A
TREATISE
ON THE
THEORY AND MANAGEMENT
OF 
ULCERS:
WITH A DISSERTATION ON
WHITE SWELLINGS OF THE JOINTS.
TO WHICH IS PREFIXED, AN
ESSAY ON THE CHIRURGICAL TREATMENT
OF
INFLAMMATION AND ITS CONSEQUENCES
BY BENJAMIN BELL,
MEMBER of the ROYAL COLLEGE of SURGEONS, one of the SURGEONS to the
ROYAL INFIRMARY, and FELLOW of the ROYAL
SOCIELY of EDINBURGH.
Ad utilitatem vitæ omnia consilia factaque nostra dirigenda sunt.-TACIT.
PRINTED AT BOSTON,
BY I. THOMAS AND E. T. ANDREWS,
FAUST's STATUE, No. 45, Newbury Street
MDCCXCI. 




TO
PERCIVAL POTT, ESQ, F. R. S.
And SURGEON to ST. BARTHOLOMEW'S HOS-
PITAL, London.  
SIR,
THE extensive practice in which you have
been long engaged, and the many useful improvements,
founded on experience, which you have introduced
into Surgery, deservedly raise you to an eminent rank
in your profession.
This alone would induce any practitioner to court
the honour of your protection to his first publication.
But I might justly be accused of ingratitude, if I did
not also seize this occasion of publickly acknowledg-
ing my obligations to you, and of expressing my
grateful sense of the advantages which I enjoyed,
when I had an opportunity, not only of observing
your practice in Surgery, but of becoming acquaint-
ed with the principles and opinions by which it was
directed.
To render these sentiments of my respect and grat-
itude as public as they are sincere, was my only view
in this address. To fay more, or to assume the usual
language of dedication, would, I know, be offen-
sive to you. Permit me to add, that I am, with
great respect,
SIR,
Your obliged, and
Obedient Humble Servant,
Benjamin Bell.
EDINBURGH, Jan, 20, 1784.




PREFACE.
SINCE the commencement of the present
century very considerable improvements have been
made both in Medicine and in Surgery: the latter
particularly, during the course of this period, seems to
have been enriched with more real knowledge than it
was ever before possessed of.
From this consideration, it may possibly be alledged
by some, that nothing new can now be offered on the
subject of surgery; and therefore, that any farther
publication in that line must, in some measure, be su-
perfluous. Although much, however, has been writ-
ten, and a great deal of light thrown upon the princi-
pal and more leading parts of Surgery; yet still, from
less attention having been paid to some of its branches,
there are many chirurgical diseases which are neither
so well understood, nor so accurately treated, as we
might otherwise have expected.
This seems, in a great measure, to proceed from the
same and reputation commonly acquired by success
in the more capital operations of Surgery; which
having a greater effect; with the public than the most
successful treatment of complaints not evidently of so
much consequence, has naturally prevented practi-
tioners from paying to diseases of this nature that at-
tention which they certainly deserve.
And in consequence of this, though the real opera-
tive part of the profession is, in general, carried to as
great perfection as it may probably ever attain; yet
Surgeons daily meet with disorders which baffle all their
ingenuity; by their failure in which, not only their
own private reputation, but that of the art in general,
A3 suffers 


vi PREFACE.
suffers more than can be ever compensated by any
temporary eclat from an operation.
Many complaints might be enumerated, which have
suffered from such neglect; but none, it is presumed,
are in general less understood than some of those which
make the subjects of the following Essays. The the-
ory and treatment of ulcers especially, although a great
deal has been written concerning them, are still very
defective: The descriptions given of them by authors
are so tedious, and the distinctions so complicated and
various, that, to a young practitioner particularly, it is
no easy matter, either to comprehend rightly such dis-
tinctions, or to apply the different remedies recom-
mended for each.
Applications and medicines for ulcers, as pointed
out by foreign writers especially, are indeed so numer-
ous, and frequently so contradictory, that even the
oldest practitioners find it impossible to reconcile them
to reason; but being generally recommended as in
consequence of experience, that circumstance alone
makes them too frequently adopted, without being ex-
amined into; whereas a little attention would render
it evident, that few publications on this subject, which
have appeared for perhaps a century past, contain any
thing new, the practice pointed out by all of them be-
ing in general merely copied by one author from an-
other.
It was this, together with my meeting with more
frequent disappointments in the cure of ulcers than of
any other complaint, which made me first pay more
particular attention to their management. In conse-
quence of which, I found a much less complicated
treatment than had been generally recommended,
prove more efficacious, and a great deal of trouble sav-
ed


PREFACE. vii
ed thereby both to my patients and myself. How far
the same methods may with others be found to suc-
ceed, I shall not pretend to say: This, however, I
must observe, that there is nothing recommended in
the following sheets, but what has been confirmed by
repeated experience.
I am far from imagining, however, that any thing I
have to advance, either exhausts the subject, or ren-
ders farther improvements in it unnecessary. But
whatever, deficiencies the present publication may la-
bour under, this advantage may at least be expected
from it, that it will point out to others a material
branch of Surgery, which for a long time has been very
much neglected; a subject, too, that still deserves
their attention, and in which many useful improve-
ments are yet probably to be made.
The treatise on inflammation and its consequences
was read, several years ago, before the College of Sur-
geons of this place; and as it was approved of by
some of my friends, I now insert it here with some ad-
ditions and alterations: As many of the observations,
too, relating to inflammation, apply with equal pro-
priety to different circumstances of ulcers, the con-
sideration of that subject could not, it was presumed,
be any where more properly introduced.
White swellings of the joints is another complaint,
in the treatment of which we are exceedingly defic-
ient; and I am sorry to observe, that what I have to
offer upon it does not tend so much to its farther elu-
cidation as I could have wished. But no regular ac-
count having ever been given of white swellings; and
as I have had many opportunities, both of seeing such
complaints treated in the ordinary way, and of dis-
secting the diseased joints after amputation, I thought
A4 it 


viii PREFACE.
it might prove acceptable to the reader to have a full
account of the practice employed in them, as well as
of the observations I have made in dissections. This
I have endeavoured accurately to do; but having
nothing altogether satisfactory to communicate on the
method of cure, prolixity on any other part of the sub-
ject would not, I know, to the generality of practition-
ers, prove very acceptable.
I must here observe, however, that although noth-
ing very material be pointed out in the treatment of
the more inveterate species of white swelling; yet the
distinction proposed to be established, of such disor-
ders, into two distinct species, is a matter of no incon-
siderable importance. Swellings of this nature are
evidently produced by two sets of very different
causes; the one occasioning a disguise which will prob-
ably be always considered as incurable; and the other
a complaint which may frequently not only be palli-
ated, but even completely carried off. Practitioners
ought therefore, in all such disorders, to be as accurate
as possible in distinguishing the different causes which
appear to have produced them; and not indiscrimi-
nately to consider every case of white swelling as in-
curable, and to proceed accordingly, as is generally
done, to immediate amputation.
As the former editions of this work have met with a
very favourable reception, I have considered it as a
duty which I owe to the public to do all in my power
to render this edition of it as correct as possible: Much
pains have therefore been bestowed upon it; a good
deal of new matter is now introduced; every late im-
provement relating to the subjects treated of is taken
notice of; and to the whole a copious Index is added.
CONTENTS. 


CONTENTS.
PART I.
On INFLAMMATION and its CONSEQUENCES.
SECTION I.
Of the Symptoms and Causes of INFLAMMATION, 17
§ 1. Of the Symptoms and Terminations of
Phlegmon, 18
§ 2. Of the exciting and predisposing Causes
of Inflammation, 20
§ 3. Of the proximate Cause of Inflamma-
tion, 21
SECTION II.
Of the Treatment of INFLAMMATION by RESO-
LUTION.
§ 1. Resolution of inflamed Tumors, is, in some
instances, not to be attempted, 25
§ 2. Of the Remedies to be employed for the
Resolution of an inflamed Part, 27
§ 3. Remarks on the Preparations of Lead
and other sedative Applications, 28
SECTION III.
Of SUPPURATION.
§ 1. General Remarks on suppuration, 38
§ 2. Of


x CONTENTS,
§ 2. Of the Formation of Pus, 38
§ 3. Of the necessary Remedies for promoting
Suppuration, 42
§ 4. Of Abscesses, and of the proper Period
for opening them, 49
§ 5. Of the different Methods of opening
Abscesses, 51
SECTION IV.
Of MORTIFICATION.
§ 1. General Remarks on Gangrene, 61
§ 2. Observations on Carbuncles, as a Species
of Gangrene, 63
§ 3. Of the Causes of Gangrene, 64
§ 4. Of the Prognosis in Gangrene, 66
§ 5. Of the necessary Remedies in Gangrene, 68
PART II.
On the THEORY and TREATMENT of ULCERS.
SECTION I.
Observations on Ulcers in general, 79
§ 1. Of the Arrangement of Ulcers, 81
§ 2. Of the Causes of Ulcers in general, 83
§ 3. Of the Prognosis of Ulcers in general, 84
§ 4. The Cure of every Ulcer may, with certain
Cautions, be safely attempted, 87 
§ 5. Of


