints there is a swelling, from 
extravasation, into the cellular membrane and cavities, as in the 
knee above the patella, where there is a sacculus mucosus. In 
inflammation from accidents the treatment must be similar to that 
in other parts, but here suppuration is particularly to be prevented 
if possible. Rest, topical bleeding by leeches and cupping, fomen- 
tations, blisters, purgatives, &c., are here to be particularly em- 
ployed ; but as joints are very apt to become scrofulous, the patient 
should go to the sea when the swelling becomes chronic and appears 
to be at all stationary. Another cause of accidents here, besides 
strains, is extravasation of blood. 
Of loose Substances found in Joints.-These are ligamentous, 
cartilaginous or bony. Though there are often extravasations into 
joints, yet they seldom produce adhesions, although sometimes 
there are appearances as if blood extravasated into a cavity of a 
joint had become vascular. To explain this we must have recourse 
to the living principle of the blood. This, I suppose, when it is 
extravasated into a cavity, adheres to the cavity, and is not absorbed 
nor loses its living principle, but becomes vascular, and afterwards 
membranous, cartilaginous, or bony, according to circumstances. 
Its attachment being rendered small by motion, it becomes easily 
broken off, The treatment of these cases we have before mentioned 
when the joint was sound ; sometimes there is more than one of 
these substances. I know a gentleman who has four'; therefore if 
an operation was to be performed we must take care to manage it 
so as to extract all of them at once. 
They may often occasion lameness in other joints where they 
are not discoverable ; but they are most liable to form in the knee- 
joint, from its greater size, and other joints might not so readily 
show their existence. These loose bodies can only be removed by 
making an opening into the joint, and this should only be done 
when they are evident. On the inside of the upper end of the 288 
HUNTER'S PRINCIPLES OF SURGERY. 
patella is the best place; the loose pieces should be squeezed to that 
part, and then carefully surrounded by three or four fingers of an 
assistant: the incision should be longitudinal and in length propor- 
tionate to the size of the loose bodies. The wound should be closed 
immediately by adhesive plaster and the uniting circular bandage, 
and the patient kept in bed for some days to procure the first mode 
of union if possible, the leg being kept quiet and extended, and the 
occurrence of inflammation carefully watched. 
Anchylosis.'-This is an union of bone with bone which ought 
not to be united, and is of two kinds,-one by soft parts, the other 
by bone. In inflammations of joints we often have adhesions by a 
soft medium. Very considerable inflammation is necessary to 
produce anchylosis in joints, and much time is necessary for their 
perfection, as we see in white swellings. The adhesions are some- 
times partial, sometimes universal. The soft is from two modes, 
viz. adhesion and granulation. The soft only can take place when 
there is naturally no intermediate substance, and the joint is sur- 
rounded by capsular ligament. 
Bony Anchylosis.-I shall divide bony anchylosis into five kinds, 
four of which are in the surrounding parts, by ossific inflammation, 
the other by an entirely new substance, betwixt the extremities of 
a bone. Distinct and separate bones are naturally united, either 
mediately or immediately; that between rib and rib, between tibia 
and fibula, and radius and ulna, is lateral attachment. The second 
is when there is an appendage for the union of two bones, as in 
joints in general; this is of two kinds, viz. 1st, when the whole 
surface is united by soft parts, or ligament, as vertebrae to vertebrae; 
the other, when only round the extremities by caspular ligament. 
These will have different effects. When there is no continuity of 
soft substance, but only the bones, then the inflammation is obliged 
to shift the ligaments for bone. 
Of the first, from lateral attachment where there is no joint.'-This 
generally takes place only when the bones are so near as to partake 
of the ossific inflammation between them, as in the tibia and fibula. 
This anchylosis is of little inconvenience, except between the ulna 
and radius, when their motions W'ill be rendered imperfect. [A 
preparation was exhibited which showed the union of a tibia and 
fibula, by the ossification of the interosseous ligament; another, the 
union between two ribs; and another, the union between two of the 
metatarsal bones.} 
The second, or in surrounding parts.-This often takes place in 
bones united by their whole surface, as between vertebrae and 
vertebrae, and I have seen it between sacrum and ilium; it often 
occurs in the human species, but much oftener in horses. The 
ossific inflammation would appear in such to arise from the bone, 
as it is found to be in different degrees. Sometimes the ossific 
inflammation attacks the periosteum around the connecting sub- 
stance, leaving this as free from bone as ever. In a horse the 
vertebrae unite, not by ossification of the intermediate substance, OF THE DISEASES OF BONES AND JOINTS, ETC. 
289 
but by the periosteum covering them becoming ossified. The same 
also occasionally happens in the human vertebras, the intermediate 
substance not being at all ossified. 
Of the third, or between bone and bone.-Within joints, but with 
a continuity of substance, anchylosis often takes place in the 
vertebrae, by ossific inflammation having existed in the interme- 
diate substance, These specimens [exhibiting them] show the 
intermediate substance ossified, while the external parts are little or 
not all affected. In the spine of a lion both are affected. 
The fourth, by capsular ligament.-This is much worse than the 
former, here the bones having a considerable motion, and this 
motion very necessary; but in some of these joints there is more 
inconvenience from anchylosis than in others; it is from the cap- 
sular ligaments taking on the ossific disposition, after strains and 
other injuries; however, this is much less frequent than the others 
and very long in coming about throughout and all around the 
ligament, though a partial anchylosis may take place which will 
render the joint stiff. \_A preparation of the os ilium, anchylosed in 
part with the glenoid cavity, by the surrounding capsular ligament 
becoming in part bony, was shown. In the elbow another was 
shown, of this species of anchylosis.] 
The fifth, by the whole substance of the articulation.-This is of 
two kinds, and these kinds are the only ones which can admit of 
the soft anchylosis. It is somewhat similar to the union which 
takes place in soft parts; it arises from two causes, viz. 1st, from 
inflammation of the parts themselves; 2dly, from the inflammation 
of the surrounding parts, the parts themselves partaking of it. 
Sometimes the cartilages are ossified, and a new substance is 
formed on them, which 1 rather think arises from granulations 
without suppuration. Joints have lost their motion from inflamma- 
tion in surrounding parts. A lady had an inflammation come on 
from the opening of a sacculus mucosus on her elbow, w'hich 
inflammation was very violent, and extended to the joint, soon after 
which she lay in, and died of puerperal fever. On opening the 
joint, soft union was found to have taken place, which, if she had 
lived, would probably have become bony, and the joint would have 
been anchylosed, merely from adhesive inflammation. 
Of Suppuration in Joints producing Anchylosis.-This is of two 
kinds, viz. truly inflammatory and scrofulous; the former we shall 
now treat of principally. If the inflammation is carried on, an 
abscess is formed in the cavity, as in any other part; and the sup- 
puration is more universal in the cavity than in other parts, being 
diffused through the whole. This continues to approach nearer 
and nearer the external surface, and either breaks or may be 
opened: so far as they are connected with bone they are similar 
to compound fractures; but the suppuration is slow, and takes 
place with difficulty, and then generally falls into the natural scro- 
fulous disposition, which renders it tedious. The suppuration is 
then imperfect, appearing to partake of both the adhesive and 290 
HUNTER'S PRINCIPLES OF SURGERY. 
suppurative. The ulcerative disposition is slow in bringing the 
matter to the skin, which arises from the indolence of the prior 
suppurative disposition and inflammation. The ulcerative inflam- 
mation sometimes goes on, so as entirely to alter the joint, that is, 
the receiving cavity becomes larger, and the received part less; 
this is often the case in the hip joint. These cases then become 
very tedious, and generally very uncertain in their cure. Before 
they are opened they are generally become so indolent that opening 
has very little effect; and often when scrofulous such a disagree- 
able inflammation comes on as to destroy the patient, and therefore 
amputation had better be performed at once if this disagreeable 
inflammation does not take place immediately after opening ; yet 
a fistulous opening is generally the consequence. 
Soft Anchylosis from Granulations.-A joint so healed has no 
cavity left, the surfaces uniting. A joint coming to suppuration from 
not being resolved in the first mode, but forming granulations, is 
more tedious than in the soft parts. The granulations cannot con- 
tract here, as they do in the soft parts, and the powers of restora- 
tion in them are very weak. 
Bony anchylosis takes place when the granulations ossify, so that 
the two bones are united into one exactly similar to a compound 
fracture. [Preparations icere shown; one, of the thigh united to the 
acetabulum; another, of the ulna to the os humeri; and another, of 
the metatarsal bones.] But when the suppuration is healthy the 
joints sometimes recover: in such cases the matter is soonei' dis- 
charged, and the parts are more disposed to return into their origi- 
nal state. 
The modes of cure.-The first attempt should be to resolve the 
suppuration without opening. In some the cartilages have been 
destroyed (which may be known by the bones rubbing against each 
other,) and replaced. This I have seen in the knee. When a 
healthy process is going on, the joint should be attended to. Rest 
should be prescribed, both before and after it has taken place ; 
when it is recovered pretty well, a little motion, and gently repeated, 
should be allowed; thus a cartilage will gradually form on the 
parts moved. 
The second mode of cure is the formation of granulations, which 
makes anchylosis complete by their union. 
Of Muscles losing their Action from injuries done to Joints, Ten- 
dons, and Ligaments.--It is remarkable that an injury done to ten- 
dons, ligaments, fasciae, &c., especially of the strain kind, impair 
the muscles more than when the muscles themselves are injured, so 
that these muscles appear to sympathize with those parts of little 
action, and become wasted and weakened in consequence. I think 
this arises from sympathy, or a consciousness of the parts being 
unable to answer to the action of the muscles, and it comes nearest 
to human reason of any thing in the body. If the affection be 
temporary, as in common inflammation, the muscles do not waste, 
being then conscious that the parts will recover. If one tendon is OF THE DISEASES OF BONES AND JOINTS, ETC. 
291 
materially weakened, the muscle will also; and then, if the motion 
of the joint depends on that muscle, lameness will be occasioned, 
and the other muscles will become also affected. If a joint recovers, 
the powers of the muscles begin to recover in proportion. This is 
the case after injuries of the joints, as fractures, or ruptured ten- 
dons ; and the first intelligence of recovery in a joint will be the 
enlargement of the muscles. This is the case in paralytic parts, 
from the cutting of a nerve ; the wasting is not occasioned by the 
deprivation of the nerve depriving it of nutriment, but from the 
muscles losing their power of exertion. If the hip is affected, the 
muscles of the leg or knee will waste, whilst those of the foot will 
not be altered, which would be the case was their wasting owing 
to. want of nutriment from the nerves. If the elbow is affected, the 
muscles of the arm surrounding it will waste, whilst those of the 
hand will not be affected. When the muscles waste, in consequence 
of a disease in the joint, the surgeon will often say it is from want 
of action ; but if he will only observe the other leg, he will find the 
muscles nearly of their full size, though they have had no more 
motion than the mnscles of the diseased leg. The mind, likewise, 
loses its power over the muscles, for the will has never any power 
over muscles while the parts they move are unfit for motion, even 
although the muscles are not wasted. 
The effects which a disease of a parthas on distant parts.-Many 
diseases of this class produce diseases of debility, as for example, 
involuntary contractions of muscles, oedema, inflammation, and 
sometimes mortification in parts beyond them ; thus, in a disease of 
the loins some of these effects follow in the lower extremities. 
Though they only arise while a disease is present, and is in its 
height, yet the disease may be cured, and the inability in the joint 
remain, as is the case in anchylosis. But here I may observe, con- 
cerning the contraction of muscles just mentioned, that it may take 
place together with these diseases, as in white swellings of the knee. 
But then it is very different from these diseases, the contraction 
proceeding from an endeavour of the muscles to adapt themselves 
to the state of the joint, whilst these are only like symptoms of 
beginning dissolution in the parts. This debility is not like common 
paralysis; the latter is a wasting of power in the muscles, from a 
want of stimulus; but this is a real disease from irritation. It is 
perhaps reducible to a species of sympathy similar to general hectic, 
from a local disease, and it may be called local hectic; but it 
sometimes goes beyond hectic, even to mortification. 
Effects of local diseases on Joints.-Joints that have a secondary 
motion with the diseased part, from having muscles common with 
it, may be included These joints gradually creep into the middle 
state of motion, but sometimes beyond this, so as to be more bent. 
Thus, the thigh is often bent forward, and also drawn more inward, 
so as to be immoveable, from diseased loins or hip. The knee also 
is frequently affected, even as if it was itself diseased. The limb 
first wastes; next is cedematous; and afterwards often inflames and 292 
HUNTER'S PRINCIPLES OF SURGERY. 
suppurates, which is sometimes very extensive. From continuation 
of one position, and want of action in the antagonist muscles, the 
joints, from necessity, become unfit for motion, and are after- 
wards often very imperfectly restored. 
Exfoliation.-This is the separation of a dead bone from the living, 
and is not generally understood. By the term wre should be 
led to suppose that only the common separation of scales from a 
bone was meant, for the other exfoliations are not answerable to the 
term. We have many opinions of this process from different 
authors, but all very imperfect. The bone that separates cannot 
come away by rotting, for it is only dead, and not in the least putre- 
fied. Bone is composed of two parts,-an animal substance, and 
an earthy substance intermixed with the animal. Hard bones, and 
the hard part of bones, have a larger proportion of earth than the 
soft or spongy bones; they have also fewer vessels. 
When a piece of bone becomes absolutely dead, it is then to the 
animal machine as any other extraneous body, and adheres only 
by the attraction of cohesion to the machine. The first business of 
the machine, therefore, is to get rid of this cohesion and discharge 
it. For effecting this separation there are several natural and suc- 
cessive operations going on. 
The first effect of the stimulus is on the surface of the living bone, 
which becomes inflamed ; whether new vessels are formed, or the 
old ones become larger, is undetermined; but by injecting the sur- 
face of the part it appears evidently much more vascular than the 
other parts. The surrounding parts also inflame, as the periosteum 
and cellular membrane, and often take on ossific inflammation. 
This produces another process: first, absorption of the earthy matter, 
and all the surface between the living and dead parts of the bone 
become as soft as if steeped in acid, w'hile the dead part remains as 
hard as ever. To complete the separation, the absorbents continue 
their office, and absorb the living parts also, and the first process is 
in a small degree attended with the second. The operation of sepa- 
ration does not take place equally; it begins at the circumference, 
and continues on to the centre; and before the centre has begun the 
absorption of the earth, the circumference has begun the second. 
This progressive process in the suppuration causes the exfoliation to 
be tedious, so that the centre is the last place that separates. In 
pretty broad exfoliations, long before the centre has gone through 
the operation, the living parts perform their office, in producing 
granulations from the surface, and continue, in proportion to the 
waste, to fill up the space. When the dead part is wholly loose,'it is, like 
all extraneous bodies, pushed up to the surface. It often happens 
that the granulations ossifying, the exfoliation is locked in at the 
edges, thus giving it the appearance of internal exfoliation. Thus, 
w'hile Nature is busied in getting rid of that part of the bone which 
is dead, she is laying on additional bone on the outside, the intention 
of which seems to be that of keeping up the strength of the bone, 
which would, without this addition, be lessened by the loss of sub- OF THE DISEASES OF BONES AND JOINTS, ETC. 
293 
stance. This opinion is, I think, supported by this circumstance 
seldom occurring in this manner in any bones but those of the lower 
extremity, which support the animal. If this is true, it is a curious 
process, by which Nature endeavours to support the strength of 
these bones during a loss of substance, by throwing on the outside 
bone in proportion to the loss of substance within. Nor is the 
process by which this adventitious bone is afterwards removed less 
curious, and the piece of dead bone set at liberty ; for from all that 
living bone adjacent to the dead piece, granulations arise, which push 
up the dead piece against the upper sides of the cavity; and in con- 
sequence of this pressure against the newly formed bone, the 
absorbents are set to work to remove it, and in proportion as this is 
absorbed the piece is pushed out, the granulations filling the space 
behind it. That in the separation of a dead piece a part is absorbed, 
I think is very evident; and that there is a loss of substance at the 
time of separation is obvious from this circumstance, that if a cir- 
cular piece is taken out of the skull, and the circular edge of the 
remaining bone has its life destroyed by the actual cautery, to any 
distance, this deadened part will separate and come away, which it 
might not be able to do without a loss of substance between the living 
and dead bone. Another proof of the loss of substance in this sup- 
posed case is, that the side of the circular piece which is separated 
will retain its spiculte, while the edges of the remaining bone, so far 
from corresponding with them, are quite smooth. Now, as there 
is room in this circular hole to allow the ring of bone to come out, 
its regularity cannot be the effect of new matter added between the 
spiculae, but is in consequence of the absorption of those spiculse. 
It appears from this last supposed case that it is my opinion that the 
absorption is of the surface of the living bone; but I by no means 
wish to be understood that no absorption of the dead piece can take 
place ; for, on the contrary, I believe that Nature sometimes finds it 
necessary to the completion of her process ; it generally takes place 
when the separation is slow, and the granulating process is quick. 
This absorption of the dead bone takes place in the fangs of the 
shedding teeth. [See note, p, 50.] 
The first appearance of separation is an alteration in the part 
round the exfoliating piece. This alteration is first a sponginess ; 
next, its becoming fuller of little holes; then a small groove is pro- 
duced, a kind of worm-eaten canal about the thickness of a shil- 
ling, becoming gradually deeper and deeper : and the depth is irre- 
gular, according to the extent of the original cause. The small 
holes appear at first in the surrounding parts, and these appear more 
vascular, the more so the nearer the diseased bone. Sometimes 
parts become dead without any change of colour, dying almost 
suddenly, perhaps by exposure or a blow, and the surrounding part 
becomes spongy ; the dead portion then looks the soundest; but 
when killed by previous diseases it is black. It is astonishing to 
see what little curiosity people have to observe the operations of 
Nature, and how very curious they are about the operations of Art. 294 
HUNTER'S PRINCIPLES OF SURGERY. 
Aftei' exfoliation, the living surface still continues soft until bone 
is formed. If it be a cylindrical bone, it has the appearance of a 
foetus's bone deprived of its epiphysis: it is hollow, but fills like a 
growing bone, in every respect, by bony matter deposited. Hard 
bones exfoliate quicker than soft, and the harder parts of soft bones 
sooner than the soft: the bones of full-grown people sooner than 
those of the young.* If you lay a hard bone bare to any extent, it 
always dies, but not always if the soft ones. Situation has the 
same effects as in other diseases: in the foot or leg it is slower than 
in other parts less removed from the centre. In exfoliations we 
often find considerable pulsations in the matter, lying in a hole 
which communicates with the granulations, which are formed under 
the exfoliating bone; sometimes it is hardly perceptible; this will 
depend much on the state of the. granulations, their health, fulness, 
&c.; if all these are joined, the pulsation is very considerable : also 
according to the proportion which the size of the hole bears to the 
granulations underneath. After trepanning, the whole expansion 
of the arteries of the brain becomes visible, by being seen at one 
point: so it is with granulations, when the quantity is considerable 
in proportion to the hole. This depends on mechanical principles ; 
so it is with mercury in a thermometer; we see it rise when in the 
stem, while in the ball it would be invisible. 
Exfoliation from accidents,-as from a blow, which is often of 
sufficient force to kill a sound portion of a bone, as in compound 
fractures, gun-shot wounds, at the ends of bones after amputations, 
&c., all of which do better than when it arises from diseased parts, 
the common processes of separation being carried on more vigor- 
ously. 
Exfoliation from Disease, as Caries.-Disease is often carried so 
far as to produce death in a part of a bone, and exfoliation is often 
very salutary, but not always so. Surgeons have endeavoured to 
cure a diseased bone'by killing it: but this is often not so salutary 
as when it is spontaneous; for in the latter the whole diseased part 
generally dies; but it is often the contrary, or partial, when 
it is produced by art. The actual and potential cautery have 
been used for this purpose, and the practice probably arose from an 
idea that all diseased bones were disposed to separate by exfolia- 
tion, and that this would hasten it; but exfoliation is not, as has 
been supposed, a necessary consequence of disease in a bone, but 
it is the death of the bone which makes exfoliation necessary, to 
separate the dead piece. Now caustics neither hasten the process of 
separation either here or in soft parts ; but the actual cautery, 
indeed, often has the power of inflaming the living surrounding 
parts, which invigorates and stimulates them to what they were 
* [The great attention which Mr. Hunter bestowed on all matters connected 
with diseases of the bones entitle his opinions to the greatest respect. Believing, 
however, that the bones afford no exception to the general principle, that the 
actions of parts are vigorous and rapid in proportion to their vascularity, I am 
compelled to dissent from the fact expressed in this paragraph.] OF THE DISEASES OF BONES AND JOINTS, ETC. 
295 
before incapable of, its use in this, and its superiority to the poten- 
tial cautery not being commonly known. When the actual cautery 
can deaden the whole diseased part, a cure may be expected ; when 
art is to be used it is uncertain, as the quantity of disease in a bone 
can seldom be known : however, at times it may be guessed at, and 
as the seat and thickness of the bone vary, the cautery must be 
varied also. If the bone is diseased deeply, the cautery should be 
much heated, and very thick, so as to retain its heat longer: but 
these means are often insufficient, and the disease goes on teazing 
the part a long time, particularly in the lower extremities. In cau- 
terizing, it is better to burn beyond the diseased part than not 
enough. But its frequent failure has occasioned the use of it to be 
much laid aside. 
Situations of Exfoliations.-There can only be two species of 
exfoliations, viz. external and internal; but they are often mixed, 
and then admit of a third kind, which I call the inclosed exfolia- 
tion. The external arises from internal causes, and is in many 
parts a simple operation, meeting with no obstructions, as in the 
head, ribs, &c. But in the extremities it is often complicated, and 
becomes inclosed, and then appears as an internal exfoliation. 
Internal Exfoliation.-These less frequently arise from accidents 
than the former ; but may arise from the two last suppurations of 
bones. The part which is to be exfoliated loses its life, and ulcer- 
ation goes on in the internal surface of the surrounding living bone, 
to make room for the exfoliation. 
In internal exfoliations a part of the centre of the bone becomes 
dead, while the enlargement of the cavity lessens the substance of 
the surrounding part, and consequently weakens that part. But 
Nature washes to furnish a substitute ; for the stimulus of weak- 
ness being felt, the surrounding parts become affected, and undergo 
the ossific inflammation, by which the bone is thickened ; and 
this continues in proportion, and as long as the internal part is 
unremoved, or not cast off. 
Mixed Cases of Exfoliation.-The first is when an external one 
appears to be internal; the second is an exfoliation of the whole 
thickness of the bone in one part; the third of the whole bone. 
These I call inclosed, or incased exfoliations, generally occurring 
in the lower extremities. These three being different at first, are 
not very easily conceived. 
First species of Inclosed.-Sometimes when the surface of a 
bone becomes dead, before the separation of the piece of bone 
takes place, the ossific inflammation comes on, and entirely covers 
the exfoliating piece, leaving only a little hole for the discharge of 
matter. This takes place, first, when the periosteum is inflamed, 
and the granulations from the edges of the exfoliated pieces also 
ossify; but the process for freeing the portion of bone has been 
described already. 
The second species is when a piece of any given length becomes 
dead throughout; the appearance of internal exfoliation is here 296 
HUNTER'S PRINCIPLES OF SURGERY. 
still stronger than in the last case. Exfoliation or separation begins 
on the living surface of contact, at the two ends of the dead bone 
or piece, and ossific inflammation comes on in the surrounding 
parts, so that it becomes incased. This rarely happens, but when 
it does, the separation of the exfoliated piece is very tedious, as the 
stimulus is given to all surrounding parts. 
The third species is where the ossific disposition takes place in 
the soft parts, from end to end, and the whole becomes inclosed in 
a case of bone. The difficulty lies in conceiving how it becomes 
inclosed at the ends where the joints are constituted; but probably 
it is from these ends being alive, and exuding coagulable lymph 
from their surfaces, or else from lymph being exuded from the 
surrounding ligaments, and that becoming a basis, so as to keep 
the joint complete. 
Of extracting Exfoliated Bones.-As it is uncommon for parts to 
heal before the exfoliated pieces are extracted, or if they do heal, 
not to break out again, their extraction becomes proper, if practi- 
cable ; but this is often difficult in many cases, from the situation, 
as also from the obscurity respecting the real circumstances, of the 
exfoliated piece : but in internal and in the incased kinds it becomes 
still more difficult, even though all the circumstances attending the 
exfoliated piece were known perfectly. The surrounding soft 
parts render many things respecting bones obscure; but wherever 
the bones are found loose and bare, attempts should be made to 
remove them. 
The pressure of a probe on a piece of bone will generally satis- 
factorily inform you if the part is detached, by its mobility. If 
detached, we may often gain time by removing it, and in general 
this is proper and the best practice. If it does not allow of a 
removal from its extent, it is best to break the exfoliated part into 
pieces: though it may be often difficult to ascertain this, as the 
edges are often covered with surrounding soft parts. The internal 
exfoliations, and also all the mixed species may be often assisted : 
but the difficulty lies in ascertaining the state of the incased piece, 
without which little can be done, nor should much be attempted. 
In the internal and mixed, which are not only covered by soft 
parts but also living bone, it will be difficult to ascertain. In mixed 
cases it may be evident that exfoliation has taken place, and is 
incased by bone; and for such, a dilatation must in order to expose 
some of the living bone. The next thing is to separate the dead 
bones; probably some of the living bone must be sawed through, 
(the best saw for which purpose will be one in form of an axe,} 
to allow of the extracting the dead pieces and such living parts as 
are broken off, which often happens; or the dead must be broken 
into many pieces. Both these I have done, as I will illustrate by a 
case. 
A young gentleman had an abscess form about the middle of the 
arm; when this was opened, the bone was found bare. It was 
opened in two places; first, on the outside of the arm above, and OF THE DISEASES OF BONES AND JOINTS, ETC. 
297 
next on the inside below. The openings did not heal, and the bone 
could plainly be felt at both. He had been in this way some years, 
when he came to London. On examining the parts I could plainly 
feel the bone with a probe, and move it upwards and downwards a 
little, but at the extent of each motion it seemed to be fast. It was 
plain that the bone should be removed, if possible ; but how was it 
to be done? I chose to expose the bone at the upper and outer 
orifice, this being less engaged with the nerves, vessels, &c., and 
also being more convenient to operate upon. An incision was 
made on the bone downwards and forwards on the outside of the 
biceps flexor; the end of the exfoliation was exposed, as also the 
upper part of the bony case. I followed this downwards and 
obliquely inwards, and when I had exposed the whole, I sawed it, 
in the direction of the exfoliated bone, to the exfoliation itself; but 
as this did not open so as to allow the disengagement of the bone, 
I put in the spatula to force it open, but could not; however, I did 
it in part, so as to get a wedge of wood into the opening, which 
kept its position. The next time I forced it open a little more, and 
pushed in a thicker wedge, and in two or three trials more I was 
able to bring out the exfoliated bone. It was a piece of the middle 
of the os humeri, about three inches long, and of its whole thick- 
ness. 
Of Rickets, or the Constitutional Defects of Bones.-This com- 
plaint would appear either to be a fault in the general constitution, 
or in the principle of the formation of bones themselves ; but as it 
is peculiar to one class of constitutions, which are all weak ones, 
it might be thought to arise from weakness. If weakness is neces- 
sary to produce this disease, it must be one attended with a peculiar 
disposition. And this is probably the case; for we can hardly 
suppose that such a disposition in the bones could produce this 
species of constitutional weakness. However, as it is a weakness 
attended with a disposition of a particular kind, it is possible it may 
arise from this fault in the bones, so far as the constitution sympa- 
thizes with the state of the bones. It is of a particular kind, as all 
weak people are not affected with it. This peculiarity of disposi- 
tion, I suspect, is somewhat of a scrofulous nature, at least the two 
effects are often found in the same subject, whether the causes are 
the same or not. It would appear to be a want of power in the 
bones, or of disposition in their vessels, to form calcareous earth 
and animal matter, but less of the last than of the other. It is most 
common in young subjects, and is generally attended with enlarge- 
ments, and the bones often bend from the incumbent weight. From 
the increase of size in growing subjects, it would appear that the 
propei' quantity of earth is the cause of the limitation of size of 
bones, or that the bone has a greater freedom of growth when not 
checked by a due quantity of earth or its own solidity. This is 
more perceptible in the joints, as they are there softer than in other 
parts, and hence these parts are most subject to this disease. It is 
only in young and growing bones that this increase of size from the 298 
HUNTER'S PRINCIPLES OF SURGERY. 
deposition of the two substances can take place, it being only an 
effect; but a full-grown person may be rickety without any increase 
of size, their bones not admitting of it. The definition of rickets, 
then, is a deficiency of earthy matter in growing or full-grown 
bones. In the adult we see the bones bent by the action of the 
muscles. 
But the cause in the adult is different, it being a disposition to 
remove what is already formed and deposited by absorption ; how- 
ever, a disposition to absorb would appear very different to a want 
of disposition to deposit, and may probably arise from a very 
different remote cause; for though the effect is similar, yet I can 
conceive both to have the same original cause. If a softening of 
the bone is to be the disease, it is only taking place by two differ- 
ent means ; for as there is probably a constant replacement of the 
earthy matter, this disease may arise in adults from a want of 
power or disposition to supply the place of that which the absorb- 
ents remove. 
Of Rickets in Adults [mollities ossium*'].-The disposition to 
absorb the hard substance of a bone, or the disproportion between 
the process of deposition and absorption, which produces rickets in 
adults, is often in a much greater degree than in young subjects ; 
for in the most rickety child I have always observed some earth in 
the bones, but in adults I have seen the bones become as flexible as 
a tendon almost. In different parts of the bone we find different 
dispositions ; but the disposition of absorption gets the better of the 
ossific disposition in other parts of the bone, or of the disposition to 
deposit earth. 
Of the Effects of Mechanical Pressure and Muscular Contraction 
on Rickety Bones.-The bones are often bent by mechanical pres- 
sure of the body, and by muscular actions, into very peculiar forms, 
* [Mollities ossium differs from rickets in respect of the age at which it occurs, 
being a disease of adult age affecting the whole of the bones, whereas rickets is 
a disease of childhood which is principally manifested in the bones of the lower 
extremities and spine, and but rarely in the bones of the pelvis or upper extremi- 
ties. They agree, however, in this, that when a section is made, the bone is 
found to be more cellular than usual, the cortical part is reduced to a mere shell, 
the cells are filled with a bloody or gelatinous-looking substance, and the defi- 
ciency of earthy matter is such that the bone is easily divided with a common 
knife. Dr. Bostock found in some instances of mollities ossium that the quan- 
tity of earthy matter was not more than one-fifth, instead of being two-thirds of 
the weight of the bone. It may further be observed that the disposition to molli- 
ties ossium is rarely overcome when once formed, but the disposition to rickets 
is generally worn out as children grow up ; and, in proportion as this happens, 
the long hones at the seat of curvature are found to be flattened laterally and 
strengthened on the concave side, where the support is required. Fragilitas 
ossium, depending on the superabundance of the phosphate of lime in old people, 
accompanied with a disposition to ossific deposits in the different structures of 
the body, may be considered as a vice of nutrition of the opposite kind. A re- 
markable case of this sort of ossific transformation of the muscles and other 
structures is preserved in the Hunterian Museum, in which the movements of 
the patient must have been as effectually manacled as by the enchanted wand of 
Comus.] OF THE DISEASES OF BONES AND JOINTS, ETC. 
299 
and often impede the actions of other parts. The joint forms a 
more acute angle than it would in health, and then the muscles get 
a greater power of action. It is most frequent in the back-bone, 
pelvis, and thigh-bones, in the angle made by the cervix femoris, 
knee, tibia, &c. In these it is most frequent, from the two powers 
acting (viz., weight and muscular action). The ribs are made 
straight, or rather bent inwards, by the pressure of the atmosphere, 
so that the child can hardly breathe ; a bad formation of the skull 
will affect the senses; crooked spine will affect the health from 
an alteration in many of the viscera. In the female pelvis many 
dreadful consequences occur in delivery. When a bone has ad- 
mitted of a bias, a disposition takes place on the side unnaturally 
pressed, for a deposition of bone, so that we find a bony substance 
formed there which acts as a prop. 
In the leg the bone is bent forward from the muscular action 
behind. We have seldom these bends in the upper extremities, as 
only one of the powers is acting, viz. that of the muscles : however, 
they are sometimes bent, as an example of which an os humeri was 
shown. In the thigh the curve is generally forwards and towards 
the upper part, as was seen in an os femoris in which Nature had 
deposited a quantity of earth on the concave part. Rickety people 
are generally knock-kneed, from one condyle being less than the 
other; it always is somewhat less, unless in bow-legged people. 
Bow-legged people are in fact straightest with respect to the bones, 
the femur and tibia in them being in a straight line. 
Of the Cure.-The cure is not yet discovered, nor is the prevent- 
ative of absorption in the adult yet known. The original cause 
being the same in both, the treatment should be the same. The 
indication is to give strength and tone to the system by bark, 
sea-bathing, &c.; but these only seem to give general health. 
However, I have the greatest opinion of sea-bathing, bark, and 
chalybeates. 
Of Exostosis.-This is in a great measure peculiar to youth. It 
is an increase of bony matter in particular parts of bones. It is of 
two species : one is local, and may be supposed to be similar to 
many tumours growing in the flesh, and probably may occur in 
any constitution ; the other requires particular constitutions, and 
seems to be constitutionally interwoven with the formation of bones 
in such people. They are principally connected with the soft parts 
of bones, appearing generally at their extremities. When universal, 
the whole soft parts of the bone^ are affected. It sometimes appears 
suddenly, and is of various figures, sizes, &c.; but sometimes it 
comes on gradually and increases gradually. These protuberances 
often swell to a considerable thickness beyond their origin or 
attachment, by which means a small neck is formed. Sometimes 
they have a power of growth within themselves, and do not in all 
cases continue to grow from their origin. Sometimes it affects 
only one bone, at other times almost every bone in the body. It is 
a shooting out of bone from a bone, as the horns of a buck's 300 
HUNTER'S PRINCIPLES OF SURGERY. 
head. It is not the effect of ossific inflammation. The substance of 
the bones in these constitutions is often enlarged in the soft parts, 
as in rickets, which leads me to suppose the same original cause is 
common to the two diseases. 
When near the joints it often produces lameness, and disturbs the 
action of the muscle so as to alter the motion of the joint. The 
cases of a gentleman and lady were mentioned who were subject 
to the former of these processes, which was very troublesome ; the 
lady was evidently scrofulous. 
Cure of Erostosis.-As it appears to be more connected with the 
natural formation of bone than with disease, it is of more difficult 
cure than if it arose from disease; for disease is always producing 
action tending towards a cure. It is hardly ever to be cured by 
medicines either external or internal; but as it is sometimes spon- 
taneously removed, we should endeavour to promote the absorption 
of it, by rousing up this power. If, however, we are not masters 
of this power, and we know of no such, they may be removed by 
art, if this can be done with safety. The situation first should be 
well understood, and the parts covering it well known. The instru- 
ment must be adapted to the kind of exostosis and to the situation; 
the common ones are a saw, cutting pincers, and chisel. First lay 
the part bare, either by removing a part of the integuments, or by 
making the incision somewhat longer than the tumour, so as to 
make more room, after the separation of the lips, for its removal. 
If anything more than skin covers the exostosis, as muscle, it should 
be only divided, not removed. When there is a hard root, and 
deeply situated, a cutting pincers or chisel is necessary; but if 
superficial, as on the tibia, it may be sawn off. I have removed 
them from under the deltoid muscle, and also from the tibia. The 
immediate dressings must be suited either for healing by the first 
intention or by granulations from the bottom of the bone. If the 
first, exfoliation may take place ; but this is of little consequence, 
therefore it should generally be attempted, as it frequently will suc- 
ceed ; and if not, suppuration ensues, and it is easily and speedily 
thrown off. 
Diseased Exfoliations of Cartilages.-Cartilage is a peculiar 
animal substance, and composed wholly of animal substances, 
coming nearer to horn than any other structure. I divide them 
into two kinds : first, such as constantly change into bone at a 
certain age ; secondly, such as do not change into bone, as that 
of the nose, ears, &c. They appear to have but weak powers. 
When there is a fracture, the union is bony by ossific inflamma- 
tion in the cartilages, which change into bone; but in the permanent 
cartilage there is a renewal of its own substance. Sometimes the 
inflammation goes on to suppuration; but they seem to have insuf- 
ficient power to admit of ulceration: yet they may be absorbed 
by the absorbents of other parts; as in white swellings, when 
suppurated, the cartilaginous ends are removed by the absorbents 
on the surface of the ends of the bones that the cartilage covers. OF THE DISEASES OF BONES AND JOINTS, ETC. 