CONTENTS. xi
§ 5. Of the Effects of Issues in the Cure of
Ulcers, 89
§ 6. The Effects of Ulcers on the Constitution
depend more on the Quantity than on the
Quality of the Matter discharged. 90
SECTION II.
Observations on the SIMPLE PURULENT ULCER.
§ 1. Of the Symptoms, Causes, and Prognosis
of the simple purulent Ulcer, 101
§ 2. Remarks on the Growth of new Parts
in Sores, 103
§ 3. The Decay of the contiguous sound Parts
a necessary Circumstance in the Cure of
Ulcers, 105
§ 4. Of the Effects of Compression in the Cure
of Ulcers, 110
§ 5. Of the Advantages to be obtained from
Art, in the Production of Granulations in
Sores, 114
§ 6. Remarks on the Indications of Cure, and
on the Remedies necessary in the Treatment
of the simple purulent Ulcer, 118
SECTION III.
Observations on the SIMPLE VITIATED Ul-
CER, 133
§ 1. Of the Symptoms, Causes, and Prognosis
§ of the simple vitiated Ulcer, 134
§ 2. Of 

xii CONTENTS.
§ 2. Of the Cure of the simple vitiated Ulcer, 136
SECTION IV.
Observations on the FUNGOUS ULCER, 142
§ 1. Symptoms and Causes of the Fungous
Ulcer, ibid.
§ 2. Of the Cure of the Fungous Ulcer, 144
SECTION V.
Observations on the SINUOUS ULCER.
§ 1. Of the Symptoms and Causes of the Si-
nuous Ulcer, 149
§ 2. Of the Cure of the Sinuous Ulcer, 151
SECTION VI.
Observations on the CALLOUS ULCER.
§ 1. Of the Symptoms and Causes of the Cal-
lous Ulcer, 155
§ 2. Of the Cure of the Callous Ulcer, 157
SECTION VII.
Observations on the CARIOUS ULCER.
§ 1. Of the Symptoms and Diagnosis of the
Carious Ulcer, 160
§ 2. Of the Causes and Prognosis of the Ca-
rious Ulcer, 166
§ 3. Of the Cure of the Carious Ulcer, 169
SECTION VIII.
Observations on the CANCEROUS ULCER.
§ 1. Of


CONTENTS. xiii
§ 1. Of the Symptoms and Diagnosis of the
Cancerous Ulcer, 181
§ 2. Of the Causes of Cancerous Disorders, 182
§ 3. Of the Treatment of Cancerous Disor-
ders, 195
SECTION IX.
Observations on the CUTANEOUS ULCER.
§ 1. General Remarks on Cutaneous Affections, 208
§ 2. Of the different Species of Herpes, 209
§ 3. Of the Cure of the Cutaneous Ulcer, 213
SECTION X.
Observations on the VENEREAL ULCER, 228
§ 1. Varieties of the Venereal Ulcer, 229
§ 2. Of the Cure of the Venereal Ulcer, 236
SECTION XI.
Observations on the SCORBUTIC ULCER.
§ 1. General Remarks on Scurvy, 244
§ 2. Symptoms and Causes of the Scorbutic
Ulcer, 245
§ 3. Of the Cure of the Scorbutic Ulcer, 248
SECTION XII.
Observations on the SCROPHULOUS ULCER.
§ 1. Of the Symptoms and Causes of the Scro-
phulous Ulcer, 252
§ 2. Of the Cure of the Scrophulous Ulcer. 253
SECTION


xiv CONTENTS.
SECTION XIII.
General Corollaries relating to the Manage-
ment of Ulcers, 256
PART III.
OBSERVATIONS on WHITE SWELLINGS of
the JOINTS.
SECTION I.
Of the Symptoms and Causes of WHITE SWELL-
INGS.
§ 1. General Remarks on White Swellings, 261
§ 2. Different Species of White Swellings, 262
§ 3. Of the Symptoms of the first, or Rheu-
matic Species of White Smelting, 264
§ 4. Appearances observed on Dissection, in
the first Species of White Swelling, 266
§ 5. Of the Symptoms of the more inveterate
or Scrophulous Species of White Swelling, 268
§ 6. Appearances observed on Dissection, in
the Scrophulous Species of White Swell-
ing, 270
§ 7. Of the Causes of White Swellings of the
Joints, 27l
§ 8. Diagnosis, 273
SECTION 


CONTENTS. xv
SECTION II.
Of the Treatment of WHITE SWELLINGS
§ 1. Of the Effects of an Antiphlogistic
Course in the Rheumatic Species of White
Swelling, 275
§ 2. Of the Effects of Mercury, Friction, and
other Remedies, in the more advanced
Stages of White Swelling, 277 



CHIRURGICAL
ESSAYS.
PART I.
On INFLAMMATION and its CONSEQUENCES.
SECTION I.
Of the Symptoms and Causes of Inflammation.
AS Inflammation is, in many disorders, and espec-
ially in Wounds, Contusions, and Ulcers, the
most troublesome symptom with which Surgeons
have to contend, an investigation of its causes, of the
circumstances attending it, and of the method of treat-
ment best adapted to its removal, naturally occurs as
an object of importance: And this is accordingly a
sufficient reason for its consideration being introduced
as one of the first articles in every chirurgical disserta-
tion.
Inflammation, it is well known, is a disorder to
which every organized part of the body is liable. But,
as its attacks upon the internal parts are generally at-
tended with symptoms, the treatment of which more
B properly 


18 Of the Symptoms and Part I.
properly belongs to the province of Medicine, we do
not at present intend to enter into the discussion of
these; but merely to consider the complaint, with
its several consequences, as it is most frequently ob-
served to occur externally. And as the greatest part
of the phenomena that in general attend it, will  be
understood from the consideration of phlegmon, or
local inflammation, we propose more particularly to
confine our observations to that species of the disorder.
§ 1. Of the Symptoms and Terminations of Phlegmon.
Phlegmon is a term commonly applied to a circum-
scribed tumor, attended with heat, redness, tension,
and a throbbing pain. These are the first appear-
ances observed in every case of phlegmon; and when
they are slight, and the part affected is of no great ex-
tent, they have commonly very little, and sometimes
no apparent influence on the general system. But,
when they are more considerable, and the inflamma-
tion becomes extensive, a full, quick, and generally a
hard, pulse takes place; and the patient, at the same
time complains of universal heat, thirst, and other
symptoms of fever.
If, either by an effort of nature, or by the applica-
tion of proper remedies, the pain, heat, and tension,
are removed, the other symptoms we have mentioned,
and which in a great measure or altogether depended
on these, likewise abate, and the patient soon gets well.
This is reckoned the first, and is generally the most
desirable, mode of termination, and is termed Reso-
lution.
If, however, in the course of a short time, and not-
withstanding the application of the usual remedies,
the several symptoms of heat, pain, and redness, in-
stead 

Sect. I. Causes of Inflammation. 19
stead of diminishing, rather increase; if the febrile
symptoms are likewise augmented, and the tumor
gradually acquires a larger size, turns soft, somewhat
prominent in the middle, or towards its most depend-
ing part, gets a clear shining appearance, and becomes
less painful; the different symptoms of fever then a-
bate, and a fluid, upon pressure, is found to fluctuate
underneath. This is another manner in which in-
flammation terminates, and is called Suppuration.
But if the pain, redness, and tension of the part
increase, while the fullness of pulse and other febrile
symptoms are augmented, at the same time that there
is little change in the tumor in point of size, there is
then great reason to suspect that Gangrene or Morti-
fication will soon take place.
Mortification first appears by a change of colour
in the part affected, which, from being of a bright red,
comes to acquire a leaden or livid cast, while small
vesicles containing a thin acrid serum are dispersed
over its surface—the pain abates—the pulse sinks—
but continues frequent—the tumor at last loses its
tenseness—turns quite black and flaccid—and so ter-
minates in a real mortified or dead spot.
These are the several ordinary consequences of in-
flammation. By many authors, however, another
disorder has been treated of as one of its terminations,
viz. Scirrhus. But although that complaint does,
perhaps, in some instances, succeed to inflammation,
yet it is far from being a common consequence of it:
so that, though inflammatory affections may justly
enough be mentioned as one of the many exciting
causes of Scirrhus, yet the consideration of that disor-
der can never with propriety, it is presumed, be intro-
duced in a treatise on Inflammation.
B2 The 


20 Of the Symptoms and Part I.
The different appearances which in general occur
in phlegmon being thus pointed out, together with
the manner in which they usually terminate, we shall
now proceed to the consideration of the most frequent
exciting causes of the disorder, and likewise of that
which appears most probably to be the immediate or
proximate cause; and shall conclude with the progno-
sis, and method of treatment adapted to the several
modes in which the disease is found to terminate.
§ 2. Of the exciting and predisposing Causes of
Inflammation.
The exciting causes of inflammation, are in general
whatever tend to stimulate, or to produce pain and
irritation: Such as wounds of all kinds, whether sim-
ple, lacerated, or punctured, and with whatever in-
strument they may be produced—also bruises and
burns, whether by the actual or potential cautery—
likewise all corrosive and irritating applications, as the
different strong acids, cantharides, and all the class of
rubefacientia. Ligatures may likewise be mentioned,
and tumors that act as ligatures by producing an un-
due compression on any of the blood-vessels and nerves;
as also, violent exercise of any particular member, and
cold applied to a particular part.
These are the mot common external causes of
phlegmon: but there are some others which tend to
produce the same effect, which we are to consider en-
tirely as of an internal kind;  such are the different vi-
tiated states of  the fluids, excited by the presence of
morbid matters of different kinds, as those of Lues
Venerea, Small Pox, Measles, and Scrophula. Fevers
too that end in critical inflammations and consequent
abscesses, seem likewise to act in the same manner.
Under 


Sect. I. Causes of Inflammation. 21
Under one or other of these heads are comprehend-
ed, we presume, almost all the exciting causes of in-
flammation. It is not improper, however, here to ob-
serve, that there are other causes which with propriety
may be said to be of the predisposing kind; by tend-
ing to produce such a state of the system, as renders it
more susceptible of inflammatory complaints than na-
turally it ought to be. The most remarkable of these
is, a full plethoric habit of body, induced either by a
very nourishing diet, or by want of exercise; or, per-
haps, by a combination of both. These disorders, too,
are observed to be more frequent in young than in old
people, and in men more than in women,
§  3. Of the proximate Cause of Inflammation.
Various opinions have been delivered with res-
pect to the proximate cause of inflammation: many of
which, by not having much probability to support
them, have never been generally admitted; and others,
after having prevailed for a time, have at last too been
rejected.
The doctrine on this subjected, which for some years
has prevailed in this University, as it readily accounts
for the action of the several exciting causes of inflam-
mation, for the effects of the disorder, and for the op-
eration of the medicines employed in the cure, will in
future be probably considered as explaining with most
clearness the proximate cause of all inflammatory af-
fections.
From observing the different phenomena which oc-
cur in inflammation, an increased action in the vessels
of the part affected seems in every case evidently to
take place; and as from an increased action in the ar-
teries of a part, all the circumstances of inflammation
B3 are


22 Of the Symptoms and Part I.
are easily explained, we are induced, therefore, to con-
sider such a state of the vessels as the proximate cause
of the disorder.
This opinion, as we have already observed, is great-
ly supported from a review of the several exciting caus-
es of inflammation; which being in general of an ir-
ritating or stimulating nature, their application to any
living or sensible parts must of course be always at-
tended with a preternatural exertion of the vessels in
such parts. Thus, to reason from analogy, we ob-
serve, that sternutatories applied to the internal mem-
brane of the nose—the aliments to the stomach and
intestines—and the blood to the internal surfaces of
the vessels, all serve as so many stimulants to action in
these different parts; and, in the same manner, corro-
sive or other irritating substances, when applied to the
coats of the arteries, naturally in them produce the same
effects as in other muscular organs.
We thus in a very probable manner account for the
action of all direct stimulants in the production of in-
flammation. It frequently happens, however, that in-
flammation takes place when the application of stimu-
lants, or irritating substances, cannot in any degree be
suspected. In such cases, the increased action of the
arteries, and of the heart when it occurs, seems to be
supported by a spasm or constriction of the extreme
vessels, either of a particular part, or of the general sys-
tem. And hence, from the known tonic or astringent
power of cold, we account for the frequent occurrence
of inflammatory affections in our cold seasons of win-
ter and spring; and hence, too, the throat and lungs
are more especially subject to disorders attended with
inflammation, from these parts being more particular-
ly liable to the immediate action of cold.
Dr. Cullen, who considers spasm as the sole proxi-
mate 


Sect. I. Causes of Inflammation. 23
mate cause of inflammation, when treating of this sub-
ject, says, " That a spasm of the extreme vessels takes
place in inflammation, is presumed from what is at the
same time the state of the whole arterial system. In all
considerable inflammations, though arising in one part
only, an affection is communicated to the whole system;
in consequence of which, an inflammation is readily
produced in other parts besides that first affected. This
general affection is well known to physicians, under the
name of Diathesis Phlogistica. It most commonly ap-
pears in persons of the most rigid fibres; is often man-
ifestly induced by the tonic or astringent power of cold;
is increased by all tonic and stimulant powers applied
to the body; is always attended by a hardness of the
pulse; and is most effectually taken off by the relax-
ing power of blood-letting. From these circumstanc-
es, it is probable, that the diathesis phlogistica consists
in an increased tone, or contractility, and perhaps
contraction, of the muscular fibres of the whole arteri-
al system."*
An increased action in the vessels of a part being
admitted as the proximate cause of inflammation, we
can pretty certainly account for the operation of the
several predisposing causes; and upon the same sup-
position may be explained the different symptoms
which occur in the course of the disorder.
Thus the increased action of an artery, by forcing or
propelling into the smaller sets of vessels, red globules,
and other dense parts of the blood which they cannot
easily transmit, very readily accounts for the redness,
tumor, tension, and throbbing pain, which occur in
every case of phlegmon: As likewise in some measure
for the augmentation of heat, which increased attri-
tion must in such cases always produce, It is proba-
ble,
* See First Lines of the Practice of Physic.
B4 


24 Of the Symptoms and Part I.
ble, however, that the accumulation of animal heat
alone, which must necessarily arise from a larger pro-
portion of blood being sent to a part than what natu-
rally it should receive, will have a considerable influ-
ence in the production of an increased degree of heat.
The method of cure, as we have already observed,
tends also to confirm the general doctrine with respect
to the cause. Thus the most effectual remedies, in
almost every case of inflammation, are exactly such as
would be recommended for the removal of an increas-
ed tone in any particular part, were we convinced that
this alone was the disease, viz. A low diet, blood-let-
ting, with other weakening evacuations, together with
emollient sedative applications: but this, when we
come to speak more particularly of the different reme-
dies, will more fully appear.
In almost every case of external inflammation, ex-
cept, perhaps, when it is very extensive, and runs deep,
and the different symptoms are all very violent, the
prognostic should in general be favourable. For, if
Resolution, which is the easiest and most desirable ter-
mination of the disorder, is not effected, Suppuration
will most readily be the consequence; and the dan-
ger attending it in that state, if the constitution is oth-
erwise healthy, is not commonly very material.
When, however, the inflamed part is of any consid-
erable extent, while the different local and general
symptoms of fever at the same time are violent, a good
deal of danger is to be dreaded. For, independent of
the risk to the constitution from the fever itself, if the
symptoms continue high for any length of time, with-
out showing some tendency either to Resolution or
Suppuration, Gangrene will pretty certainly follow;
and in what manner that may terminate, is always
uncertain.
SECTION 


Sect. II. Treatment of Inflammation. 25
SECTION II.
Of the Treatment of Inflammation by Resolution.
§ l. Resolution of inflamed Tumors is, in some Instances,
not to be attempted.
IN the treatment of phlegmon, the principal cir-
cumstance, in general, to be kept in view, is its
Resolution; as being by much the safest and most
speedy method of cure. I have said, however, only
in general; as in some particular cases it is otherwise,
and Resolution is by no means to be attempted.
Thus, inflammatory swellings, that occur in, or
succeed to, fevers, and other internal disorders, ought
always to be brought to suppuration; for nature in
that way pointing out an exit for some superabund-
ance of fluids existing in the system, it might probably
be attended with danger to give her any interruption.
It is, indeed, on the contrary, always in such cases the
safest practice to assist her as much as possible, by the
use of such applications as will soft readily bring the
swellings to suppuration.
There are other tumors again, proceeding from an
internal cause too, in which it is perhaps best to do
nothing at all, either with a view to resolve or suppu-
rate, but just to leave them entirely to nature.
Thus, in swellings of an inflammatory kind which
sometimes appear in scrophula, it might be dangerous
to make use of repellent applications, at the same time
that it is not often advisable to promote their suppu-
ration, from their treatment, when opened either by
nature or art, proving always very troublesome. And
such swellings, it is well known, may remain for a
great 


26 Of the Treatment of Part I.
great length of time, without any sort of risk to the
patient; so that, in general, we think it most prudent
never to meddle with them.
In Lues Venerea too, as we are possessed of almost
a certain antidote for the disorder; and as buboes, and
other inflammatory swellings that occur in it, are com-
monly, when opened, exceedingly troublesome, and
very difficult of cure; it is perhaps for these reasons,
the most prudent practice always to attempt their dis-
cussion: And this more especially, as their being
brought to suppuration, can by no means free the
patient from the disorder; but leaves him, on the con-
trary, under as great a necessity of undergoing a mer-
curial course, as if no evacuation from the tumor had
taken place.
In cases of Erysipelas likewise, which is a species of
inflammation, but which is easily distinguished from
real phlegmon by the colour of the inflamed part not
being of such a bright red, but having a more dark
copper like appearance; and by any swelling that
occurs in it, not rising evidently into a tumor, but be-
ing rather diffused, and ending as it were impercepti-
bly upon the surrounding parts: in such cases, it ap-
pears always to be the best practice to attempt their
discussion; as, when swellings of this nature come to
a suppuration, they seldom either afford good pus, or
heal kindly when opened.
So that, the only cases in which we should not at-
tempt the resolution of inflammatory swellings, are
such, as are either of a scrophulous nature, or appear
to be evidently critical in some disorder; and this,
whether in fevers, or other internal disorders of even a
chronic nature. But whenever the exciting cause has
been of an obvious external kind, and especially when 
the 