It may be ulcerated in this manner in other joints also; in the knee 
we find all the different stages of absorption of cartilage; granula- 
tions will shoot from under, through the cartilage, and sometimes 
when there is not much matter in the joint, these granulations will 
inosculate and form a bony union. [Preparations of cartilage were 
shown peeling off the ends of bones.'] 
Changes of Cartilages of Joints by exposure.-The only effect 
seems to be that they become softer, which is occasioned by inter- 
stitial absorption, which sometimes proceeds so far as to remove 
the whole and leave the bone bare; a case of which was given in 
the finger after amputation. When the cartilage is exposed, the 
surrounding parts granulate and surround the cartilage like a purse, 
not adhering to it for some time after the wound is healed, for 
cartilages will never heal by the first intention. A woman had 
her arm amputated at the shoulder-joint, with a flap by Mr. Brom- 
field ; and in two years afterwards she died of a fever in St. George's 
Hospital. Upon examination, I found that the cartilage had not 
adhered to the flap, which in that part had a smooth surface; nor 
had any granulations arisen from the surface, which appeared 
unaltered. 
Exfoliation of Cartilages.-The separation of a dead part is 
called exfoliation, for there can be no ulceration of cartilage. 
However, this is very uncommon, as the absorbing powers are 
very deficient in cartilages to remove dead parts. I have never 
seen it. I have seen them black and dead, but then the whole 
cartilage came awray, together with the end of the bone ; therefore 
it could not be called exfoliation of cartilage from cartilage, but of 
bone from bone. But the cartilages are capable of being absorbed 
from the granulations formed under them on the surface of bones. 
The permanent cartilages are just similar in their separation, &c. 
I have seen them separated in sores of the part, as the nasal 
cartilages. 
301 HUNTER'S PRINCIPLES OF SURGERY. 
302 
CHAPTER XIX. 
OF HEMORRHAGES AND ANEURISM. 
Causes of hemorrhage-Hemorrhage : 1st, natural; 2d, diseased ;-arising 
from irritation ;-stimulating styptics to be avoided ;-occurring on mem- 
branous surfaces ;-3d, from wounds ;-checked by contraction of arteries ; 
-artificial modes of checking hemorrhage ;-oil of turpentine.- Coagulation 
of blood ;-stretching of arteries ;-ligature ;-modes of applying it.-Second- 
ary hemorrhage. 
Of aneurisms ;-true and spurious ;-different kinds of each according to 
authors ;-divisions fanciful;-definition of an aneurism.-Cause of aneurism ; 
experiments on coats of arteries.-Situation of aneurisms.-Action of heart 
not the only cause of aneurism ;-local disease in the artery; and want of 
equable support round the vessel.-Natural cure of aneurism from obstruction 
of the artery ;-oedema of the limb -sloughing of the skin over an aueurism. 
-Treatment of aneurism.-Objections of Pott and Bromfield to operations for 
aneurism.-Strictures of the latter on Mr. Hunter's operation.-Necessity for 
early operation ;-improper practice of waiting for the dilatation of collateral 
channels.-Mr. Hunter satisfied of the propriety of his operation ;-arteries on 
which it might be practised.-Mode of operating where a tourniquet cannot 
be applied ;-when it can. 
From what we have said of the blood, it must appear to be of great 
consequence that it should be distributed to every part of the body 
in its due proportions ; but in disease a much nicer proportion is 
necessary than in health. 
Effusions of blood arise from three causes: 1st, from natural 
causes ; 2dly, from disease ; and 3dly, from violence. Of the first 
species is the menstrual discharge. The second kind arises from 
many diseases both constitutional and local: those from the con- 
stitution are numerous, as bleeding at the nose, &c., which often 
appears to be a species of derivation, or the effect of a diseased 
action on this part, as is sometimes the case in piles, where they 
may b„e considered as produced by the constitution ; those from 
local causes may be called spontaneous, as bloody flux, bleeding 
from piles, vomiting or spitting of blood, diseased menses, &c. 
The third proceeds from violence, destroying the continuity of the 
vessels, among which must be classed aneurism. 
Of Hemorrhage from Disease.-At present I shall only speak of 
the second and third hemorrhages, from disease : these I have 
divided into constitutional and local. The constitutional should in 
general be encouraged rather than checked; but the local are next 
to our present purpose. The local arise from two causes: 1st, 
from a peculiar irritation, which can be cured only by quieting the 
irritation; or, secondly, from a species of relaxation, or want of 
power oi' action, in the vessels of the part. The first I have seen 
in many operations, when a new irritation had taken place; as OF HEMORRHAGES AND ANEURISM. 
303 
when the divided vessels had contracted and checked the bleeding, 
they have opened again on the application of a cautery near them. 
The intention of this would appear to be the removal of the extra- 
neous body; it also occurs in many wounds and sores which do 
not secrete good pus, but pus mixed with blood. 
For the cure of this species, instead of styptics, we should apply 
sedatives, the best of which is opium; and sometimes, probably, 
solutions of lead. The effect of these will be according to the 
peculiar irritation. A boy, for instance, had a bloody sore on his 
shin from an accident, for which he first used a common poultice; 
but as it still continued to bleed and not to heal, I ordered a poultice 
made with poppy-head decoction, under which it went on well, and 
soon healed. Nothing affects the system more than too great a 
loss of blood; the body becomes languid and cold, and the heart 
seems disposed to suspend its action, as if a natural method was 
instituting to stop the bleeding, and also to keep the actions of the 
machine proportionate to its power. But J know not what the cold 
sweating is to do. An animal cannot subsist long in this state but 
the constitution will begin to rouse up its actions again; there will 
be a full pulse and seeming strength; but if the weakness is very 
great, this apparent action or reaction of the system does not long 
continue. When the pulse is strong and the body warm, it would 
appear an indication for bleeding; but this is improper, and the 
loss of a small quantity of blood at this time would probably kill 
the patient.* The rising of the pulse in hemorrhage is often an 
effort of Nature to live, and cannot be reduced, although it still 
further increases the irritability of the system. 
Hemorrhage from the second cause always exists in the small 
vessels, and commonly in the membranes of some outlet or excre- 
tory duct, and also in sores which have become in some measure 
like those secreting surfaces. It probably arises from a want of 
disposition to contract. The cure is the same as that from violence 
viz. the application of powdered resins, oleum terebinthinae, and 
other styptics. 
Of Hemorrhage from Violence.-All wounds do not admit of 
union by the first'intention, as when a large vessel is wounded, 
when the second mode of union is necessary. But large vessels 
are sometimes wounded without much harm, which either depends 
on the mode of division, or their situation with respect to surround- 
ing parts. The bleeding from vessels has in many cases a good 
effect, as in fractures, and is then in small quantity; but when 
copious it hinders this salutary effect, as is sometimes the case in 
simple fractures, and commonly in compound. 
The suppression of Hemorrhage is effected by three modes, viz. 
the natural, the accidental, and the artificial. 
* [Dr. M. Hall has amplified on this observation in an able paper in the 
seventeenth volume of the Medico-Chirurgical Transactions, in which he has 
pointed out the dangerous consequences which may arise from mistaking the 
reaction consequent on repeated losses of blood for an indication for further 
depletion.] 304 
HUNTER'S PRINCIPLES OF SURGERY. 
The first is from the contraction of the muscular coats of the 
arteries: this power is one of the natural ones, and the accident is 
the cause of this contraction by its stimulus. It is most powerful 
in the small vessels, as the blood's motion is less in them; but even 
in large vessels it is considerable. I am of opinion that an ampu- 
tation below the knee in most cases would not kill by its hemor- 
rhage, even if left to itself; but this experiment can only be ascer- 
tained by accident- The artery in the thigh of a boai' stopped 
bleeding before the animal was at all weakened, and the carotid 
artery of an ass also stopped bleeding after being divided: but I 
believe that the arteries of most animals have more of this power 
than those of man. It sometimes appears as if this contraction 
was not permanent, but relaxed and contracted at intervals; but 
when vessels repeatedly bleed there is probably a want of contractile 
disposition, for then the whole surface is bloody, and the patient 
becomes very weak from the loss of blood, and often dies. This 
contraction of the vessels can be increased or diminished according to 
circumstances. The first cause of increased contraction is expo- 
sure, which is very evident in operations; for when the wound is 
dressed it will bleed again, and again cease when exposed, so that 
here the contraction must be from exposure. I conceive that 
leeches occasion a free discharge of blood by their having a specific 
power or acting as a poison on the vessels, so as to weaken them 
and prevent their contraction thereby. 
The assistance which may be given to the natural contraction 
is by means of stimulants, which, however, can only affect the 
small vessels; them action is simply stimulating them to contrac- 
tion. Whatever stimulants are used, they will be assisted by the 
power of the vessels and their sympathy with each other. A dossil 
of lint dipped in oil of turpentine, after having first wiped the wound 
clean in order that it may reach the vessel, is the best, and may be 
renewed pretty often. I have seen it immediately stop vomiting of 
blood from the stomach after all other means had failed [see p. 254], 
given internally with white of egg as often as the stomach would 
bear it. In external hemorrhages where it had not the desired 
effect applied externally, I would give it internally: it is the best, if 
not the only true styptic; thus, in a case of nasal hemorrhage which 
nothing would stop, I gave ten drops of oil of turpentine in a 
draught, and repeated it every two or three hours, which entirely 
stopped the bleeding in less than twenty-four hours, and it never 
returned.* 
* [It is scarcely necessary to observe, in the present day, that this eulogium 
on the oil of turpentine is unmerited. Of external styptics, (if any really de- 
serve that name,) a saturated solution of alum is much to be preferred ; and 
certainly no internal medicine has equally acquired the general confidence of 
medical men as the superacetate of lead conjoined with opium. 
The arrest of hemorrhage is attended by the following circumstances : 1st, the 
retraction of the artery within its sheath ; 2d, its diametrical contraction ; 3d, the 
effusion of blood into the cellular spaces between the vessel and its sheath ; 4th, OF HEMORRHAGES AND ANEURISM. 
305 
The second, or accidental, mode is of two kinds: first, the coagu- 
lation of the blood as it flows, not within the mouths of the arteries, 
as has been always described by authors, but around them. This 
can only take place when the arteries can contract a little into the 
surrounding cellular membrane by which the blood is divided, and 
this assists its coagulation; and the pressure of it on the mouths of 
the bleeding vessels assists in stopping the hemorrhage. This dis- 
position can be increased by spongy bodies applied to the mouths 
of the vessels; in some cases lint is sufficient, and flour will assist 
the lint; cobwebs also are useful on the same principle, and the 
process of coagulation will also be increased by agaric, from its 
increasing the surface of coagulation, as well as by its pressure on 
the vessels ; but these can only be useful in wounds of small vessels, 
where the circulation is slow, so that the blood can coagulate, 
and are improper in wounds of the larger vessels. The tourniquet 
may be applied here, but it should not be twisted too hastily. 
Another mode arises out of the natural, and may be considered 
in some degree as natural. It is a property in flexible bodies to have 
their diameters contracted as they are lengthened ; in arteries this 
might be carried to a great degree when permanent effects are to 
be produced. It is necessary that they should be lengthened so 
much as to destroy the contractile power; for this is the way 
Nature takes to stop the bleeding of ruptured vessels. Thus we see 
that arteries which are lacerated will more readily stop bleeding 
than if cut with a sharp instrument, as was proved in the case of 
the miller related by Cheselden; and this is the way Nature takes 
to stop the bleeding of the navel-string in beasts. Surgeons do not 
take advantage of this; but farriers and gelders do, as their practice 
of tearing the artery through in gelding animals shows.* 
the formation of a eoagulum or plug within and around the vessel ; 5th, the. 
effusion of lymph; and, lastly, the contraction and obliteration of the cavity of 
the vessel to the next principal branch, and its final degeneracy into a ligamen- 
tous cord.] 
* [The principle of torsion, as practised by several of the French surgeons, is 
precisely the same as that which is here laid down in respect of lacerated 
arteries ; that is, the extremity of the artery is drawn to a point, and does not 
return to its original calibre, in consequence of the destruction of its elasticity. 
We may also further add, that the rupture of the internal and middle tunics, 
which generally happens on these occasions, will tend to occlude the mouths of 
the vessels still more completely by entangling the blood among the lacerated 
fibres and promoting its coagulation. But how far the first of these effects, or 
the obliteration of the calibre of the vessel, depends on the destruction of any 
vital property, as of muscular contractility, may well be questioned, since the 
same effect takes place on dead arteries when similarly treated. 
A preference is given by some surgeons to this means of arresting hemorrhage, 
inasmuch as it obviates the necessity for ligatures, and does away therefore 
with one cause of obstruction to union by the first intention. Torsion, however, 
is objectionable : 1st, because it cannot generally be depended on where large 
arteries are concerned ; and 2dly, because it requires a considerable isolation of 
the vessel from the surrounding parts, and sometimes leads to a sloughing of 
the extremity of the artery, which must operate as a much more dangerous 
foreign body in the wound than a simple ligature.] 306 
HUNTER'S PRINCIPLES OF SURGERY. 
Of lateral Wounds in Arteries.-The lateral wounds in arteries 
are commonly, though improperly, called false aneurisms, on 
account of the formation of a tumour with pulsation; it having been 
supposed that only the external coat of the artery had been wounded, 
and that the internal had given way in consequence of having lost 
the support of the external coat; but the fact is that the blood 
escapes into the cellular membrane, and, coagulating there, forms 
a kind of sac, cutting off all communication with the other cellular 
membrane, and, assisted by external pressure, may stop the bleeding 
foi' the present; nay, the wound may heal up by the first intention; 
but by constant and increasing pressure, the surrounding cellular 
substance, containing the blood, by degrees gives way and forms a 
perfect cyst. These may be divided into two stages; first, while 
the case is yet recent; secondly, when the cyst is formed. 
The first of these will either kill or come to the second, if not 
operated upon; after which, if the operation is not performed, the 
patient must die; therefore it is best to perform the operation as 
soon as possible, as the second will also kill if not operated on. In 
the first stage, then, if possible, the artery should be taken up. The 
operation is very simple: first apply the tourniquet, then lay the 
artery sufficiently bare, and tie it above and below the wounded 
part; the part included between the ligatures will, when it becomes 
dead, slough off, therefore does not require to be cut out. The liga- 
ture should be first made on that side of the artery next the heart, 
and the tourniquet then slackened a little, to satisfy the surgeon of 
its safety; afterwards the whole should be dressed as a recent 
wound. 
Of the artificial Means of stopping Hemorrhage.-The method is 
to stop the mouths of the bleeding vessels; but this is often very 
difficult, on account of the vessels being hid by being deeply-seated, 
and is made more so by the continuation of the bleeding, especially 
in a part where a tourniquet cannot be applied. I shall consider 
the artificial means employed for this purpose under two heads : 
1st, chemical; 2d, mechanical. The first acts by destroying the 
natural texture, and of course the life, of the mouth of the vessel. 
The most powerful of these is heat, viz. the actual cautery, which 
should not be too hot, nor should it indeed be used at all unless 
other means fail. It acts by drying and coagulating the blood, and 
destroying the life of the part to which it is applied.* The iron 
should be thick, not too short, as large as the part will admit of, of 
a reddish heat or approaching to it. Concentrated acids have been 
applied with success, and whatever assists in coagulating the fluids, 
as ext. saturni; and I have sometimes thought of trying boiling 
water. 
The mechanical method of stopping bleeding is by compression, 
and is the most secure : we therefore have recourse to it when 
* [Besides this, the actual cautery corrugates and shrinks the animal textures, 
by which the bleeding orifice is obliterated. A similar but less powerful effect 
s produced by the mineral acids.] OF HEMORRHAGES AND ANEURISM. 
307 
every other means has failed. It consists in inclosing the vessel in 
a ligature. The spasms and convulsions which appear after ope- 
rations, have been attributed to the nerve being inclosed with the 
artery in the ligature; but this seems false, it being only in parti- 
cular habits that such symptoms occur, patients more generally 
recovering after the use of the ligature with no bad symptom than 
otherwise. I have sometimes tied nerves on purpose along with 
the artery, particularly along with the radial artery in amputations 
of the fore-arm, and never observed that any bad symptom suc- 
ceeded.* 
There are two methods of applying the ligature, viz. the needle 
and the tenaculum ; the last cannot be employed on all occasions, 
only under particular circumstances. But the needle admits of 
application on almost all occasions. It has been objected to as 
taking up surrounding parts ; but this is essentially necessary in old 
persons, where the arteries have lost their elasticity. An artery in 
the centre of a muscle should be taken up by the needle. The 
tenaculum should only be employed where we have sound arteries 
to deal with, and when these are situated in the interstices of mus- 
cles. If the artery is in the substance of a muscle, the tenaculum 
would take in more of the surrounding parts than a needle would 
do, and the lisature will be less secure. I think the ligature should 
be larger than it generally is made : the proper tightness is not 
easily ascertained ; but it should be drawm more tight in proportion 
to the bulk of the parts inclosed. The degree of force used in this 
case would cut through the artery alone. The size, consistence, 
and roundness of the artery, and quantity of surrounding flesh, 
must direct us in the force which is necessary to make the ligature. 
The thicker' the ligatures, the greater surface they compress. In 
small arteries the ligature need not be tight, slight compression 
answering the purpose. 
Of secondary Hemorrhage after Operations.-This happens more 
particularly to the large vessels, and generally occurs a few days 
after the operation, owing to some circumstance or accident there- 
in : the ligature not having been made tight enough, or else too 
tight; or from much surrounding parts being included, and some 
of these ulcerating, the ligature gives way. If there is not a loose 
tourniquet about the limb, the patient may soon bleed to death, or 
the bleeding lays the foundation of future disease, as lingering 
* [It can scarcely, I imagine, be necessary to warn the reader against so 
slovenly a practice, which may be attended with the most painful and dangerous 
consequences. In every case it is desirable to secure the extremity of the vessel 
as distinct from the surrounding parts as possible, which will not only lessen 
the irritation, but be the best security against the occurrence of secondary 
hemorrhages. 
The ligature should be of as small a size as possible consistent with strength, 
and be drawn with sufficient strength to cut through the internal tunics, which 
will then heal as incised wounds in other situations : but an artery which is 
diseased or inflamed becomes brittle, and will not bear the same strain as a 
healthy vessel. HUNTER'S PRINCIPLES OF SURGERY. 
308 
weakness or dropsy. This secondary bleeding is very difficult to 
be stopped, especially when granulations are formed, as the artery 
at the bleeding part cannot be seen. However, an anatomical 
surgeon will not be at a loss to know the situation of the vessels ; 
but admitting this, even then, the taking up an artery far above 
the surface of the wound will be a considerable operation. It will 
be right however, especially if the extremity of the artery be sup- 
posed to be diseased, to lay it bare above the diseased part, and 
then take it up where it is sound. 
A. B. came into St. George's with a white swelling, for which it 
was thought necessary to remove the limb. Instead of granulations 
ulceration came on: the artery bled at times; but before any one 
could come to his assistance it would stop : at length, however, the 
bleeding was so great that he was considerably weakened, and soon 
died. Upon examining the limb the artery appeared sound, till we 
got within an inch of the stump, when it appeared black, and seemed 
to have lost its elasticity: the circumstance of the bleeding stopping 
and returning again, I am inclined to attribute to the patient's being 
low and faint at the time he was losing the blood, but returning again 
on the recovery of his strength. In these cases a diseased artery 
should be suspected ; and I think it would be best to dissect for the 
vessels, and see whether it be so or not, and if found diseased, to take 
it up in a sound part. It is recommended by some surgeons to make 
a strong compression on the stump, which may be done by means 
of a thick pad, covered over with tin, and applied to a screw tour- 
niquet, to preVent bleeding; but I would observe that the long 
pressure of the tourniquet is painful and inconvenient. Exposing 
the stump to cold air will at times stop the bleeding. These second- 
ary bleedings as far as my observation goes, happen oftener to the 
radial and ulnar arteries than any other. The artery not healing 
by the first intention may be attributed to various circumstances, 
as ossification, extreme weakness, or the neighbourhood of a con- 
siderable branch. 
Of Aneurisms. 
The injuries and diseases of arteries, called aneurisms by authors, 
are so various as to render it impossible to give a definition of them. 
They have been divided into true, and false or spurious aneurisms. 
The true, by Le Dran, are divided into three kinds, and Heister 
multiplies the division greatly. Le Dran's first is a regular dilata- 
tion of the coats of an artery; 2d, where one coat has given way, 
and the other coat, unable to sustain the force of the circulation, 
allows itself to be dilated ; the third is a mixture of these two. 
The false are numerously divided by Heister and others : one is a 
true aneurism burst; another is a wound in an artery, which will 
produce various effects according to the treatment, all of which OF HEMORRHAGES AND ANEURISM. 
309 
are called so many aneurisms ; but I do not consider a wound in 
an artery an aneurism, even if an aneurism itself. Heister gives 
us the size of aneurisms as described by authors, which is only 
showing us the ignorance of those authors in allowing them to 
come to such a size before the operation was performed; but I 
wish never to see one that can be made the subject of an operation 
largei' than a walnut before it is operated on. I have already 
shown that a wound into an artery is not an aneurism; so that I 
conceive there is only one disease which is properly to be called 
an aneurism, viz., the first, or true : nor is this divisible into 
different kinds ; the second kind is only ideal; and the third is the 
consequence of one part of the sac giving way sooner than another. 
By an aneurism, then, I understand the dilatation of the coats of 
an artery, arising probably either from disease or accident, pro- 
ducing weakness, which becomes the remote cause, while the force 
of the circulation is the immediate cause. It probably may also 
arise, however, from a disproportion in the blood's motion, and. then 
the disproportion between the force of the circulation and strength 
of the artery is both the remote and the immediate cause ; but this 
is probably only in the larger arteries, where the force is greatest. 
However, whatever may have been either the remote or immediate 
cause, it must in fact in all cases arise from a disproportion be- 
tween the force of the blood and the strength of the artery, the 
coats being weakened so as not to be able to support the force of 
the blood in its passage along its canal, which therefore gives way. 
This weakness of the coats of the artery would appear, in most 
cases, to depend on disease ; for accidents, cceteris paribus, have 
generally the powers of recovery. As a proof of this, I will relate 
an experiment made to ascertain the truth of the existence of the 
mixed kind, which was supposed to arise from a partial destruction 
of the coats of an artery, and that the remaining coat being too 
weak to sustain the force of the circulation, gave way, and dis- 
tended. That the artery might have the full force of the blood's 
motion, I chose the carotid artery, as being near the heart. 
One of the carotid arteries of a dog, for an inch in length, was 
laid bare, and its coats removed, layer after layer, until the blood 
was seen through the remaining transparent coat, and I had gone 
as fai' as I dared ; I then left the artery alone for three weeks, 
when I killed the dog, expecting to find a dilatation of the artery, as 
had been asserted ; but to my surprise the sides of the wound had 
closed on the artery, and the whole was consolidated to and over 
it, forming a strong bond of union, so that the whole was stronger 
than ever. 
Mr. Cruickshank has, I think, produced an experiment in oppo- 
sition to mine, where, after the artery was denuded and thinned, 
the parts surrounding it were kept from uniting with it, and an 
aneurism formed : but this experiment does not apply here ; for in 
what instance could such an alteration be made in the artery, and 
the surrounding parts not unite to it ? So that the blood's motion 310 
HUNTER'S PRINCIPLES OF SURGERY. 
was insufficient to produce the proposed effect. The force of the 
heart, however, has some power in operating as a remote or first 
cause of aneurisms. Aneurisms are most frequent in the largei' 
arteries, as at the arch of the aorta ; and more frequent in the 
second order of arteries than in the third; but they are sometimes 
found even in the fourth or fifth. I have seen an aneurism of the 
arteria pudica where it was passing out of the pelvis, and in which 
we must suppose a previous disease of the artery, as the force of 
the heart is small. The nature of the artery contributes likewise, 
the structure of the large arteries being chiefly of elastic matter, 
and not near so muscular as the small ones, which have therefore 
greater powers of resistance. It would appear that there must be 
a specific disease of the artery in most cases, for dilatation is too 
local for so general a cause as the force of the heart. 
As aneurisms have hitherto been allowed to go on till they have 
either destroyed the use of the part, or killed, little has been known 
with regard to their nature or manner of appearance at first. In- 
stances discovered in dissection have given us the only insight into 
their original appearance. In several which I have seen there was 
a pretty regular dilatation of the coats of the artery; but in many 
there was great reason to believe it began at one side. If we were 
to form our ideas of the first formation from the appearance of those 
of long standing, we should suppose the dilatation always began on 
one side; for when we open an aneurism that is very large, and 
examine the internal surface, we find that the coats of the artery 
are commonly still remaining on one side of the sac and not on the 
other; but I suspect that the appearance arises from the dilatation 
going on faster on one side than on the other after the artery has 
been considerably distended, which may arise from the vessel being 
not equally diseased all round, or being more exposed to the force 
of the heart on one side than another, or less supported by sur- 
rounding parts. 
From the knowledge of the greatest force of the heart in the dif- 
ferent arteries, and from the knowledge of those arteries which are 
not equally supported on every side, let us see if we could not, a 
priori, say where the swell would be, if such and such arteries were 
diseased on every side equally, and became considerably dilated. 
First, in those arising from the force of the blood's motion; for 
instance, when an aneurism takes place at the curve of the aorta the 
dilatation is upwards, because it is there that the blood pushes with 
most force, passing in a straight line when in the ascending aorta at 
the fore part, and when in the beginning of the descending at the 
back part. When in the carotids, the swell is outwards and forwards, 
because there is less resistance; in the subclavian, forwards ; in the 
axilla, downwards; in the abdomen and thigh, forwards; in the 
ham, backwards; but in the leg, on which the pressure on the artery 
is equal on all sides, it is difficult to say on what side the swell would 
be, and hence it is that the bones of the leg are so often diseased 
when aneurism happen there, caries or ulceration ensuing when the OF HEMORRHAGES AND ANEURISM. 
311 
dilatation increases to a considerable size. Even in the last-men- 
tioned situation the force of the heart directs, in some degree, the 
swell of the tumour; but that is not until the sac is a good deal 
enlarged. The force of the blood against the most distant part of 
the sac endeavours to carry it on further in the direction of the 
motion of the blood, which in time makes a pouch; therefore it is 
elongated in the direction of the sound artery. The sac often, by 
its increase, presses on the sound part of the artery, and becomes 
the cause of its obliteration, as I have seen more than once. Hence 
the blood becomes irregular in its motion, and has time to coagulate, 
till the sac becomes filled with coagulum, which is strongest and 
densest on its external surface. The coagulation takes place at the 
most distant parts from the direct current of the blood; the firmness 
and colour of the lamina? in different parts of the tumour are such 
that it is easy to distinguish an old coagulum from a new one; the 
external laminas are of a dusty brown colour, and these laminae 
grow gradually redder as we advance inwards towards the current 
of the blood. As the dilatation increases, the coats of the artery 
are either thickened by the thickening process, or the cellular mem- 
brane already thickened becomes firm, and adheres from a con- 
sciousness of weakness. When the aneurism proceeds to this state 
it generally gives way to the circulation. 
It must be observed that the force of the blood on the sides of 
the sac diminishes in an inverse ratio to the increase of its sides,* 
which therefore are longer in dilating than might be imagined; but 
after proceeding to a certain length the adventitious coat gives way, 
and the blood is effused into the surrounding cellular membrane, 
producing distention; and when the artery is a considerable one, 
there is an obstruction to the blood's motion in the collateral branches, 
producing mortification. When the artery opens externally, it is 
always on that side where the artery gives way most. ■ The ultimate 
effect of such events will vary somewhat, according to the situation 
of the aneurism ; thus, if it be of the carotid artery the effusion on 
its bursting will soon occasion suffocation, &c. When an aneurism 
is in an artery whose dilatation brings it to the skin, the coagulum 
comes first, and obstructs the circulation in the skin: the skin 
inflames and mortifies, forming a black slough, which dries and 
adheres to the coagulum. As the slough separates, there is an 
oozing of blood at the edges, which becomes more and more, till at 
last in a large artery, as the aorta, the plug may be wholly pushed 
off, and the patient die instantly. If in a smaller artery death 
will be more gradual. 
* [The author does not seem to have been acquainted with the hydrostatical 
law%f equal pressure contained in the following words; viz., that when a quan- 
tity of fluid contained in a vessel is submitted to compression, the whole mass 
of the fluid and the whole surface of the vessel, however large, is similarly and 
equally affected : consequently the enlargement of the sac can make no diffe- 
rence as to the quantity of pressure which any given portion of that sac has to 
sustain. See Arnott's Physics, Vol. I., p. 242, 4th edit.} HUNTER'S PRINCIPLES OF SURGERY. 
312 
Of the Method of Treatment, with the Opinions of Messrs. Brom- 
field and Pott.-This disease, if not attended to, is as dangerous as 
any that can affect the human body, because it is such as must 
always, even in the smallest arteries, kill; for as it arises from 
disease, the artery has neithei' the disposition nor power to relieve 
itself. Death must therefore be the consequence, eithei' from the 
bleeding, or the consequences arising in the parts into which the 
blood is effused. Nor does it appear that the artery, either above 
or below the swelling, where it is sound, takes the alarm, or is 
stimulated to action; so that there is no resource, and death is the 
consequence. However, this disease is often capable of removal. 
When increased to a large size it is a very difficult operation; but 
I should wish it to be performed when the tumour is small. Messrs. 
Bromfield and Pott having written on this operation, and their 
opinions being different from mine, it is necessary that I should 
defend those opinions which I have adopted, and which I have 
spread abroad. 
Mr. Bromfield objects to every operation, either amputation, or 
for the aneurism ; this would be just if what he asserts was true, 
viz., that the whole of the arterial system is in general diseased, which 
however is certainly not the case. He says, too, " that the inject- 
ing of parts in dead bodies having shown that in particular subjects 
the branches sent off have now and then formed anastomoses with 
other branches given off lower down, has led to very extravagant 
notions of the smaller branches being always able to carry on the 
circulation; and an extravagant proposition has been suggested by 
some people to tie up the principal trunk of an artery in the extre- 
mities. I once saw an attempt of this kind in a true aneurism of 
the ham, in which 1 shall only remark that the patient died; and I 
do believe that the embarrassments which occurred, as well as the 
event of the operation, will deter the gentleman" (meaning me) 
" who performed it from making a second attempt in a similar case." 
Now, unfortunately either for Mr. Bromfield or myself, this is the 
very case from which I have formed favourable ideas of the suc- 
cess of future operations of a similar nature. Mr. Pott, after de- 
scribing the disease in its last and most violent stage, just preceding 
dissolution, and when it has done all the mischief it can do without 
destroying the life of the patient, says, " If a man was to be asked 
how the disease was to be treated, he would answer, from theory, 
that the artery should be tied above and below the tumour, and the 
coagulated blood be evacuated; but that the artery is generally 
diseased some way above the dilatation, especially the popliteal." 
He also observes, " that the want of collateral branches of sufficient 
size to carry on the circulation is another powerful impediment to 
the operation." 
When the aneurism has arrived at the stage which Mr. Pott 
describes, perhaps the only thing is to amputate above the dilated 
part of the artery: but Mr. Pott should have considered, that before 
these threatening symptoms there is a stage when all the surround- OF HEMORRHAGES AND ANEURISM. 
313 
ing parts are sound. If this be true, would any man allow a disease 
in a part to go on till the surrounding parts are diseased and past 
cure ? 
The events of all diseases are of two kinds : first, where the ter- 
mination is certain; 2d, where it is dubious. The aneurism is of 
the first kind ; its event is certain. Now I do aver, then, that there 
is a stage of the disease in which the operation is safe. I do not, 
certainly, know how to judge of this state from the external appear- 
ance, but from what I have seen of aneurisms, I believe it will allow 
of considerable latitude. My opinion is, that the operation should 
be performed, 1st, when the disease has done no mischief to the 
surrounding parts ; 2d, where it is distinct and circumscribed, not 
connected with parts which may not be curable when exposed, as 
bones; 3dly, when there is a distinct pulsation. How early the 
operation may be performed I do not certainly know, but my opi- 
nion is that it may be done as soon as the aneurism is known to 
exist. By some it has been recommended to permit the disease to 
exist some time first, because, say they, as the circulation becomes 
obstructed, a freer communication will take place between the 
branches above and below; but this would not be until the obstruction 
had subsisted some time, and I would not wait for this, for fear of 
the consequences described by Mr. Pott. 
When the disease is in an advanced stage, I agree with Mr. Pott 
in thinking amputation necessary and preferable, but not under the 
circumstances above mentioned. The earlier, therefore, the opera- 
tion for the aneurism is performed the better, not waiting with the 
expectation that an increased size of the aneurism will produce an 
increased size of the collateral branches. That the popliteal artery, 
according to Mr. Pott, is oftener diseased above the aneurism than 
other arteries, I cannot well determine, but can see no reason why 
it should be so. If the artery, however, cannot be tied above the 
aneurism in the operation, where can it be tied if the limb be ampu- 
tated ? Why not tie it up higher in the sound parts, where it is tied 
in amputation, and preserve the limb? 
The circumstances to be regarded chiefly turn upon the collateral 
branches being sufficient to carry on the circulation. The only 
arteries which admit of this question are the popliteal, femoral, and 
brachial; the other arteries either having a very free anastomosis, 
or being out of the way of any operation. 
In this account it may be supposed that I carry my notions too 
far ; but it is to be understood that I only give my own feelings upon 
this subject, and I go no further in theory than I would perform in 
practice, if patients, being acquainted with the consequences of the 
disease, would submit to, or rather desire, the operation; nor do I 
go further than I now think I would have performed on myself were 
I in the same situation. Not that I would have it supposed that I 
would recommend this at large : I would have no one perform an 
operation that he is not clear about the propriety of himself, espe- 
27 314 
HUNTER'S PRINCIPLES OF SURGERY. 
cially when it requires more anatomical skill than falls to the share 
of most practitioners. 
Of those Arteries which admit the Operation.-These are, first, 
the carotids above the sternum; 2d, any of the branches of the 
external carotids; 3d, the subclavian (after having passed the 
scaleni muscles), and of course its trunk and branches down the 
arm ; 4th, the crural, immediately after having passed Poupart's 
ligament, and given off the large muscular artery. How far it 
would admit of an operation above the giving off of that artery I 
do not know, but I have seen one instance of that branch and the 
vessel itself being obliterated by an aneurism, and yet the limb was 
supplied with blood. 
Some of the branches of some of these arteries which I have 
mentioned will be very difficult of access; therefore, if not in 
parts that will admit of amputation, the patient will be likely to die. 
It will be very difficult to take up the anterior and posterior tibial 
and interosseous arteries, and it will be often necessary to ampu- 
tate, from the difficulty attending taking them up, besides that the 
bone will often be diseased before we discover the disease, and this 
will make amputation necessary. 
If an aneurism should take place in the axilla, I should doubt of 
the propriety of taking up the artery above the clavicle, because I 
should doubt of its being sound. The same with the femoral 
artery, where it passes from under Poupart's ligament; unless the 
aneurism was lowrer down, and I might expect to find the artery 
sound. 
In dissecting tumours from the neck I have frequently laid bare 
the carotid artery; now, if by any accident during the operation 
the artery had been wounded, I should certainly have taken it up 
with a ligature ; or if the tumour had been so engaged with the 
artery that I could not disengage it, I should have tied it above and 
below the tumour, with every hope of success. 
The operation wdl be easiest, both to surgeon and patient, while 
the disease is in its infancy. Although I would perform the opera- 
tion on all the arteries I have mentioned, and if I laboured under 
them myself would have them performed on me, yet I would wish 
every person to judge for himself, and not attempt an operation if 
he is fearful. 
General Observations on the Operation*-In performing this 
* [It will be observed that the operation Hunter here describes is not the one 
which goes by his name, but that which was usually practised previously to the 
general adoption of the Hunterian operation. The first case in which Mr. H. 
operated according to the latter method occurred in December, 1785, rather more 
than a twelvemonth before the delivery of this lecture ; and he did not as yet 
feel sufficiently sure of its superiority to the generally received method to recom- 
mend it strongly to his pupils for their adoption. 
I gladly avail myself of this opportunity of referring to Mr. Guthrie's able and 
elaborate exposition of this department of surgery, in his work " On the Diseases 
and Injuries of Arteries," in which the extent and accuracy of Mr. Hunter's la- 
bours are set forth with great judgment. The Hunterian operation for aneurism OF HEMORRHAGES AND ANEURISM. 
315 
operation the first attention should be paid to preventing the flowing 
of blood during its performance, which alone leads to two methods 
of performing it: 1st, where the tourniquet can be applied; 2dly, 
where it cannot. 
Where the tourniquet can be applied, this should be first done. 
In the next place make a longitudinal incision in the course of the 
tumour, of greater extent than the tumoui'; cut gradually into this, 
scoop out the coagulated blood, and sponge the inside of the sac ; 
we should then slit up the sac, to discover the openings of the 
arteries into it. The inferior orifice will be most readily discovered, 
as it will throw out some little blood of a venous appearance. To 
discover the superior orifice the tourniquet must be slackened ; the 
artery then should be tied, at least an inch from the sac, at the 
superior part; but it is not necessary to observe this rule with the 
inferior part. 
When a tourniquet cannot be applied between the heart and 
aneurism, as in the carotids, an incision is to be made through the 
integuments ; the sac is to be laid bare, but not opened ; the artery is 
to be searched for, and tied above and below on the sound part. 
The sac is then to be opened, and the coagulum scooped out; and 
after being cleansed and spunged, the sac may be left to slough, 
and the wound dressed as other fresh wounds. 
The blood which comes from the lower orifice has become dark 
by stagnation, oi' slow motion: hence also the dark coloui' of blood 
when an artery is wounded below, while the tourniquet is applied, 
the blood not being venous, as some have thought, but arterial, 
which has taken a retrograde course. I believe we should not be 
anxious about the collateral branches ; I have lost several advan- 
tages from this mistaken delicacy. I believe the circulation will 
always go on after the femoral artery is secured by ligature. 
Cases of Aneurisms.-1st, a young man had for two years a pain 
in the calf of his leg, similar to cramp ; at length he received a 
blow in the ham, and a swelling, with pulsation, appeared soon 
after. I gave it as my opinion that the aperation should be per- 
formed, and if it did not succeed, then to amputate. The operation 
was performed, and the patient apparently was going on well, till 
the fifth day, when the ligature giving way, the artery burst above, 
either from its being tied too tight or too loose. I was now obliged 
was not the result of fortuitous discovery, but of accurate and minute knowledge, 
derived from a laborious investigation of the morbid anatomy of the arteries, and. 
of just reasoning upon the data which he thence derived. The preparations and. 
drawings relating to this subject contained in the museum of the Royal College 
of Surgeons, convincingly show that Mr. Hunter anticipated the greater number 
of modern discoveries, at the same time that they evince the indefatigable zeal 
with which he pursued his researches on professional subjects. By referring to 
the valuable work above mentioned, I shall save myself and the reader a great 
deal of trouble in these notes ; and I am very happy in having the opportunity 
of expressing my acknowledgments to the worthy author. I also beg leave to 
refer the reader'to Sir Everard Home's paper on the same subject, and to the 
remarks in "the Life."} 316 
HUNTER'S PRINCIPLES OF SURGERY. 
to dilate the wound still higher, and take up the artery higher up; 
but, apparently from the loss of blood before the tourniquet could 
be applied, the patient died a day or two after. The leg and thigh 
w'ere both found to be putrid and emphysematous, and that was the 
case even above the aneurism. When I saw this man dying from 
the loss of blood, it struck me as a proper case for transfusion, and 
if I had been in his situation I would have had the blood of a sheep 
or hog transfused into my vessels. I do not know exactly how to 
account for the failure of this operation, whether from the unsound- 
ness of the vessel, or the tightness or the smallness of the ligature ; 
but from the appearance of the limb before the bursting of the 
artery, and the injection of the vessels after death, all seemed 
favourable for the operation. The artery also was sound above 
the part where the first ligature was applied. From these consi- 
derations, I should certainly be encouraged to perform the operation 
again, though this was the case which led Mr. Bromfield to con- 
demn the operation. The second was a case of femoral aneurism 
in the middle of the thigh, in which the operation was performed 
by Mr. Bromfield, jun., in presence of Mr. B., sen., after his publi- 
cation. The tumour was oblong, and extended five or six inches 
in length, and the operation was performed in a short time, and 
with success. In the third, where the operation was performed by 
Mr. Martin for the popliteal aneurism, the patient soon got well, 
and was able to dance. The fourth was an aneurism in the gluteus 
muscle. In cases where the arteries in several parts had the dis- 
position to this disease, or, in other words, where many aneurisms 
were formed, the operation would not be advisable. 
In December 1785, I performed the operation at St. George's 
Hospital, in a case of popliteal aneurism, in a manner different 
from that ordinarily practised, and with success. The particulars 
of this case are given in the London Medical Journal. I would 
only observe, that in future I would advise only tying the artery 
in one part, and not to endeavour to unite the wound by the first 
intention. In that case four ligatures were applied upon the artery. OF SPECIFIC DISEASES, ETC. 
317 
CHAPTER XX. 
OF SPECIFIC DISEASES, TUMOURS, HYDATIDS, ETC. 
Of Ulcers and the causes which retard their cure.-Abscesses.-Specific dis- 
eases.-Irritable and indolent dispositions.-Hypertrophy of parts from 
chronic inflammation.-Varicose veins.-Corns.-Chilblains.-Of the unnatu- 
ral growth of parts.-Preternatural accumulations of fat.-Elephantiasis.- 
Observations on the cure of indolent dispositions.-Tumours.-Encysted tu- 
mours.-Tubercles.-Solid tumours.-Warts.-Polypi.-Tumours in the cel- 
lular membrane.-The removal of tumours.-Tumours of bones;-their 
varieties.-Encysted tumours.-Hydatids.-Cuticular tumours.-Of the in- 
flammation of adventitious substances.-Fistulas.-Fistula lachrymalis.-. 
Fistulas of the buccal glands.-Fistulas of Cowper's glands.-Fistula of the 
parotid gland.-Fistula in ano.-Fistula in perineo.-Cure of Fistulae.-Of 
the treatment of contracted joints.-Of tetanus. 
I come now to speak of what I call specific diseases, but before 
doing so I shall notice the causes which retard the cure of ulcers 
in sound parts. 
These often arise from circumstances not at all connected with 
the soundness of the parts, as their situation, depth, nearness to 
tendons, or vicinity with respect to the heart. The situation may 
make it tedious, though the parts are otherwise strongly disposed 
to heal, which is often the case in deep-seated abscesses ; the nature 
of the parts may retard the cure, as when abscesses are situated in 
parts endued with slow or weak living powers, as bones, ligaments, 
or tendons. In such cases the matter goes a considerable way 
before it reaches the skin, while the superficial parts are more 
disposed to heal than the originally diseased deep-seated parts, so 
that abscesses soon become fistulous. 
The cure depends on removing the obstacle of depth by free 
opening, exposing, as much as the nature of the part will admit of, 
the bottom of the wound, and preventing the healing up of the 
superficial parts ; but this must not be done unless or until the 
deep-seated parts are as much disposed to heal as the superficial, 
so far as respects their natural power, as in cases of exfoliation. 
Many are slower in healing from the nature of the parts themselves, 
as bones ; but the treatment in such indolent dispositions is very 
different from that of acquired indolence ; for in these there is a 
disposition to act, whilst in indolence, which is natural, this is 
wanting. Hence it is dangerous to rouse these parts much, and 
accordingly we find that the mildest treatment is generally the best, 
often employing sedatives to lessen the consciousness of danger, as 
opium, which has often the best effect on parts naturally slow or 
indolent in disposition, as tendons. 
Many sores which go on well at first take on afterwards a 318 
HUNTER'S PRINCIPLES OF SURGERY. 
quality contrary to health. All kinds of sores are subject to this 
change ; but in specific and poisonous ones, the poison must first be 
destroyed before a good disposition can take place. The causes 
of this change of disposition are many, but few of them are visible. 
The most visible is their situation in the body, as in the legs, which 
are far removed from the heart, and where the healing is prevented 
by much walking. The slowness often arises from exercise and 
intemperance, which are first to be attended to in the cure. A 
horizontal posture, with temperance, should be the first thing 
advised in sore legs in general, as removing the accidental impedi- 
ments to healing. 
When sores do not heal, after having removed the above causes, 
some other cause must be remaining, as either an indolent or irri- 
table disposition, or some specific quality, which is frequently to 
be discovered by experiment. If irritable, sedatives are to be used; 
if indolent stimulants ; but if it is not known which of the two exists, 
first try one, and then the other; if neither of these is effectual, a 
variety must be tried till you find that which agrees best. Some- 
times one of these does good for some time and then loses its 
efficacy, the sores becoming stationary, when we must change the 
application. When sores are indolent in healing, there is a sur- 
rounding thickening, but this is seldom the case when healthy 
granulations arise; in such compression is proper; and if walking 
cannot be avoided, then light bandages, and sometimes a thin 
plate of lead, which is also often useful when the granulations are 
loose and there is a disposition to thickening. But these sores are 
very apt to return, which points out some particular remote cause, 
which I will presently describe. The sores of poor people are 
often in a bad condition from bad living, much exercise, or cold, and 
are often mended by rest, a horizontal position, fresh provisions, 
and warmth in hospitals, and the change is generally very speedy. 
Jf they do not soon improve I always suspect that something more 
is operating, as irritability or indolence, when I try experimentally 
different remedies till I pitch on one that is serviceable. 
The surface of the sore will easily discover if there is disease 
beneath, as of the bones or periosteum. If the granulations are 
broader than the disease underneath, the granulations over the 
diseased part are unhealthy, whilst those not so are healthy, and 
heal so that the sore becomes smaller and smaller by the gradual 
contraction of the granulations. 
Sores are often forced, as it were, to cicatrize, but the cuticle is 
not good, and the part removes it, and removes it again and again, 
till sometimes at last it becomes a good one ; at other times the 
cuticle becomes very thick, and irritating the cutis underneath, 
which is very tender, it is then thrown off like a scab, and leaves 
the skin underneath ulcerated. These cases must be treated as 
they were before they wrere cicatrized; that is, they must be kept 
moist, and any cuticle which is unnecessary and thick must be 
scraped off. The medicines that first healed the sore, combined OF SPECIFIC DISEASES, ETC. 
319 
with water, should be applied to the sore ; as, when tar agrees, tar- 
water should be applied. 
Abscesses.-In all abscesses we should consider, in the first place, 
whether their seat is on or in the part at which they appear, for 
often they are abscesses of parts that are distant from that in which 
they appear. Thus, the external appearance of lumbar abscess is 
in the thigh, the loins, or between the ilium and sacrum. Abscesses 
of the liver also make their appearance externally; likewise spurious 
empyema and abscesses of the kidneys, which last often resemble 
lumbar abscesses, although their seat has been ascertained by the 
extraction of a urinary calculus. All these generally pass through 
and between some bands, as tendons, ligaments, or bones, and their 
first passage is small; but the abscess, getting into the cellular 
membrane, spreads, and gives the appearance of a large abscess of 
that part. None of these, however, penetrate so far as the lumbar 
abscess, owing to the position of the body, and the disposition of 
the inflammation having no tendency to set bounds to the spread 
of the matter. 
Treatment.-Little can be done for these cases ; they should be 
opened slightly or not at all. In the lumbar abscess opening is 
often productive of hectic fever, much sooner than if left to itself, 
and consequently death takes place much sooner. But when 
internal abscesses, whether pointing at a distance from the seat of 
disease or not, are likely to heal, as those of the liver, they should 
be opened as freely as possible, in order to know the extent of the 
disease. If they cannot be traced to the bottom, injections may be 
used, as they are apt to become indolent. I have used stimulating 
solutions of caustic, infusion of myrrh, lime-water, and injections of 
decoction of bark. 
Or Specific Diseases. 
I am now to treat of dispositions and actions which are not 
productive of restorative actions ; those which we have hitherto 
treated of, where a salutary disposition is" put on, in consequence 
of violence done to a part, I do not call disease. This is the most 
complicated part of surgery, as it requires a knowledge of sores 
and of every local action that can be in a part: it is the physiology 
of surgery, as a knowledge of the constitution is of medicine. The 
diseased sores alluded to will admit of being divided into local and 
local constitutional; but none are entirely constitutional. The 
first includes many diseases, as cancer, chancre, mortifications, 
and many others, which have simply some specific quality. The 
second, all the poisons and some mortifications. All uncommon 
actions, commonly called diseases, are divided into common and 
specific. The common I have treated of. The irritable and indo- 
lent may be thought improper to be placed among the following, 
which are the specific, because either of them may attend all 
specific diseases; but almost all uncommon actions are in some 320 
HUNTER'S PRINCIPLES OF SURGERY. 
measure specific, all arising from a specific tendency, or suscepti- 
bility, brought into action by some leading cause, and therefore not 
taking on the restorative process as they ought to do. 
Every specific disease must have some peculiar action distinct 
from another. A true specific disease is that which has only one 
peculiar action. Some have many causes, as gout, yet have only 
one specific mode of action; others, as the morbid poisons, have 
only one specific cause. The first is divided into two ; regular and 
irregular. The regular are truly specific, as agues; of the irre- 
gular there are many which show disturbed modes of action, as 
inflammation in scrofulous habits; but these always are very 
imperfect, from the specific action hindering them from going on 
properly. These are the opposite to the salutary dispositions for 
restoration. 
Unsound dispositions may be divided into two classes; such as 
have too much action, and such as have too little action ; or better 
perhaps, into irritable and indolent. The remote causes are many, 
but the immediate cause may be the same in both: few of the 
remote causes are known. Irritable and indolent might be classed 
amongst the common diseases, and not with the specific, as every 
specific disease may be accompanied with them, and all specific 
diseases are generally attended with one of them ; but some specific 
diseases are more irritable or indolent than others, and are also 
different in different constitutions. 
Of the Irritable Disposition.-Irritability is that disposition which 
cannot remain at rest under an injury either in a part or the whole, 
nor can it set about a restorative action. This depends on some 
peculiarity both of the nerves and living principle, for there is often 
much sensibility as well as irritability in a part; or, on the contrary, 
it may be confined to one only. The one would show that there 
is an affinity or connexion between these two principles; the other, 
that this is not absolutely necessary. 
Irritability is of various kinds, but generally may be called 
passive; as even in the most irritable constitution there must be 
some other disease or some violence to bring this disposition into 
action. Thus, convulsions, are induced by tickling the skin. Many 
constitutions are thrown into violent actions from injuries, produ- 
cing irritable inflammation. But all inflammations are not to be 
called irritable; those which are exactly sufficient for restoration 
cannot with propriety be called irritable. 
Irritability is most commonly constitutional, but not evidently so 
altogether, as one part is often irritable, while other parts are not: 
for example, a lady had a vesication on her shoulder, which all 
throughout its action gave amazing pain; yet at the same time she 
had one in the arm which gave very little inconvenience. And we 
find disease producing irritability in parts which were not irritable 
before; therefore it cannot be said to be constitutional altogether. 
Irritable inflammation most frequently arises from injuries done 
to an irritable habit. A local disease may produce irritability in a OF SPECIFIC DISEASES, ETC. 
321 
part, whilst the constitution is not irritable at all; it is then entirely 
local. But the constitution may be rendered irritable from a local 
cause, as in bubo. An irritable disposition is generally known by 
a disposition to inflammation, and that inflammation not termina- 
ting in any crisis. It would appear to be a mixture of the suppu- 
rative and erysipelatous, at least the erysipelatous seems to attack 
irritable constitutions most frequently; but probably the erysipe- 
latous attacks when there is weakness, and erysipelatous goes off 
as in other habits. The effusion and extravasation in irritable 
inflammation is more watery, so that the swelling is rather cedema- 
tous and more diffused; the continued sympathy is very strong, so 
that it spreads often to a very great extent, and sometimes becomes 
universal. In many of the irritable inflammations of the skin, 
excoriation takes place, and the water exudes like a blister. When 
it is local it is very circumscribed, terminating all at once; in 
many cases it cannot be distinguished from common inflammation 
terminating soon, but here the irritability is slight. These often 
terminate in the indolent, as those arising from cold. 
Of the Cure by Resolution.-To cure irritability is extremely 
difficult, as lessening sensibility is more difficult than exciting parts 
when indolent. Whilst the parts are only inflamed, we should first 
avoid every thing which would irritate or hasten suppuration. A 
cataplasm of bread and milk is the most simple resolutive appli- 
cation, and the best till we know how further to proceed. But 
when from any accident there is too much irritability, something 
to lessen susceptibility should be used, as opium in the poultice, a 
fomentation of poppy-heads, or the preparations of lead. However, 
I think preparations of lead may do harm, as they lessen the resto- 
rative power as well as the irritability. 
If suppuration takes place, it should be suffered to go on to the 
true suppuration. Cutting is very disagreeable to these irritable 
parts, for the irritability still remains, and they will not heal kindly. 
Caustics are much better adapted for opening abscesses in such 
constitutions, and should always be preferred, and more especially 
if opium is joined to them, as either with or without opium they 
irritate much less than cutting. The matter is generally of a con- 
sistence little more viscid than serum. There is often coagulable 
lymph on the sore, in which case there is little discharge of pus, 
which is also often the case in the indolent. 
The milder the after-dressings are the better; none is preferable 
to the opium poultice, as they are apt to ulcerate and spread, which 
opium prevents better than any other dressing. When they begin 
to have a healing disposition, a mild cerate is preferable to dry lint. 
Bark internally, as lessening irritability and giving strength to the 
system, is of considerable service, together with the exhibition of 
opium ; but in some we find a treatment directly opposite necessary, 
the mildest dressings giving the greatest pain, whilst warm dres- 
sings, as oleum terebinthinae, give agreeable ease, although at first 
they give great pain in such sores. There is some peculiarity in 322 
HUNTER'S PRINCIPLES OF SURGERY. 
the part which is removed by these stimulants; but unfortunately 
all these fail at other times, and we do not possess a sufficient 
number for the variety of constitutions we meet with. 
Of Indolent Dispositions and Actions.-Local diseases attended 
with indolence produce generally the following effects, viz., an 
increase of the parts diseased, which is of three kinds: 1st, increase 
of growth of the natural parts; 2d, a thickening of the diseased 
parts: 3dly, an entirely new-formed substance. 
The first has no variety; the second is occasioned by adventitious 
matter extravasated and effused into the cells, which I call interstitial 
increase, which will produce two different effects: either general 
swelling, which I call the diffused interstitial; or circumscribed 
increase, which I call the circumscribed interstitial. But the last has 
two causes, and is of two kinds; therefore the first owes its figure 
to the part being circumscribed, the other is from the nature of 
the disease. The third is always circumscribed, which I call the 
circumscribed adventitious. They are often spontaneous in their 
origin. 
Indolent dispositions may be either with or without inflammation, 
and also suppuration; they arise from either a disposition of the 
constitution or part. This is more rare than the irritable, and is 
seldom carried so far. 
Few constitutions are so quiet as not to call forth their powers 
when a part has received any injury. But specific affections may 
sometimes prevent them, and then the common powers have no 
effect; for in lues and scrofula thickened sores are very frequent. 
There may be indolence without any known specific cause; yet I 
suspect that there must be something specific concealed, which arises 
from peculiar constitutions in different complaints, as when tumours 
that are indolent are formed in glands. All constitutions, however 
indolent, are susceptible of inflammation, and very few diseased 
parts are exempt from it; yet sometimes indolent sores are not 
inflamed by the common causes of inflammation, as exposure; 
sometimes, in the irritable, sloughs are formed, which is a cure by 
the disease itself. After indolent parts are once inflamed, they are 
very apt to become indolent again, when the inflammation is removed. 
When indolence is in a diseased part it cannot be totally consti- 
tutional, but sometimes local, as in cancer and scrofula. When this 
indolence takes place in a part, the cause often steals on gradually, 
so that the part is not roused by it. Indolence is natural to tendons, 
ligaments, and bone, and when all these causes cooperate, the dis- 
ease is worse; but indolence may take place in other parts, from 
some visible cause, as in muscles, and skin producing thickening. 
Many thickenings are owing to specific causes, as the induration 
of cancer, venereal diseased glands, sometimes affections of gout 
and rheumatism, and bone is subject to the same disease as in exos- 
tosis. Thickenings of parts are either from visible or invisible causes ; 
the first arise from some external inflammation; the second from OF SPECIFIC DISEASES, ETC. 
323 
some diseased action in the part. The remote cause may be predis- 
position, climate, or way of life. 
Local indolent diseases are generally confined, yet they sometimes 
spread; but here the cause must be more diffused. They spread 
but little, because indolence is but a small cause of sympathy; the 
sympathy is more continued when the sympathizer is of the same 
indolent disposition as the diseased part. Indolence in local diseases 
is attended with an increase of the part, sometimes similar to that 
produced by adhesive inflammation: this effect attends many 
unnatural actions of parts as well as inflammation. The parts swell 
more in this disposition than in the others ; for in this there is neither 
any disposition to suppuration oi' resolution, and therefore there is 
an increase in the thickening disposition. 
The division of this thickening is of three kinds, as before 
observed. The first is most visible in the adipose membrane; the 
second, as before; the third, adventitious, and which forms a 
tumour. The immediate causes are: 1st, a preternatural increase 
of the part itself: 2dly, interstitial increase ; 3dly, the formation of 
an entirely new part. The first consists in an increase in the figure 
of a part, as of a gland, a cell, any whole limb, or other whole part; 
the second is often circumscribed in cellular membrane, appearing 
to be newly formed ; but it is not so, but interstitial, as scirrhus in 
a glandular or cellular part, which becomes loaded with cancerous 
coagulable lymph formed by inflammation: the third is an original 
circumscribed swelling, arising in common cellular membrane, 
skin, bones, &c., and which should be called true tumour. In some 
of these diseased parts another disposition or mode of action, viz. 
ossification, arises; whether from a peculiar disposition arising 
from this disposition, or to increase the strength of the part, I am 
uncertain. The first is most probable, as strength is unnecessary 
where it is generally formed, viz. on the edges, &c. I shall lay it 
down as an axiom that all thickened parts are to be accounted 
new-formed parts, although they may be in original parts. The idea 
of their being all new parts shows why they should be disposed to 
form calcareous earth. 
Thickening, which is generally the first symptom of indolent com- 
plaints, often gives little or no pain ; so that the sensibility is often 
not observed till some time after. The thickening gives so little 
pain as hardly to be communicated to the sensorium: but the heavy 
dull kind of pain afterwards often becomes very disagreeable, pro- 
ducing sickness, which is more peculiar to some parts than others. 
The colour is of no particular kind, which shows a languor of the 
blood in them. The hardness is sometimes so great as to become 
cartilaginous. 
The causes of this thickening are with difficulty assigned. In 
common inflammations there is increased action, and this is proba- 
bly the case in indolent inflammation: but this increased action is 
of a peculiar kind, which may be called indolent inflammation, which 
is a peculiar mode of inflammation. The immediate causes are 324 
HUNTER'S PRINCIPLES OF SURGERY. 
various ; but what the final intention is in most cases is very obvious. 
In common inflammation it is to form adhesions and limit the 
disease, but in the indolent it is to give strength. 
The visible causes of indolent disposition are various. 1st, The 
thickening may depend on a diseased part being accustomed to an 
irritation, till this irritation, losing its power, leaves the part in an 
indolent state and incapable of recovery. Probably all may be first 
ranked under the irritable. 2dly, From effects being produced by 
a disease not indolent in itself, but violent at first, as the gout. 3dly, 
From a slow alteration in structure taking place, in consequence of 
gentle irritation, as gentle pressure, which will take place in every 
part. 4thly, a long application of cold, which produces weakness. 
5thly, Peculiarities in climate; as bronchocele in Derbyshire, and 
swelled legs in Barbadoes. These, and especially the four first, 
have no connexion with the constitution, yet may be assisted by a 
constitutional predisposition. They are seldom very diffusive, from 
their confined sympathy. The first of the first division are most 
frequent in the lower extremities, these parts being most frequently 
interrupted in their salutary actions. The second, arising from a 
disease in itself violent, as the gout, are apt to be very indolent. 
The third cause is mechanical and very extensive, even universal, 
and seems to be the consequence of a stimulus, as if increase of 
strength was wanted, as in the tunica vaginalis, from the increased 
quantity of water in hydrocele, cysts of hydatids, &c. Veins from 
this cause become varicose, and the cuticle is often thickened by 
this in working people ; but this is frequently carried too far, and 
produces corns, or it may produce ulceration if the pressure exists 
in a still greater degree. 
Varicose Veins appear to arise from pressure. A long column of 
blood presses along the inside of the veins of the lower extremities, 
and the veins being weak are stimulated, which increases their thick- 
ness and strength to resist this distention; sometimes they are so 
much thickened as to obliterate the whole cavity. The smaller 
veins are more or less affected, probably in the same manner as the 
large ones are in the legs, and hence the whole leg is indolent: they 
often suppurate, when it is almost impossible to heal them. This 
disease is in general too extensive for extirpation, although when it 
can be done this practice is very proper. 
Corns.-The cuticle admits of being thickened from pressure in 
all parts of the body : hence we find that on the soles of the feet of 
those who walk much the cuticle becomes very thick; also on the 
hands of labouring men. We find this wherever there is pressure, 
as on the elbow, upper part of the little toe, ball of the great toe, 
&c. The immediate and first cause of this thickening would appear 
to be the stimulus of necessity given to the cutis by this pressure, 
the effect of which is an increase of the cuticle to defend the cutis 
underneath. Not only the cuticle thickens, but the parts underneath, 
and a sacculus is often formed at the root of the great toe, between 
the cutis and ligaments of the joints, arising from the same cause, OF SPECIFIC DISEASES, ETC. 
325 
to guard the ligaments below. Sometimes, when the pressure is 
uncommonly great, inflammation takes place in this part, especially 
if there are corns, the sacculus suppurates and opens externally, and 
this forms what I believe is called a bunion. The sacculus then 
closes again, and leaves the parts much as they were before. 
The cuticle is not only thickened from pressure for salutary 
purposes, but it is also carried to disease. A corn is a thickened 
cuticle arising from external pressure, which is preternatural and 
continued. Uncommon or preternatural pressure on the surface 
must always affect the cutis more or less, producing a disposition 
in it to guard itself; but pressure is capable of producing another 
effect, which is according to the amount of pressure: when applied 
in a moderate degree, it gives a disposition to the cutis to continue 
the growth of the cuticle, forming layer upon layer. By this con- 
tinuation of growth the cuticle becomes thicker; but if the pressure 
is too violent, then a diseased increase of the cuticle takes place, 
commonly in a very small portion of the part pressed, often in a 
point. This thickened part being pressed from without commonly 
sinks its own thickness into the cutis, which is the cause of the 
pain and troublesome symptoms. The cuticle being formed in 
layers peels off in layers, and if inflammation attacks the cutis 
underneath, this takes place : and hence the term ' onion,' which 
has been applied to these corns. 
There is often a sort of joint formed by a sacculus mucosus under 
the cutis allowing of motion in the corn: if this inflames and suppu- 
rates, a cure is often effected. 
When corns are of long standing and run pretty deep, they gen- 
erally produce a degree of indolence in the healthy actions of the 
parts pressed on, which makes the cure tedious. 
The cure of corns is of three kinds, viz. natural, palliative, and 
radical. The first is by removing the primary cause, or pressure, 
which is done by leaving off shoes, or by introducing a soft sub- 
stance, as plaster, between the corn and shoe. Two plasters 
are necessary, one with a hole opposite the corn, and another to be 
applied over this; and these should be continued as long as the 
cause is continued. Leaving off the pressure is the best mode, and 
then the effects are easily removed. The palliative consists in 
removing as much as possible the external surface, -which relieves 
the pressure. This is done by holding the corn half an hour in 
warm water, when it swells, and then paring off as much as pos- 
sible of it. Jt is difficult to remove the whole without injuring the 
.surrounding cutis, which is often of bad consequence in old people, 
where fatal inflammation and mortification have been caused by it. 
The radical cure consists in removing the whole corn or thickened 
cutis. The cuticle may be raised here, as it is in every other part, 
by blisters: but its thickness prevents this effect taking place so 
early. Warm stimulating plasters will in general be sufficient. 
The causes of corns when carried too fax' often produce inflamma- 
tion and suppuration, and whichever way the suppuration is pro- 326 
HUNTER'S PRINCIPLES OF SURGERY. 
duced, it is liable, if not attended to, to become very tedious; for 
the skin having a greater disposition to heal than the parts under- 
neath, produces a fistula ; so that such sores should be dressed to 
the bottom, and if they are indolent at the bottom should be stimu- 
lated by appropriate dressings. 
Indolence from Cold.-Cold is a powerful obstructor of the 
natural animal powers, whilst at the same it is exciting action, pro- 
ducing irritable inflammation and death. It is a true cause of 
mortification. Indolent swellings from cold arise from two different 
modes of action: 1st, when so gradually applied as not to excite 
irritable inflammation, but a gradual sluggishness ; 2d, when it pro- 
duces irritable inflammation from the parts being weakened. Cold 
does not immediately obstruct the natural actions of the whole or 
part, but excites the whole or part to another action, viz. the pro- 
duction of heat. The extremities, from their great distance from 
the seat of the living power, and from being smaller, are most 
liable to this. Thus these parts become first irritable and then 
inflamed; but it is an increased disposition to act, with lessened 
powers. Hence the effects of cold are greater or less, according 
to the constitution. The weakly, the fair, and the delicate have 
the least powrer of generating heat. 
Chilblains are the common effects of these causes, and from the 
foregoing effects of cold we are led to a rational cure; first, to 
remove the cause, then to apply warmth, or rather to keep the 
parts temperate. Chilblains commonly get well in summer. The 
cure, perhaps, should be divided according to the two stages of 
the disease, viz. the irritable and indolent; but how far the treat- 
ment should correspond in this way I cannot say. They have 
been cured when they looked purple and livid by gentle stimulants, 
as oleum terebinthinae, or camphorated spirits of wine. Such 
applications bring on the florid red of inflammation, which generally 
terminates w'ell, for they seem to counteract the stimulus or irrita- 
tion of cold. Steeping the parts in warm vinegar has done much 
good ; when they ulcerate, the same exciting mode seems best. 
But they are sometimes so irritable as to require quieting; for 
which purpose a poultice or decoction of poppyheads is equal to 
anything. When the itching begins, rubbing the feet over with 
powdered chalk will be effectual to prevent it: the rubbing is useful, 
and the chalk keeps the feet warm by being a bad conductor of 
heat. 
The invisible causes of indolent dispositions are also various. 
The 1st of the spontaneous is a diseased increase of growth ; 2d, 
interstitial swelling; 3d, new formed substance. This division, 
according to the mode of increase, is into three kinds, viz. increase 
of natural parts, the interstitial, and the tumour. All these are liable 
to happen in every part of the body. These increases are either 
known by the sight or by the feel. 
Of the unnatural Growth of Parts.-These often form what may 
be called a species of monstrosity of parts, either diffused or cir- 
cumscribed. They are generally situated in the cellular membrane. OF SPECIFIC DISEASES, ETC. 
327 
and feel doughy and soft, and are usually superficial, extending to 
the skin till it hangs as if by its own weight, sometimes having a 
broad base, but often hanging by a small neck: they appear to be 
in the cellular membrane what exostosis is in bone. These parts 
are less ductile than the natural parts. I have seen the double 
chin become one of these; I have seen them on the belly. Perhaps 
they produce absorption in the parts on which they press; for the 
bones underneath have been sometimes found deficient. 
Preternatural accumulations of fat take place in the same man- 
ner ; not depending on a deposit of interstitial substance, nor being 
adventitious, but a preternatural growth ; and are common to every 
part of the body, not excepting the internal parts. People have 
died of fat on the pericardium, and sometimes it is found in the 
bellies of cattle, as sheep. In the human subject these accumula- 
tions acquire an immense size, being composed of very solid fat, 
and in some degree moveable, being in separate parts, orlobulated, 
when between the skin and muscles. They may in general be 
distinguished by the former being of a regular uniform softness, 
whilst the latter appeared to be composed of solid pieces of fat, 
having a surface irregular to the feel. 
The interstitial or diffused thickening of a part arises from the 
interstitial deposition of matter in the cells of the part, and is of three 
kinds. 
Elephantiasis.-The first, or diffused, is very slow in increase, 
forming gradually. A whole leg will become stiff and feel tight by 
a loaded cellular membrane. It is most frequent in the legs, and 
almost peculiar to some countries and to some peculiar constitutions. 
A similar increase occurs in the thyroid gland: but this is of the 
second kind. The diffused is very common in the legs of Barba- 
does' people; I have also seen it in this country, but very rarely. 
The legs of young people I have seen so swelled as to be all of a 
size. It arises from an extravasation of coagulable lymph equally 
diffused ; the parts become firm and similar to dropsy, only there 
is no pitting : it may be a kind of dropsy, for dropsical swellings 
often degenerate into this kind of swelling ; yet the cause of the 
two may be very dissimilar': it is most frequent in young people. 
From its being so diffused and general, and in the legs, and most 
at the lower parts, I should think one of its immediate causes was a 
depending situation, with a weakened action of the system in general, 
as a simple bandage to support these parts often prevents it. [A 
preparation was shown in which a thickening of the leg put on the 
appearance of brawn. ] There is no fixed cure. In the easel saw 
I recommended mercurial ointment to be rubbed into the parts, and 
a slight bandage. The ointment was omitted ; but the patient got 
perfectly well in a few months. If these had failed, I should have 
sent him to bathe in the sea. Pressure hinders the extravasation of 
more fluid, and we see that tight boots make the legs thinner. 
The second kind is an original disease, though it may be attended 
with pain and inflammation. It is not circumscribed, though con- 328 
HUNTER'S PRINCIPLES OF SURGERY. 
fined to a spot, but gradually lost in the surrounding parts. It 
spreads in proportion to the power of continued sympathy. A node 
is similar in appearance to what this is of the soft parts, and per- 
haps is of the same kind. 
The pain of indolent swellings is very little or none at first, which 
is owing to the slow increase of the part not arousing the sensibility; 
but afterwards they have a heavy dull pain, producing sickness. 
This is often from the size, as well as from the tumour itself pressing 
on some other parts ; for sometimes there is more pain in the sur- 
rounding parts than in the tumour itself. I may also observe that 
they seldom or ever inflame, but continue increasing till they press 
on surrounding parts, and raise inflammation in these parts and not 
in themselves ; they are then often broken down into a curdly sub- 
stance, but appear not to be dead, as they do not give the stimulus 
of extraneous matter: though the surrounding parts become thick- 
ened, yet they cannot properly be called encysted. If it appears 
to be scrofulous, the cicuta, sea-bathing, sal sodse, sea-water poul- 
tices, &c., are to be tried ; but these are sometimes useless, and 
extirpation becomes necessary ; or sometimes cutting into them is 
sufficient. They sometimes suppurate, and then the sores are very 
difficult to heal. . 
The third kind consists in the interstitial increase of a circum- 
scribed part. This is it when the swelling keeps to the original 
part, that part being circumscribed, as lymphatic glands, and also 
tumours or enlargements of the liver or spleen. They seldom affect 
the cellular membrane till they suppurate, and often not then at 
first, which shows they have something specific in them ; for if 
merely indolent the surrounding parts would sympathize with them, 
as is often the case in the mixed cases. Although these diseases 
are interstitial increases, yet they often become similar to a tumour, 
and are understood as such. 
Observations on the Cure of Indolent Dispositions in Diseases.- 
We must first inquire whether they are wholly constitutional, 
partially so, or merely local, as upon this rests our treatment. We 
must not be satisfied with the present symptoms, but inquire into 
the constitution, whether it is indolent or irritable. Such as arise 
from the constitution are generally more diffused, and are often 
in many parts: and such constitutions as produce local complaints 
show something wrong in them ; however, the symptoms are not 
always satisfactory. I suspect these indolent dispositions of the 
constitution require a specific stimulus, having something specific 
in their nature. They do not spontaneously take on steps of cure, 
as inflammation does; and if they suppurate, they do not suppurate 
kindly; and a variety of things are required to assist them. The 
first thing to be done is to remove the cause, if practicable, which 
it often is not, as changing the country and situation. In all, 
resolution should be preferred if possible, by absorption; for suppu- 
ration will do much harm. To procure suppuration in such, a 
particular mode is required, for we are not to lessen the living OF SPECIFIC DISEASES, ETC. 