Sect. II. Inflammation by Resolution. 27
the complaint is not as yet far advanced, we may then
always proceed with safety and freedom in what is
termed the Repelling Method.
§ 2. Of the Remedies to be employed for the Resolution
of an inflamed Part.
In cases of incipient phlegmon, when the symptoms
are not so violent as to have affected the general sys-
tem, topical remedies merely, with a due attention to
regimen, often answer in dissolving them. But when,
on the contrary, the inflammation runs high, with
general symptoms of fever, it then becomes necessary
at the same time to pay attention to these.
In every case of phlegmon, it has been the prevail-
ing practice to have recourse to warm fomentations
and cataplasms: but, as warm emollient applications
of all kinds have the most powerful influence in pro-
moting suppuration, as will hereafter be more partic-
ularly taken notice of, and as is allowed indeed by ev-
ery practitioner, the use of such remedies, while the
resolution of swellings is practicable, must therefore,
it is evident, be attended with much impropriety.
The first circumstance to be attended to, in every
case of phlegmon, when resolution of the tumor is to
be attempted, is the removal of all such exciting causes
of the disorder as may happen to present themselves:
Such as, extraneous bodies in wounds; pieces of frac-
tured bones; luxations; and, in short, whatever may
appear to have had the least influence in keeping up
the inflammation.
Of the various applications usually employed for
an inflamed part, those of a sedative nature are
chiefly to be depended on; and next to these, emol-
lients.
Of 


28 Of the Treatment of Part I.
Of the former kind, may be considered all the dif-
ferent preparations of lead dissolved in vinegar; and
it is presumed too, that the vegetable acid, by itself,
acts in the same manner.
As emollients, all the bland expressed oils are often
used with advantage: as also ointments of a soft con-
sistence made with any of these and pure wax.
§ 3. Remarks on the Preparations of Lead, and other
sedative Applications.
It is not, in any part of this dissertation, proposed
to enter into minute discussions on the modus operandi
of such medicines as are recommended; as that would
not only extend the length of it much farther than is
intended, but to many would probably appear to be
very superfluous. It may not, however, in some cir-
cumstances, be improper, to deviate so far from the
general plan, as to render as obvious as possible, the
propriety of what at any time may be advanced: for
mere practical assertions, unsupported by some foun-
dation in reason, can never, it is imagined, prove either
so useful or so agreeable as they might otherwise be.
With respect to the use of sedative applications in
cases of external inflammation, it is not, by any means
intended to recommend, universally, the whole class
of medicines which in different circumstances are
found to be of this nature. Thus opium, though
one of the most powerful of all sedatives, yet, as its
external application to the human body is always at-
tended with some degree of irritation, however useful
it may at times have been found in some particular
species of inflammatory affections, it will never prob-
ably, as an external application, become of general
use in such disorders.
Warm 


Sect. II. Inflammation by Resolution. 29
Warm emollient fomentations, too, though they
no doubt are very powerful sedatives, as tending, from
their nature, more effectually to remove tension and
pain, than perhaps any other remedy with which we
are acquainted; yet, from a great deal of experience
of their effects, in different local inflammations, I have
long been convinced, that when the resolution of in-
flamed tumors is wished for, such applications are al-
ways very improper: As they constantly either tend
to bring swellings of this nature to suppuration, that
might otherwise have probably been discussed; or,
when not attended with this effect, they very com-
monly induce such a relaxed state of the parts, as ren-
ders the thorough removal of the disorder always ex-
exceedingly tedious.
Upon a proper examination of all the different ar-
ticles said to be of a sedative nature, similar exceptions
to their use in every case of phlegmon might perhaps
be made to the greatest part of them.
So far, however, as my experience goes, together
with that of many others of this country, as well as of
Mr. Goulard and other French practitioners, no such
reasons have occurred against the use of lead and its
preparation in such cases. On the contrary, indeed,
it may be certainly affirmed, that, as discutients in in-
flamed tumors, they prove more serviceable by much
than any other application in ordinary use.
And although Mr. Goulard, in extolling a favour-
ite remedy, has been induced to assert its effects to be
more general and more considerable than they proba-
bly will ever be found to be; yet still the world is
much indebted to him: not, however, for a new med-
icine, as every preparation of lead, recommended by
him, was formerly in some form  or other, known to
every 
 

30 Of the Treatment of Part I.
every practitioner; but for introducing, to a more gen-
eral use, a very effectual remedy for the discussion of
inflammatory swellings.
With respect to the preparations of lead being here
said to be of a sedative nature, the term, it is imagined,
is far from being improperly employed; not only
from many of the more striking effects of lead, when
taken internally, being all evidently of a sedative ten-
dency, but from its immediate and obvious operation
when applied externally to an inflamed part: Which
when the preparation is of a proper strength, is almost
constantly an abatement of the different symptoms of
pain and tension, at the same time that there is com-
municated an agreeable soothing sensation to the part.
Having likewise, to a certain degree, in particular
circumstances, observed the same effects from the ve-
getable acid, it could not, it was supposed, be so pro-
perly taken notice of under any other head.
Mr. Goulard, in his dissertation upon the external
use of the preparations of lead, recommends them as
almost equally proper in every stage of inflammation.
Even when tumors have come to a full suppuration,
a proper use, he says, of his Extractum Saturni, not by
its repelling quality, for he will not allow it to be pos-
sessed of such, but by its occasioning an exsudation of
the contained matter, renders it almost always unne-
cessary to open them.
The same remedy is likewise mentioned by him as a
proper application in every case of gangrene. From
my own experience, however, of the preparations of lead
I cannot take upon me to recommend them in either
of these cases. I have indeed made trial of them in
gangrenous cases, but without any evident effects be-
ing produced by them; and, however strongly they
may 


Sect. II. Inflammation by Resolution. 31
may be recommended by Mr. Goulard, in the cure of
abscesses or collections of completely formed pus, I
must own, that, in this state of the disorder, I never
thought of employing them. So that it is in the real
inflammatory state of the complaint only, and while a
cure by discussion may still be expected, that such ap-
plications are here meant to be advised.
From the known deleterious effects of lead when
taken into the system, an objection has, by some au-
thors, been raised against a free use of the preparations
of it, even when externally applied.
That lead, in different forms, has, upon being taken
into the constitution, frequently proved poisonous,
there is no reason to doubt; and that, in some partic-
ular instances, disagreeable symptoms have occurred,
where some of the preparations of lead have been ex-
ternally used, is also pretty certain. That such bad
symptoms, however, if they were not merely accident-
al from some other cause, are, least in general, very
rare effects of the remedy in question, I can venture,
I think, certainly to affirm. For in all the experience
I have had of the external application of lead and its
preparations, and in many cases, particularly of burns,
I have known the greatest part of the whole surface of
the body covered with them for days, nay, even for
weeks together, I do not recollect a single instance of
any disagreeable symptom being ever produced by
them.
Of all the preparations of lead for external use, Sac-
charum Saturni is perhaps equal, if not superiour, to
any, as it has all the advantages of the others, with this
difference, that, in it, we are much more certain of the
exact strength of our preparation, than we can ever be
with any other. For although in the Extrait de Sa-
turn 


32 Of the treatment of Part I.
turn of Goulard, as likewise in the Acetum Lythargi-
rites of our Dispensatories, which are both, it may be
observed, very nearly the same, we may be very cer-
tain of the quantity of lead employed to the vinegar;
yet we can never, but by crystallization, know exact-
ly, or even nearly, how much of the former the men-
struum may have dissolved, as that must depend upon a
variety of accidents, and particularly on the strength
of the acid, and exact degree of heat employed; which
are circumstances we have not always in our power
exactly to regulate. For these reasons, therefore, the
salt, or sugar of lead as it is called, should, for external
use, be always preferred.
The best mode of applying the remedy seems to be
in the form of a watery solution; for the preparation
of which, the following proportions are, in general,
found to answer:
R. Sacchar. saturn. unc. ss.
Solve in acet. pur. unc. iv.
Et adde aq. fontan. destill. lb. ii.
The addition of vinegar renders the solution much
more complete than it otherwise would be; and with-
out it, indeed, when such a large proportion of the
lead is used, a considerable part of it commonly sepa-
rates and falls to the bottom.
This is the form which I commonly employ for the
use of this remedy; but as Goulard's extract and wa-
ter are preferred by many, I think it right to mention
his method of preparing them.—The extract is pre-
pared as follows.
To each quart, containing thirty-two ounces of
French wine-vinegar, add one pound of litharge of
gold. Put them into a glazed earthen vessel, and let
them simmer for an hour, or an hour and a quarter,
upon 