329 
powers, as in adhesive inflammation that is healthy, but to increase 
them. The earlier the treatment is pursued the better, before the 
habit has suffered, or the surrounding parts have sympathized: 
sometimes a constant application of mercury to the part, which 
produces a kind of irritation short of inflammation, is advanta- 
geous ; if this is insufficient, fumigations with cinnabar, or with 
plants which have essential oil in them, may prove serviceable. If 
these fail, we must remove the indolent disposition by exciting an 
action which they are incapable of taking on themselves. Salutary 
inflammation in surrounding parts will produce other good effects 
in indolent diseases, for indolence arises from a want of predispo- 
sition to healthy action; thus, blistering the parts, and giving 
cordials internally, are often of use; but the more violent the 
inflammation, the more effectually is the indolence of the part 
removed, if it can bear it. Many indolent swellings are content 
with their own natural actions, as natural parts are with theirs : but 
this is not so always; but they take on an inflammatory action, not 
salutary, but leading to a bad kind of suppuration. The means of 
restoring the thickened parts is healthy inflammation, which as it 
goes off, does not leave them in their former state, but occasions an 
absorption of the extravasated matter; nevertheless the part, after 
healing, often retains somewhat of the original disposition. This 
treatment will not do either in cancer or scrofula. 
Of the Suppuration of Indolent Parts.-Resolution cannot always 
be effected, and suppuration will take place, which suppuration seems 
to arise from defective animal powers, and not from exerted powers. 
The matter is glairy, and the superficial parts are so little susceptible 
of this that the matter is long in coming to the skin; so that stimu- 
lating medicines must be applied to bring on, if possible, good suppu- 
ration, which can seldom, however, be done. Quick ulceration is best 
effected by exciting and hastening the inflammation; this is neces- 
sary in sound abscesses even, but much more necessary in indolent 
ones. The next thing is opening them, which should not be done 
too early, as the matter which remains in may increase the inflam- 
mation, which is necessary to the cure. When an opening is made 
it should be as large as possible; and even crucial incisions are 
frequently necessary; in many cases scarifying the sides of the 
abscess is proper, to excite quick inflammation, and if there are any 
sinuses these should be traced to their full extent: the parts then 
feel a greater necessity of action. But this is not always sufficient, 
for after good granulations are formed, the indolent state often 
returns, the granulations becoming dark-coloured, and the mattei' 
thin and glairy, according to the specific nature of the indolence; 
this is the case often in old sores which have become habitual from 
bad treatment. In old indolent parts and encysted tumours the sac 
is often thickened, and even ossified, and the inflammation then is 
sometimes so violent as to threaten mortification. But these parts 
often become insensible to the common causes of inflammation, and 
when inflammation does arise it is sluggish. In such, nothing can 330 
HUNTER'S PRINCIPLES OF SURGERY. 
cure but dissecting out the parts. Many abscesses, if out of the 
reach of surgery, or ill-treated, run into an indolent state. Many 
means are necessary in treating them, but we know of few useful 
ones: balsams and warm dressings are commonly used; sometimes 
they do good, at other times they have no effect; and when they 
agree they lose their powers by continuance, when it becomes 
necessary to change them, or increase their power. These balsams 
should often be mixed with red precipitate. Tincture of myrrh 
also is often very useful in indolent sores, requiring to be applied 
often, as it soon loses its efficacy; solutions of alum, tincture of 
bark, solution of lunar caustic, aqua camphorata, &c., are often 
useful, and require to be applied as often as three times a day, or 
oftener if the disease is considerable. 
Of Tumours. 
By this term is generally understood a circumscribed enlarge- 
ment in a part from disease, not strictly a disease of a natural 
circumscribed part, as a thickened diseased gland. 
Of circumscribed interstitial enlargements in common parts.- 
These seem to depend on an accumulation of extravasated coagu- 
lable lymph, either in the adipose or cellular membrane, or both. 
They are of two kinds; one is probably scrofulous, and not so 
circumscribed as the other. The wen is commonly found in the 
cellular* membrane of every part, but how formed it is difficult to 
explain; perhaps there is an absorption of the natural original parts 
underneath. The increase of cancer- is much in the same way ; a 
good deal of the cancerous matter appears to mix with the natural 
parts; but these natural parts appear to be lost as the cancerous 
matter increases. The specific quality of wens is not yet known.* 
They retain their living properties, and sometimes swell to an enor- 
mous size; sometimes they remain stationary, and sometimes they 
become solid throughout, so as even to be as hard as cartilage ; when 
cut into they look like a lemon, but not so regular; they seem to 
have no leading cause, constitutional or local. Calcareous earth is 
often deposited in them. The first mode of preventing them, if we 
* [Sir Astley Cooper has described a species of encysted tumour or wen of the 
common integuments, which evidently depends on an obstruction of the follicu- 
lar ducts of the skin, in consequence of which the sebaceous follicles become 
distended by the accumulation of morbid secretion. Ranula, and the enlarge- 
ment of the labial glands, are analogous cases, and it is extremely probable that 
many other forms of tumour, such, for instance, as the serous cysts which are 
developed in the viscera, and the solid tubercles which occur in similar situations, 
owe their orgin to a like cause, that is, to an obstruction in the primary branches 
of the excretory ducts. In general, however, the origin of adventitious growths, 
(see note, p. 150,) and the distinction of their specific natures, is involved in 
much obscurity, so that every attempt which has yet been made to classify them 
according to their natures has failed. The truth of this observation respecting 
the classification of tumours has been generally felt, and will be perceived in 
the ensuing observations of the author.] OF SPECIFIC DISEASES, ETC. 
331 
had any, would be by resolution, both by topical and internal appli- 
cations; but we have none of much power in this respect. For 
those which are external, as in the cellular membrane, such remedies 
as were recommended in the diffused are proper; but these are 
more difficultly removed than the diffused, and, being circumscribed, 
are less capable of sympathy, and more indolent; perhaps mercury 
is the best resolvent for them; electricity is not so much to be 
depended on as mercury; suppuration of them, by cutting, or any 
other mode, will do no good. They produce a sore which it is 
impossible to heal, and which often becomes cancerous; therefore 
suppuration should be avoided, as it diffuses the cancerous dis- 
position. Extirpation is the only remedy, so that the earlier this is 
acceded to the better. Theii' situation makes caution necessary, in 
the avoiding to wound surrounding parts. I have laid bare the 
carotid in the necks of women, also the temporals for two inches, 
and often have laid the trachea bare. By care and attention these 
operations are very easy and safe. The jugular vein I have also 
laid bare; but I would tie its two ends, as it is afterwards very apt 
to slough. 
Tubercles may be classed under the head of spurious tumours : 
they are most frequent in the viscera. They are mostly of the 
lymphatic kind, and are often formed in the lungs of young people, 
and sometimes grow to a considerable size : they are often on and 
in the liver, the spleen, the uterus, the coats of the intestines, the pe- 
ritoneum, and sometimes on the epiploon: the lungs are frequently 
full of them, and they are the cause of most consumptions. How 
they are formed, and whether glandular or not, I cannot determine; 
but I think they arise from scrofulous dispositions taking place in 
the lungs : their texture is often smooth. 
Solid Tumours.-Tumours may be divided into solid and encysted, 
which are very different diseases. Solid tumours differ from wens 
in being an entirely new-formed substance, and of new structure. 
Their situations are three: 1st, on the skin, forming warts, wffiich 
are also sometimes seen on the mouth, lips, and oesophagus; 2d, 
in the inside of membranes, or canals, which are termed polypi; 
3d, in the cellular membrane of every part of the body. They 
commonly arise from one fixed point, as a root, and then spread out 
in all directions, if the surrounding parts allow of it. These tumours, 
formed in solid substances, are perfectly circumscribed; they are 
generally more detached from the cellular membrane than the lym- 
phatic glands. 
1st. Warts are external or superficial: they also form on the 
inside of the lips, beginning of the vagina, and prepuce. Warts 
differ, according as the cutis and the cuticle differ, in different parts : 
when these parts are firm, the warts are hard, as on the hands ; but 
if soft, the warts are soft, as on the mouth or lips. They appear to 
arise from the true skin of the parts, and generally arise from, and 
are fixed on, a small extent of surface, projecting considerably, so 
as sometimes to be even pendulous, with a narrow neck. In hard 332 
HUNTER'S PRINCIPLES OF SURGERY. 
parts they arise only to a small height, and appear to split into many 
parts, and often by accident become painful, bleed, and inflame. 
Those on the penis sometimes have a broad basis, and rise not so 
high, and divide into points. On the inside of the labia pudendi 
they often grow very large. It is difficult to assign their cause, but 
sometimes we see an immediate cause, as the venereal disease in 
the genitals. 
2d. Polypi arise on the canals, or passages, each of which seems 
to produce a kind peculiar to itself, as the nose, vagina, uterus, &c. ;* 
they are supposed also to arise in the urethra, and I have seen them 
in the rectum in men. They have generally small necks, and require 
extirpation; those from the Schneiderean membrane are generally 
in a cluster, numbers arising from the same root; internally they 
consist of a reticular membrane, whose interstices arc filled with a 
watery fluid, and, besides this, an external covering, both of which 
coats are vascular, but more particularly the external. They are 
inconvenient according to their size, often causing a tickling in 
the nose, which excites sneezing; when large, they are evident to 
the eye, either externally or internally, appearing to be semitrans- 
parent bodies within the nostrils; but when protruded so low as to 
be exposed to the air, they become opake, &c., and are then some- 
times supposed to be cancerous ; and, indeed, we should be cautious 
in extirpating them, as cancerous tumours are sometimes found in 
the nose. The best mode of removing them is with a forceps, but 
seldom more than one can be removed at the same time. If the 
polypus is forward, it must be extracted anteriorly by the nostril, 
the patient blowing the nostril as much as possible, to bring it for- 
ward. When the operation is simple, it is merely necessary to twist 
it off by a rotatory motion of the forceps. 
3d. Of the third species.-This is an entirely new substance in 
the cellular membrane, often irregular, attached by loose cellular 
membrane to the surrounding parts ; we have also often such in 
bones which have been diseased: they seem to occasion the ab- 
sorption of natural parts. Pressure often hinders their growth, and 
sometimes even occasions their removal by absorption; but this 
is not always efficacious, and then extirpation is the only remedy. 
When in soft parts, we use the knife, and each incision may go as 
close to the tumour as possible, the surrounding parts not at all 
sympathizing ; but if there is a root, then a little deeper : if the root 
goes to the surface of the bone, we cauterize it. On the bone, 
* [It is questioned by some pathologists whether polypi, analogous to those 
which arise from other mucous membranes, are ever found in the uterus ; at all 
events, those tumours which are usually called polypi of the uterus are ascer- 
tained to be of a different kind. These latter are in fact precisely similar in 
structure to the fibrous or fleshy tubercles so frequently found imbedded in the 
tissue of that organ, which vary in their appearance according to their situation, 
which allows them sometimes to assume the pedunculated form. This I think 
is rendered quite certain, from the fact that they occur on the outside of the 
uterus as well as on the inside, and in that case hang into the cavity of the pelvis, 
just as in other cases they do into the cavity of the uterus.] OF SPECIFIC DISEASES, ETC. 
333 
pressure will keep them down, or even make them lower than the 
common surface of the surrounding bone. Tumours often arise 
and shoot out from the alveolar processes, and the alveolar process 
often takes on the ossific disposition along with them: sometimes, 
but not always, they have bony matter in them. 
On the Removal of Tumours.-We should first consider the kind 
of tumour and part; if a simple body, the knife is the best mode of 
removing it. The first difficulty in the mode of opening it is, at 
first setting out, to know whether one or two incisions should be 
made in the skin. One incision is often sufficient, and two are often 
necessary; one is sufficient where the tumour is small, or very 
loosely attached to surrounding parts ; but two are necessary when 
the tumour is large, or where the skin is diseased over it, so as to 
confine it much, even if small, as on the head, or sole of the foot. 
A simple incision is sufficient in fatty tumours, except wffien very 
large. In the dissection of common tumours we need not be at all 
nice about the tumour, nor in removing any of the surrounding 
parts; but in scirrhus, or cancer, the incision must be extended to 
surrounding parts, and this is not for convenience, but for the suc- 
cess of the operation. 
For these wounds there are two modes of treatment; some heal 
by the first intention, others by suppuration. The first, when the 
skin will cover the whole sore, bringing the ligatures out at the 
under angle, when any are required to secure the vessels ; but 
when the sides cannot be brought perfectly in contact, or when 
sloughing is expected, suppuration must take place ; but in many 
such cases some part may still be healed by the first intention. 
Of Tumours in Bones.-Besides ossific inflammation, as before 
mentioned, we have sometimes tumours, arising from extravasation 
of blood or scrofulous inflammation. 
1st. Those from extravasated blood appear sometimes to arise 
from the surface of the bone, or else from its substance. The bone 
becomes lost in proportion to the size of the tumour ; which arises 
from an unnatural accumulation of matter pressing on the part, 
occasioning absorption : this is most remarkable when the tumour 
is on the inside of the bone, which then appears as if scooped out; 
and as the cavity enlarges by absorption, the body is in proportion 
accumulated. This kind of tumour, arising from disease, differs 
from that arising from accident, as from fractures, these not exciting 
ossific inflammation in the surrounding parts; except, indeed, when 
in the leg and thigh, where, strength and support being needed, 
Nature forms new bone to supply the deficiency of the old. I can 
hardly tell whether the extravasation of blood is a cause or effect. 
Bones will break from this kind of tumour by very slight causes, 
such as by turning in bed ; for before the whole cavity of the bone 
is absorbed, the bone generally gives way, and is fractured by a 
very slight cause: after the bone gives way, the extravasation 
increases from the continued disease and new-ruptured vessels. 
This kind of fracture happened to the Archbishop of Canterbury. 334 
HUNTER'S PRINCIPLES OF SURGERY. 
Mr. Grindle has many examples of this in different bones in his 
possession. 
2d. The second of these diseases in the bone which have the 
same appearance, is an accumulation of curdly substance; pro- 
bably it is coagulable lymph, and may be reckoned among the 
encysted tumours. The ossific inflammation often goes on here, 
till the bone acquires great size, but in these the outer ossific accu- 
mulation is not in proportion to the absorption, and therefore, being 
only a thin shell, it gives way; this is most common in the head of 
the tibia, and is called spina ventosa. Scrofula, attacking bones, 
makes them soft, and also thick, although their structure often 
remains ; however, sometimes it is altered, scrofulous matter being 
deposited, and then the natural matter is removed, till at length all 
the matter which forms the bone becomes scrofulous. Such cases 
in a bone generally increase so much as to approach the skin, 
which inflames, ulcerates, and exposes the parts ; and this increases 
the internal disease, which neither nature nor art can possibly 
cure ; and then a hectic, sooner or later, according to the habit of 
the patient, seizes and destroys him. These two different causes, 
perhaps, have some connexion, yet the last is most scrofulous. In 
the treatment, we ought first to prevent the extravasation, &c.; 
but we neither know the disease, nor how to effect this intention. 
If known early, perhaps exposure and sea-bathing would be the 
best cure. 
3d. These tumours are of two kinds: 1st, tumours simply, which 
are often scrofulous to appearance; 2d, the cancerous, which at 
present I defer. The first kind I have often seen, and most fre- 
quently in the lower jaw, and upper part of the tibia. The latter is 
probably a species of spina ventosa. If the disease seems to be 
true scrofula, then sea-bathing may cure it, but this is more diffi- 
cultly known than in soft parts. When of the soft kind and con- 
venient, pressure should be tried, which often is of great service, as 
in Mr. Squire's case ; but when this fails, electricity, or the mercu- 
rial ointment and camphor should be used; and when this also fails, 
an operation often becomes necessary ; an incision should be made 
upon it, and it should then be dissected out as in scalping, as close to 
its root as possible, with a little of the surrounding parts with it. 
If from bone, it is impossible to remove any of it by the knife, and 
it becomes necessary to cauterize it. Sometimes a saw oi' pincers 
are necessary for its removal, and cauterization of the cavity after- 
wards. 
Encysted Tumours.-These commonly consist of a bag, or cyst, 
filled with a substance softer and different from the surrounding 
parts, though not necessarily so. The cysts are of too kinds, viz., 
natural and acquired. Natural, as the tunica vaginalis containing 
a fluid morbid in quality or quantity ; Fallopian tubes ; the uterus or 
oviducts of animals; when, for instance, their foetus or eggs are 
preternaturally retained; these parts then taking on the nature of 
the coat of an encysted tumour. Sometimes they arise from an OF SPECIFIC DISEASES, ETC. 
335 
obstruction of the duct of some gland, which forms a tumour: I 
have seen them on the inside of the lip from this cause. The second, 
or acquired, are in consequence of disease in solid parts, and have 
much the feel of common tumours. It might be supposed they 
were common tumours suppurated; but they are original specific 
diseases. They contain varieties of matter; and hence they are 
divisible into several kinds: as, 1st, hydatid, from their contents 
being watery; 2d, various matters of different consistency; 3d, a 
curdly substance. The thickened cellular membrane, condensed 
by pressure, forms the coats of the first and second; but I know 
not how the third coat is formed: some of them probably are scro- 
fulous : and if so they are no more than very indolent abscesses in 
those parts, having acquired a strong coat, which I think is some- 
times the case. 
1st. Hydatids vary in kind, from the variety of their situation. 
All accumulations of water in cavities, are properly hydatids. 
(See note, p. 229.) The water may either be in a natural cyst, as 
the tunica vaginalis, pericardium, &c., or in a cyst formed by 
disease. This second division is of two kinds, but both occur in the 
cellular membrane. The first is filled with serum, and there- 
fore similar to the above; the second is lined with a peculiar 
substance. Those of the first kind are most frequent in those parts 
which have an enveloping membrane, as the abdomen and thorax; 
and are more common to some of these than to others, though it 
does not arise from their having a cavity, but from a peculiar dispo- 
sition of these parts ; these hydatids project into the cavity. Those 
in the cellular membrane are very uncertain in their situation. 
The first kind, or simply watery, are often in women's necks, or 
in the thyroid gland. I once saw a large cluster in the neck of a 
woman. As they increase in size their coats increase in thickness: 
those in the cellular membrane thicken soonest: for the lining mem- 
branes, or cysts, only thicken by a species of adhesive inflamma- 
tion. The second differ from the former, and are made up of two 
parts : the strong external coat is lined by another, of a dusky 
white colour, much like the retina of the eye, and gelatinous; this 
coat is generally as thick as thin pasteboard, and as strongas thick 
wet paper. In many hydatids there is an additional or third coat 
on the inside of this, which is less opake; and sometimes a fourth, 
and so on, till at last nothing is seen but coats; none of which, 
except the external one, is vascular. It is easy to account for the 
formation of the external coat; but difficult for the internal ones. 
Whether the external is the first, and the parent of the others, or 
the consequence, is not easily determined; but the last is most pro- 
bably the case, as when formed, they stimulate so as to produce a 
vascular coat; but whichever' is formed first, we must suppose that 
it is capable of continuance. I suppose the first formed is the 
nucleus, and so on; similar to a nest of pill-boxes, one within 
another. There is another somewhat similar, but more irregular ; 
the external vascular coat being full of small ones, as shown in 336 
HUNTER'S PRINCIPLES OF SURGERY. 
this preparation [exhibiting it]. Does this last species proceed 
from indolence ? Many animals die of them in the liver, in cold 
climates, especially sheep: it is in them called the rot. Hydatids 
cause little sensation, and are seldom known till of a considerable 
size. 
Hydatids of the Uterus.-Those of the uterus and ovaries are 
generally circumscribed bags,* and generally are numerous, espe- 
cially in the ovaries, and appear somewhat similar to those of the 
scrotum ; forming a species of hydrocele of the part. At first they 
are thin, containing a transparent fluid ; but afterwards they be- 
come thicker, and the fluid is bloody, or like a jelly. They have 
when small but little attachment, but afterwards get to adhere to 
each other, when they grow often very large, and increase the size 
of the belly, forming ovarian dropsy. The history and progress 
only of the case can in general distinguish it from ascites; at first 
there is a partial, moveable swelling, rolling from side to side in 
bed. Afterwards they become fixed, but even then, in thin peo- 
ple, inequalities may be felt; when large, they become fixed to the 
parietes of the abdomen ; and if the person is not very fat, a fluc- 
tuation may be felt. The health is but little affected by them. 
Hence the cause is very different from ascites, where the health is 
first injured. Tapping is only a palliative cure, and a large trocar 
is required, as the fluid is generally gelatinous, and then only one 
cell is opened. If taken in the incipient stage, they might be taken 
out, as they generally render life disagreeable for a year or two, 
and kill in the end. There is no reason why women should not 
bear spaying as well as other animals; it would be simply opening 
the cavity of the abdomen, which we often do without inconve- 
nience in healthy constitutions.! 
Hydatids in the Kidneys.-They are of the first species, of the 
adventitious, and are generally situated between the first and second 
laminae of the external coat; but they are certainly often in the 
internal substance of the kidney. Sometimes there are a great 
number. Those in the coats are never detached or pendulous ; the 
* [The hydatid which forms in the uterus is peculiar to that organ, at least in 
the generality of cases, being of a pedunculated form, and generally grouped 
together like a bunch of grapes. Hydatids in this situation often attain a great 
size in the aggregate, and are expelled by a parturient effort. There is reason 
for suspecting that this form of hydatids most frequently arises from impregna- 
tion, in which case the destruction of the ovum is almost universally the conse- 
quence.] 
f [This recommendation has been adopted in several cases, but the success 
has not been found to warrant its repetition. The difficulty of ascertaining whe- 
ther one or both ovaries is affected, as well as the obscurity in which the disease 
is involved in its earliest stages, are insurmountable objections to the operation; 
for I do not suppose that any one would be so bold as to propose it after the cyst 
has attained any considerable magnitude. Besides, it sometimes happens that 
the disease remains stationary for many years; and in other cases a cure is 
effected by the suppuration of the cyst consequent on tapping, the danger of 
which is scarcely greater than that which would attend the operation of extirpa- 
tion.] OF SPECIFIC DISEASES, ETC. 
337 
coats are thin, and look like a red grape; they give no symptoms 
of any kind, nor do they require or admit of any remedy. Some- 
times those about the kidneys burst into its pelvis, and come away 
by the urethra. A gentleman had a considerable swelling on the 
left side of his belly which had been a long time collecting, and 
evidently contained a fluid ; on a sudden a considerable quantity of 
fluid was discharged from the bladder through the urethra, and 
along with it a large number of hydatids ; some whole, others 
burst; but the swelling of his abdomen subsided and he got well: 
however, he afterwards filled again; but he again emptied them by 
the ureters, and he is now perfectly well. 
Hydatids of the Liver.-The liver may be said to have none but 
those of the second species of the adventitious; they are generally, 
but not always, on the exterior substance of this viscus. In some 
rare cases they have produced ascites by their coats bursting in- 
ternally ; and sometimes they have been discharged externally by 
their coats adhering to the peritoneum, and inflammation and 
suppuration coming on. When known to be a bag containing 
fluid it may be opened, but I would not be in a hurry to do this. 
Hydatids of the Lungs.-These are of two kinds : first, a collec- 
tion of water simply in one or more cells; the second, of the ad- 
ventitious kind, either external to, or in the substance of, the lungs. 
Some open into the trachea, and are coughed up in abundance ; 
sometimes they produce spurious empyema, when they should be 
opened pretty early, to prevent their affecting the substance of the 
lungs by pressure. 
Hydatids of the Brain.-These I have never seen increase so far 
as to cause inconvenience. In some animals they are common 
when young, and are successfully taken out. They are very fre- 
quent in the plexus choroides. 
Hydatids of the Thyroid Gland.-Sometimes these are very large, 
and produce difficult respiration and deglutition. 
Hydatids of the Cellular Membrane.-These are generally of the 
first species of the second division of the adventitious, containing a 
transparent fluid. Some parts, and more especially women's necks, 
are more subject to them than others. They are also pretty com- 
mon on the inside of the lips of men. 
2d. The second kind of encysted tumour contains matter of 
various kinds, and are very similar to hydatids, often containing in 
part a watery fluid. In the ovaries, fatty, cuticular, and hairy 
tumours are sometimes formed. 
The treatment for the two first is the same. From their situation 
we may divide their cure into two kinds ; one admitting of external 
applications, the other not; but I know no medicine which will 
cause their absorption. When external, therefore, the only means 
is opening them, when they will inflame, suppurate, and may be 
managed as in common hydrocele; but so much nicety is not here 
required, as the sac, being generally thick, will not collapse. In 
some a free opening is only necessary; sometimes they inflame 338 
HUNTER'S PRINCIPLES OF SURGERY. 
spontaneously, but rarely, and even then a free opening is necessary, 
on account of their indolence. If the sac is much thickened, the 
exposure by opening will generally kill it, and cause sloughing; 
yet exposure is not always sufficient, but the whole sac will require 
dissecting out, and especially when wre consider that there is some- 
times in these a cancerous disposition. 
Of the Cuticular.'*-The adhering cellular membrane forming 
the sac, takes on the disposition of the cutis, or more properly is 
changed into cutis, and is capable of generating an external one 
when exposed ; it is lined, indeed, with a cuticle. These cysts 
often have so much the disposition of the external part, as to have 
hair grow in them, which is the same as that which covers the 
animal, as, for instance, wool in the case of sheep. Every part of 
the body is subject to them, but some parts particularly so. The 
ovum is subject to all kinds of encysted tumours, and to these 
more than other parts ; and they probably throw off the cuticle 
every year, or oftener, the cuticle being filled with hair. They are 
also filled with various matters; sometimes with a caseous sub- 
stance, in others with oil, fat, bones, &c.: they occur also in the 
eyelids, in the skin near the eyes, and in the lips, and all grow to 
a large size. 
There are two methods of cure, one dissecting out the tumour, 
the other opening it freely, or taking off the projecting part and 
leaving the basis : on the eyelids, when very superficial, they often 
burst, matter is discharged, and they get well. On the head they 
are opened and get well. I have seen the external skin only 
taken off, which gave rise to an inflammation round its edge, 
which suppurated and granulated, and healed over, producing a 
cure. 
A gentleman had a large encysted tumour on the muscles of the 
abdomen ; this was opened by taking out a circular piece of the 
integuments, comprising the fore part of the sac. The wound of 
the integuments suppurated ; but the internal surface of the sac, 
which was now fully exposed, never suppurated the least, so that 
the wounds of the integuments granulated and healed, tucking 
down the integuments to the thin surface of the sac. The patient 
has remained well ever since ; but has a large cicatrix, part of 
which is composed of what was the internal surface of the sac. 
The surface of the internal coats of these tumours has a skin 
somewhat like that which covers the glans penis, different in some 
respects from that with which the rest of the body is furnished, but 
not of such a nature as to suppurate on exposure. 
3d. Encysted tumours, in a part depending on an indolent dis- 
position or suppuration are commonly deep-seated, and their pro- 
gress is very slow at first; they appear as an abscess, and might 
* [The reader is referred to Cooper and Travers's " Surgical Essays," p. 215, 
for an account of encysted tumours forming on the scalp and face. These strictly 
come under the designation cuticular, and have been adverted to in a previous 
note, p. 330.] OF SPECIFIC DISEASES, ETC. 
339 
be suspected to be encysted, from their giving no pain. I have 
seen sometimes a chain of them leading from the skin; that nearest 
the skin appeared to be the original of them. These often deceive 
the surgeon, who is either satisfied by opening or dissecting 
them out, suspecting no more of them; and I know no character- 
istic mark of their presence when the original one is deep-seated ; 
when external, the examination after the removal of the first may 
distinguish them. 
Of the Inflammation, Suppuration, and Ulceration of new-formed 
parts or substances.-We shall find these parts more liable to dis- 
solve than the natural parts are, having weaker powers of action. 
In proportion, therefore, to the quantity of new matter, is the part 
weaker; and these parts go through their diseases much quicker 
than original ones. When new-formed parts are under the neces- 
sity of inflammation, a very slight cause is sufficient; and the 
inflammation goes on more rapidly than in original ones; and it 
requires more attention and care to stop its progress. They are 
both more ready to mortify and suppurate. If in the adipose mem- 
brane or skin, and the inflammation is beyond resolution, then no 
suppuration, but ulceration, takes place, and mortification rapidly 
ensues; but it will be confined to the new-formed part, except in 
very bad constitutions. When suppuration has taken place, or mor- 
tification, there must be also ulceration, which is very rapid; so 
that an abscess in parts where an abscess had been before, will be 
much quicker than before in pointing, or than in other sound parts: 
if mortification takes place, the separation will be almost imme- 
diate. Hence it appears that it is a deposit of matter originally 
from the constitution, and she lays a claim to it in removing it and 
repairing it again at pleasure. Simple fractures sometimes dis- 
unite, though stronger than by granulations : in these cases no inflam- 
mation is produced, at least not so much as to produce suppuration. 
Union of parts by granulations often disunite, both in soft and hard 
parts, hence old sores and old fractures disunite. This disposition 
of fractures to disunite is most frequent in the lower extremities; 
the substance appears to be shorter lived than the original part was, 
as in old sores, which so frequently break out again. In parts 
united by simple extravasation, and adhesive inflammation, which 
again ulcerate, there is no suppurative inflammation, but there will 
be in parts united by granulations and suppurations. Ulceration, 
though frequent after compound fractures, is seldom so considera- 
ble as to destroy the new-formed bone wholly, though often in part; 
these are the causes of bad ulcers, and of what are called foul bones. 
It most commonly occurs from a fault in the general system, as 
scurvy; and upon this principle, sloughs take place soonest in new- 
formed parts, the separation depending on ulceration. 
For the cure of these cases we must first examine into thecauses: 
if from scurvy, when the patient is at sea; or if from their depending 
position and too much exercise, when the ulceration is in the legs; 
in which case rest and a horizontal posture are to be used; but 340 
HUNTER'S PRINCIPLES OF SURGERY. 
there is something very peculiar in the lower extremities ; they will 
become better and yet again slough. 
Of Fistula, in general.-The term fistula gives a very inadequate 
notion of the disease, the fistulous canal being only the sign of the 
disease,-the means of conveying a fluid or extraneous matter to 
the surface. 
A fistula is the consequence of the powers of a part not being 
able to remove the original eause, so that the original cause and 
some of its effects remain. 
The causes of fistula are various, but may be divided into two 
classes: first, the obstruction of the passage of some natural secre- 
tion, as fistula of the parotid gland ; or of the canal for the passage 
of extraneous matter, as the intestines being strangulated so as to 
mortify, or being wounded; but all obliteration of the ducts where 
the fluids make a new passage will not be termed fistulas : secondly, 
the formation of pus or extraneous matter in a part requiring a 
passage, as in fistula in ano, fistula in the joints, and fistula from 
diseased bone. 
We shall first consider the first cause of fistulas. 
1st. The obliteration of ducts, or canals, is the first cause. This 
arises from obstruction of the natural passages, in consequence of 
which a new one is formed for the passage of the natural secretion. 
These obliterations often arise from a thickening of the sides of the 
ducts, as in the urethra, nasal duct, &c., from inflammation; some- 
times from the venereal disease or scrofula ; and sometimes from 
accident, as in the parotid duct. These obliterations are often very 
troublesome, obstructing the evacuation of the natural secretions, 
which is very teazing to the part, and when complete is very serious 
in its consequences. In most there is a new passage when com- 
plete, wThich is made by inflammation and ulceration ; these new 
passages are called fistulous: the discharge is the natural secretion, 
mixed with the pus from the inflamed vessels of the sides of the 
passage. If this new passage answers all the purposes of the ori- 
ginal one, it cannot well be called fistulous; when from a mortified 
or wounded intestine, it is called an artificial anus; when in the 
perinseum, it is for the passage of the urine. There are often accu- 
mulations of secreted juices besides the above, arising from the 
same causes, and producing the same consequences, yet not called 
fistulous. 
Of the Fistula Lachrymalis.-This arises from an obstruction 
taking place in the passage of the tears from the lachrymal sac into 
the nose. The causes are often foreign to the nature of the parts 
themselves, as the small-pox oi' measles. This I suppose not to ori- 
ginate, as has been supposed, from a pustule at the end or mouth of 
the duct, but from inflammation running along the duct and causing 
the sides of it to adhere; it also may arise from ulceration of the 
duct from a venereal or scrofulous disposition in the part; but most 
frequently from obliteration of the canal from inflammation. The 
tears not passing, the inner surface of the sac becomes stimulated OF SPECIFIC DISEASES, ETC. 
341 
by pressure and distention, and the salts of the tears, which have 
little oi' no effect while the sac is natural, when diseased irritate it 
and produce inflammation. The sac swells, suppurates, and opens 
externally, and discharges the tears by this opening till the natural 
passage opens or a new one is made. If the os unguis had been 
susceptible of the stimulus and had ulcerated, it would have been 
fortunate, but it only thickens to defend itself from the disease ; for 
we find Nature has made internal parts less susceptible of such 
stimuli, the ulceration only taking place next the skin, so that it 
would perhaps be betterffor us if Nature would sometimes vary from 
her usual course. This internal thickening is sometimes so great 
as to unite the external part of the nose to the septum, and render 
the operation of perforating the os unguis less successful. Opening 
the old passage seldom succeeds, as it is very liable to become dis- 
eased again, as in strictures in the urethra, which are so apt to 
recur; and here bougies cannot be had recourse to, occasionally, 
as in the urethra. The operation, however, should not be done 
precipitately, as the duct often clears of itself and the patient gets 
well. 
Of the Obliteration of the Ducts of the Glands of the Lip.'-These 
glands lie immediately under the skin of the lips, and when there is 
an obliteration of any of these ducts, a tumour is formed, which 
sometimes bursts of itself. As the secretion goes on, the new opening 
cannot heal, and it is then, though improperly, called fistulous, as it 
does the office of the natural passage, and yet is often stopped again: 
sometimes thay do not burst, and I have dissected them out; for 
although they occasion little pain they are very troublesome. 
Obliteration of the Diccts of Cowper's Glands in the Female.-This 
may be the case in the male, and probably would occasion fistula in 
pcrinteo. An accumulation of slimy matter takes place, and the 
ducts swell just under the skin, on the inside of the labia, near the 
carunculae myrtiformes. They increase in size, and sometimes are 
mistaken for hernia : they should be opened before becoming very 
large, by a crucial incision : and to prevent their union by adhesion 
aftei' opening, they should be touched with lunar caustic : perhaps a 
round hole made by the lapis septicus would answer better than an 
incision. They first appear like a little encysted tumour, which 
increasing, becomes so troublesome as to prevent the person sitting. 
A lady had a very large one, which was taken for a hernia of the 
foramen ovale. She went to Paris, where it was thought an abscess 
and opened. 
Obliteration of the Duct of the Parotid Gland.-The parotid 
gland, from its superficial situation as it passes over the masseter 
muscle, is very liable to be wounded. Such a wound will after- 
wards become the orifice of the duct, and will heal in part, to a 
fistulous size: the duct itself going to the mouth probably closes, 
as the saliva must then be lost; and as its flowing here is very 
inconvenient, it is necessary to direct it to the mouth, which may 
be done with a needle, threaded with a round thread passed to the 342 
HUNTER'S PRINCIPLES OF SURGERY. 
bottom of the fistula, then directing it to the mouth and feeling for 
the point internally, pushing it to the finger and drawing it through, 
leaving the thread in; and perhaps it will be necessary to bring the 
thread out of the corner of the mouth, and to tie the two ends 
externally. The thread should be left in till the new duct has lost 
its healing disposition, and then heal the external one; but it may 
perhaps be necessary to make it a new surface before it will heal 
by making the fresh surfaces adhere by placing them in contact. 
2d. The second species of fistula, or that from disease, arises 
from the disproportion in the disposition to heal of different parts, 
viz. the internal and the external; the skin healing, while the deeper- 
seated parts, or seat of the disease, have no disposition for it. It 
may arise from two causes: 1st, from any extraneous substance in 
the inner parts; 2dly, from a diseased state of the original part, 
when the disease formed. The first happens in large deep-seated 
abscesses, which are prevented healing at the bottom by the pres- 
sure of the matter. The second has two causes, the first from the 
part being naturally indolent, as tendons: the second from a disease 
in parts naturally ready to heal, but the disease being deep-seated, 
the skin is more ready to heal than the bottom of the fistula, and 
thus obstructs the necessary free discharge. 
Fistula in Ano-Generally originates two or three inches up the 
side of the rectum. The first process is inflammation, and the 
formation of an abscess; then the matter comes down by the side 
of the gut, and opens on the buttock. Sometimes the gut is so 
diseased as to give way, and then we have an opening into it, 
which being the easiest and readiest way for the matter, it is thus 
discharged, and then we may have no external opening; but if 
there has been one, it does not heal. The cellular membrane about 
the anus is sometimes the seat of encysted tumours, which are 
mistaken for fistula, although they do not proceed from inflamma- 
tion. The treatment differs in these two very considerably; the 
tumour is often opened or breaks, but the inner surfaces of the two 
are very different. The abscess only requires opening, and then 
cures itself; but the encysted tumour, when opened externally, 
generally becomes fistulous, and opening into the gut will often not 
succeed, if attention is not paid to make them heal from the bottom; 
therefore it is necessary to keep them well open by dressing, or the 
two divided parts will unite at the edges after opening. When a 
fistula in ano has both an external opening and an opening into the 
gut, surgeons are in general satisfied with opening from one to the 
other; but the fistula sometimes runs higher up by the side of the 
gut than the inner opening, and then we should not attend to this 
opening, but get to the bottom of the sinus. 
Fistula in Perinceo.-In whatever part of the urethra the seat of 
the disease is, whether the prostate gland, or the membranous or 
bulbous part, the external opening seldom heals as long as the seat 
of the disease has no disposition to heal. This, I apprehend, 
arises in most cases from sympathy with a disease in deeper-seated OF SPECIFIC DISEASES, ETC. 
343 
parts: or, in other words, a deep-seated disease is capable of stimu- 
lating superficial parts, so as to prevent the natural action for 
healing. Let us compare this disease with the state of parts after 
lithotomy. If the incision is made in sound parts, and the whole 
injury be a stone, which is extracted, the parts readily heal, in 
spite of the urine passing through that channel. This, then, shows 
that there is another cause of their not healing. Now if the parts 
higher up are unsound, as the prostate, &c., though the incision 
was made in sound parts, it does not heal: if perchance it does, 
the disease still continuing, you will have probably two or three 
fistulas. If the parts are unsound beyond the fistulas, you will be 
continually plagued with a return of them. Bougies should not 
be kept in too long, as they sometimes make fresh fistulas in perinaeo. 
Several fistulas may arise from one disease. A diseased bottom 
may have many fistulous sores leading to it both in the perinasum 
and anus: and if one of these be laid freely open, so as to expose 
the diseased part, the rest will heal. 
When the disease is in one fixed part, there is a canal leading to 
it, which I have called a fistula; but if more than one, these 
different ones are called sinuses. A fistulous orifice is generally a 
small opening in the skin, having no sore surface in view, and is 
easily distinguished from other sores; if the diseased part is deep 
and of long standing, the external skin will be thickened more or 
less near the orifice, from the contraction of granulations within 
the canal, so that sometimes there is a protuberance even by the 
contraction. But this appearance is also common to all diseased 
parts some way under the skin, when the skin does not partake of 
the disease; when it does, this appearance is less considerable. If 
near a bone, this is suspected to be affected. When the seat of 
disease is near the skin, as when on the tibia, then we may be 
certain the diseased cavity below is not large. 
The cure of fistula consists in first removing the immediate cause ; 
for frequently they get well by simply removing the obstruction. In 
fistula lachrymalis, a new opening, or the restoration of the old one, 
is the cure. A fistula in perinaeo will often be cured by stretching 
and dilating the canal of the urethra by bougies, which removes 
the obstruction. The cause of our first division of fistulae, arising 
from confined matter, is sometimes easily removed, but not always, 
by opening the suppurated part in the most depending situation, 
when, if the parts are readily disposed to heal, a cure takes place. 
The second, from a diseased state, must have the disease removed 
or extirpated if possible; but this is often impracticable. A perfect 
exposure is the next object; but the case will not often admit of it, 
and then becoming incurable it sometimes produces hectic, as in 
lumbar abscesses, and abscesses of the liver, which open externally 
but cannot be exposed. The constitution in such cases is to be 
most attended to, and everything done to lessen the irritation; but 
in most cases life is miserable, and we only protract it a little longer 
by our best efforts. Fistulas in the lungs and liver in consequence 344 
HUNTER'S PRINCIPLES OF SURGERY. 
of abscess, and in the intestines from old obstruction, can only have 
their orifice kept open for the discharge of the matter. Fistulas in 
ano are generally easily come at, and are then of easy cure. At 
first it is simply an abscess from disease on the outside of the rec- 
tum ; if not, it becomes so by inflammation and suppuration. This 
is proved by the cure, which is not simply a free opening where 
the abscess points, but opening the abscess from its original seat is 
necessary for the cure: slitting up the gut to the origin of the ab- 
scess is necessary in all cases of fistula in ano.* 
Of the, attention necessary in diseased and wounded Joints re- 
specting their motion.-I shall now speak of the preservation and 
acquirement of motion in joints when diseased, and after disease. 
We must consider in both the necessity of removing the first cause 
of the disease, or we shall be increasing it by endeavouring to pre- 
serve or to acquire the lost motion: nothing can promote contrac- 
tion of the joint so much as motion before the disease is removed. 
In healing wounds in general, and especially those connected with 
joints, great attention should be paid to the motion of the joint: 
when all inflammation is gone off, and healing has begun, a little 
motion, and frequently repeated, is necessary to prevent their heal- 
ing in one position, Wherever there has been an inflammation, a 
stiffness will remain ; but the parts will stretch, and the motion 
again become free, by gradual motion and friction. But in healing 
of wounds by granulations there will be more rigidity. When there 
has been loss of substance, from mortification and gun-shot wounds, 
there will be still greater rigidity, and consequently more attention 
is requisite. In violent inflammation there is a union, by a broad 
surface and close contact, and then motion is sometimes altogether 
irrecoverable. The parts may often be made to stretch by degrees: 
this is either by active or passive motion. The active or muscular 
motion is insufficient, if the disease has existed long, as the muscles 
often lose the power of acting. The passive or foreign power may 
be of three kinds: 1st, the hands of another person ; 2dly, the addi- 
tion of matter to the moving part, so as to increase its momentum ; 
3dly, putting the moving part into such a position as to increase its 
gravity, which will produce the same effect as the two former; 
but yet the assistance of the muscles are necessary also. The posi- 
tion is either the middle state of action, which is natural in disease, 
or it is in consequence of gravity. The arm in diseases of the 
shoulder, if in bed, lies a little out; but if up, it hangs by the side 
naturally. Joints are of two kinds, some with flexors and exten- 
sors, with a given power; the other have not only the above, but a 
given support, which support acts generally in the centre of gra- 
vity. This division makes a material difference in the position of 
joints. If in the former of these there is a disease, the part natu- 
rally falls into a half-bent state, and will heal so if not prevented; 
* [The reason of this necessity is the constant action of the sphincter muscle, 
which is divided in the operation.] OF SPECIFIC DISEASES, ETC. 
but it is different in the other kind, for in whatever position they are 
placed, when there is a weight, the weight becomes the object of 
the mind, and not the motion; and the joint must be kept wholly in 
this position, which is a position rather contrary to that which it 
was meant to be kept in. This is most remarkable in the ankle- 
joint, because the point of support will not be the natural one: the 
foot will be hanging in a straight line with the leg, which is just 
the contrary to that which arises from the elongation of the muscles 
of the ankle. Suppose the elbow contracted, and I want to put the 
flexor muscles into an elongated state, neither the muscles nor mind 
being able to do this; the hand, apparently, is not heavy enough; 
but suppose I should then put a little weight into the hand, in order 
to assist a little, then the mind will be fixed on the weight to sup- 
port it, the flexorswill support it, being influenced by the mind; and 
thus we shall do harm by increasing the power of the flexors. But 
if the mind is fixed on the extensors, and not at all on the support 
of the weight, then the weight will be serviceable by extending the 
flexors while contracting the extensors. 
In the endeavour to elongate the muscles in any part of the body, 
they should never be allowed to contract, which would counteract 
the elongating powers. In contractions of the gastrocnemius 
muscle, the heel should be always supported, to take off the mind 
from the support of the body ; the body should be supported by art, 
by supporting the heel, but this should be incomplete, and gradually 
made more so. When the knee is bent, the above method will 
assist when the person is obliged to walk; for when sitting, throw- 
ing and swinging the limb about will assist most, and sometimes 
attaching a weight to the limb. I would advise lying on the face, 
and with such a position of the knee that the foot should touch the 
plane on which the body was, and then raising the foot more by 
bending the knee more. When the contraction is in the thigh, we 
cannot have all these auxiliaries. With respect to the shoulder it 
will be much the worst, as it will scarcely be possible to assist its 
position by any auxiliary. I have thought a pulley might be con- 
trived to raise the arm, with the weight fixed to the end of the 
cord; or the patient might be requested to lay on that side, having 
his arm through a tube and hanging out the other side. Every 
possible method should be tried: if a man could walk on his hands 
awhile, the arm would then by its own weight come to a right 
position with the body, which would be sufficient. 
345 
Tetanus. 
The symptoms of this disease are involuntary contractions of 
the voluntary muscles of the body, and sometimes of the involun- 
tary, which makes it fatal. This affection is sometimes only par- 
tial, and at othei' times general. When on the muscles of the jaw, 346 
HUNTER'S PRINCIPLES OF SURGERY. 
it is called locked jaw ; when on the fore part of the body, as the 
pectoral and anterior muscles of the neck, emprosthotonos ; when 
on the muscles of the back, drawing the head backwards, opistho- 
tonos. Tetanus should first be properly arranged as to class and 
species. It may be properly classed with every unnatural con- 
traction of muscles which may be called spasm, of which there are 
many species, most of which have some specific difference. It is 
of the same genus as spasmus cynicus, cramp, wry neck, subsultus 
tendinum, &c. It may be also classed with St. Vitus's dance, and 
it seems to have great affinity with ague, as this disease sometimes 
attends it; but the ague is only the predisponent, or immediate 
cause. It also seems to be allied to catalepsy and epilepsy : these 
arise from affections of the brain and nerves, but they may arise 
from different causes. Most of the above diseases are acted upon 
by affections of the mind, and this is sometimes the case with tetanus. 
This disease sometimes occurs in animals, as horses, cows, sheep, 
&c., from which it might be supposed that these animals were sub- 
ject to it from their way of life being somewhat similar to man's. 
I had a stag which died from locked jaw, from a compound frac- 
tured leg. 
Some muscles are more liable to it than others; those of the 
lower jaw are the most so; but as the disease increases, another 
order of muscles is affected, which I think arises from a species of 
sympathy: other involuntary actions have also their predisposed 
parts, as the cramp, which is mostly in the lower extremities. 
The muscles of the neck are most liable to that species of perma- 
nent contractions which constitutes the wry neck. 
Of the Causes of Tetanus.-The principal inquiries which have 
hitherto been made have been on the cure, and not on the nature 
of the disease, or its similarity to others. This part of the subject 
I shall now consider, and also in what climates it is most frequent. 
Irritation from an injury done to a nerve, ligament, or tendon is 
generally supposed to be the cause, as it generally occurs from 
wounds of tendinous or ligamentous parts. This at first would 
seem reasonable; but we must determine first what is irritation. 
That is called irritation which excites inflammation, and a patient 
is said to be irritable when a part of the whole constitution is easily 
affected by any slight cause. But everything relative to locked 
jaw does not arise from irritation of the wound itself, neither from 
inflammation or symptomatic fever ; for in such states the constitu- 
tion is not disposed to it. It arises from an irritable habit, 
which may be increased or produced by irritation, but not such 
as is capable of producing inflammation. When there is in- 
flammation, the locked jaw arises only when that is subdued. 
When from causes incapable of exciting inflammation, the irrita- 
tion may be considered the immediate, but not the remote cause ; 
for there must be a disposition for the disease, such a cause being 
insufficient for producing such effects : thus also madness is produced OF SPECIFIC DISEASES, ETC. 
347 
from the slightest causes when the mind is predisposed ; so it is in 
agues and fevers, the constitution being particularly predisposed at 
the time to such diseases. If it were from inflammation, the 
locked jaw would come on at first, or when the inflammation is 
most violent; but then the constitution is strong, which is a state 
unfavourable to the disease. It is perhaps impossible to say what 
are all the remote causes which produce this effect; probably many 
combined ; and it would be impossible to give all the immediate, 
but I shall give as many of both as I have observed. 
Constitutions most susceptible of the Disease.-First, there is a 
disposition of the nerves, and that principally of the nerves of the 
voluntary muscles and sensation, rendering sensibility more acute 
in such, so that they can scarcely bear to be touched. This appears 
to be from irritability of the nerves, and not from irritability of the 
living principle. To produce the disease only a slight immediate 
cause is necessary, which is the case also in most irregular actions 
of the nervous system, as we see in tickling, which will produce 
convulsions, though these would not be produced by a bruise in the 
same part. Those most susceptible of the disease are of weakly 
delicate frames and of suspicious minds, and not of strong and 
robust ones. It is common to have involuntary actions of the 
muscles in weakly constitutions, as we see in pregnant women, who 
are subject to cramps, fits, &c., although the living principle is 
acting at the same time vigorously; this was also the case with 
myself, at a time when wreak. I threw a stone at a deer, and over- 
exercised the muscles of the arm, which produced cramp and extra- 
vasation in my arm, and loss of the use of the muscles: this pro- 
duced sickness and paleness, and after a little time cramp came on 
in my leg; but at last this and the other symptoms w^ent gradually 
off: if the irritation had continued, a locked jaw might have come 
on. Now here, from the irritation, a spasmodic affection was pro- 
duced in a person in health. This species of irritation is very dif- 
ferent from irritation of the living principle causing inflammation. 
Climate seems the first of the predisposing causes, and that which 
can probably produce it without other causes: the second is the 
consequence of considerable local inflammation : the third is irrita- 
tion. The immediate cause is often a small wound of a part pos- 
sessing but little living powers. In warm climates it is most fre- 
quent, and consequently it is seldom found in cold weather. In the 
West Indies and in the Mediterranean, besides tetanus, we also find 
the diseases with which I have classed it very frequent. Sweden, 
Denmark, and other cold climates are not subject to it. The cramp 
is most frequent in warm climates, and also in bed: fits also are 
most frequent in bed, for warmth seems to have a peculiar effect in 
producing a particular disposition in the nerves ; and when there is 
an immediate slight cause, such diseases readily take place: nay, 
some are disposed to such actions without any immediate cause, 
which probably arises from climate, joined with a strong natural 
predisposition. The cases which I have seen from wounds were 348 
HUNTER'S PRINCIPLES OF SURGERY. 
those of the tendons, for these parts heal less readily, and the 
constitution is much weakened by wounds of such parts, so that 
sometimes a limb will waste from such a cause,-wounds being 
much more irritable here than in other parts, and particularly when 
attended with loss of blood. Nothing produces irritability more than 
a great loss of blood, especially when accompanied with a wound, 
and with this disposition of constitution. The wounds producing it 
are either considerable or slight: the first is a predisponent, the 
second an immediate cause. When I have seen it from the first, it 
was after the inflammatory stage, and when good suppuration was 
come on; in some where it had nearly healed, and the patient was 
considered healthy, under the disease as well as before. Some haver 
had locked jaw after the healing was completed. In such I have 
supposed the inflammation was the predisponent cause, rendering 
the nervous system irritable as soon as it was removed. When it 
comes on in horses, as after docking, it is after the wound has sup- 
purated, and begun to heal. A young man burned his face with 
gun-powder: in a fortnight after he was nearly well; but a short 
time after a locked jaw came on, and continued for two months, 
and then recovered ; but before that time his wounds were per- 
fectly healed. It arises from slight wounds, before either inflamma- 
tion or suppuration comes on. A man had a locked jaw about a 
fortnight after a nail entered the sole of his foot, which he did not at 
the time regard as of any consequence, the wound not being larger 
than that from bleeding, and not attended with any pain, inflamma- 
tion, or hardness : he died ; and after death I found a black line 
continued to a hard body under the skin, which could be dissected 
out almost like a lymphatic gland, and was found to be a bit of 
leather, surrounded by coagulable lymph: the black line was the 
mark of the nail. Here was no pain which could be the cause, and 
little, if any, inflammation, and the suppuration had not begun: 
hence it appears that the spasm arose from the slight irritation. 
Would producing a greater irritation have prevented or cured in 
this case? or would dissecting out the extraneous body have done 
this ?* These two kinds of wounds appear very dissimilar: I con- 
sider that the inflammation is the predisponent cause in the large 
ones, and that in the case of slight wounds there must already exist 
a predisposition, which only requires an immediate cause to bring it 
into action. The disease oftener arises from slight wounds than 
large ones, which may partly, but not entirely, arise from such being 
most frequent. Locked jaw arises from other weakening causes; 
it sometimes arises at the termination of a fever, and also at the 
termination of a flux, which is one of the most weakening diseases 
we have. It is singular that it should begin in the muscles of the 
lowei' jaw, and extend from these as a centre; but this is not a 
* [We should probably answer this question in the negative, considering that 
the progress of the symptoms is not in any degree checked by the entire removal 
of the irritation by amputation of the injured part. The fatal result, on the con- 
trary, is generally precipitated by this means.'] OF SPECIFIC DISEASES, ETC. 
349 
general rule, as it has been known to begin in the muscles of the 
neck. When it is confined to the muscles first attacked it may then 
be considered as mild. 
Tetanus appears to have a dangerous period, in which it is most 
liable to attack vital parts, which period seems to be before the con- 
stitution has become much accustomed to it; when of longer 
continuance, not having attacked vital parts, its liability to attack 
them seems lessened, which is generally in a fortnight, as the consti- 
tution has then become accustomed to the spasms, and can better 
bear them: I have never seen one die where it had existed three 
weeks, and after this it often continues, sometimes for several months. 
Sometimes they may recover in three days, which is generally the 
most fatal period ; but sometimes they may go on three weeks, and 
afterwards recover. If violent, it kills about the third or fourth day 
from the attack. 
As it appears to attack parts not necessary to life, it seems strange 
how it kills ; and, seemingly, the patient is in good health at the 
time without inflammation, and with a good appetite ; and, yet, 
though not starved to death, from the difficulty of deglutition, it kills: 
however, it is sometimes combined with other diseases, and then it 
is difficult to say which disease kills ; but when it is alone, the fol- 
lowing seems to be the case: the disposition increases, and the effect, 
spreading to vital parts, affects the muscles of respiration, as the 
diaphragm and intercostal and abdominal muscles, as we see in gout 
when it attacks a vital part. 
The first symptom is a stiffness in the muscles of the lower jaw, 
or neck ; but before the patient is sensible of it, its progress is ge- 
nerally gone some length, not having had occasion to open the mouth 
wide, for when it is perceived it is probably only by accident: this 
stiffness makes the arti'culation imperfect. When the spasm is per- 
ceived, a hardness maybe felt in the temporal and massetei' muscles, 
and most of the muscles of the face become contracted: if it extends, 
the muscles posteriorly on the neck become stiff, consequently the 
head is erect, and generally drawn backwards; the spasm extending 
to the muscles of the back, it becomes one concave arch, preventing 
the patient from lying on his back, and a heavy pain is felt at the 
lower part of the sternum, from the spasm probably of the dia- 
phragm : from this and the abdominal muscles being contracted, 
respiration is almost suspended, and the pain is similar to that of the 
cramp. By this pain, and the dyspnoea, we judge of the muscles of 
respiration and the diaphragm being affected. General spasms 
next come on, as subsultus tendinum, cold sweats, and death; and 
it is remarkable that the patient generally, if not always, retains 
his reasoning faculties during the whole progress. 
Of the. Treatment.'-All the antispasmodics have been given, but 
without apparent success; opium has kept its ground the longest, 
but with little reason, as it only quiets ; but from some patients 
having got well undei' its use, its name has been raised: I have tried 
it, both in large and small doses, though always unsuccessfully. I HUNTER'S PRINCIPLES OF SURGERY. 
350 
think medicines have no power without they produce some visible 
effect: opium never removes the cause, though it will prevent the 
effects; it cures spasms, and removes pain, but it does not remove 
the cause. It often does good, by not allowing the symptoms to do 
harm to the constitution. The first appearance of a cure is a 
recovery of strength, as weakness is a predisposing cause; and the 
first indication should be to strengthen the system. I should recom- 
mend everything to produce extreme external cold, as cold appli- 
cations, consisting of snow with salt, to the part, and that the 
patient should be put into an ice-house or sent to a cold climate as 
soon as possible.* I know of no internal medicine. The pain is 
somewhat relieved by counteracting the violent contraction of the 
muscles: opening the mouth by force has eased it; but this has also 
killed, by causing a translation of the disease: keeping the back 
bent has also given ease; but these have relieved only in the incipient 
state. Electricity has a temporary effect, in relaxing the muscles, 
and in partial affections has cured, by rendering the contractions 
gradually less violent. 
A man fractured his arm, and about a fortnight after had symp- 
toms of a locked jaw. I found several pieces of bone in the wound, 
which I supposed produced irritation; these I extracted, and gave 
two grains of opium every two hours, dressed the wound with tinc- 
tura thebaica, and over all applied a poultice; he continued as bad 
as before. The next day I directed bark and opium : on the fourth 
day he was better; on the fifth much more so, and his pulse good : 
he was bled, which was repeated on the sixth, immediately after 
which he fell into a fit, and died in half an hour. This sudden change 
could not be from the loss of blood, though assisted by it, and by 
his natural aversion to bleeding: he was of a nervous constitution, 
and his spirits were easily affected. It was probable that this 
affection of the nerves was transferred to the heart and brain, and 
probably the mind had something to do in this business. In another 
case of locked jaw I gave three grains of opium every quarter of 
an hour, but the patient died ; the opium had no effect, and the mus- 
cles were not relaxed by death. On opening him no preternatural 
appearances were found. In one case I tried saccharum Saturni, 
because lead produces paralysis, and as I conceived the locked jaw 
a disease directly opposite to paralysis; I gave it in pills, and it 
produced costiveness, and a peculiar sensation: a glyster relieved 
him, and he was better, and they omitted the pills because he sup- 
posed they made him costive, and would not be persuaded to take 
any more. He was at last seized in.the night with a difficulty of 
* [A remarkable case of tetanus, which was cured by an accidental exposure 
to cold and inclement weather for upwards of sixteen hours, is related by Sir 
James Macgrigor in the 6th vol. of the Medico-Chirurgical Transactions, p.450. 
Dr. Elliotson has also alluded to a case of tetanus in a horse, which recovered 
under nearly similar circumstances. Med. Gaz., Vol. XL, p. 474. It is needless, 
however, to say that not any remedy has yet been discovered which is uniformly, 
or even generally, successful in controlling the symptoms of this disease.] OF SCROFULA. 
351 
breathing, and spasms on the abdominal muscles, which killed him. 
In this case I lamented that the lead could not be continued. The 
ol. animale has been tried, unsuccessfully. 
I attended another patient in England, with Sir N. Thomas. 
Asafoetida and opium were given without effect; these were left 
off, and bark given in large quantities. Dr. Warren being called 
in, advised, among other things, a bath prepared of milk and water. 
After this he seemed better, but died soon after. 
I discovered, to my amazement, the different modes of different 
physicians. Sir N. Thomas had read much, and knew all the 
antispasmodics from the days of Hippocrates downwards. Dr. 
Warren having just cured his son of locked jaw, implicitly followed 
the same practice in this case, being unable to alter his rules of 
practice in the smallest degree, as occasion might require. 
CHAPTER XXL 
OF SCROFULA. 
Symptoms well marked, and usually easily distinguished ;-a specific disease, 
but without a morbid poison ;--appears to have a sedative quality ;-not con- 
fined to man;-certain constitutions most susceptible of it;-certain parts 
most liable to its attacks;-certain ages also;-not proved to be hereditary; 
-climate a predisposing cause;-and season;-immediate causes numerous. 
-Inflammation of scrofula;-suppuration;-pus;-ulceration ;-cicatrization; 
-difference according to the nature of parts.-Disease of the hip.-Lumbar 
abscess.-White swelling.-Consumption.-Scrofulous testicle;-scrofulous 
breast;-.distinguished from cancerous testicle and breast.-Cure of scrofula; 
-warm climate;-medicine;-sea-bathing;-regimen ;-local applications ; 
-surgical treatment. 
Scrofula is so well marked, and has so many characteristics, that 
few can mistake it; yet I suspect there are three diseases which 
have a great affinity to it, viz. spina ventosa, exostosis, and rickets. 
The first seems to be a pure case of scrofulous suppuration in 
bones ; the two last to be only varieties of scrofula. Scrofula is to 
be classed as a specific disease, but not as a poisonous one. It 
has, in a degree, the power of making neighbouring parts sympa- 
thise, by continued sympathy. It seems to have resident in it a 
sedative quality, as the disease goes on without any increased ac- 
tion, and from there being no adhesive inflammation. The pus 
which is formed passes along the interstices of the muscles, and is 
there even incapable of irritating. 
Other animals, besides the human subject, are liable to it, and 
probably from the same causes; thus, we find a disease very simi- 
lar to it in young turkeys, and also in monkeys, and I had once a 
young boar which died of a similar disease ; that is, it had swelled 352 
HUNTER'S PRINCIPLES OF SURGERY. 
lymphatic glands almost everywhere, and thickenings of the joints, 
like white swellings : but every constitution is not equally susceptible 
of it, although probably every constitution is more or less suscepti- 
ble of it. In some there is peculiar susceptibility, so as to have it 
produced by a slight immediate cause ; but this susceptibility is lost 
by age. So, likewise, some parts are more susceptible of it than 
others. Those most susceptible of scrofula are the delicate, who 
cannot bear much fatigue or cold without being affected, who are 
very irritable, and cannot bear strong impressions, as of mercury, 
who are of irritable minds, light-haired, and of fair complexions. 
In fair people there is a more languid circulation than in dark, 
and they would appear to have less red blood. When it attacks 
after the age of puberty it seems not so much confined to colour. 
When it attacks dark people I think they have a thin skin. Every 
part has in some degree its specific disease, and this disease has its 
parts. Some parts are even disposed to it without the above causes, 
even by the slightest accident. 1st. The lymphatic glands, par- 
ticularly the superficial, and those most exposed, as those of the 
neck and lungs, which last may be reckoned external. As the 
office of these glands seems to be for giving passage to the absor- 
bents, with their contents, it might be supposed it was only depen- 
dent on absorption; but as this is a specific disease, and not con- 
fined to these parts, we must look for another cause, and then too 
the lymphatic vessels might be supposed subject to it; which they 
are not; hence these glands must have some specific properties 
rendering them liable to it. Joints also are particularly liable to it, 
and especially those of the feet and hands, from their having so 
many joints, with ligaments and tendons. The elbow and knee 
come in next, and sometimes the hip and shoulder, and frequently 
the vertebras. In short, every part is subject to it, but no part more 
than another, except the above mentioned. The skin has less dis- 
position to it than any other part, for the skin will resist the neigh- 
bouring disease for a long time. 
Although all ages under the above circumstances are in some 
degree subject to it, yet youth is more particularly so, foi' beyond 
the age of fifteen the disease is less frequent, although it will occur 
from that, period up to forty; few cases, however, occur above 
forty-six. In youth it principally attacks the lymphatic glands ; at 
a later period, the testicle; and the same things happens in other 
animals. 
I do not think that scrofula can be proved to be hereditary, for 
if we compare the number of scrofulous subjects who have, and 
who have not scrofulous parents, we shall find them pretty nearly 
equal. I have known many families where it has arisen sponta- 
neously, the parents or predecessors having never been subject to 
it; and on the other hand, I have known parents who have had it, 
and their children have perfectly escaped. It certainly often runs 
in families, but only when the natural predisposition and immediate 
causes are present; fair delicate children will probably have it by OF SCROFULA. 
353 
the influence of climate. An hereditary disease should act univer- 
sally ; it should pass to all the descendants of a diseased parent; 
to the dark as well the fair complexioned; to the old and young, 
and in all countries and climates alike. The children may have 
the predisposition, but this does not come up to the meaning of 
hereditary disease. It is only the predisposing cause which can be 
hereditary. It is hereditary for people to be born with lymphatic 
glands, but it is not necessary for people to be born with them 
diseased. Probably a susceptibility of peculiar irritations may be 
hereditary, as we see in families with regard to small-pox, &c.; 
but this is an infectious disease. The weak and delicate are inca- 
pable of supporting the changes of temperate climates: the most 
delicate go into this disease, and the parts most subject to it are 
those which are the most delicate. Climate may be considered 
both as an immediate and a predisponent cause: the different kinds 
of weather, as damp and cold, seem to be the great disposers to the 
disease; however, in cold climates, where there is most constant 
dryness, it is less frequent. That irregularity of cold and moisture 
is one of the greatest disposers to it, is evident, from its never 
happening in warm climates; but the inhabitants of warm climates 
coming into cold ones often become affected with it. Some parts 
of the same country are more subject to it than others, which is 
also the case in other diseases, as agues, consumption, &c. -The 
animals of warm climates often die of indurated lymphatic glands 
when brought to cold ones, as turkeys, the joints of their toes being 
first affected, in a similar manner to white swellings. The disease 
which is called the pip in fowls is also the scrofula. 
The seasons likewise have considerable effect; for, indeed, they 
may be said to form temporary climates in some parts of the 
earth. Thus, in summer the disease is less frequent than in winter, 
and often that which is produced in winter is carried off by summer. 
But the regular cold of winter does not affect these people so much 
as spring, for the spring disturbs the constitution, and rouses parts 
disposed to scrofulous action similarly to a slight fever. The autumn 
has the same effect as the spring, but not so powerful. Every 
unnatural affection of the constitution has the power, in some 
degree, of calling forth scrofula; but the disease is nevei' an act of 
the constitution. Though there is constantly a constitutional 
susceptibility, its effects are always local. It is a constitutional 
local susceptibility. 
Scrofula appears spontaneously to arise up every day, the suscep- 
tibility in some being so strong that by the simple continuance of 
the immediate predisposing circumstance (climate) they fall into it, 
without any other immediate cause. The immediate causes are 
many. Everything capable of producing unnatural actions in a 
part is capable of exciting scrofulous action where the suscepti- 
bility exists; thus, the fevers of small-pox, measles, and chicken- 
pox often produce it. The lues produces scrofulous buboes; the 
irritation of mercury in curing the lues produces nodes; cold also 354 
HUNTER'S PRINCIPLES OF SURGERY. 
produces it, principally in the glands of the lungs or neck; and 
strains, gout, and rheumatism often leave the affected parts in a 
scrofulous state. These causes are more violent than that of 
climate, and produce the disease usually from a pretty considerable 
irritation, attended with inflammation arising from the accident, 
combined with that of the specific kind; but the swelling soon 
becomes indolent, so that it does not soon get wmll, and if opened, 
the sore is still not healable. We should therefore avoid opening 
it as long as possible. The true scrofula seems attended with little 
or no inflammation; or if it is so, its sedative quality prevents it 
from producing pain ; but when there is less of the true scrofula, it 
may give pain; however, it is attended with many of the effects of 
inflammation, as extravasation of coagulable lymph, producing 
swelling and also adhesion of the cellular membrane, or of the 
sides of circumscribed cavities. I have seen the whole of the intes- 
tines adhering to the peritoneum, seemingly from a scrofulous 
cause, and having scrofulous tumours and suppurations in them 
also: the symptoms were tightness in the belly, without pain and 
costiveness; at other times purging. The adhesions in the lungs 
of consumptive people are probably of this kind. Theii' indolence 
and want of pain led me to suspect that scrofula has sedative 
qualities which it gives to the matter, which does not irritate the 
parts unconnected with the disease. Where the inflammation is 
visible its colour is of a purplish red, which is a proof of a languid 
circulation. 
The progress of scrofula is commonly very slow, but some- 
times the lymphatic glands swell considerably in one night; but 
then there is a quick and immediate exciting cause, such as cold 
or fever, in which case there is common inflammation joined with 
the specific, which soon leads to suppuration, although after the 
phlegmonous inflammation is gone off it becomes truly scrofulous. 
The swelling at first is interstitial, but after some time there appears 
to be a change of structure, as in the lymphatic glands, the testis, 
and more particularly the bones, the whole bony structure of which 
is absorbed, so as to leave nothing but a true scrofulous deposit, 
similar in appearance to a scrofulous gland. When in the extre- 
mities of the joints, the part in view is thickened, with little pain ; 
this is principally seated in the ligaments; the joint loses its motion, 
and the whole limb becomes weak and wastes away. 
Scrofulous suppuration is very imperfect if it is truly of this 
kind, and there is often none at all. The extreme parts may lose 
their life entirely; yet they do not mortify, but form a curdly 
matter, similar to that in encysted tumours. This want or loss of 
life, if there was no specific action, would cause inflammation, as 
othex' dead parts would; but scrofulous parts are incapable of this 
stimulus. Many scrofulous tumours suppurate and ulcerate, espe- 
cially when near the skin ; but this is not entirely the suppuration 
of the original disease, but from the inflammation of the neighbour- 
ing parts. The matter, like common matter, is often a mixture OF SCROFULA. 
355 
of pus with coagulable lymph, which last is often most in quantity, 
it is a kind of glairy and often a curdly matter, being a mixture 
of the solid parts which are dead with the vitiated secretion. 
The ulceration is generally very slow, and when near the skin is 
often stationary, even after the appearance of redness ; sometimes 
it will remain in this state for several months, with a broad surface, 
not coming to a point, the skin assuming a shining purplish hue; 
but there is no absorption of the matter, as is generally supposed, 
from the scrofulous indolence. It seldom happens that granulations 
form, the sore remaining months, and sometimes years, without 
any. When formed, they look transparent, as if loaded with water, 
and have little power of contraction. The cicatrization is as slow 
as the other processes, from the essential and leading steps to it 
being backward. The skin around loses its natural elasticity, and 
so does not give to the contiguous granulations a skinning disposi- 
tion. 
To describe the appearance of scrofulous tumours and sores is 
impossible, but we can easily distinguish them by sight. A scrofu- 
lous swelling generally begins in one of three ways : first, by a 
circumscribed tumour; secondly by a more diffused tumefaction ; 
thirdly, by suppuration, without any tumefaction. These all fre- 
quently appeal' in the same person at once. The first is seated in 
the lymphatic glands, and assumes this form from the part being 
circumscribed, and also because the parts do not give the stimulus 
by contiguous sympathy to the adjoining dissimilar parts ; but there 
are some which seem scrofulous, and yet are not in the lymphatic 
glands. These I have called tumours; as, for example, those in 
the uterus, the breasts, &c. Of the second kind are scrofulous 
joints, and the diffused swellings on the skin, toes, fingers, hands, 
and also on the testicle; although, when the whole testicle is 
affected, it is generally circumscribed. Of the third kind are cer- 
tain loose bags of matter, without any tumefaction to distinguish 
them, although near the skin ; these are often pretty deep, and 
therefore are adapted to the parts they are in. There is no true 
adhesive inflammation in these cases, when they occur in true 
scrofulous habits. In the breast it begins like a scirrhus, and is 
sometimes taken for one; but it has no pain, and is so gradual in 
its growth that it produces no tumour in the axilla, so that it may 
be safely removed. In the testicles it often goes off and returns 
again. The second kind, when near the skin, often ulcerates, and 
hollows the skin by the cellular membrane, giving way more readily 
than the skin ; so that when suppuration comes on, the swelling 
does not subside, as in other cases. When in a bone, it is generally 
very slow, and the matter consists of a curdly substance. If the 
bone is dead, exfoliation is very slow, and in such cases the bone 
is eaten away by the exfoliations, as we mentioned when on the 
subject of exfoliations; that is, the absorbents of the surrounding 
granulations take it up. 
The different appearances in scrofula will vary according to the 356 
HUNTER'S PRINCIPLES OF SURGERY. 
nature of the part, and to these we have given different names; 
scrofula in the joints we have called white swelling ; in the loins, 
lumbar abscess; in the lungs, consumption; in the hip, hip-case. 
Some of these are not suspected to be scrofulous. When it attacks 
particular parts, it produces symptoms peculiar to the part; but in 
some parts which are not very necessary to health, it is not easily 
discovered. If the extremities are attacked, we find a lameness; 
and if a joint, a wasting of the limb. When it attacks visible joints, 
it is in general easily known; when it attacks the knee, it has com- 
monly true inflammation conjoined with it, probably from its being 
frequently excited by accidents. 