Sect. II. Inflammation by Resolution. 33
upon a gentle fire, taking care to stir them during the
ebullition with a wooden spatula: The vessel is now
to be removed from the fire; and the fæces being al-
lowed to subside, the liquor upon the top must be
poured into bottles for use.
The water used by Mr. Goulard, which he terms
the Vegeto-mineral water, is prepared by adding two
tea spoonfuls, which he specifies to be one hundred
drops of this extract, to a quart of water, and four
tea spoonfuls of brandy. The quantity of the extract
and brandy to be diminished or increased according
to the nature of the disorder, or degree of sensibility
in the part affected.
In making use of either of these solutions in cases of
inflammation, as it is of consequence to have the parts
affected kept constantly moist, cataplasms prepared
with them and crumb of bread, in general answer that
intention exceedingly well. But, when the inflamed
part is so tender and painful as not easily to bear the
weight of a poultice, a circumstance by no means un-
common, pieces of soft linen, moistened with the solu-
tion, answer the purpose tolerably well: Although,
when this objection to the use of cataplasms does not
occur, as they retain the moisture longer, they should
always be preferred. These applications should be al-
ways made when cold, or at least with no greater
warmth than is merely necessary for preventing pain
or uneasiness to the patient; they should be kept al-
most constantly at the part, and renewed always before
turning stiff or hard.
Among the remedies recommended for external use
in cases of inflammation, we mentioned Emollients.
These, when the tension and irritation on the skin are
considerable, prove often very serviceable: the parts
C affected, 


34 Of the Treatment of Part I.
affected, being, in this state of the disorder, gently rub-
bed over with any of the mild expressed oils two or
three times a day, the tension, irritation, and pain, are
thereby much relieved, and the discussion of the tu-
mor thereby greatly promoted.
In every case of inflammation, indeed, emollient ap-
plications would afford some relief. But as the pre-
parations of lead already recommended, prove, in all
such disorders, still more advantageous; and as un-
guents of every kind tend considerably to blunt the ac-
tion of lead; these two sets of remedies should as sel-
dom as possible be allowed to interfere with one anoth-
er: And emollients should, accordingly, never be pre-
scribed but when the circumstances already mention-
ed, of irritation, tension, and pain, are so considerable
as to render their application altogether necessary.
Unctuous substances have likewise been condemn-
ed in cases of this nature, but upon a different princi-
ple; viz. from their tending to stop the pores, and
consequently to obstruct the perspiration of those parts
to which they are applied. It is not, however, proba-
ble, that in this way they could prove very hurtful in
preventing the resolution of inflammation; which
must always, it is imagined, be effected in a very dif-
ferent manner than by perspiration.
When the part affected with inflammation is not ve-
ry tender, or when it lies deep, applications of the ve-
getable acid are often had recourse to with considera-
ble advantage; and the most effectual form of using
it seems to be by way cataplasm, made with the strong-
est vinegar and crumb of bread. In such cases, too,
I have sometimes thought, that an alternate use of this
remedy, with the saturnine solution already recom-
mended, has produced more beneficial effects than are
commonly 


Sect. II. Inflammation by Resolution. 35
commonly observed from a continued course of any
one of them.
At the same time that these applications are contin-
ued, bleeding with leeches, or cupping and scarifying
as near as possible to the part affected, proves general-
ly very useful, and in no case of local inflammation
should ever be omitted. In all such cases, the whole
body, but more especially the diseased part, should be
preserved as free as possible from every kind of mo-
tion; and, for the same reason, the necessity of a low
cooling diet in every inflammatory disorder, appears
very obvious, as does also a total abstinence from spi-
rituous and fermented liquors.
In slight cases of inflammation, a due perseverance
in the several remedies we have mentioned, will, in gen-
eral, be found sufficient for every purpose. But,
when there is likewise a full, hard, or quick pulse, with
other symptoms of fever, general blood letting be-
comes then always necessary; the quantity of blood
taken away being always to be determined by the vio-
lence of the disorder, and by the age and strength of
the patient. The use of gentle laxatives, too, together
with cooling diaphoretic medicines, are always attend-
ed with very good affects.
These evacutions being premised, the next object of
importance is to procure ease and quietness to the pa-
tient; which is often, in cases of inflammation, of
more real service than any other circumstance what-
ever. The most effectual remedy for this purpose is
opium; which, when pain and irritation are consider-
able, as in extensive inflammations very frequently
happens, should never be omitted. In large wounds,
especially after amputations and other capital opera-
tions; in punctures of all kinds too; large doses of
C2 opium 


36 Of the Treatment of Part I.
opium are always attended with remarkably good ef-
fects. In all such cases, however, opium, in order to
have a proper influence, should, as we have observed,
be administered in very large doses: otherwise in-
stead of proving serviceable, it seems rather to have
the contrary effect; a circumstance which is, perhaps,
the chief reason why opiates in general have been very
unjustly condemned in every case of inflammation.
By a proper attention to the different circumstances
we have mentioned, in the course of three or four days,
and sometimes in a shorter space of time, the resolu-
tion of the tumor will in general begin to take place; at
least before the end of this period, it may for the most
part be known how the disorder is to terminate. If the
heat, pain, and other attending symptoms, abate; and
especially if the tumor begins to decrease, without the
occurrence of any gangrenous appearances; we may
then be almost certain, that, by a continuance of the
same plan, a total resolution will in time be effected.
But, on the contrary, if all the different symptoms
rather increase; and especially, as was formerly re-
marked, if the tumor turns larger, and somewhat soft,
with an increase of throbbing pain; we may then with
tolerable certainty conclude that suppuration will take
place: And should, therefore, immediately desist from
such applications as were judged proper while a cure
was thought practicable by resolution; and endeavour
to assist nature, as much possible, in the formation of
pus, or what is called maturation of the tumor.
For this reason, in every case of inflammation, the
different evacuations, especially blood letting, which
may have been advisable while we were attempting to
remove the swelling by discussion, should never be
carried a greater length than may be merely necessary
for 


Sect. II. Inflammation by Resolution. 37
for moderating the several febrile symptoms. For, by
reducing the system too much, if a suppuration after-
wards takes place, its progress in that case becomes al-
ways much more flow and uncertain than it would
have been had a due attention been paid to these eva-
cuations; nor will the patient be afterwards so able to
bear, especially if it is considerable, the discharge that
must necessarily ensue from opening the abscess.
Although it was remarked above, that if, in general,
in the course of three or four days, there do not some
appearances of resolution occur, suppuration will most
probably take place; and that, consequently a change
of treatment becomes necessary; yet this, it must be
observed, is only to be taken in a limited sense. For
the time of desisting from one mode of treatment and
commencing the other, must always depend very
much on the seat of the inflammation; such disorders
being in some parts much more apt to terminate in a
speedy suppuration than in others,
Thus, in the cellular membrane, as well as in every soft
part, inflammatory tumors of all kinds terminate much
more readily and quickly than when any of the tough
membranous parts are affected. Hence, in the coats
of the eye and of the testicles, very violent inflamma-
tions often continue for many days, nay, even for
weeks, without either abating in the symptoms, or
ending in suppuration. In such cases, therefore, that
go on even to a very considerable length, we need not
be afraid of continuing the discutient applications for
a much longer time than what, in general, would oth-
erwise be proper; and should never be deterred from
using them, unless either an evident suppuration has
taken place, or there appears from the violence of the
symptoms a considerable risk, either of gangrene, or of
C3 some


38 Of Suppuration. Part I.
some incurable obstruction: In which event, we must
no doubt always endeavour to promote the suppura-
tion of the tumor.
SECTION III. 
Of SUPPURATION.
§ 1. General Remarks on Suppuration.
BY the term Suppuration, in general, is understood,
that process, by which the contents of tumors
and ulcers are converted into a whitish, thick, opaque,
somewhat fetid matter, termed Pus. This, by many,
has been supposed to be effected by a natural exertion
of the system; but art undoubtedly can, in all such
cases, afford a great deal of assistance. Before going
on, however, to consider the treatment necessary for
this purpose, it will not be improper to premise an ex-
amination of the different opinions that have been of-
fered with respect to suppuration; and this the more
especially, as it will tend to elucidate many of the ob-
servations that will afterwards occur.
§ 2. Of the Formation of Pus.
By many authors, Pus has been imagined to con-
sist in a dissolution of the blood vessels, nerves, mus-
cles, and other solids, in the fluids of the parts in
which inflammatory tumors occur.
This is the opinion of Boerhaave*, Platner†, and
many others.
Others,
* Aphorism, 387.
† V, Institutiones Chirurgiæ, § 54, &c.