Disease of the Hip.-In most cases of lameness, or wasting of 
the lowei' extremities, the affected limb appears longer than the 
other, in consequence of the patient pressing most on the sound 
limb, and putting the diseased one further out from the pelvis, so 
as to raise the ilium. This is particularly the case in diseases of 
the hip, although the leg is not found to be longer than the other, if 
the patient is laid on the back. It arises from the centre of motion 
in the pelvis being rather altered by habit, which is removed if laid 
on the back. But sometimes, when the muscles are much wasted, 
the limb is shorter, which I cannot account for, nor why the limb 
is sometimes drawn up more, and sometimes put out further than 
the other. Mr. Cline says the limb is actually longer and shorter 
in different stages of the disease, and accounts for it thus: in the 
first instance, inflammation takes place in the ligaments of the 
joints, occasioning the parts to swell, and a large quantity of syno- 
via to be accumulated in the joint, which displaces and pushes out 
the head of the femur, thus occasioning a lengthening of the limb; 
but as the disease advances, absorption takes place, not only of the 
accumulated synovia, but also of the bone itself, with the surround- 
ing ligaments; and the head of the bone being drawn into the new 
enlarged cavity, by the action of the gluteus and other muscles, 
occasions a shortening of the limb; and this lengthening and short- 
ening of the limb is peculiarly evident on laying the patient on the 
belly. The glands in the groin of the affected limb becomes en- 
larged, from absorption of the matter. The first appearance of 
scrofula in the hip is announced by a weakness in the limb, followed 
by a wasting; but sometimes there is a thickening of the surround- 
ing parts before suppuration comes. It is sometimes difficult to 
distinguish it from lumbar abscess, which I shall next proceed to 
speak of. 
Lumbar Abscesses.-The mode of their coming on evidently 
proves them to be scrofulous: lumbar abscess comes on almost 
insensibly, but sometimes the patient can remember a pain in the 
part, a pain on the knee, or a pain on the outside of the thigh, lead- 
ing to the foot. These are often called growing pains, which shows 
that the disease is affecting other parts; which symptoms, arising 
from sympathy, are often more severe than the original disease. 
The progress is often so slow, that the weakness is frequently not OF SCROFULA. 
357 
apparent even when matter is approaching the surface, as on 
the thigh or loins. It often arises or is caused by injuries, as strains; 
in which case it is attended with more than usual sensibility and 
weakness. Its occasional removal by sea-bathing proves it to be 
scrofulous. It seldom occurs after thirty years of age, except from 
accident, so that it is most frequently met with in young subjects, 
who have other symptoms of scrofula. 
White Swelling, in its beginning and progress, is generally similar 
to other scrofulous cases; stealing, as it were, upon the part, and 
occasioning stiffness. There is sometimes a fluctuation with pain, 
but then it is not truly scrofulous; the pain is sometimes scarcely 
perceivable, but at other times it is considerable. These cases are 
of two kinds, one of which is truly scrofulous, the other is only 
common inflammation, mixed with more or less of scrofula; the latter 
terminates in adhesion or suppuration. In scrofulous sores on the 
fingers of children, the pieces of bone are often destroyed, and 
come away insensibly, the finger becoming shorter and alarming 
the friends, to whom it is necessary that we should explain the cir- 
cumstance. 
Of Consumption.-Most consumptions are of a scrofulous nature, 
which is evident from the attending circumstances and cure. They 
are very frequent, in this and other scrofulous climates, in the fair 
and delicate, and in the young and middle-aged. They come on gene- 
rally in a true scrofulous way by catching cold. By this the glands in 
the neck are enlarged, at the same time that tubercles form in the 
lungs, which afford a scrofulous secretion, or are converted into a 
curdly substance, which in the end ulcerates and opens into the 
bronchi. Sometimes thay occasion pain, and generally a cough, 
difficult respiration, and expectoration. The pain is considerable if 
the immediate cause is violent, as great cold ; and the dyspnoea 
and cough will be according to the degree of inflammation. The 
spitting varies according to the inflammation, being at first mucous, 
but after ulceration is formed purulent. The patients generally 
die ; but as all consumptions are not scrofulous, we should distin- 
guish them. The diagnosis may be formed by the violence or mild- 
ness of the attack; by the slow or rapid progress of the disease ; 
by the degree of pain in some one part, and by the hardness and 
quickness of the pulse, &c. Spitting of blood, which is sometimes 
violent, at other times trifling, is not always followed by a consump- 
tion. Does this bleeding arise from a disease in the lungs, or from 
a small vessel giving way I I cannot answer this question ; but 
this I know, that such symptoms often precede a consumption. If 
the lungs are affected, the symptoms will arise from the functions 
of the part being impeded, as difficult respiration. When we ex- 
amine consumptive people after death, we generally find a true 
scrofulous appearance; and as it is clearly scrofulous, it admits 
only of one mode of cure, which strengthens the opinion of its 
being scrofulous. The physicians here keep their patients as long as 
they can, and then send them away to Bristol and other places to 358 
HUNTER'S PRINCIPLES OF SURGERY, 
die. But, if we see the symptoms pretty early, and consider it as 
scrofula fallen on parts which are essential to life, we should not 
trifle with it as with a finger; we should send them to a warm cli- 
mate at once, or near to the sea-side; for bathing and short voyages 
tend much to cure scrofula, and consequently to cure consumption. 
Bleeding, however, is often necessary, to proportionate the quantity 
of blood to the quantity the lungs are able to circulate; otherwise 
bleeding is very injurious, as tending to produce greater weakness, 
when already great delicacy exists. 
Of the Scrofulous Testicle.-The testicle is the next part in order 
of susceptibility for the disease, and when so affected has been 
often supposed to be cancerous. Scrofulous testicles begin with out 
any visible cause, are slow in progress, and are often cured by sea- 
bathing : when they suppurate, the suppuration is scrofulous. I 
have seen them in lads of sixteen years of age, but never sooner ; 
from whence we might think that they are not scrofulous. They 
are seldom seen in old people : for as the action of the testicle before 
and after puberty differs, its diseases probably differ also. 
Of the Scrofulous Breast.-I have only seen one truly scrofulous 
breast, which came on at the age of twenty-six, and increased gra- 
dually to thirty-eight. It was sixteen or eighteen pounds in weight. 
In this case there was no disease leading to the axilla, as in cancer; 
so that I dissected it out, and it healed kindly, although the patient 
had other scrofulous appearances at the time. It was perfectly 
circumscribed, which is never the case with cancer, when of any 
size. Cancel' may be so at first, when small and loose in the cellu- 
lar membrane ; but when as large as a large egg, it affects the sur- 
rounding parts, and is more diffused. True scrofula, however, if 
attended with inflammation, will also adhere, and diffuse and lose 
itself in the surrounding parts, so as to put on a cancerous appear- 
ance. 
Diagnosis between Scrofula and Cancer in the Testicles and 
Breasts.-A cancerous testicle affects the absorbents going from the 
testicle and the spermatic cord; but I do not think that this is uni- 
versal, since we sometimes find the cord unaffected, but in scrofula 
it is never enlarged or affected at all. The distinction, however, 
in some cases, is very difficult. As we operate in cancerous cases 
because the cord is sound, so we must often do so in scrofulous 
cases which have no cancerous disposition. In the scrofulous breast 
we have no thickening leading to the axilla, or in the axillary glands, 
but in cancer they are thickened from continued sympathy; and 
this is, perhaps, the best criterion. 
From the circumstance of the cancerous disposition spreading by 
what I call continued sympathy, the surrounding parts being con- 
taminated and taken in with the original disease, the skin in all 
these parts takes on the same disease with the cancer; but in scro- 
fula it does not do so strongly: therefore when a cancer breaks it 
spreads, but in scrofula the skin seems rather to have a disposition 
to heal. OF SCROFULA. 
359 
Of the Cure of Scrofula.-The remedies must be directed both to 
the constitution and to the part affected; but if we had a specific 
medicine, then attacking the constitution alone would be sufficient, 
as it is in the venereal disease. As to external parts, the only cer- 
tain cure is extirpation, and this is very confined and is often impro- 
per, because the parts frequently get well of themselves ; still we are 
often obliged to have recourse to this means. Internal medicines 
have very little power; they cannot alter the constitution of fair 
people, or prevent the effects of climate, or change the disposition 
of parts ; neither can they make young people old. They can only 
lessen the susceptibility of the constitution, but do not reach the 
cause; hence there will soon be a relapse, if they are disconti- 
nued, climate being often of itself an immediate cause of the 
disease. 
We'can sometimes affect the constitution by changing the climate ; 
but changing the climate will not always effect a cure, for when 
vital parts are affected it is seldom done till too late. Change of 
climate is equally necessary in other cases as in tubercles of the 
lungs, these all depending on the same constitutional disease. Scro- 
fulous patients should go towards the South, or near the sea-side, 
or take short voyages. Sea-bathing in consumption appears tre- 
mendous, but it should be adopted in a warm climate. When these 
means cannot be complied with, strengthening remedies are useful, 
as bark and cicuta, with cold bathing; but these have no specific 
effects. Mezereon seems to have great power in the cure of this 
disease : a man with a very large swelled elbow, which appeared to 
be scrofulous, (although he had more pain than is usual in scrofula,) 
had been under a course of mercury for a venereal affection when 
the swelling came on; he rubbed it with a liniment composed of 
acetum scillae, but with no advantage : he was then directed the 
mezereon decoction, and soon recovered the motion and natural 
figure of the arm. The cure was completed in twelve days without 
any sensible effects from the medicine or the liniment, wffich he 
continued to use. A woman with enlarged lymphatic glands of the 
neck, which did not subside as usual with warm weather, I cured 
by mezereon. I gave it in the following manner: mezereon root, 
one ounce ; water, six quarts; liquorice root, half an ounce. Boil 
down to four quarts. Half a pint to be taken twice a day, or as 
much as the stomach will bear. 
Sea-bathing seems to have the greatest specific power. In general 
it is used in summer; but the disease requires it most in winter. It 
is to be considered in two lights; first, as a simple bath; secondly, 
as to its specific quality. Baths are of three kinds: cold, warm, 
and tepid; the specific effect being the same, whatever may be the 
temperature. When other diseases attend scrofula, for which baths 
of certain temperatures would do harm, the sea-bath should be 
regulated accordingly. In some constitutions a different degree of 
warmth is suitable from what is suitable in others. In some cases 
two good purposes may be answered, for in some the cold and 360 
HUNTER'S PRINCIPLES OF SURGERY. 
specific are both wanted, and in others the tepid and specific. The 
directions for sea-bathing are in general insufficient, but they should 
be particularly attended to, as with some the cold bath will disagree 
independently of all disease; some will be rendered cold all day 
by it, though they will recover by its specific effect, which is always 
the same in all constitutions. I do not think that the sea-bath 
lessens permanently the susceptibility to the disease, but that it is 
a temporary cure for the present diseased action, and prevents the 
effect of immediate exciting causes; but after leaving it off, the 
susceptibility returns, and the disease often returns in winter after a 
summer course of bathing. Next to sea-bathing and mezereon, 
hemlock seems to have the greatest specific power. Burnt sponge 
has been recommended, but I am in doubt of its specific powers 
Mineral alkali is serviceable, but its specific powers are very weak. 
Warm clothing, and that next the skin, is most proper, because 
it keeps the warmth constantly the same. This is Nature's method 
in the cure of animals, and it should be particularly attended to in 
children : the outward clothing may be according to people's fancy. 
Children of this disposition should never expose their naked feet to 
cold and wet, as is frequently the case. The exercise should be 
gentle, and the diet principally of a vegetable kind: but I consider 
this of little service, as the disease is frequent in those countries 
where little else but vegetable diet is eaten. 
From the indolence of scrofula we might a priori think that 
many local applications would be serviceable, especially those of 
a stimulating kind; but these all prove injurious, as mercury, cop- 
peras, balsams, &c.; indeed, few applications are of any service. 
I have myself only found benefit from cicuta and sea-water. The 
juice of hemlock made into a poultice is serviceable after suppu- 
ration has come on; and poultices made with sea-water have done 
good, when the cicuta has failed, especially in white swellings, 
before suppuration has taken place; and I may also mention that 
this water, as a lotion, applied to sores, often gives them a healing 
disposition. 
The best surgical treatment for those cases which will not admit 
of removal, is to do nothing. Where suppuration is superficial, 
openings into the abscess should not be made, as they are often 
absorbed spontaneously, and when they break of themselves they 
heal the soonest: but exceptions may arise, as when an opening is 
required to extract an exfoliated bone; otherwise openings only 
add to the causes which produce such diseases. Those parts which 
cannot be removed, as lumbar abscesses, are generally incurable; 
and the question is, are they to be opened or not ? The only answer I 
can give is, that before opening them patients are generally pretty 
well, but immediately after opening them they become unhealthy 
and hectic, which continues till death. Hence the practice of 
opening them shortens life; but sometimes they get well by this 
practice, that is, perhaps, about one in a hundred; and it may be 
thought right to treat all as if they were curable, as we cannot OF MORTIFICATION AND CARBUNCLE. 
361 
distinguish; this must be left to the surgeon and the particular 
circumstances of the case. 
The common effects of surgical treatment will not be found to 
arise in cases of scrofula; cutting always does harm. In common 
indolent abscesses, free openings is the best remedy, and the pro- 
duction of as much violence as we can; but this will not do in 
scrofula and cancer. In scrofula, irritable inflammation frequently 
supervenes, or erysipelas extending to the cellular membrane, and 
produce sloughing: for we find that no violence can increase the 
restorative action without also increasing the original disease. We 
find few actually die from the disease, although the vital parts are 
attacked. When the lungs are affected, it is the difficulty of the 
respiration which kills; when the mesenteric glands are affected, 
death happens from the want of nourishment; when there is lumbar 
abscess, the constitution is worn out by long-continued discharge 
and teazing complaints; but when superficial parts only are affected 
they generally get well. Accident produces many visible causes 
of cure, as fevers, &c.: and probably many invisible ones too. 
Climate is often a cure as well as a cause of the disease. Children 
are most favourably situated for a cure, from the daily variation 
of their constitutions. Puberty often produces a cure, which may 
be called the natural, and is most manifest in women. When the 
disease begins at a later period it has not these resources, but is 
more tedious. 
CHAPTER XXII. 
OF MORTIFICATION- AND CARBUNCLE. 
Mortification ;-death of parts;-accompanied by pain :-with or without inflam- 
mation ;-treatment.-Caustics and cauteries.-Carbuncle ;-peculiarity of 
situation ;-often numerous ;-attacks free livers ;-appearance, progress;- 
constitutional and local treatment. 
The effects of life are preservation and action : death is the loss of 
both. Life may exist in the whole, or only in a part; but it must 
always be in a vital part. Other parts may be dead, without 
affecting materially the machine. The immediate cause of death 
in a part would appear to be a loss of circulation: this may arise 
in various ways, but it must be the effect of some cause. Mortifi- 
cation is very different from universal death : the loss of natural 
life arises from some universal action having taken place, the same 
structure still remaining; but it is altered in mortified parts, all is 
blended in one mass of animal matter, and cannot possibly be 
injected. 
Partial Death, or Mortification, arises from various causes, yet 362 
HUNTER'S PRINCIPLES OF SURGERY. 
there is probably in all of them some cause which may be called 
specific. There are many others which may be considered as 
immediate and remote causes, as happens in gout, which may be 
produced by many causes, yet the specific cause has a peculiar 
mode of action in this as it has in other diseases. Mortification is 
commonly attended with great pain, characterised by burning, and, 
if it is in view, the stagnation of blood in the vessels always pro- 
duces a livid colour. The same burning sensation takes place from 
pressure, if carried sufficiently far to produce mortification, and is 
familiar in people's heels after lying long in bed. There are two 
kinds of mortification, one without the other with inflammation. 
The first arises from causes less visible than the other; that is, 
there is no increased action, or sensible heat, although the burning 
pain is considerable. What the predisponent cause is I cannot 
tell :* I have suspected something like a spasm of the small vessels, 
but I cannot be certain: we know spasms will sometimes threaten 
mortification, as we see in priapism, by which I have seen mortifi- 
cation produced in a dog. When the disposition is present, the 
action goes on ; as we see in sores, some parts being of a purplish 
hue, and going on in this way, while health is in the other parts. 
In some of these cases, a part withers and dies, and does not stimu- 
late the living parts, so as to produce separation, for a long time; 
but I have seen too few of these cases to judge of them accurately. 
The second kind seems to arise from a change taking place before 
death. Inflammation seems to be the immediate cause ; but this 
inflammation has two remote causes, of which one is weakness, 
which is the commonest cause of mortification ; but the other, or 
that which produces carbuncle, is not well known. 
Inflammation sometimes depends upon an increased action with 
increased power of the vessels ; but in mortification it must depend 
on an increased action with diminished power ; in all cases where 
this kind of mortification takes place, we have evidently a defi- 
ciency of the animal powers. In young people, mortification is 
generally preceded by fever ; in old by debility ; and the weakest 
parts generally give way first, as the toes. But debility alone does 
not produce mortification, if there happens to be strength in the 
part sufficient for the action which is induced : debility, therefore, 
is only a predisposing cause. We see this in scarifying anasarcous 
legs, in weakness from accident in weakened parts, in bruises, in 
frost-bitten parts, or wherever action is produced beyond what the 
powers of the part or system are able to sustain. But the increased 
action is not necessarily inflammation ; it may be a salutary en- 
deavour of the part to restore itself; which salutary action the 
powers of the part cannot support, and hence it gives way and 
dies. When frost-bitten parts are exposed to heat, the debility is 
* [Later observations have rendered it highly probable that dry gangrene 
always depends on a more or less complete obliteration of the great vessels : 
either the arteries or veins, but particularly the latter.] OF MORTIFICATION AND CARBUNCLE. 
363 
increased by the necessary action, which action the strength of the 
part cannot bear. Heat is congenial to life; but it should be pro- 
portioned to the degree of life, otherwise it will increase the debility. 
On this principle it is that cold air is so serviceable to people weak- 
ened by disease. In frost-bitten parts, for example, the living prin- 
ciple is much diminished by the previous cold, and heat must be 
gradually applied, in proportion to the quantity of life which 
remains ; but as the manifestations of life increase, so should the 
heat be increased also, otherwise by applying a degree of heat, at 
once, too great in proportion to the life, the part will mortify, which 
is invariably the case in man and all other animals; for warmth 
induces a more than ordinary exertion of the living powers, which 
may even be so considerable as to destroy the powers themselves. 
This proportion of power and action should be attended to in many 
common diseases : as appears from a case which I have already 
■described. 
Parts which have been weakened seem much disposed to take on 
the continued sympathy; and the parts, finding this disposition, 
become irritable, and are easily inflamed, which inflammation pro- 
duces death oftener than any specific inflammation. Mortification, 
however, is neither peculiar to weakened habits nor to accidents; 
but is often consequent on common inflammation, as in compound 
fractures. In a state of health the powers are much greater than 
the action; but when this state does not exist, either the powers or 
the action must be predominant. Thus in mortification the powers 
are too weak for the action ; but this weakened power is produced 
by various causes, such as old age, accidents, or erysipelas. The 
skin of such as take on this irritable action is generally opake, and 
looks withered even in the young subject. 
Of the Cure.-If our principles are just, it will be easy to lay 
down a rational practice. Practitioners have been conscious of the 
predisposing cause, which is debility, but not of the immediate one, 
which is increased action. Hence bark, cordials, wine, &c., have 
been given, by which an artificial or temporary action has been 
excited ; but this practice produces an increased action, without 
producing increased powers, and afterwards the debility is greater. 
Antiseptic substances have also been employed, such, for instance, 
as preserve dead flesh ; but this is very absurd. The local treat- 
ment has been equally so : consisting in the application of warm 
dressings in the wounds made by scarifications ; thus stimulating 
parts, the actions of which were already too violent. This practice 
might be suitable enough in the first kind of mortification, where 
death comes on without any increased action or effort. Will any 
thing lessen action, and increase also the power I Wine will not; 
bark is the only remedy of this kind we have : other medicines 
may be given on this principle, but none of them are so efficacious; 
opium for instance is useful, from lessening the action, but it does 
not increase the strength : it is, as I have ascertained by experi- 364 
HUNTER'S PRINCIPLES OF SURGERY. 
ment, more especially useful when applied to the part than when 
given internally. 
Of Caustics and Cauteries.-The death of a part may be pro- 
duced by a deficiency or privation of the living principle, and is 
then called mortification; but it may also be produced by mecha- 
nical and chemical causes, as bruises, the actual cautery, or caus- 
tics. Too much action will also arise from a violent stimulus, as 
arsenic, and kill a part, and in proportion to the deficiency of the 
living principle, the sooner will death be induced: as happens in 
bruises, in which the cellular membrane sloughs before the skin, 
though the skin is the part which is most injured. The more vas- 
cular a part is the greater is the power of life; hence muscles, 
glands, skin, &c., difficultly part with their life; whilst bones and 
tendons soon die by exposure, from want of living power to support 
the necessary inflammation. The actual cautery coagulates the 
juices, in consequence of which the living principle cannot exist. 
When caustic alkali is combined with animal or vegetable substance, 
the compound forms a kind of soap which is soluble in water. The 
operation of a caustic is not immediately on the living principle, 
but chemical; but its effects are retarded in some measure by the 
living principle, so that it acts more rapidly on some parts than it 
does on others. As no substance acts chemically till in solution, 
the caustic must first be dissolved, which is slowly effected by the 
perspiration on the skin. By the application of a caustic, a blister 
is raised, and serum accumulated, which dissolves a greater quan- 
tity of the caustic ; and this effusion is the consequence of all irri- 
tations, and is intended to get rid of the cause of irritation. Alkalies 
are in many cases to be preferred, although from their ready 
solubility they are disused in some cases. Their action is so very 
expeditious that the presence of the surgeon is required: they 
ought, therefore, only to be used in superficial abscesses, as they 
give much pain and spread,, and would take up too much of the 
surgeon's time when the parts to be destroyed are deeply seated. 
The caustic alkali, or lapis infernalis, should have its end wetted 
with water previously to its being applied to the living part; as 
soon as it is through the cuticle, the cutis effuses serum, which 
should not be allowed to extend beyond the intended slough, but 
should be wiped off with an armed probe. It is impossible to say 
what time will be necessary for this effect, as it will depend on the 
thickness or depth of the part; but when a very long time is neces- 
sary, we may scarify the upper part so as to quicken its effects; 
and this I may observe is a very ready way of opening superficial 
abscesses, when near the skin. When we make an issue in this 
way, we should go as low as the cellular membrane. The common 
caustic consists of caustic alkali and quick lime, which should be 
mixed with soft soap, or with liquid caustic alkali, if its powers 
require to be increased ; the concentrated acids are likewise em- 
ployed, as for example the vitriolic and nitric, which should be 
applied, like the caustic alkali, by means of a piece of glass, or OF MORTIFICATION AND CARBUNCLE. 
365 
some othei' substance which will not be acted upon. The metallic 
salts are chiefly employed to destroy luxuriant granulations, as blue 
vitriol, lunar caustic, &c.; but if they are used to produce a deep 
slough, they must be used in powder, mixed with some soft sub- 
stance. These last substances only coagulate the parts, but do 
not chemically combine with them, as the alkalies do. Arsenic 
seems to have both a chemical and a poisonous effect upon the 
living textures. 
Now as most parts are capable of communicating their sensations 
to the brain, the gradual destruction which caustic occasions pro- 
duces considerable pain. This may be alleviated by mixing opium, 
or extractum thebaicas with the caustic, or by the application of an 
opiate plaster an hour or two before the caustic, which will have 
a very good effect, especially in women and children who cannot 
well bear the caustic long enough to produce its proper effects 
without these alleviations.* A long while generally elapses before 
we can bring a cut issue to a proper degree of suppuration, as the 
means which are employed for keeping it open prevent a good 
suppuration, by keeping up inflammation ; but caustic seems to 
answer better, by destroying a certain quantity of substance, which 
separates in the form of an eschar, and leaves an open sore that 
will generally suppurate freely. In some the eschar is slow in 
separating; in others it will be thrown off in about ten days; but 
in others it will require three weeks, the separation being always 
more rapid when the caustic goes fairly into the cellular membrane, 
which has less life than the cutis. 
The separation of a dead part from a living is performed by the 
absorbents, which take into the circulation the edges of the sound 
parts which adjoin to the dead, and thus the dead part being set at 
liberty drops off. But in order to effect this, inflammation is first 
produced, and then ulceration or absorption follows. The separa- 
tion takes place sooner or later, in proportion to the life of the part; 
hence the skin, muscles, and parts which are nearest the heart, 
slough readily: tendons and bones slowly; and cellular membrane 
less readily than the skin. Life in a part is in proportion to the 
number of vessels it has for its simple support, the vessels for other 
purposes not adding to its powers of life, considered in itself. In 
new-formed parts, however, the separation is not so slow as in 
original parts, although they are disposed to slough more readily; 
but this depends on a different principle, viz. on weakness, which is 
consistent with what has been already observed. How far the 
brain is capable of sloughing I cannot determine, but I should 
imagine that people would never live long enough for this process 
to take place. In vegetables we find dead parts rot; but they are 
* [Nothing is so effectual for alleviating the pain occasioned by potassa fusa, 
as the application of common vinegar, which immediately combines with the 
alkali to form a neutral salt. It possesses also another advantage, in restraining 
the operation of the caustic, which in some instances is very apt to spread 
beyond the assigned limits.] 366 
HUNTER'S PRINCIPLES OF SURGERY. 
not separated as the dead parts of animals, because they have no 
absorbents; but if they separate, they do so by a process of putre- 
faction. 
Soft parts, when about to slough, first become darker coloured, 
and if exposed to the air become dry and hard. The separation 
always begins at the external edge, forming a groove between the 
living and dead parts; this groove becomes gradually deeper, till 
at last it is quite through, and the slough drops oft'. Why the sepa- 
ration should begin at the surface I do not know, except that the 
external parts are more ready to take the alarm, or that the skin 
goes through its operations and separates more rapidly than the 
cellular membrane; but as we find in bones that the exfoliation 
always begins at the external edges, I cannot offer the above as an 
explanation. Its beginning from the edge makes the separation at 
first only from the circumference, but sometimes it is from the 
centre, as when matter is formed underneath. 
The separation of which I have been treating is of two kinds; 
first, where the cause is constitutional, as in mortifications; secondly, 
where it is local, as by caustic. To the first kind of separation 
much attention is to be paid, as the mortifying disposition must cease 
before the part already mortified can be removed. When the sepa- 
ration is begun, if the parts are small, they may be allowed to go on 
their own way ; but where it is a whole limb, it is necessary to remove 
it, as the length of time required for the separation would often wear 
out the patient's constitution. The when and the where this is to 
be done is a matter of great importance. We should certainly 
remove the bulk of the mortified limb ; but as there is danger of 
inflammation and fresh mortification being brought on, from cutting 
the living parts, even though the mortification should be stopped, 
from the constitution being mended, we must wait till we see a 
healthy line of separation, and, by the appearance of the granulations, 
judge of the propriety of amputation. I would recommend removing 
the part in mortifications of the leg, by cutting into the dead parts 
near to the living; and after a time, if it be necessary (which can 
only happen in the legs,) the irregularities can be removed. In 
sloughs from caustic, practitioners used to cut out the eschar ; but 
as a part remains which requires the same length of time to separate 
as the whole, nothing is gained by this proceeding. 
Carbuncle, or Anthrax, is an inflammation of a specific kind, 
which is shown by its regular termination. It may in some measure 
be reckoned a cutaneous disease, commonly beginning in the skin. 
The mortification which takes place in the parts succeeds inflam- 
mation ; yet it does not always arise from inflammation, attended 
with general debility ; nor docs it always take place in the weakest 
parts, as the foot, but commonly near the source of circulation. 
That there is some peculiarity in the constitution, is perfectly evi- 
dent, from the patient being apparently otherwise well, with a good 
pulse. It seems to be a specific effect of this inflammation to pro- 
duce death in the part. It most frequently appears on the back or OF MORTIFICATION AND CARBUNCLE. 
367 
the neck, and seldom in the fore part of the body, which is very 
singular. Carbuncles seldom come alone; but seldom more than 
one begins at the same time, but in succession: I have seen them 
extend over the whole back. Another peculiarity is, that they sel- 
dom attack any but those who have lived above par, especially in 
eating ; in which respect they resemble gout, as well as in the cir- 
cumstance that they are generally inclined to occur in fat people. 
I suspect that any irritation, applied to those in whom there is this 
peculiarity of constitution, brings them on; therefore to an elderly 
man of this disposition I am cautious of applying blisters. The 
inflammation is in the cellular membrane, and though very similar 
to the erysipelatous, is yet very different. It does not produce adhe- 
sive inflammation, but runs into mortification, as the erysipelatous 
does; neither does it produce true suppuration. At first it appears 
like a pimple or small-pox pustule, in the cutis, the matter of which 
would seem to penetrate to the cellular membrane, and affect it; but 
perhaps the disease itself extends to the cellular membrane in the 
first place, although the first idea is most probable, as there is no 
adhesive inflammation to prevent that being the case. The tume- 
faction is considerable, but flat: the cells being filled with pus, mixed 
with coagulable lymph. The matter approaches to the skin by 
ulceration ; or if very tight, it mortifies. The matter oozes from 
several openings, like water out of a sponge. At last, in most cases, 
the cellular membrane dies, and the ulceration in the skin extends. 
Sometimes the whole sloughs off together, leaving a wide chasm, 
with inflamed lips. When suppuration takes place, there is con- 
tinued sympathy in the surrounding contiguous parts, and then the 
inflammation becomes more of the adhesive kind. The local pecu- 
liarities are as follow : 1st, it begins like a pimple ; 2dly, the inflam- 
mation spreads a little, giving it the appearance of a boil; 3dly, 
the inflammation spreads under the skin, and a doughiness takes 
place, the skin itself not being much affected, the tumour having a 
defined edge, and being six or seven inches perhaps in diameter. 
The skin now becomes affected, beginning at the first point of the 
disease, and spreading throughout; little pimples are frequently 
formed upon it, which often communicate with the cellular mem- 
brane beneath. Bounds are at last set to it by the surrounding 
adhesive inflammation. The practice should be to open it as soon 
as it begins to form a base, to prevent its spreading further. When 
it has gone through all its stages the process of cure begins, and it 
heals as soon as other sores, and one is often healing while others 
are forming. 
Boils, I suspect, are all of the carbuncular species, but less in 
size, with more of the adhesive inflammation, which prevents their 
spreading. Boils have another distinction, which is, that they 
seldom produce suppuration equal to their inflammation ; and, as in 
carbuncle, there is produced a visible slough, so there is a core in 
boils which answers to the slough. When boils are very large the 
constitution is in fault, but not so when few and small; they are 368 
HUNTER'S PRINCIPLES OF SURGERY. 
then supposed to be salutary. Boils are most frequent in youth, 
carbuncles in age ; yet we find boils in old people; but carbuncles 
are seldom in people below the middle age. 
Treatment of Carbuncle.-As carbuncles begin with a species of 
inflammation, which terminates in mortification, the patient being 
generally of a full habit and in apparent health, it might be asked 
if the constitution should not be treated by evacuants. I would 
treat it always according to circumstances; but in the latter stage 
I have always found evacuations improper. Evacuations never 
answer in constitutional specific inflammations, -as they do in com- 
mon inflammations. Bleeding in gout and erysipelas is often very 
injurious, yet it is occasionally necessary ; neither in inflammation 
from poisons has it a good effect, unless where the constitution is 
ready to run into violent common inflammation, in addition to that 
produced by the specific power of the poison ; hence, in small-pox, 
gonorrhoea, &c., bleeding is sometimes useful: but evacuations and 
bleeding never agree so well with those who have lived above par 
as in the temperate ; hence they are more useful in acute rheuma- 
tism than in acute gout. Cordials and bark, and warm medi- 
cines, are commonly given, and made more stimulating by the 
addition of tinctures ; and these are given for two reasons ; first, 
because the part is dead ; and secondly, because the patient often 
becomes much debilitated. But such medicines can only keep up 
the strength and the action depending upon strength, but cannot 
overcome the specific nature of the disease: therefore we should 
give others, that we may at last find out a specific ; yet, if we had 
a specific, these remedies would be often also necessary, as they 
are in lues. I have, however, tried other means, but w'ith little 
success. 
A gentleman, a3tat. 70, w7ho had lived well, and had had a 
universal dropsy, which he appeared to be cured of, was attacked 
with inflammation on the left shoulder, which turned out to be true 
carbuncle, which, as soon as it was opened, was followed by several 
more near the spot. The person under whose care he was gave 
him one drachm of powder of bark with ten drops of tinct. thebaica 
every hour, wdiich rather' purged him ; he also took calomel and 
opium, the former of which was increased, to see if mercury would 
do good; but it had no effect; neither did it prevent more from 
forming. One was very large, and there were several smaller ones 
in different parts of the back ; one was opened pretty early, which 
seemed to stop its increase, and I opened another at its orifice, with 
caustic, which discharged the matter, and seemed to stop its progress. 
The first during this time was healing. When the first appeared he 
seemed to be in good health, but afterwards he gradually lost it, 
his appetite became bad, his pulse quick and small, and his ankles 
a little swelled. As neither bark nor calomel and opium had been 
of any use, I said to Dr. David Pitcairn, " Now do not let us permit 
this patient to be lost, whilst we are only using such means as expe- 
rience shows to be of little oi' no effect; let us try something new; OF MORTIFICATION AND CARBUNCLE. 
369 
for David, this is a case more belonging to my province than yours, 
and I, being an older man, have seen more of them than you have, 
and can tell you what perhaps you did not know, that we have no 
powers in this case that are known." Now David is a truly sensi- 
ble man, and not governed by form ; he therefore agreed, but wanted 
to know where we were to begin. " Why, with the first letter of 
the alphabet, and go through the catalogue of the materia medica, 
so as we do not stop too long on the letter B (Bark), as is gene- 
rally done." As cicuta was a medicine of considerable powers, 
and then not thoroughly known, we began with that, of which the 
patient took half a drachm in the day, but without effect. I then 
tried sarsaparilla, both in powder and decoction ; the powder was 
made into bread and pudding, to eat through the day, but with no 
good effect. Dr. Pitcairn now proposed decoction of elm bark, 
from having seen it of use in erysipelatous inflammation, there 
appearing an affinity between this disease and erysipelas ; this I 
assented to, but from a thought which had struck me, I wished to 
try the fossil caustic alkali (soda); so they were given together, 
and we thought they were of service, as it was during this course 
that the patient recovered, though it must be confessed it was very 
slowly; but some fresh ones which had shown themselves disap- 
peared again. I have given fossil alkali to several since with good 
effect. 1 was myself always troubled with boils, until I took forty 
drops of this lixivium night and morning in milk for two months, 
when all my boils disappeared, and I have since had no return of 
them. Another gentleman asked my advice on whom two or three 
carbuncles had begun to appear, and he was perfectly cured by this 
treatment. 
The topical treatment consists in the free dilatation of the skin 
which covers the sloughing cellular membrane ; but as this comes 
after all the mischief is done, I think it a bad practice at the lattei' 
stage, although applications to the part are useless until the slough 
is separated. Small openings at the beginning, to prevent the 
increase, is all we should do, and not make any openings after- 
wards.* 
* [The practice of modern surgeons is to make free openings in all stages of 
the disease, for ■which the best reasons may be given. An escape is thus 
afforded to the diseased sloughs and secretions, and an opportunity given to 
apply appropriate dressings to the sore ; but the propriety of this treatment 
chiefly arises from the indisposition of the skin to ulcerate sufficiently extensive 
to allow the sloughs to come out. See note, p. 196.] 370 
HUNTER'S PRINCIPLES OF SURGERY. 
CHAPTER XXIII. 
OF POISONS. 
General considerations respecting poisons ;-definition of a poison.-Mineral 
poisons.-Animal poisons, natural and morbid.-Morbid poisons ;-their ori- 
gin ;-effects local, constitutional, or mixed.-Of local diseases.-Itch ;- 
nature;-cure.-Cancer, definition of;-origin and progress;-effects only 
local;-does not affect the constitution ;-reasons for this opinion ;-exten- 
sion of the disease by three modes ;-absorption of the poison ;-does not pro- 
duce specific fever;-no proof of poisonous disease of the constitution.- 
Local effects of cancer ;-predisposing causes.-First appearance and symp- 
toms of cancer ;-progress towards suppuration ;-treatment;-destruction of 
cancer;-extirpation;-mode of effecting it, and cautions to be observed.- 
Cancerous testicle.-Fungated sores.-So-called cancer of the penis. 