Sect. III. Of Suppuration. 39
Others, again, have supposed purulent matter to be
formed in the blood; and that it is secreted, in its
complete state, into Abscesses, Wounds, and Ulcers.
The first of these opinions seems sufficiently confut-
ed from this consideration, that very extensive wounds
and ulcers continue often for a great length of time,
without being attended with any loss of substance;
which they necessarily always would be, if the several
discharges afforded by them were found to consist in a
dissolution of the solids of the parts in which they are
situated. Issues, too, afford instances of the same
kind; by their yielding, for a number of years, even a
daily discharge of pus, without producing any evident
alteration whatever in the state of the solids.
The other opinion has probably arisen from abscess-
es being sometimes observed to form suddenly, and
without any evident previous inflammation; so that
the matter contained in them has been supposed to be
at once deposited from the blood in a state completely
purulent.
Previous, however, to the formation of pus in any
part, if due attention was given, some degree of inflam-
mation, it is probable, would be always observed. But
as inflammation, in many cases, occurs in only a very
slight degree, and without being attended with much
pain, it may often, very readily have proceeded to the
state of suppuration, without being sooner observed
by the patient: and this we know in internal abscesses
especially, is not unfrequentely the case. We are told,
indeed, of very quick translations of matter from one
part of the body to another: but if such instances do
ever occur without the intervention of inflammation,
a circumstance, however, much to be doubted; yet,
still, it is no material objection to our argument, as
C4 such


40 Of Suppuration. Part I.
such cases can never be considered in any other light,
than as particular, and very unusual, exertions of the
system.
It may be remarked also, that if purulent matter fre-
quently existed in the blood, as it undoubtedly would
do if the opinion now under consideration was well
founded; in some cases, at least, it would surely have
been liable to detection: but no matter of this kind
has, it is imagined, ever yet been discovered in it.
Such pus, too, as is found in wounds and ulcers, would
not at first appear thin and serous, as it always does,
if deposited completely formed from the blood.
The most probable opinion hitherto advanced with
respect to the formation of pus, is, that it is a change
produced by a certain degree of fermentation, upon
the serous part of the blood, after its secretion into the
cavities of ulcers and abscesses; and this in conse-
quence either of the natural heat of the part, or of
heat artificially applied.
That it is the serum only of blood, which is proper
for the formation of pus, and that it is produced by
the application of a certain degree of heat, was first
rendered very probable by an experiment related by
Sir John Pringle in the appendix to his treatise on the
diseases of the army*; and it was afterwards fully con-
firmed by several others of the same nature made by
Mr. Gaber, and related by him at full length in the
second volume of the Acta Taurinensia.
Sir John Pringle found, that pure serum, kept for
some days in a furnace regulated to the human heat,
after becoming turbid, dropped a white purulent sed-
iment. The crassamentum of blood, in the same space
of time and degree of heat, changed from a deep crim-
son
* Experiment xlv. 


Sect. III. Of Suppuration. 41
son to a dark livid colour; so that, when any part of
it was mixed with water, it appeared of a tawny hue.
Serum, digested with a few red globules, and in the
same circumstances, was of the same colour.
Mr. Gaber's experiments, as we have already re-
marked, all tend to elucidate and corroborate the same
opinion, namely, That pure unmixed pus is formed
only from serum. The addition of red globules to
serum, and crassamentum digested by itself, exhibited
much the same appearances as those quoted above
from Sir John Pringle.*  Fat, which is thought by
many to be a principal ingredient in the composition
of pus, was found by Mr. Gaber, when exposed to the
above mentioned trial, to exhibit no appearances of
that matter; nor were any of the fleshy parts, when
digested either with serum or water, convertible in-
to it.
From all which, it may be concluded, that the ad-
dition of any of these articles to serum, instead of ren-
dering it capable of producing good pus, has always
the very contrary effect; and that it is pure serum a-
lone from which that matter can be obtained.
It may here be remarked, once for all, that what is
meant by pure serum, is not that finer halitus, which,
in a healthy state of the body, is constantly secreting
into the different cavities, merely for the purpose of
lubricating and keeping them moist, and which is a-
gain generally absorbed ; but it is a serous fluid, of
the same nature with that which separates spontane-
ously from blood, upon that fluid being allowed to
remain at rest when discharged either from an artery
or a vein: And in which, though there is never sup-
posed to be any mixture of red globules, yet there is
certainly
* V. Act. Taurin. vol. ii. page 87. 


42 Of Suppuration. Part I.
certainly always more or less of the coagulable lymph;
some proportion of which seems absolutely necessary
for serum to be possessed of, to render it capable of
producing pus.
The several effects we have already mentioned as
being produced by digestion upon serum out of the
body, will very readily occur, it is presumed, on the
same causes being applied to it when collected in the
cavities of ulcers and abscesses; and, from the result
of the different experiments alluded to it, it is proba-
ble, that, according as it is there deposited more or less
free from mixtures of fat, red globules, and other sub-
stances, it will yield pus of a more pure or vitiated
nature.
This account of the formation of pus is the most
satisfactory, it is conceived, of any that has as yet been
given; and this more especially, as it renders evi-
dent, as will afterwards appear, the operation of all
the remedies commonly found most effectual in pro-
moting suppuration.
§ 3. Of the necessary Remedies for promoting Suppura-
tion.
When, for the reasons we have already enumerated,
it is judged most proper to use means for promoting
the suppuration of an inflamed part, then all the rem-
edies we have been recommending with a view to res-
olution, must immediately be laid aside.
No farther evacuations, as was observed, are to be
admitted; and if the patient has been much weaken-
ed, a full allowance in point of diet, and even a pro-
portion of wine, may probably be necessary.
For although a very violent degree of inflammation
proves always unfavourable to suppuration, by pro-
moting 


Sect. III. Of Suppuration. 43
moting the progress of Gangrene, as will afterwards be
taken notice of; or as tending to propel into the cel-
lular membrane, which in general is the seat of ab-
scesses, a quantity of red globules, together with the
serum of the blood, which alone ought to be extrava-
sated for the formation of good pus; yet, in order to
have a due quantity of serum secreted for the purpose
of suppuration, and at the same time to have its fer-
mentation properly carried on, the different inflam-
matory symptoms must never be allowed to subside
suddenly; otherwise an abscess containing very ill
digested matter, as it is termed, will most probably
be produced.
Thus we find in small pox, which are so many
small phlegmasiæ, that although blood letting and
other evacuations to a certain extent prove frequently
useful, yet a proper suppuration never takes place if
the patient has been much debilitated by any consid-
erable discharge; and the same thing very certainly
occurs, in similar circumstances, in abscesses of a larger
size. The patient therefore should neither be allowed
to live so fully as might raise the inflammation too
high, nor should he be reduced in such a manner, by
evacuations and low diet, as to induce the contrary
extreme.
Having in this manner endeavoured to procure a
discharge into the cellular membrane, of serum proper
for the formation of pus, the next circumstance re-
quiring attention is, that a due fermentation be excit-
ed, and preserved in it, so that its progress towards
perfect maturation may go easily and regularly on.
This indication is chiefly effected by the use of
such applications as tend to preserve a proper and
constant degree of heat in the part: in so much, that
it 


44 Of Suppuration. Part I.
it seems probably owing to a want of attention to this
circumstance, that the greatest part of all the softer
swellings do not come to suppuration; and that ac-
cording to the degree of heat in which they are kept,
whether from the proportion of inflammation by
which they are at first produced, or from the natural
heat of the part they are seated in, they form into tu-
mors of melicerous, steatomatous, and other consist-
ences. For unless a due degree of heat be applied
and continued, serum being merely extravasated will
never produce pus: hence, in ascites, and other drop-
sical disorders, large quantities of it remain in this
state for a great length of time, without any suppura-
tion taking place; and that merely from such col-
lections being produced without any inflammation at
first, so that no assistance is afforded from any degree
of preternatural heat; and the natural heat of such
parts, in which serous collections usually occur, is sel-
dom considerable enough to produce such an effect.
The degree of heat best suited for promoting sup-
puration is not perhaps easily to be determined; but
the more considerable it is, at least to a certain extent,
the more quickly, it is probable, pus will be formed.
This we find, indeed, from Mr. Gaber's experi-
ments, is so far the case:* and the observation is
likewise confirmed by daily experience in every
case of phlegmon; in which the tumor, cæteris
paribus, always proceeds more quickly or more slowly
to suppuration, as it is seated nearer to, or at a greater
distance from, the heart. Hence, in any of the ex-
tremities, particularly in the legs, inflammatory disor-
ders
* When speaking of pus being formed in, and subsiding from, serum
digested in a degree of heat equal to that of the human body, Mr. Gaber
says, " Eo autem citius subsidbat quo calor erat  major."  Loco citato. 