No unexceptionable definition of a poison can be absolutely given, 
for almost everything capable of injuring in a healthy or unhealthy 
state may be considered as a poison. They are such as destroy 
either the structure or the functions of an animal. The last may 
be similar to the weather, which often affects the mind, and may 
be called a poison of the mind. But there are many substances 
which, when applied to a healthy state of the body, may injure, as 
poisons; yet when applied to an unhealthy state they will coun- 
teract that state, and keep up health as long as they have the power 
of irritation. The healthy action, then, being a tertium quid of the 
unhealthy and poisonous, these are to be considered as medicines 
which have different effects at different times, and under different 
circumstances, as food; sometimes they are capable of curing one 
diseased state and not another, even of the same specific disease ; 
indeed, each disease has its own peculiar specific. Many substances 
act as poisons in some constitutions and not in others; as muscles, 
&c., thrown into some stomachs poison them ; also strawberries 
and cider in some persons cause flushing and erysipelatous inflam- 
mation. Whatever our idea of a poison may be, we must gene- 
rally exclude the idea of quantity, for even the most innocent sub- 
stances may become poisonous by quantity, as common food. Some 
cannot eat meat of any kind without being affected, but can eat 
fish or fowl without harm. If we do not pay regard to quantity 
we cannot distinguish poisons from medicines, as many of our me- 
dicines may even be given so as to poison or to produce no effect 
at all. So vague are our ideas of poison that we do not give the 
name of poison to all the actions of the same substance when it is 
formed to act in two different ways, though it may kill in both 
ways. A man killed by swallowing a piece of glass could not be 
said to be killed by a poison, because we know its effects ; but 
powdered glass swallowed would irritate the coats of the stomach, OF POISONS. 
371 
and kill, and would, hence be called a poison. Many other things 
might be called poisons, as cold water drunk when a person is hot, 
producing fever, erysipelatous inflammation, the eruption called a 
surfeit, &c. 
Poison is not only what is taken in by the stomach, but also by 
the lungs, as mephitic air, which kills immediately, and has no 
cure; so likewise many applications administered externally are 
called poison. Our present idea is that they act in three wrays, viz. 
mechanically, chemically, or on the living principle. The two first 
always act locally, but the third either on the whole or on a part. 
We do not call everything a poison which acts mechanically, as 
swallowing a knife ; but we suspect a different mode of action from 
powdered glass or hair, and therefore call them mechanical poisons, 
imputing the effects to some hidden power, which is in some mea- 
sure right, it. being their irritating effects on the living principle of 
the coats of the stomach, not simply cutting and lacerating mecha- 
nically as the knife does. These ought not therefore properly to 
be called mechanical poisons. Melted lead or boiling water will 
kill chemically, yet cannot properly be said to be poisons. Some 
only irritate the part, the substance being too weak to have any 
chemical effect. Nor is everything which acts on the living prin- 
ciple to be called a poison ; but we should distinguish between poi- 
sons of this kind and medicines; yet we find " a slow poison" is a 
common saying, as brandy. Arsenic kills by inflaming the sto- 
mach, and not by a peculiar action, therefore it is not a poison; nor 
is anything else which kills by common inflammation or common 
effects. I w7ould define poison to be a substance which has a pecu- 
liar mode of irritating, a peculiar mode of affecting the living prin- 
ciple, and which produces its effects more or less in any quantity, 
however small. Of this kind are most of the morbid poisons ; but 
small-pox falls short of the definition, in not keeping up its effects 
after having once affected the same person. 
Of the different ways in which Animals may be affected by Poi- 
sons.-There are three ways of their acting, and also a mixed wTay. 
The first is where the poison affects only the part in contact with 
it, and no part of the general system, except from the local injury. 
This includes the three kinds of poison, viz. mechanical, chemical, 
and those acting on the living principle. Examples of these are 
glass acting mechanically, sublimate of mercury acting chemically, 
and the matter of cancer, which acts only on the living principle. 
The second is when the poison affects the constitution, which con- 
stitutes it a morbid poison entirely, as, for instance, the jail distem- 
per; but how it gets to the constitution is unknown. The third is 
when the whole nervous system is affected, as by poisoned arrows, 
honey, muscles, nux vomica, and probably also the bite of a mad 
dog, which produces no visible effects on the injured part. The 
mixed, or compound, is of two kinds: first, when it produces in- 
flammation of the part, as was observed of cancer and itch, and at 
the same time affects the whole constitution, as the venereal dis- 372 
HUNTER'S PRINCIPLES OF SURGERY. 
ease, which the cancer and itch do not. The second is that which 
has three different modes of contaminating a part, like the third class, 
viz. 1st, locally, as in the itch; 2d, like the jail fever, which acts 
first on the constitution; and 3d, like the first of the compound, 
producing local inflammation; of this kind is the small-pox, &c. 
We might make a fourth out of those in which the poison might 
be taken into the constitution without producing local effects in the 
first place, as in jail fever, natural small-pox, &c.; but these are 
then received by contact, and not by insertion. In some the con- 
stitution is unaffected till ulceration has taken place, from knowing 
which we can often prevent their general effects. How a poison 
lies inactive so long is with difficulty explained, but it is a principle 
belonging to each, each having also its own specific latent period 
before it affects the constitution. 
Mineral Poisons.-The mineral poisons are mostly metals, the 
poisonous qualities of which depend on their solution in our juices ; 
their virulence is often increased by their combination with acids, 
as, for instance, mercury with the muriatic acid; but they can 
poison either by affecting the living power, or by acting chemically; 
chemically when strong, and by irritating when diluted. Minerals 
are capable of acting in the three different ways; when mechani- 
cally, it might be supposed to be by altering the composition or 
arrangement of the animal fibre, so as to injure without destroying 
the living principle : but such cannot properly be called poisons. 
They may act chemically by combining with animal substances, 
as the vitriolic and other acids, and caustics. When they act on 
the living principle without seeming to alter the part to which they 
are applied, they are probably absorbed, and excite universal irri- 
tation, as for instance, lead and mercury, which, when given too 
largely, seem to have this property; but each of these will kill by 
their action on the stomach. I know of no mineral poison that 
produces universal sympathy when locally applied, except it is 
applied to the stomach. Most of them produce peculiar complaints 
as we see from lead, mercury, arsenic, opium, &c. 
The Vegetable Poisons appear to be of three kinds; first, the 
natural juice of plants without having undergone any secretion; 
secondly, the secretions of plants, as honey and the essential oils; 
thirdly, those which have undergone a change by a chemical pro- 
cess, as the oil of tobacco. These produce their effects in two 
different ways, similar to the mineral, viz. chemically, and on the 
living principle. Their power on the living principle is much more 
extensive than that of the mineral, and their effects are peculiar 
and different from those of any other disease, so that they are 
generally well characterized. 
The Animal Poisons act principally on the living principle. 
Nothing shows the variety of animal matter more than the poisons. 
The blood may be considered as the fluid animal, because it con- 
tains all the parts which compose the animal, and the whole body 
is composed out of it. The solids which exist already must have OF POISONS. 
373 
the power of decomposing this fluid according to the stimulus of 
each part, and on that the natural and morbid secretions depend. 
I shall consider these under the heads of natural and morbid 
poisons. 
1st, Natural Poisons.-Many of these first affect the stomach, as 
some kinds of fish; others consist of animal secretions, which are 
produced by particularly formed organs, provided with an appro- 
priate apparatus and ducts, for the especial purpose of secreting 
and inserting the poison in the bodies of other animals. These 
secretions do not affect the parts which contain them, although 
they would probably poison the animal itself if inserted into any 
other parts than those which naturally contain them, as, for instance, 
in scorpions, which poison each other, although the Abbe Fontana 
denies this as to the viper. The second species produce their effects 
in two ways, by contact or by insertion. Those which affect the 
skin by simple touch are various, as sea insects, the ant, &c.; but 
before the others can possibly operate they must be conveyed into 
a wound, which brings them to the living principle, on which they 
will always act under these circumstances, but not when the cuticle 
is entire; hence all these animals make a wound before they can 
act. This second species are all of them very active, producing 
immediate effects, both locally and constitutionally, otherwise they 
would not answer theii' intended purpose, which is the defence of 
the animal. According to the quantity, they would appear to be 
more or less violent in their effects, as in small animals the effect 
is the same in kind, but not in degree, as in a large one ; thus a 
large one kills, while a small one does not; the rattlesnake being 
longer and larger than the common viper, kills much sooner. 
Those which poison by the touch, first produce a soreness, and 
some swelling and inflammation, which latter is of the adhesive 
kind, although the swelling is generally oedematous. Those which 
act externally and locally do not occasion swelling at any distance, 
so that the continued sympathy is not great, as that from the ant. 
These all appear tQ have their peculiar distance, unless the effects 
areincreased by rubbing,itching being generally their consequence. 
Those which become constitutional have also local effects, which, 
however, are not so fixed as those from the other sort; for in these 
a kind of continued sympathy exists, and a dissolution of the parts 
comes on, which produces extravasation of blood, and consequently 
a dark colour. The first symptom is pain, and if the poison is 
absorbed there is also a sore red streak, extending to the lymphatic 
glands, situated between the injured parts and the thoracic duct. 
The glands also, which are principally in the bend of the great joints, 
swell, and become painful, show ing either absorption of the poison 
or that the lymphatic system sympathizes. A cold fit often follows, 
and sometimes convulsions and death in a short time. The injured 
parts likewise swell, and become dark and livid, from vessels car- 
rying red blood which did not originally do so; but the continuance 
of the local effects does not arise from the constitution, otherwise 374 
HUNTER'S PRINCIPLES OF SURGERY. 
similar effects would manifest themselves in other parts of the body. 
Suppuration of the part to which the poison is applied rarely hap- 
pens ; but by absorption this may sometimes happen, as in common 
buboes. Effects such as we have been describing are seen in the 
viper, scorpion, &c. Some insects poison in the act of sucking 
their food, as the gnat and bug, and these seem to produce specific 
diseases; that is, they appear not to suck the common red blood 
from the vessels, but to produce an inflammation, and afterwards 
suck the extravasated blood from the inflammation which they have 
occasioned. 
2d, Of Morbid Poisons.-These probably arise from a diseased 
state of the body or part, which originated either spontaneously, or 
from the application of similar matter from another animal. This 
is proved by the late origin of all of them. We have many daily 
arising spontaneously, and which continue their excitement. The 
cancer is a proof of this, and I once thought the same of hydro- 
phobia ; but Mr. Meynell tells me he never had a hound mad but 
what had been bitten. Some of the morbid poisons are lost, and 
others are losing ground every day for want of frequent commu- 
nications : some of these act in a fluid state, and others in a state of 
vapour. The venereal poison requires contact, and possesses itself 
of those parts which are most frequently in contact; some affect 
the secretions so as to make them poisonous, as the saliva in the 
mad dog. It may perhaps in time happen that the human race shall 
be extirpated by poisons alone; but it is more probable that many 
poisons are extirpated, and that new ones arise in their stead every 
day. Morbid poisons differ from the natural in requiring a morbid 
action in the body to produce them, as cancer, which is either the 
produce of a similar disease, or arises spontaneously. These pro- 
duce greater variety of effects than the natural, some of which are 
local, and others both local and constitutional. 
Some affect the whole system rapidly, as the variolous matter; 
but not so the venereal. Many of them are not content with simply 
poisoning those people w'ho come within their influence, but com- 
municate it to others, who in their turn are capable of affecting 
others. Every part of the body is more or less susceptible of being 
poisoned. The effects of some poisons seem confined to peculiar 
animals; as cancer, which occurs only in the human species. 
Others affect various animals; as hydrophobia, which attacks horses, 
cows, dogs, cats, geese, fowls, &c., when they are bit. Others only 
affect animals of the same species, as the variola. Some appear to 
choose peculiar ages; as the cancer, which never occurs in young 
people. Many choose a peculiar sex, or peculiar parts only are 
affected by them, some parts being more susceptible of some actions 
than others: as, for instance, the breast, of cancer; the skin, of 
small-pox ; and the salivary glands, of hydrophobia. Both the great 
and small effects of morbid poisons depend less on quantity than 
those of the natural do. Some poisons perform their own cure, as 
in those cases where the constitution is only capable of being affected OF POISONS. 
375 
by them once; which, as we have no artificial cure, is a happy cir- 
cumstance. But others seldom ox' ne vex' affect the system in such 
a manner as to oblige it to discharge the poison. Some perform 
their own cure, when the mode of their action is on a peculiar part, 
as gonorrhoea. 
Of the Modes of receiving Morbid Poisons.-If morbid poisons are 
applied in a solid state, they must become fluid, by the moisture of 
the part, before they can act. The manner of receiving them and 
being affected by them is in three ways : 1st, when the effects are 
always local and never reach the constitution, as in cancer; 2d, 
when the constitution only is affected, as in jail distemper; the 3d, 
or compound, is when the poison can affect one only oi' both at the 
same time, as the lues and small-pox. The first is of two kinds: 
first, when the patient contracts a poisonous disease, eithex' from 
known causes, or from violence committed on parts which are 
capable of running into diseased action, and of communicating 
the same to others, as cancer and lues ; the second is where the dis- 
ordei' is external and local, so as to affect only the cutis, as the 
itch. The mannei' of receiving the second, or entirely constitutional, 
may be either by effluvia or contact. The first, or that by effluvia, 
is owing to the air being impregnated with poisonous vapours 
arising from the animal body ; but how the poison is received into the 
constitution is unknown, there being no traces of it before it shows 
itself by the fever, as in the jail distemper and hooping-cough. The 
second of this division of constitutional poisons is the plague, which 
is caught by contact; but whethex' it could oi' could not be produced 
by inoculation is unascertained. The mode of receiving the third, 
oi' compound kind, is twofold: first, it differs from merely local 
poisons, because it seldom acts locally at first, as the variola; for 
we receive this disease naturally without knowing it until the con- 
stitution is affected. Secondly, it can affect both the constitution 
and the part, as the above; but generally there is local inflam- 
mation, and sometimes ulceration, previously to the constitution 
being affected, as in lues. 
Of the Itch.-This is one of oui' first class of the first division of 
morbid poisons, which affect by simple contact and are always 
confined to the parts to which they are applied. Scabies never 
affect the constitution ; from which I conclude that it is never 
absorbed. Howmvei' it originated, it is now become a common 
poison. It produces small ulcerations, which are generally much 
confined ; but when the disease is of long standing they are as 
large as a sixpence, and covered with a scab. First there is a 
small vesicle, which discharges a kind of matter, which gradually 
thickens until genuine suppuration takes place ; the matter which 
is thus formed produces ulcers of the same specific kind, although 
its powers of contaminating are evidently weak, as cleanliness pre- 
vents contamination. The irritation of it is scarcely sufficient to 
produce inflammation, and continued sympathy hardly evex' takes 
place in it. It gives no pain, but occasions a sense of itching. It 376 
HUNTER'S PRINCIPLES OF SURGERY. 
is generally caught by shaking hands, or from lying together, as 
the lower orders of people commonly do, who are most subject to 
this disease. Uncleanliness aids this effect; therefore washing the 
hands, even after the matter is on them, prevents the disease from 
taking place. When it arises from lying in an infected bed, or 
from a nurse, it is generally communicated to every part of the 
body ; a fact which gave rise to an opinion that its origin was 
derived from nastiness. The disease has been said to arise from 
animalculm ; but these, if present, are, I am sure, unnecessary for 
the existence of the disease, as I have often examined the matter 
and found no animals in it; yet they may sometimes be in the 
matter. I forget who was telling me lately that Dr. Teigh had 
shown them to be, not in the pustule, but in the skin near it, as little 
black specks. It is capable of affecting the cutis when covered by 
cuticle, but not where the cuticle is thick. It affects parts thinly 
covered with cuticle most, as between the fingers, but often no part 
escapes, making the cure very troublesome ; for as the cure is 
effected by local applications, it then becomes necessary that they 
should be extended over every part of the body. 
Although a specific disease and a poison, yet it has several cures, 
which act in various ways; but all must have powers to remove 
the irritation of the disease. Mercury often cures and often fails ; 
yet a girdle often will cure when the unguent will not. Solution 
of sublimate of mercury sometimes cures, as does a decoction of 
hellebore. A sulphureous unguent is most efficacious ; but it is 
volatilized by the heat of the body, and is disagreeable. If mixed 
with water, the smell is somewhat prevented; but it is then less 
efficacious. Sulphur given internally reaches the skin, and pro- 
duces a smell thereupon, and will then cure ; but to produce this 
effect it must be given so largely that it is apt to prove purgative : 
opium therefore should be conjoined with it. Sulphur, however, 
is the only certain remedy ; and when properly used, it may be 
depended on. 
Of Cancer.-The diseases commonly classed undei' this name 
are in appearance very different, and probably are very different 
in their nature ; they should not, therefore, be called by the same 
name. I would call that cancer which produces the following 
effects; viz., a circumscribed tumefaction with much hardness, and 
a drawing in of the skin covering it, as if the cellular membrane 
underneath was destroyed : then a species of suppuration takes 
place in the centre, and ulceration of the external surface. This is 
its most frequent appearance. It most commonly attacks the con- 
glomerate glands, and first the female breast; also the uterus, the 
lips, the external nose, the pancreas, and the pylorus; besides which 
the testicle is very subject to it, though that is not to be classed 
among the conglomerate glands. So that when I speak of cancer, 
I mean a peculiar disease in some of the above parts. There is 
another disease which is also called cancer, which I have called 
fungated ulcer. The frequency of a disease in any one part is apt OF POISONS. 
377 
to lead us to suspect that this one disease is peculiar to that parti- 
cular part; but scrofula attacks these parts also, in the form of a 
tumour, and a distinction between them would be a great advan- 
tage, although this probably can only be made in the breast, which 
is subject to both diseases. When small, they probably cannot be 
distinguished ; but as they increase, the distinction is more easy. 
If cancer, it will vary its appearance by becoming less circum- 
scribed, not having so determined an outline, from the cellular 
membrane around becoming diseased ; the skin will be less move- 
able, the nipple more or less retracted, and the lymphatic glands 
going to the axilla will swell. But in scrofula there will be no sur- 
rounding disease, no affection of the nipple or axillary glands, no 
adhesion, even though the tumour be large; I have seen one loose, 
when it weighed eighteen pounds; the veins become also enlarged. 
When scrofulous tumours are large, and become slightly inflamed, 
they get more diffused, and put on a greater resemblance to cancer ; 
but in cancel' the inflammation comes on earlier, and goes on with 
the disease. In cancer, the surrounding parts that are affected by 
continued sympathy also become cancerous near the skin, that is, 
all the parts become blended in one mass; but in scrofula, although 
the surrounding parts are in action, yet that action is not so scrofu- 
lous as the part itself; so that the skin will sometimes heal over 
the scrofulous tumour, as 1 have seen in the testicle when suppura- 
tion had taken place, by which I determined the disease was no 
cancerous. The tumefaction is from interstitial extravasation of 
coagulable lymph, and the tumour is more ready to inflame than 
in the scrofula. Cancer is one of the first class of our first division 
of poisons, viz. that which only produces local effects, though it 
has been supposed to contaminate the constitution; which would 
be terrible indeed, as we have no specific nor even a palliative 
for it. 
The reasons for this opinion are the following. When a cancer- 
ous tumour has been removed often, the sore does not heal, or 
breaks out again. Sometimes it breaks out again in another part 
of the body; which has been thought a proof of its arising from 
the constitution. This last circumstance as often arises where 
there has been no operation as where there has been one ; it does 
not therefore depend on that circumstance as a cause. However, 
the operation having or not having been performed does not affect 
their argument, unless they could prove that cancel' is an act of 
the constitution, and acts as a drain or concentration of the cancer- 
ous poison, and that by stopping this it must go somewhere else. 
But the proportion of those who have it break out in two different 
parts of the body, compared with those who have it only in one, is 
about half what the latter bear to those who have not the disease 
at all, or about five hundred to one. I never saw it in two different 
parts of the same person; but I have seen it in more than two dis- 
tinct points of the same part. It often arises in distinct points of 
the same breast, but seldom at the same period; and some of these 378 
HUNTER'S PRINCIPLES OF SURGERY. 
may be so much in their infancy when the operation is performed 
as not to be observable, but afterwards increase and require a se- 
cond operation. 
The surrounding substance of the breast has often little tumours, 
sometimes containing a blackish fluid ; these may be called cancer- 
ous hydatids. It is therefore best to extirpate the breast completely 
at once, to remove the whole complaint. It must further be proved 
that the continuance of the disease, or contamination of other parts, 
is not owing to the healing or not healing of the sores. The above 
reasons for believing it constitutional would satisfy any one not of 
the profession; but for surgeons to be influenced by them shows 
an ignorance of the first principles of the animal economy. They 
should recollect that though it affects the neighbouring parts, and 
the parts through which the poison passes, by sympathy, producing 
a similar disease, it does not affect distant parts, like those which 
really affect the constitution. A scirrhus or cancer appears to 
have three modes of contaminating: 1st, by continued sympathy, 
which is common to other diseases; 2dly, by remote sympathy, 
which is peculiai' to itself; 3dly, by contact or communication of 
its matter to other parts by contamination. I have called these 
consequent cancers, in opposition to the original. Absorption would 
appear to arise during both stages of the disease : first, by the ab- 
sorption of the tumor in a scirrhous state, that is, the coagulable 
lymph, which possesses the cancerous property; secondly, by the 
absorption of matter produced by suppuration. Both appear capa- 
ble of contaminating the absorbents through which they pass, and 
so far agree with local morbid poisons ; but it may be a compound 
poison, so as to affect other parts, as small-pox does. Whether it 
is a compound poison I will leave you to judge from the following 
remarks on the effects of poisons on the constitution. 
Whether a poison be a compound one or enti ely constitutional, 
it first produces a fever that is universal, a specific general irrita- 
tion ; and, if compound, local irritation also, which local irritation 
produces a discharge, as in small-pox and measles, the discharge 
being similar to the original in these, but not so in the venereal 
disease. 
Let us now see how far cancer agrees with these : if it does 
agree, it must be a compound; if it does not, it must be entirely 
local. A cancer in the breast or testicle is similar to the inflam- 
mation and ulceration after inoculation, or to a chancre, only differ- 
ing in specific properties. The matter of lues and variola may be 
absorbed and cause inflammation of the absorbents, and the can- 
cerous matter is also capable of absorption and of contaminating the 
parts as it goes along, so as to form buboes, or what I call conse- 
quent cancers; so far therefore these diseases are similar. But 
the above diseases are very quick in their effects, while the cancer 
is very slow : and so far their cases are dissimilar. The variolous 
poison occasions fever and an eruption similar to the original one; 
but the venereal poison docs not do this, its effects being merely OF POISONS. 
379 
local, consisting of blotches on the skin, &c.; neither does the can- 
cerous poison when in the constitution produce fever, nor is there 
any local effect which arises strictly from the constitution. Does 
cancer then produce any effect on the constitution ? 
When it has existed a long time we find slight fever and hectic; 
but this is no more than the effect of all long continued irritations, 
or sores which are not disposed to heal, but no peculiar effect is 
produced from this affection on the constitution. The effect which 
has been mentioned is produced even by the venereal poison when 
of long standing, but it is different from the specific. I have seen 
locked jaw and difficult respiration produced from a cancer in the 
breast; but these were occasioned by the irritation of a non-healing 
sore ; small-pox does not produce this hectic. It has been said that 
cancers are produced by ill health, as rheumatisms are; but this 
arises from the age of cancer being the age of such complaints, 
and being thus the predisposing cause of both, but not particularly 
of the cancerous disposition. Let us compare the cure of cancer 
with that of the venereal disease, when the latter can be extirpated 
externally. If we remove entirely a chancre, the sore heals readily 
and does not return, and if this is done before any absorption 
has taken place, then there will no future disease; but if after 
absorption has taken place, and after a bubo has formed, then, 
although the sore will heal, the bubo will go on, and the con- 
stitution will be affected. So likewise, if we remove a cancer, and 
no absorption has taken place, the sore will heal and the constitu- 
tion will not suffer; but then the whole must be removed, as in the 
local venereal disease, otherwise it will return. If removed, and 
there has been absorption, the parts heal, though the consequent 
cancel' goes on; but if the whole cancerous parts are removed, the 
constitution is free; here it differs from the venereal; for there, 
when absorption has taken place, sores break out in other parts, 
but this is not the case in cancer. The general opinion has been 
the reverse of this. This shows that a cure is the consequence of 
a total removal of the parts, notwithstanding absorption has taken 
place, if all the diseased parts are removed. 
The only powers of contamination of this poison are; 1st, when 
it spreads from the centre, thus producing a disposition to the 
disease in the surrounding parts, and an extravasation of interstitial 
matter; 2d, when the disease extends to distant parts, as when 
little tumours form under the skin at some distance, not in the line 
of absorbents; and 3d, when it produces the same disease in the 
absorbents and glands. This last is easily conceived, from its 
being a poison; but the affection of a part that seems to have no 
connexion whatever with the diseased part is not so easily accounted 
for. 
When scirrhus is entirely let alone, it is commonly very slow. 
A small lump in the breast may sometimes continue for many 
years : but whenever inflammation takes place, its progress is 
accelerated, in as much as inflammation is an increased action of 380 
HUNTER'S PRINCIPLES OF SURGERY. 
the part itself, as well as of the surrounding parts; so that if we 
remove the tumour in this condition the glands in the breast will 
probably inflame and sometimes suppurate, although often these 
effects are not cancerous. When inflamed, the tumour increases 
very fast, but the sympathy is very slow, which is common in many 
diseases. When distant parts, not in the line of the absorbents, 
are affected, it would appear that such parts are very slow in taking 
on the diseased action, although the disposition has been formed, 
for we frequently see that they do not take on an active form for 
some years after. In those cases where there is absorption of 
coagulable lymph, it becomes a question whether the lymph is can- 
cerous, or whether the affection is only sympathetic ; most probably 
it is the last. The last two forms of the disease are generally very 
slow, which circumstance makes them dangerous, as it cannot be 
ascertained when parts are really affected with the disease, which 
often necessitates a second operation, it being necessary to remove 
all the parts which have undergone the disposition, although the 
inflammation or tumour itself is circumscribed. 
The predisposing Causes of Cancer are three in number, viz. 
age, parts, and hereditary disposition; perhaps climate also has 
considerable effect, though not itself a predisposing cause. The 
cancerous age is from forty to sixty in both sexes, though it may 
occur sooner or later in certain cases. The testicle for instance, 
often becomes cancerous at twenty or thirty; but then not from the 
disposition of the parts alone, but from accident.* Cancer has 
been supposed to be in young people's eyes; therefore it is most 
probable that the breast is less subject to it at this age, and other 
parts are not so much confined to age in this disease. We 
often see tumours in the breast at thirty, and probably some of 
them are cancerous, although scrofula is more to be suspected. 
When cancer occurs in the breast of women under forty, it is more 
rapid in its progress than when the patient is older, and also more 
extensive; remote sympathy likewise takes place more readily in 
them than in the old, so that the operation succeeds better in the 
latter on this account. However, we seldom find it in the young 
or very old ; although of the two it is most frequent in the latter. 
When it occurs in the young, does it not show a very strong dis- 
position for the disease, and therefore more danger, from a greater 
likelihood of its returning? 
The parts most disposed to Cancer are those peculiar to the sexes, 
as the breasts and uterus in women and the testicles in men. Can- 
* [The distinction between the.various forms of medullary disease and cancer 
was not well understood in the time of Hunter, and consequently he has classed 
together several diseases which modern pathologists have very properly sepa- 
rated. It is unquestionably true that cancer may exhibit itself before the age of 
forty, and fungus haematodes after that period ; still, as a general rule this does 
not happen, nor is there any individual fact more characteristic of the difference 
of these diseases than the different periods of life at which they respectively 
occur.] OF POISONS. 
381 
cers are more frequent in women than in men, in the proportion of 
three to two ; owing, perhaps, to the more frequent changes taking 
place in these parts in the former. It is that change which renders 
them unfit for conception and changes the whole system, which is 
particularly obnoxious. Thus, the three disposing causes are : 1st, 
a peculiar part; 2d, the age of the patient; and 3d, the peculiarities 
of the part at this age. The parts next in order and frequency, 
and which are common to both sexes, are the conglomerate glands 
about the lips, nose, throat, tongue, pancreas, stomach, especially 
the pylorus; intestines, especially the rectum. Besides these, we 
have it in the eyes and glans penis. The disease also appears in 
other parts of the body ; but, as most other parts are similar in 
structure, it does not attack one more than another. It sometimes 
falls on the bones from contamination, but on no one in particular. 
Whether Hereditary-Some suppose cancers to be hereditary; 
but this I can only admit according to my principles of hereditary 
right; that is, supposing a person to possess a strong disposition or 
susceptibility for a particular disease, the children may also ; but I 
have not yet ascertained the generality of this fact. In many per- 
sons it would appear that some of the predisposing causes are suffi- 
cient to become the immediate ones ; as when the diseased action 
takes place at a certain stated time, without any immediate cause. 
Are they more frequent in one country than another? I have 
heard they are very rare in the West Indies; and they do not 
seem to be frequent in the Friendly Islands, where the women fight 
for prizes, and aim chiefly at the breast; so, most probably, 
climate has some power, both in disposing to the disease and in 
preventing it. 
Symptoms.-On the first appearance of a cancer it is a hard 
tumour, and being specific it is circumscribed, having its specific 
distance, when it is called scirrhus, which is a cancer not yet ulce- 
rated. Sometimes the first symptoms of a cancer in the breast is a 
bleeding from the nipple, which must come from the ducts of the 
lactiferous tubes; and this I have seen in men. In the testicle it 
sometimes begins by forming a hard knot, but is generally more 
universal. When in the lip, there is a thickening of some part of 
it, and this increases till ulceration takes place: it comes on simi- 
larly in the nose. There is one peculiarity in cancers, which is, 
that when the skin is affected there is a wrinkling or tucking in of 
it, which appearance always leads to suspicion of cancer. It often 
begins in the antrum, and distends the whole face; but I rather 
suspect this to be of the fungated kind. In the bones it begins by a 
soft swelling, which I also suspect to be fungated, from its forming 
such luxuriant fungoid granulations when ulcerated. In the testicle 
sometimes a softness and even an obscure fluctuation may be felt, 
although I suspect this not to be cancerous. The pain at first is so 
trifling as scarcely to be noticed; but when there is a disposition 
to suppuration and ulceration, a shooting lancinating pain is felt, 
and also a dead heavy one, which pain increases more in propor- 382 
HUNTER'S PRINCIPLES OF SURGERY-. 
Lion than the disease appears to do. It is more violent in some parts 
than in others, depending in some degree on the sensibility of the 
part; thus, it is more violent in the breast and testicle than in less 
sensible parts. Cancer, however, produces no symptoms peculiar 
to itself; they are only such as would arise from any injury to the 
part capable of producing the above effects, independently of any 
specific quality. Cancer of the lip, of the nose-, or of any other part, 
will produce no peculiar symptoms; but in the testicle, symptoms 
peculiar to that part will be occasioned, as, for example, pain in the 
loins and sickness, with suppression of the secretion of semen; in 
the bladder, the symptoms will be like those of stone; in the rectum, 
purging and tenesmus; in the stomach, sickness and vomiting; 
within the skull, headache and coma. Cancer appears to give rise 
to no constitutional symptoms, except such as would arise in other 
diseases from the long-continued wearing pain and perpetual dis- 
charge. 
The progress towards suppuration is of two kinds: one by exter- 
nal ulceration, the othei' by the scirrhus becoming encysted. The 
first happens when the tumour reaches the skin and affects that part 
with disease, when the skin first becomes shining and then ulcerates 
and forms a sore which is called a cancer. While this is taking 
place, inflammation is beginning from internal exposure, and the 
exposure increases the inflammation. The other mode depends on 
a change in the substance of the tumour itself akin to suppuration, 
but which is very different from any other kind of suppuration. 
The cavity contains a fluid, which fluid appears of various kinds, 
and in some cases begins very early. In some breasts, where such 
an encysted tumour has been removed, many small knots are found 
during the operation, by either cutting through or against them : 
they often suppurate without any inflammation, therefore there is 
seldom any inflammation until there has first been exposure, When 
the matter has been evacuated, common inflammation and suppu- 
ration take place, and the disease then proceeds rapidly. 
Cancerous matter may be reckoned of two kinds: first, that in 
the tumour, which is various; in some serum, in some blood, and 
in others coagulable lymph, or else a yellow curdly matter. The 
second is of a bad quality, and proceeds from the internal cavity, 
which is similar in all respects to that formed externally by ulcera- 
tion. The fluid from a cancerous ulcer is most commonly of a 
purplish red, which makes the skin of that colour; the absorption 
here seems to be of the intermediate substance between the skin 
and cyst. When near to the skin, it inflames and ulcerates as in 
other ulcerations. 
Of the Treatment.-No cure has yet been found ; for what I call 
a cure is an alteration of the disposition and the effect of that dis- 
position, and not the destruction of the cancerous parts. But as 
we have no such medicine, we are often obliged to remove cancer- 
ous parts; which extirpation, however, will often cure as well as 
we could do by changing the disposition and action. Arsenic OF POISONS. 
383 
seems to have some power of this kind, and its effects might be 
increased, by being used internally and externally; but its use is 
very dangerous, and I am afraid insufficient for the disease. This 
is a remedy which enters into the empirical nostrums which 
are in vogne for curing cancer ; and among which Plunkett's holds 
the highest rank. But this is no new discovery, for Sennertus, who 
lived the Lord knowTs how long ago, mentions a Roderigues and 
Flusius, who obtained considerable fame and fortune by such a 
composition. I was desired to meet Mr. Plunkett, to decide on 
the propriety of using his medicine in a particular case : I have no 
objection to meet anybody : it was the young one; the old one is 
dead, and might have died himself of a cancer for aught I know. 
I asked him what he intended to do with his medicine. He said, 
" To cure the patient." " Let we know what you mean by that : 
do you mean to alter the diseased state of the parts 7 or do you 
mean by your medicine to remove the parts diseased ?" " I mean 
to destroy them," he replied. " Well then, that is nothing more 
than I or any othei' surgeon can do with less pain to the patient." 
Poor Woollett the engravei' died under one of these cancer-curers; 
he was under my care when this person took him in hand. He had 
been a life-guardsman, I think, and had got a never-failing receipt. 
I continued to call on Woollett as a friend, and received great 
accounts of the good effects; upon hearing which, I said, if the 
man would give me leave to watch regularly the appearance of the 
cancer, and see myself the good effects, and should be satisfied of 
its curing only that cancer, (mind, not by destroying it,) I would 
exert all my power to make him the richest man in the kingdom. 
But he would have nothing to do with me, and tortured poor Wool- 
lett for some time ; till at last I heard the sound testicle wTas gone, 
and at length he died. 
Arsenic may be given internally with safety. If applied exter- 
nally to a large surface, it will often affect the constitution, though 
to a small one it may be safe and efficacious; as, for example, a 
grain of arsenic to four ounces of water, applied in a poultice twice 
a day; this will often destroy the cancerous disposition and render 
the sore more healthy. Sometimes the quantity of arsenic must be 
increased, and when it gets better, less must be used. When the 
cancerous disposition is too strong to be removed by this means, 
we must destroy the parts; and for this there are two modes: 1st, 
by destroying the life of it; 2dly, by an operation. The destruction 
of all the cancerous parts is the intention in both : in destroying 
locally any specific disease which has the power of its own increase, 
the whole must be destroyed. That first method I divide into two: 
1st, the power which life has of destroying itself, by producing an 
action it cannot support; 2dly, by chemical effects. The second 
method is by an operation ; but the first method is not so extensive 
as the second, for with the knife we can go where the other cannot 
reach; so that the first can only be employed where the disease is 
exposed and circumscribed. When lying on a nerve or artery, the 
deadening method has the recommendation of safety. 384 
HUNTER'S PRINCIPLES OF SURGERY. 
The first mode produces too much action, as would appear from 
the effect of arsenic, which does not act chemically, but produces 
inflammation, and probably weakness also ; so that the diseased 
parts will be destroyed by it, while the sound parts will remain 
alive ; and this makes it preferable to caustic, which is not only too 
violent, but deadens the sound parts as well as the unsound. 
Plunkett's medicine is made as follows : crowsfoot, 3 drachms and 
2 scruples ; dogfennel dried, 1 drachm ; crude sulphur, 2 drachms 
and a half; white arsenic, 5 drachms: beat in a mortar, and form 
into a powder; one or two drachms of which are to be mixed with 
the yolk of an egg, and being spread on a piece of bladder to be 
applied so as to cover the sore.* Arsenic alone would produce too 
violent an inflammation, and destroy the sound parts by mortifica- 
tion. The second, or chemical mode, is by caustics, by which life 
is destroyed by the combination of the caustic with the parts it 
comes in contact with, making but little distinction between those 
which are sound and those which are unsound ; but these cannot be 
used very extensively, for obvious reasons. 
The Second mode, or Extirpation.-In considering the propriety of 
this we must often be more careful than in the above modes ; and as 
the knife may be extended further, so the diseases may be more 
complicated than in the other modes. We should first consider if 
the whole disease can be safely extirpated, and if so, the operation 
is proper. Some cannot be extirpated safely, as when in the extre- 
mities ; but in such cases the whole limb may be safely removed, 
which should in doubtful cases always be done. But sometimes in 
the breast it is so fixed to the ribs as not to be entirely removeable. 
Now to know if a cancer is proper for operation, two things should 
be considered, viz. the cancer itself, and its consequences. Great 
attention should be paid to the tumour, whether it is moveable or 
not; for as the disease is further extended, so the parts are more 
united to the tumour. If it reaches a part which cannot be removed 
as the hips, or parts w'hich cannot wholly be removed by amputa- 
tion, then nothing can be done; but if the tumour is not only 
moveable, but the part naturally so, then there is no impropriety 
in removing it, with regard to the tumour itself; but before remov- 
ing it, or a limb, we must consider if there are any consequences. 
We should examine for example, the glands in the groin or axilla 
to ascertain if they are thickened or swoln, and also the course of 
the absorbents; for if these are sound and moveable, then the disease 
may be safely removed. But if any are so deep or fixed as not to 
admit of removal, then we must consider whether the whole limb 
can be removed, above the consequent tumours ; and if not, we 
ought to do nothing. All the above circumstances being consid- 
ered, and no objections existing, the breast may be safely removed; 
and if any consequent cancers easy of extirpation are found, they 
* [Any preparation containing so much arsenic must be exceedingly unsafe 
and dangerous.] OF POISONS. 
385 
maybe safely removed also. But it requires very great caution to 
know if any of these consequent tumours are within propei' reach, 
for we are apt to be deceived in regard to the lymphatic glands, 
which often appear moveable, when, on extirpation, a chain of them 
is found to run far beyond out of our reach, which renders the 
operation unsuccessful. As this is not easily known, I would, in 
most cases, where the lymphatic glands are considerably enlarged, 
advise that the case should be let alone. We cannot be too nice in 
oui' examination, nor often too rough-handed in the operation. In 
cases where the original and consequent tumours are circumscribed, 
and sufficiently moveable, the operation has generally been suc- 
cessful, being nothing more than a common wound. But the parts 
may have acquired the diseased action, and thus render the opera- 
tion unsuccessful, although that action was invisible. Whenever 
there are such appearances the parts should be removed as soon as 
possible: on the contrary, when the disease has not been entirely 
removed by the knife, from its not having been carried into the 
sound parts, the operation is unsuccessful; and these- are the cir- 
cumstances which gave the idea of the disease being constitutional: 
but let us observe what part of the sore does not heal, and what 
part breaks out again after the operation. This is either in the 
cicatrix, or in the lymphatic glands. Now, if the whole disease is 
not removed, the sore either does not heal, or if it does, the cicatrix 
breaks out again ; so likewise, if the surrounding contaminated 
parts are not removed, although the whole original disease is, then, 
some months after, there will be a new ulceration there; and so 
with regard to the glands also, if any of these are so far diseased 
as to require extirpation, but too high up for the knife. I have 
sometimes seen, after the operation, the glands under the clavicle 
swell, and push out the clavicle on the lower part of the neck; it 
has also happened, that after removing the glands in the axilla the 
absorbents between them and the original disease have become 
contaminated, in which case they should beremoved'as soon as possi- 
ble. The contamination extends in other instances on the inside of 
the sternum, in the course of the internal mammary artery. Some- 
times these consequent cancers appear long after the operation, 
even years, when they should be immediately removed. After the 
visible disease is removed, we should minutely examine the sore, so 
as to feel and press every part, and if any thing is hard or irregular, 
remove it. After operation in the axilla, we should introduce the 
finger into it, in order to discover if any of the other glands are 
affected ; and before the part is dressed the tumour itself should be 
inspected, to see if there are any corresponding appearances, so as 
to lead to the supposition of a part being left; but this can only be 
done in those from the breast, those only being circumscribed. 
Having once had the misfortune to leave a part, I let it go on for a 
few days, when the sore granulated healthily all over, except at that 
part, which had a blueish appearance, and discharged a dark co- 
loured matter. I then dissected that bit only, and the patient HUNTER'S PRINCIPLES OF SURGERY. 
recovered. If a contaminated part is left, it comes into action in a 
few months after the operation; and if two or more are left, they 
all appear about the same time, and should be removed if they can 
as soon as possible, before they have contaminated other parts, 
when, in general, it will succeed, as far as I have seen. If these 
are not removed, other parts will be contaminated, and kill in the 
end ; but if parts contaminated do not come into action at the same 
time, after the original is removed, we shall not succeed. It is sur- 
prising to see how a young man, if he catches an idea which has 
any novelty, will write away on it and tell you wonders. Thus, 
Mr. Fearen has lately recommended healing by the first intention 
in this disease, which is the last thing to be thought of, as we have 
here only in view the total removal of the disease, and not the 
healing of the wounds. But no man should write a book without 
taking every circumstance of the disease into consideration; he 
should not write from a single idea, which many circumstances 
may render futile. I have used this plan in small circumscribed 
cases in the breast, where there was very much skin, although I 
have been very liberal of my removal at the same time. 
Of the effects of Cancer in the Breast when incurable.-When 
the glands become indurated the fluids are not absorbed, in conse- 
quence of which there is a stagnation and extravasation of serum, 
causing oedema of the parts around. The arm, and the integu- 
ments of the chest below, swell, and the fingers are sometimes 
rendered immoveable, and very painful. The inflammation about 
the diseased parts spreads, and causes a tightness around, which 
occasions dyspnoea, and in this stage sympathetic cancerous tu- 
mours often arise at a distance, and hectic fever comes on. We 
must now give large doses of opium, which yet do not often relieve 
the pain. I have seen the oedema of the arm before there was any 
tumefaction of the lymphatic glands ; but when oedema occurs, 
which is not the consequence of absorption, there may nevertheless 
be afterwards hardness of the glands from this cause: however, 
the oedema above mentioned puzzled me, having never before seen 
it without the glands being enlarged, and I have never seen another 
case. 
Of the Cancerous Testicle.-The same observations are here 
applicable as in the breast, with respect to the propriety or impro- 
priety of an operation. If the cord is thickened the operation is 
doubtful, the consequence going often further than at first appears. 
If it has not extended so high as the ring, I would advise extirpa- 
tion, it being the only resource left. When the testicle has affected 
the scrotum there may be absorption to the glands of the groin, as 
in lues; of this I have seen one case, where, half a year after the 
operation for the removal of the testicle and scrotum, the glands in 
the groin ulcerated, and killed the patient. In this case the testicle 
had become adherent to the scrotum. I cannot say how far it 
would have been proper to have removed these glands at first, but 
from the adhesion the scrotum was necessarily removed. I was at OF POISONS. 
387 
first puzzled to account for the appearance of cancer in the groin, 
as we know the testicle receives its vessels, &c., from the loins, and 
therefore the glands in the loins become affected by the disease 
extending along the course of the cord; but when I recollected that 
the scrotum was affected, I knew it to be owing to the lymphatics 
of the scrotum, which pass through the groin. In cancerous dis- 
eases the surrounding parts become contaminated, and these again 
contaminate others; but in scrofulous suppuration the surrounding 
parts, although affected, are not scrofulous, because this is not a 
poisonous disease. Before suppuration breaks out we can form 
little idea of the state of the part as to its malignancy: but after it 
breaks out we can, for if healthy it will recover itself, and granulate 
healthily ; but if the contrary, it will not; hence, in the suppuration 
of the testicle, we cannot say whether it is scrofulous or cancerous 
till it is ulcerated, when the mode of healing informs us of the 
disease. 
Of Cancer of the Lip.-If small, the operation for the hare lip 
should be preferred, and it is right in this case to have the cure in 
view as soon as the operation is done, although we should be sure 
to remove the whole disease. These principles attended to will be 
sufficient to guide us in the management of cancers in other parts 
of the body. 
Of Fungated Sores.-These are commonly called cancers, and 
are similar to them in being incurable, although they differ in other 
respects. The cancer eats, as it were, away parts, though there 
is still an increase of growth or tumefaction; but in fungated sores 
there is a spongy fungus which cannot be kept down. It is, in fact, 
a specific well-marked disease, which appears common to every 
part, which I believe the cancel' is not. I have seen it in the antrum, 
the tibia, the eye, the testicle, and the rectum. Its beginning, I 
believe, is in the form of a tumour, both of the encysted and solid 
kind ; for I have seen an encysted tumour opened which threw out 
this fungus, which is very soft, spongy, and pulpy, of a dirty black 
colour, very easily torn, and very apt to bleed : the matter does not 
seem to be poisonous, for the glands and absorbents never appear to 
be diseased by it. Here [exhibiting it] is a preparation to show the 
disease on the sole of the foot, and here another, of the tunica vagi- 
nalis, in which the fungus was very extensive, as was also this 
fungus on the penis. A woman had a large one on the upper part 
of the foot, for which I amputated the leg, and in this case the 
glands in the groin were not affected, and she recovered, which 
shows there was no poison to contaminate by absorption. A man 
had a swelled testicle, which was not very painful, and the cord was 
not affected, which led me to think that it was scrofulous; the 
scrotum became affected by local sympathy, and adhered to the 
testicle. I removed the testicle, but not entirely the adhering skin, 
and after some time a fungus arose from the skin, and his health 
became impaired by the repeated hemorrhage. I tried arsenic made 
into troches with flour, which were stuck into the fungus, but still 
these did not destroy it sufficiently, and the man afterwards died. 388 
HUNTER'S PRINCIPLES OF SURGERY. 
If this had been cancerous the progress would have been different, 
for the skin would have become cancerous from contamination, 
and the cord would probably have been affected in the same way. 
On dissection of this fungus from the cicatrix of the old skin the 
glands above were found sound. This species of fungus is pretty 
regular in structure; it is striated, and radiated, and its external 
surface is larger than that of the surface of contact. Nothing is left 
for it but to remove it, no natural cure being known ; but we should 
be careful to remove the whole of the diseased parts that have the 
disposition, as they will otherwise soon take on the action. It kills 
without appearing to have done much mischief, whereas cancer does 
much local mischief, and so do the consequent ones, before death. 
The first case of fungated ulcer from accident which I ever saw 
was one from a blow on the arm, which was afterwards obliged to 
be amputated. 
Cancerous Diseases of the Penis are somewhat similar to the 
former, consisting of a fungus, which begins on the glans, and 
increases till the whole becomes an excrescence, which resembles 
the fungated sore when cut or torn, except that it is much slower in 
its progress: sometimes it attains a large size, and appears like a 
cauliflower; and sometimes it is in the form of a tumour, covered 
with skin, and ulcerated at some parts only. These tumours may, 
I think, be classed with the true tumours, which consist of a new- 
formed substance; but I do not think they ever arise from the 
venereal disease, as has been supposed. Extirpation, in my judg- 
ment, is the only surgical resource; and if so, it should be done 
as early and as effectually as possible. 
The Hcematocele Specifica Testis takes its name from the nature 
of the contents, which are blood, serum, or often a firm coagulated 
blood, the extravasation arising from a diseased action, or a 
peculiar mode of secretion, and not immediately from accident, as 
is the case with one species, which leads me to call this haemato- 
cele specifica testis. It is often taken for a cancerous testicle, and 
removed for such, and the fluid blood is then mistaken for cancer- 
ous extravasation, though it is common extravasated blood in the 
tunica vaginalis; although I will not deny that there may be new 
cysts occasionally found that may contain blood, as other new 
cysts do matter. Those which I have seen have felt like an obscure 
hydrocele, or something between hydrocele and scirrhus testicle. 
(See note, p. 232.) As it is so uncertain what is the true case, I 
have always advised tapping in the first place. In some there is 
much serum, and this in the centre of the coagulum, which adheres 
to the sides of the sac, the whole feeling like a thickened sac; 
and often the sac is really much thickened. In some the testicle 
has been so pressed as to burst, and to fill the cavity of the 
tunica vaginalis; but whether this is a specific disease or not, 
or a cancer similar to that in the breast, I do not know. I rather 
think it is specific, but if not specific, the treatment of hydro- 
cele would be proper; but it must be distinguished from sarco- 
cele, as in that a different treatment is necessary. But we find OF POISONS. 
389 
it will not admit of the same cure as hydrocele. The coagu- 
lum adhering to the sac keeps off the stimulus of imperfection, 
and prevents a cure, so that in many cases it would be perhaps 
best to dissect out the whole tunica vaginalis. Perhaps in some 
the blood may become part of the solids, by becoming vascular, as 
was shown in a preparation. A gentleman in China had, he thought, 
a swelled testicle, for which he used mercurial ointment. On 
coming to England, I could not determine the case, but rather 
thought it a hydrocele. I tapped him; but no fluid was discharged, 
although the lancet was pushed in an inch deep. Mr. Pott was 
called in, who thought it a scirrhus testicle, and the operation was 
performed. On examining it, a bloody serum was found in it, and 
the coats of the sac (which was the tunica vaginalis,) were 
extremely thick, and the testicle was much squeezed by it. I 
should think it was a mixed case, and might have been cured as 
hydrocele; but am not certain. 
In a case of true hsematocele there was first an uneasy sensa- 
tion, and the testicle was painful to the touch afterwards; the 
swelling increased, and was mistaken by a surgeon for hydrocele; 
then the hardness increased, and the pain become acute; several 
punctures were now made, which brought on much inflammation, 
which required that an opening should be made, in order to examine 
the parts, which were found to consist of grumous blood and a 
thickened coat. It was advised that all should be removed, 
together with some of the skin: but I think not enough, for although 
the parts healed readily, yet some months afterwards a swelling in 
the abdomen reappeared, and destroyed him. On dissection, there 
was found a set of tumours extending to the diaphragm, on the 
epiploon, togethei' with some others in the liver, respecting which 
it was a question whether they were scrofulous or cancerous ; they 
went along the loins, in the course of the absorbents, showing them 
to be cancerous; but the tumours in the epiploon, which is a part 
not in the course of the absorbents, staggered me in that opinion, 
and other circumstances puzzled me still further. At present I 
know not where to class this disease, but I find it has not the 
powers of recovery when put in the way of it by exposure. ANALYTICAL TABLE OF CONTENTS 
TO THE 
SURGICAL LECTURES. 
CHAP. I.-Introduction. 
Page 
Introductory remarks ...... 7 
Fundamental principles of physiology the only guides to a just 
practice ....... 8 
Mr. Hunter's opinion of operations .... 9 
Preliminary observations on matter, attraction, repulsion, &c. . 11 
Of animal and vegetable matter . . . . .13 
Distinguished from common matter by its peculiar properties, as 
growth, propagation of the species, &c. . .14 
Errors of the mechanical and chemical physiologists . .16 
The living principle is the main thing to be taken into account in 
this investigation . . . . . .17 
The subject will be elucidated by a reference to comparative 
anatomy, disease, and monstrosities . . . .18 
CHAP. IL-Of Life. 
Difficulty of conceiving of this principle . . . .19 
Complex in its effects, although simple in its essence . . 20 
May possibly arise from a peculiar arrangement of the ultimate 
particles . . . . . . . ib. 
Erroneous comparison of life to mechanical powers . . 21 
Action not an essential property of life . . . . ib. 
Vitality of an egg . . . . . .22 
This illustrated by experiments . . . . < . ib. 
Yet action, when once established, continues life at the same time 
that it exhausts it . . . . . .23 
Peculiar form of putrefaction in certain bodies . . .24 
CHAP. III.-Of the Blood. 
Erroneous views on this subject . . . . .26 
Animalization and vivification two distinct steps in the conversion 
of foreign matter into part of a living body . . .27 
The blood not merely fluid animal matter . . . ib. 
But has also become vivified . . . . .28 
Coagulation, and its importance in determining the nature of this 
fluid . . . . . .30 
Of the varieties of this phenomenon . . . .31 392 
HUNTER'S PRINCIPLES OF SURGERY. 
Page 
Case proving the life of the blood . . . .33 
The death of blood prevents coagulation . . . .34 
The analogy between muscular action and coagulation . . 35 
CHAP. IV.-General Views of Organization and Action. 
The compounding of an animal body is according to certain esta- 
blished laws . . , . . .37 
Of the sense in which the term organization is used . . ib. 
Organization and life are distinct from each other . . 38 
An animal differs from a machine inasmuch as every part of the 
former is endued with independent action and vitality . ib. 
Of the different kinds of action and their mutual dependence . ib. 
Of elasticity . . . . . . .41 
Conclusion . . . . . . . ib. 
CHAP. V.-Of the Functions of Nutrition and Absorption. 
The Stomach 
Is the peculiar and essential part of all animals . . 42 
Is intimately connected with the other vital and internal organs 43 
In which respect it may be compared with the sympathy of~ the 
brain with external parts . . . . . ib. 
Sympathy of this organ with tendinous parts and with the mind ib. 
Vascular System. 
Its action necessary to be understood . . . . ib. 
Of the arteries, veins, and absorbents . . . 44, 45 
Relative offices of these three systems of vessels . . 45 
Of absorption, and its different kinds . . . .46 
Modelling absorption illustrated by the growth of bones . 47 
Absorption of entire parts . . . . .48 
Of the various uses of absorption . . . .49 
Of the attempts to explain this process . . .51 
Absorption induces an alteration in the matters absorbed . 52 
Table of absorption . . . . . . ib. 
CHAP. VI.-Of the Brain and Nerves, and of Sleep. 
Passive and active states of the brain, giving rise to sensations and 
mind . . . . . . .53 
Too much influence attributed to the brain in the bodily actions . 54 
Of the action of the nerves, and of the senses . . .55 
Sensation, and the laws by which it is regulated . . .57 
Connexion between the different functions of the brain . . 58 
Of sleep, and its importance in the animal economy . . 59 
CHAP. VIL-Of Susceptibility of Impressions ; of Stimuli ; of 
Dispositions of the Body ; of Habit and Custom. 
Difference between impressions on animate and inanimate bodies . 61 
Of stimuli, and the laws by which they are governed . . 62 
Of dispositions of the body . . . . .63 
Of dispositions of the mind compared with those of the body . 65 ANALYTICAL CONTENTS. 
393 
And of both with the action of machines . . .65 
Those parts which are most distant from the sources of power are 
the weakest . . . . . . .66 
Of habit and custom, and the laws to which they are subject . 67 
Particularly of the diminution of passive impressions by repetition, 
in proportion as the active power is increased . . 69 
CHAP. VIII.-Of the Heat of Animals. 
Heat is one of the first principles of action in nature . . 70 
Of the sensation of heat . . . . . .72 
The order in which the different functions cease when heat is 
withdrawn ....... 
73 
76 
Of the causes of animal heat . . . . .74 
Cases in which this function was remarkably-deranged . . ib. 
Experiments . . . . . . .75 
Diminution of heat during sleep . . . . .76 
Experiments on hedgehogs . . . . .79 
Heat of the lower animals varies with the external temperature . ib. 
Standard heat of the higher animals not uniform . . .80 
Resistance to external heat, and experiments . . .81 
Difference in the capability of different animals to generate heat . 83 
On climate . . . . . . .84 
CHAP. IX.-General Principles of Disease. 
Disease the consequence of some unnatural impression . . 89 
Diseased actions often established on the same principles as healthy 
actions . . . . . . .90 
Obscurity of the physiology of disease . . . . ib. 
Difference of susceptibility in different individuals . . 92 
Susceptibility of constitution and of parts for different actions . 93 
Universal susceptibility producing local diseases . . .94 
Temperament . . . . . . .95 
Of the disposition for restoration, of necessity, and of disease . 97 
Disease consists in a disposition for wrong action, but not in the 
aetion itself . . . . . . .99 
First symptoms of disease ..... 100 
Disease from too great and from too little action . . . 101 
Diseased actions always simple, so that two diseases cannot exist 
in the same part at the same time . . . . ib. 
Of wrong actions, as spasms, locked jaw, &c. . . . 102 
Of irritability . . . . . . .104 
CHAP. X.-Of Sympathy. 
Sympathy may be regarded as a secondary principle, introduced 
into the economy of the higher order of animals . . 105 
Connexion of principles of action in the living body . . 106 
Sympathy between different bodies .... 108 
Of natural or diseased sympathy, and division of the subject . ib. 394 
HUNTER'S PRINCIPLES OF SURGERY. 
Page 
Inflammatory and hectic fever are examples of constitutional sym- 
pathy . . . . . . .110 
Certain parts sympathize more strongly than others . .112 
Of similar and dissimilar sympathies . . . . ib. 
Sympathy between the body and mind . . . .116 
And of the mind with the living principle . . .117 
Uses of sympathy in the animal economy . . . ib. 
Of delusion, and the manner in which it may be explained . 119 
Delirium ........ 120 
Dreams ........ ib. 
Animal magnetism ...... 123 
CHAP. XI.-Of Local and Constitutional Diseases. 
Difficulty of distinguishing local from constitutional diseases . 124 
Diseases are constitutional, local, or mixed . . . ib. 
Of common and specific diseases .... 127 
Of the effects of age, climate, seasons, temperature, and the 
moon, on disease ...... 129 
The humoral doctrines examined .... 132 
Experiments of injecting medicines into the blood . . 133 
Which produced no specific diseases . . , .136 
Of hereditary diseases, and in what sense they are to be considered 
so . . . . . . . .137 
Scrofula and gout, with reference to this principle . .142 
Of the effects of the mind on disease . . . .143 
Of symptoms, local and universal .... 146 
But to judge of symptoms, the general character of the patient 
should be previously ascertained .... 148 
CHAP. XII.-General Principles of Inflammation. 
Frequency and nature of inflammation .... 148 
In a healthy constitution it has three terminations, viz. . . 149 
Adhesion . . . . . . . ib. 
Suppuration, and ....... 152 
Ulceration . . . . . . . ib. 
Causes of inflammation . . . . . . ib. 
Comparative susceptibility of parts to inflammation . .155 
Strength and weakness of the constitution and of the part affected 
modify the inflammatory process . . . .156 
Effects of inflammation on the constitution . . .157 
And on the vascular system in particular . . . .158 
Inflammation of vital and of non-vital parts . . .160 
Effects on the constitution different according to the stage of the 
inflammation ...... 161 
Rigors and exacerbations . . . . . . ib. 
Of the state of the blood in inflammation .... 162 
Colour, heat, swelling, and pain . . . . .164 
Of the resolution of inflammation .... 168 
Of the restoration of injured parts . . . . ib. 
Of ecchymosis . . . . . . .169 ANALYTICAL CONTENTS. 
395 
Page 
Of external wounds, and the method of Nature in healing them . 171 
Further observations on adhesive inflammation . . . 172 
CHAP. XIII.-Of Adhesive Inflammation. 
Inflammation a restorative action ..... 173 
Of adhesive inflammation, and the causes which limit its extension 174 
Of the utility or final intention of inflammation . . . 175 
The extravasated lymph is always of the same nature as the parts 
which produce it . . . . . . 176 
Local symptoms, viz. redness, swelling, and pain . . ib. 
Of the uses of adhesive inflammation .... 177 
Adhesive inflammation sometimes imperfect . . . 179 
Of the resolution of inflammation .... 180 
First, by constitutional means, as low diet, medicines and bleed- 
ing, and ....... 181 
Secondly, by external applications . . . .185 
Of revulsion and counter-irritation . . . .186 
Treatment of adhesive inflammation when suppuration must take 
place . . . . . . . ib. 
CHAP. XIV.-Of Suppurative and Ulcerative Inflammation ; 
Granulation, Skinning, Hectic Fever, and Dissolution. 
Of suppuration, and the circumstances under which it occurs . 187 
Does not arise from the access of air, nor from the violence of the 
inflammation simply considered . . . .188 
But most frequently on the surfaces of mucous canals . . 189 
Symptoms of suppuration . . . . . ib. 
Treatment of suppuration ..... 190 
Of suppuration without inflammation . . . . ib. 
Of granulation and cicatrization . . . .192 
Theories respecting the formation of pus . . . . ib. 
Of the globular nature of this fluid, and the modes by which it 
may be distinguished from mucus .... 194 
The quality of pus varies under different circumstances . . 195 
The final intention of this secretion .... 196 
Of interstitial and progressive absorption, together with the remote 
and immediate causes of these actions . . .197 
Of the relaxation of the skin over abscesses . . . 199 
Progressive absorption always attacks those parts which are near- 
est the skin ....... 200 
Absorption may take place without ulceration . . . ib. 
Of ulceration ....... 201 
Newly-formed parts are most subject to ulceration . . 202 
Granulations may be produced without any breach of the solids . ib. 
Of the nature of granulations ..... 204 
Of the union of granulations by inosculation . . . ib. 
Granulations have less powers, and are shorter-lived than original 
parts ....... 205 
Contraction of granulations, followed by cicatrization . . ib. 396 
HUNTER'S PRINCIPLES OF SURGERY. 
Page 
Of the formation of new skin, and the economy of Nature in this 
process ....... 206 
Of the nature of the new-formed cutis, cuticle, and rete mucosum 207 
Constitutional effects of suppuration . . . . ib. 
Hectic fever . . . . . . . ib. 
Arises from a disease which the constitution cannot overcome . 208 
But is sometimes an idiopathic disease . . . . ib. 
Symptoms of hectic fever . . . . . ib. 
Erroneous opinions respecting the cause of hectic fever . . 209 
Hectic fever is not produced by large abscesses until they are opened 210 
Treatment of hectic fever . . . . . ib. 
Of dissolution, or death, arising from excessive suppuration, inde- 
pendently of hectic fever . . . . . ib. 
CHAP. XV.-Practical Illustrations or the preceding Subjects. 
Of ruptured tendons, and particularly of the tendo-Achillis . 211 
Principles of treatment ...... 212 
Muscular exertion impossible until the injury is repaired . . 214 
Of simple fractures . . . . . . ib. 
Of compound fractures, and of the manner in which compound 
fractures may become simple, and e converso . . 216 
Inflammation, suppuration, and ulceration of circumscribed cavities ib. 
Pleuritis . . . . . . . . ib. 
Empyema and hydrothorax ..... 217 
Of the treatment of these cases . . . . .218 
Pericarditis ....... 219 
Emphysema from fractured ribs, and treatment . . . ib. 
Peritonitis, common and puerperal .... 220 
Peritonitis after paracentesis . . . . .221 
Hernia ........ 222 
Caesarian operation . . . . . . ib. 
Wounds into the cavities of joints .... 223 
Ganglions ....... 224 
Inflammation of the eye . . . . . . ib. 
Inflammation of the brain ..... 225 
Inflammation of veins . . . . . . ib. 
Inflammation of arteries ...... 227 
CHAP. XVI.-Of Hydrocele, and the Actions of Medicines. 
Theory of the cure simple, but the operation often fails . . 227 
Description of the disease, and its different varieties . . 228 
Disappears in children, but rarely in adults . . . 230 
Diagnosis . . . . . . . ib. 
Situation of the testicle varies in different cases . . . 232 
And also of the vessels ...... 233 
Of the palliative cure . . . . . . 234 
The proper feeling of the organ will often enable the surgeon to 
distinguish a hydrocele from a pulpy testicle . . 235 ANALYTICAL CONTENTS. 
397 
Page 
The sac sometimes suppurates after the simple evacuation of its 
contents ....... 236 
Of the radical cure . . . . . . ib. 
A distinction to be made between operations of convenience and 
operations of necessity ..... 237 
Observations on the different modes of radical cure . . 238 
Which failed from ignorance of the true principles of cure . 239 
The causes of failure common to the following methods, viz. . 241 
Seton, tent, and caustic ..'... 242 
Of the mode of performing these operations . . . 243 
Of the method recommended, viz. by incision . . . 244 
Of the action of medicines . . . . .247 
Medicines destroy the action, but canuot destroy the disposition to 
disease ....... 249 
In the restoration of action, as after drowning, the strength and 
action should be well proportioned to each other . . 250 
Of the effects of external applications . . . .251 
Of pressure, friction, heat, cold, and electricity . . . 252 
Of diseased dispositions and actions .... 253 
nstances in which the action destroys the disposition . . ib. 
Some parts have a greater disposition to heal than others . . 254 
Of the effects of age in this respect .... 255 
One disease often cures another . . . . . ib. 
Of the uniformity of Nature's operations in the recovery from 
disease . . . . . . . 256 
CHAP. XVII.-Injuries of the Head. 
Of the different kinds of injuries of the head from external vio- 
lence, viz. concussion, compression, wounds of the brain, 
want of due compression, and inflammation . . . 256 
Concussion ....... 258 
General observations on fractures of the skull . . . 259 
Compression ....... 260 
Wounds of the brain ...... 262 
The external table may be fractured without the internal, and 
e converso ....... 263 
Of the propriety of trepanning in the above mentioned cases . ib. 
The operation described ...... 264 
Of wounds of the dura mater, and their consequences . . 264 
Hernia cerebri . . . . . . . ib. 
Of the principles of treatment in injuries of the head . . 265 
CHAP. XVIII.-Of the Diseases of the Bones and Joints ; 
of Fractures, Dislocations, &c. 
Bones liable to all the diseases of soft parts . . . 267 
Death of bone, and caries ..... 268 
Diseased actions of bone ...... 269 
Ulceration and induration of bone . . . . ib. 
Of simple fractures, and the mode in which union is accomplished 270 
Treatment of simple fractures . . . . .271 398 
HUNTER'S PRINCIPLES OF SURGERY. 
Page 
False joints ....... 273 
Bones subject to the adhesive, suppurative, and ulcerative inflam- 
tion ........ 273 
Compound fractures, and their treatment .... 276 
Compound fractures communicating with joints . . . 278 
Question of amputation considered . . . . ib. 
Fracture of the patella, olecranon, and outer ankle . . ib. 
Periostitis . . ... . . . 281 
Spina ventosa ....... 282 
Necrosis ........ 283 
Of the contraction of diseased joints .... 284 
Sprains . . . . . . . . ib. 
Dislocations ....... 285 
New joints produced in consequence of dislocations . . 286 
Inflammation of joints, and the reason of their great danger . ib. 
Of lose substances in the joints ..... 287 
Of the different kinds of anchylosis .... 288 
Wasting of the muscles in consequence of diseases of the joints . ib. 
Exfoliation of bone ...... 292 
Necrosis ........ 295 
Of the extraction of exfoliated bone .... 296 
Rickets ........ 297 
Mollities ossium ....... 298 
Of the effects of mechanical pressure on rickety bones . . ib. 
Exostosis ....... 299 
Of the exfoliation of cartilage . . . . . 300 
CHAP. XIX.-Of Hemorrhages and Aneurism. 
Hemorrhage ....... 302 
May arise from 1st, natural causes ; 2d, disease; 3d, violence . ib. 
Of the effects of loss of blood on the system . . . 303 
Of the efforts of Nature to suppress hemorrhage . . 304 
Of lateral wounds of arteries ..... 306 
Of the artificial means of stopping hemorrhage . . ib. 
Of secondary hemorrhage ..... 307 
Aneurism ....... 308 
Classification of aneurisms and definition of the term . . ib. 
Causes of aneurism ...... 309 
Experiments to illustrate this part of the subject . . ib. 
Action of the heart not the only cause of aneurism . . ib. 
Although arteries are apt to yield most on that side where the 
force of the heart is greatest, and where they are least 
supported ...... 310 
Opinions of Pott and Bromfield on the operation for aneurism . 312 
The operation should be performed as early as possible . 313 
Of those arteries which admit the operation . . .314 
General observations on the operation . . . . ib. 
Cases ....... 315 
Notice of the first case in which the author operated by taking 
up the artery in the middle of the thigh . . .316 ANALYTICAL CONTENTS. 
399 
CHAP. XX.-Of Specific Diseases, Tumors, Hydatids, and 
Tetanus,. 
Page 
Of ulcers, and the causes which retard their cure . .317 
Of abscesses, and particularly of those which are deep-seated . 319 
Of Specific Diseases, or rather of those dispositions and actions 
which are not productive of restorative actions . . ib. 
These may be divided into the irritable .... 320 
Producing irritable inflammation . . . . ib. 
And indolent ........ 322 
Producing hypertrophy of parts . . . . . ib. 
Varicose veins ....... 324 
Corns . . . . . . . . ib. 
Chilbains ....... 326 
Preternatural accumulations of fat . . . . 327 
Elephantiasis . . . . . . . ib. 
Of the enlargement of particular organs .... 328 
Observations on the cure of indolent dispositions in diseases . ib. 
Of the suppuration of indolent parts. .... 329 
Of Tumors ....... 330 
Wens ........ 331 
Tubercles . . . . . . . ib. 
Warts . . . . . . . . ib. 
Polypi ........ 332 
Tumors in the cellular membrane . . . . ib. 
Of the removal of tumors ..... 333 
Tumors in bones . . . . . . ib. 
Encysted tumors, the cysts of which are, 1st, natural; 2d, ac- 
quired ....... 334 
Of Hydatids of the uterus, kidneys, liver, lungs, brain, &c. . 335 
Encysted tumors of the cutis ..... 338 
Of inflammation, suppuration, and ulceration of new-formed parts 339 
Of fistulas in general ...... 340 
Fistula lachrymalis . . . . . . ib. 
Fistula of the parotid duct . . . . .341 
Fistula in ano ....... 342 
Fistula in perineo . . . . . . ib. 
Of the cure of fistulas ...... 343 
Of the attention necessary in diseased joints respecting motion . 344 
Tetanus ........ 345 
Of the classification of this disease .... 346 
Causes . . . . . . . . ib. 
Constitutions most susceptible of tetanus .... 347 
Of the climate and kind of wound which have the greatest influ- 
ence in producing this disease . . . . ib. 
Of the mode of attack ...... 349 
Treatment generally unsuccessful . . . . ib. 
CHAP. XXL-Of Scrofula. 
Scrofula a specific disease without a morbid poison . . 351 
Other animals besides the human subject liable to it . . ib. 
Some parts, constitutions, and ages more subject to it than others . ib. 400 
HUNTER'S PRINCIPLES OF SURGERY. 
Page 
Scrofula not hereditary ...... 352 
Of climate and seasons in reference to this disease . . 353 
Susceptibility to scrofula may be acquired . . . ib. 
Progress of scrofula slow, and suppuration imperfect . . 354 
The different appearances of scrofulous tumours and sores . 355 
Diseases of the hip ...... 356 
Lumbar abscess . . . . . . . ib. 
White swelling ....... 357 
Phthisis pulmonalis . . . . . . ib. 
Scrofula of the testicle ...... 358 
Scrofula of the breast . . . . . . ib. 
Of the medical treatment of scrofula .... 359 
Of the surgical treatment of scrofula .... 360 
CHAP. XXII.-Of Mortification and Carbuncle. 
Mortification of two kinds, one with, and the other without, in- 
flammation ....... 361 
In the former case it arises from the action being too great for 
the power ....... 362 
Of the principles of treatment ..... 363 
Of death from caustics and cauteries .... 364 
Of the separation of the dead from the living parts . .365 
Carbuncle ....... 366 
Depends on some peculiarity of constitution distinct from mere 
weakness ....... 367 
The appearance and progress of carbuncle described . . ib. 
Boils ...... i . ib. 
Treatment of carbuncle ...... 368 
CHAP. XXIIL-Of Poisons. 
General considerations respecting poisons . . . 370 
Of the different ways in which animals may be affected by poisons 371 
Mineral poisons . . . . . . . 372 
Vegetable poisons . . . . . . ib. 
.... < first, natural ..... 373 
Animal poisons: J Jec(md; m„bid . . . . 874 
Of the mode in which morbid poisons are received . .375 
Scabies . . . . . . . . ib 
Cancer . . . . . . . . 376 
Does not affect the constitution ..... 377 
Extension of the disease by three modes .... 379 
Predisposing causes ...*.. 380 
Of the parts most susceptible of cancer ... ib. 
Whether hereditary, and in what sense .... 381 
Symptoms . . . . . . . ib. 
Progress towards suppuration ..... 382 
Treatment . . . . . . . ib. 
Extirpation ....... 384 
Cancer of the testicle ...... 386 
Fungated sores ....... 387 
Cancer of the penis ...... 388 
Hsematocele . . . . . . . ib. 
THE END. PLATES 
TO 
HUNTER'S LECTURES 
ox 
THE PRINCIPES OF SURGERY. PLATES TO HUNTER'S PRINCIPLES OF SURGERY. 
II 
PLATE I. 
F/g. i. 
Fig. 2. 
Fig. 3. PLATES TO HUNTER'S PRINCIPLES OF SURGERY. 
III 
PLATE II. 
Fig. 1. 
Fig. 2. PLATES TO HUNTER'S PRINCIPLES OF SURGERY. 
IV 
PLATE 1IL 
Fig. 1. 
Fig. 3. 
Fig. 4.