Sect. III. Of Suppuration. 45
ders proceed very slowly to suppuration; while those
of the trunk, and about the head, go on very quickly.
Thus many cases of inflammation of the ears and
throat frequently arrive at a thorough maturation, and
even burst of themselves, in the course of forty eight
hours from the first attack.
This consideration, therefore, should make us par-
ticularly attentive to the preservation of a due degree
of heat in every inflamed part intended to be brought
to suppuration; but more especially in situations very
distant from the heart, where artificial heat is most
wanted, and where, by a proper application of it, al-
most every tumor, though situated on the extremities,
might probably be made to suppurate in the same
space of time with those in the ears and other parts
just now taken notice of.
I am not only convinced, by experience, of what is
here asserted respecting the very singular advantages
to be obtained from a due attention to this matter;
but also, from a course of experiments I was engaged
in some years ago upon the same subject. But as these
turned out almost exactly similar to those related by
Mr. Gaber, no exact account was preserved of the re-
sult of them: this, however, is particularly remember-
ed, that in a heat equal to 100° of Farenheit's ther-
mometer, the deposition of matter from serum took
place in little more than half the time that was requi-
site for the same effect at even eighty degrees.
It was the prosecution of these experiments that
first suggested to me the probability of the great ad-
vantages to be derived from the preservation of a due
degree of heat in inflamed parts; and I have accord-
ingly, on many occasions since that time, found the
treatment of such cases go on much more easily than
otherwise


46 Of Suppuration. Part I.
otherwise I should either have expected or have been
able to account for.
Warm fomentations and cataplasms are the means
commonly employed for the application of heat to an
inflamed part; and when these are regularly and fre-
quently renewed, nothing, it is probable, can more
effectually answer the purpose. But, in the ordinary
manner in which they are applied, as the cataplasms
are renewed only once, or at most twice, in the day,
they must always, it is imagined, do more harm than
good. For as soon as the degree of heat they were at
first possessed of is dissipated, the moisture kept up by
them, with the consequent evaporation that ensues,
must always render the part a great deal colder than
if it had been merely wrapped in flannel, without the
use of any such application.
In order to receive all the advantages of such reme-
dies, the part affected should be well fomented with
flannels pressed out of any warm emollient decoction,
applied as warm as the patient can easily bear them,
continued at least half an hour at once, and renewed
four or five times a day.
Immediately after the fomentation is over, a large
emollient poultice should likewise be applied warm,
and renewed every second or third hour at farthest
Of all the forms recommended for emollient cata-
plasms, a common milk and bread poultice, with a
proportion of butter or oil, is perhaps the most eligi-
ble; as it not only possesses all the advantages of the
others, but can at all times be more easily obtained.
Roasted onions, garlic, and other acrid vegetables,
are frequently made use of as additions to maturating
cataplasms: When there is not a due degree of in-
flammation in the tumor, and when it appears proba-
ble 


Sect. III. Of Suppuration. 47
ble that the suppuration would be quickened by hav-
ing the inflammatory symptoms somewhat increased,
the addition of such substances may then be of service;
but when stimulants are necessary in such cases, a small
proportion of strained galbanum, or of any of the
warm gums, dissolved in the yolk of an egg, and added
to the poultices, is not only a more elegant, but a
more certain form of applying them. In some cases,
too, the same intention may be more certainly ac-
complished, by combining a small quantity of can-
tharides with any application intended to be em-
ployed.
Whenever the inflammation, however, takes place
to a proper degree, such stimulating substances can
never be necessary; and from the different observa-
tions we have already made, there is reason to think,
that in many instances they might even do mischief.
In such tumors as, from their being attended with
little or no inflammation, are commonly said to be of
a cold nature, as they are generally indolent, and pro-
ceed very slowly to suppuration, plasters composed of
the warm gums are often employed with considerable
advantage: in such cases, they are not only of use by
the stimulus and irritation they occasion, but by the
heat which they tend to preserve in the part. They
become particularly necessary, when the patient, by
being obliged to go abroad, cannot have cataplasms
frequently enough renewed, or so conveniently ap-
plied; but when some such objection does not occur,
the latter, for very obvious reasons, should always be
preferred.
Dry cupping, as it is termed, that is, cupping with-
out the use of the scarificator, upon, or as near as pos-
sible to, the part affected, is frequently used with ad-
vantage 


48 Of Suppuration. Part I.
vantage for promoting the suppuration of tumors: it
is only, however, in such as these last mentioned,
where there seems to be a deficiency of inflammation,
that it can ever either be necessary or useful; but in
all tumors of a real indolent nature, and where there
is still some probability of a suppuration being effect-
ed, I have seldom observed such good effects from any
other remedy.
These different applications, under the restrictions
we have taken notice of, being continued for a longer
or shorter time, according to the size of the tumor, its
situation and other circumstances, a thorough suppu-
ration may, in general, at last be expected.
Matter being fully formed in a tumor, is known by
the remission of all the symptoms which take place:
the dolor pulsatilis, that before was frequent, now goes
off; and the patient complains of a more dull, con-
stant, heavy pain: the tumor points at some particu-
lar part, generally near to its middle; where, if the
matter is not encysted, or deep seated, a whitish yel-
low appearance is observed, instead of a deep red that
formerly took place; and a fluctuation of a fluid un-
derneath, is, upon pressure, very evidently discovered.
Sometimes, indeed, when an abscess is thickly covered
with muscular and other parts; and when, from con-
curring circumstances, there can be little doubt of their
being even a very considerable collection of matter,
yet the fluctuation cannot be readily distinguished:
but it does not often happen, that matter is so very
deeply lodged as not to be discovered upon proper ex-
amination.
This, however, is a circumstance of much import-
ance in practice; and deserves, it may be remarked,
more attention than is commonly given to it. In no
part


Sect. III. Of Suppuration. 49
part of the surgeon's employment, is experience in
former similar cases of more use to him than in the
present; and however simple it may appear, yet noth-
ing, it is certain; more readily distinguishes a man of
observation and extensive practice, than his being able
easily to detect collections of deep seated matter:
whilst nothing, on the contrary, so materially affects
the character of a surgeon, as his having, in such cases,
given an inaccurate or unjust prognosis; for the e-
vent, in disorders of this nature, comes generally at
last to be clearly demonstrated to all concerned.
Together with the several local symptoms of the
existence of pus, already enumerated, the frequent
shiverings that patients are liable to on its first forma-
tion may likewise be mentioned; these, however, sel-
dom occur so as to be distinctly observed, unless the
collection is considerable, or seated internally in some
of the viscera; But, in every large abscess, they are
almost constantly met with; and, when they appear
along with other symptoms of suppuration, they tend
always to ascertain the real nature of the disorder.
§ 4. Of Abscesses, and of the proper Period for opening
them.
In the treatment of abscesses, it is a general rule,
not to discharge their contents till a thorough suppu-
ration has taken place; for, when laid open long be-
fore that period, and while any considerable hardness
remains, they commonly prove troublesome, and sel-
dom heal kindly.
In some cases, however, it is necessary to deviate
from this general rule, and to open them a good deal
sooner; particularly in all such critical abscesses as
occur in malignant fevers. In the plague, too, we
D are 


50 Of Suppuration. Part I.
are commonly advised to open such tumors as soon as
they are tolerably advanced, and not to wait till they
are fully maturated; for, in such instances, it is found,
that the patient receives more benefit from an early
discharge of matter, than he can suffer harm from hav-
ing any swelling of this nature somewhat prematurely
laid open.
Abscesses, too, situated on any of the joints, or up-
on either of the large cavities of the breast and abdo-
men, and more especially when they seem to run deep,
should always be opened as soon as the least fluctuation
of matter is discovered. For, when the resistance is
on every side equal, they will just as readily point
internally as outwardly; and the consequence of a
large abscess bursting into either of the large cavities
especially, is well known most frequently to prove
fatal: An instance of which, in the following case I
had some time ago an opportunity of observing, which,
with very little attention, might have been prevented.
A surgeon of eminence, and, of very extensive prac-
tice, was applied to by a young, healthy looking man,
with a large abscess upon the left side of his chest. A
fluctuation of a fluid was, upon pressure, very evi-
dently discovered; and it was agreed, by other two
practitioners who were present, that an opening should
be made to give vent to the matter. But the opera-
tor being much engaged in business, could not fix on
an earlier period for doing it than the third day from
the patient's first applying to him: unluckily, how-
ever, the patient died suddenly in his bed, the night
before the abscess was to have been opened.
On examining the body, the tumor was found to
have disappeared entirely, without any external
opening being observed; and, on laying open the
thorax, 


Sect. III. Of Suppuration. 51
thorax, the matter was observed to have burst inward-
ly upon the lungs; and hence had produced immedi-
ate suffocation.
In all other cases; however, except in those alluded
to, the rule in opening abscesses is, as was already re-
marked, to allow a thorough suppuration to take place,
before any vent whatever be given to the matter; and
it being then determined to lay the collection open,
the next question that occurs; is with respect to the
manner of doing it.
§ 5. Of the different Methods of opening Abscesses.
Two different methods of opening abscesses have
been recommended by authors, namely, by Caustic
and Incision. To the former, however, there are
many objections: It is not attended with any superi-
our advantage to a simple incision; upon a tender in-
flamed part, it gives much more pain; it is more slow
in its effects; and the surgeon never has the com-
mand of it so entirely as to destroy those parts he
would incline; and no more; for all the different
kinds of Caustic, notwithstanding the greatest atten-
tion, will sometimes spread farther, and penetrate
deeper, than was either wished for or intended. Of
this, I, some years ago, saw a very remarkable instance;
and in a situation too, in which an accident of this
nature would not be thought likely to occur.
Caustic was applied to the anterior part of the scro-
tum, with a view to produce a radical cure, in a case
of hydrocele: but whether there had been very little
water collected, or whether a preternatural adhesion
of the testis to the tunica vaginalis had, at this part,
been produced, is uncertain; but the caustic pene-
trated to the body of the testicle, and gave the patient,
D2 as 


52 Of Suppuration. Part I.
as may readily be imagined, a great deal of very ex-
cruciating pain. It did, to be sure, accomplish a cure:
but the danger attending such an accident, although
it probably might not frequently occur, is, I should
imagine, a very strong objection to the use of caustic
in all such cases; and it is now indeed very generally,
I believe, laid aside, the preference being justly given
to the scalpel.
When tumors are not very large, they are common-
ly opened by a longitudinal incision with a lancet or
scalpel. This should be so directed as to terminate
at the most depending part of the swelling, and should
be of such a size as may seem sufficient for giving a
free discharge to the matter; about two thirds of the
length of the tumor is, in such cases, generally reck-
oned extensive enough.
When abscesses, however, are of any considerable
extent, they are commonly laid open through their
whole length; and when the teguments have been
greatly stretched, it is advised by many to take part of
them away altogether. But this is a practice which
seldom, or perhaps never, ought to be followed; as
there are scarcely any abscesses so large as to destroy
entirely the contractile power of the integuments;
and while this remains in any degree in a part, there
are still hopes of its again recovering its former dimen-
sions. It is surprising indeed to what extent this ob-
servation applies. In many instances the skin has
been known to recover its tone entirely, after having
been for a time completely deprived of it.
These are the several modes of opening abscesses
by the scalpel. There are different inconveniencies,
however, found to attend all of them; and particular-
ly, that as soon as an incision is made into a tumor,
the 


Sect. III. Of Suppuration. 53
the whole contained matter is discharged suddenly,
and at once: Whereby, when the collection is con-
siderable, faintings and other disagreeable symptoms
are frequently induced; and what, in all large swell-
ings especially, is constantly attended with very bad
effects, a free admission of air is thereby given to a
great extent of ulcerated surface.
The bad effects of air on every species of sore, is
well known to every practitioner; but its pernicious
influence, on a newly opened abscess, is often really
astonishing. It first occasions a total change in the
nature of the matter, from perhaps a very laudable
pus to a thin ill digested sanies; and afterwards brings
on a quickness of pulse, debilitating sweats, and other
symptoms of hectic fever, which, for the most part,
when the collection has been considerable, either car-
ries the patient off in a short time, or terminates in a
confirmed phthisis, which sooner or later proves fatal,
This I have, in a great many instances, had occa-
sion to observe; and that, in such cases, it is the ad-
mission of air alone which produces all these bad symp-
toms, is rendered highly probable from this circum-
stance, that of a great number of patients who have
laboured under such disorders, many have remained
for a very considerable time, with large abscesses fully
formed, and without having any one symptom of hec-
tic whatever: but when they have ever exceeded an
ordinary or moderate size, I have seldom known an
instance of their being opened by a large incision,
without almost every hectic symptom taking place;
and this generally in less than forty eight hours from
the time of their being laid open.
In what manner the admission of air to an ab-
scess operates in producing such a powerful and sud-
D3 den


54 Of Suppuration. Part I.
den effect, is perhaps difficult to determine. The ir-
ritation produced by it, on a large extent of ulcerated
surface, may probably be one reason:—By acting as
a stimulus on the extremities of the different absorb-
ents opening into the sore, it may occasion a larger
absorption of matter than would otherwise take place;
and it may likewise, by rendering the matter more
putrid than before, give even to the same quantity
absorbed greater activity in producing the different
symptoms of hectic.
That this conjecture is well founded, with respect
to an increase of putrescence being the principal cause
of the bad effects produced by the admission of air to
sores, is, from different circumstances, at least exceed-
ingly probable. For, in the first place, although the
discharge from abscesses is commonly mild, and free
from any disagreeable fetor on their being newly laid
open; it almost constantly becomes thin, acrid, and
more fetid in the course of a few dressings, which is a
certain proof of a greater degree of putrescence having
then taken place. On this principle, too, we may ac-
count for the operation of many of the remedies com-
monly employed in the treatment of sores; and more
especially of that powerful antiseptic, fixed air, which
by many practitioners have been so much extolled.
We know from experiment likewise, that other sub-
stances, as well as that part of the blood from which
pus is formed, is rendered putrid, and more quickly
so, by the admission of air, than otherwise, while in
the same degree of heat, they probably ever would be.*
From these considerations, therefore, the greatest
caution appears to be necessary, for preventing, as
much
* Vide Sir John Pringle's and Mr. Gaber's Experiments on this sub-
ject. Loc. cit. 


Sect. III. Of Suppuration. 55
much as possible, the admission of air to the internal
surface of every collection of matter; and this, we
may remark, is very easily and effectually done, by
opening collections of this kind by means, of a seton
or cord, instead of having recourse either to caustic or
the scalpel.
This method of discharging the contents of tumors,
by the introduction of a cord, is attended with every
advantage of that by incision: it, moreover, empties
the swellings, of whatever size they may be, not sud-
denly, but very gradually; it effectually prevents a
free admission of air; it is not commonly attended
with near so much pain and inflammation; nor is the
cicatrix occasioned by it ever inconvenient, or un-
seemly, which it frequently is after a large incision.
In the Royal Infirmary of this place, large abscesses,
as well as those of a smaller size, used formerly to be
opened in the usual manner, by extensive incisions;
the consequences were such as have been already re-
lated; many of the patients were thrown into such
obstinate hectic fevers as they never recovered from;
and others, though they did get better at the time,
were commonly so much debilitated as to be very lia-
ble to be seized with other disorders, from which they
seldom entirely recovered.
This was the most frequent result of our treatment
of large abscesses by incisions; and similar conse-
quences will still be found to prevail where this prac-
tice is continued: but since the seton came to be gen-
erally used here, few or no such disagreeable circum-
stances have occurred. Many of the largest tumors
have been opened in this manner: and when the pa-
tients are otherwise in good health, they very com-
monlv do well; and with this additional advantage,
D 4 that

56 Of Suppuration. Part I.
that a cure is frequently obtained in little more than
half the time usually found necessary after a large in-
cision has been employed.  
The opening of abscesses by the introduction of a
seton has been mentioned by different authors, and in
small collections of matter has been frequently prac-
tised; but never so generally, I imagine, as it has been
here within these last twenty years, both in the hos-
pital and in private. And in justice to Mr. James
Rae, surgeon in this place, it must be acknowledged,
that we are chiefly indebted for it to his recommenda-
tion, he having first proposed the general use of setons
in such cases, at the same time that he invented a set
of instruments, by which they are easily inserted in
almost all abscesses, however deep seated, and among
whatever parts they may run; and this too without
any risk of wounding the large blood vessels, nerves,
or tendons, in the neighborhood.
Several sets of these instruments, for abscesses of dif-
ferent sizes, are kept in the Infirmary here: they ful-
fil the intention, as was already observed, exceedingly
well, and are a very ingenious contrivance. But as
the curved director we have delineated in the plate,
answers the purpose equally well, and is in itself fully
more simple, it will for that reason be in general found
more convenient. It is used in the following manner.
An opening sufficiently large for the cord, being
made with a lancet in the superior part of the abscess,
the director, threaded with a cord of candlewick cot-
ton, or of soft silk, proportioned in thickness to the
size of the tumor, is then to be introduced, and its
point to be pushed downwards till it is felt externally,
exactly opposite to the most depending part of the
swelling. The director being kept firm by an assist-
ant


BELL ON ULCERS page 56
A The Curved director described page 56
B An Abcess on the Joint of the knee open'd
by the introduction of a cord as directed
pages 56 and 57. C. a flat Trocar with
a lancet point-




Sect. III. Of Suppuration. 57
ant, an incision is to be made with a scalpel upon its
under extremity, of a length somewhat more consid-
erable than the opening first made by the lancet : for
when this circumstance is not attended to, and when
of course the under orifice is made no longer than the
upper, the matter is very apt to transude above; which
always proves inconvenient to the patient, but which
in this manner is very easily avoided. The director is
now to be drawn downwards, with so much of the cord
as to leave two or three inches of it hanging out at the
lower orifice. In order to cause the cotton run easily
on its first introduction, as likewise at the subsequent
dressings, as much of it as is to be used at the time
should be well rubbed over with any emollient oint-
ment.
In twenty four hours or thereby from its introduc-
tion, the cord may be moved, and so much of it should
be drawn downwards as to admit of all that part of it
being cut off which had been lodged in the abscess;
and in this manner the same quantity of it is to be
moved daily, as long as from circumstances it may ap-
pear to be necessary.
A regular and slow discharge of the matter is thus
produced; the sides of the abscess are thereby allowed
to contract gradually; and a slight inflammation be-
ing kept upon their surfaces by the friction of the
cord, they are from that circumstance brought to unite
and to adhere firmly to one another, much sooner than
they otherwise would do. As the discharge dimin-
ishes in quantity, so the size of the seton should also
be gradually lessened; and it is easily done, by with-
drawing a thread of the cotton once in two or three
days. At last, when there is little more matter afford-
ed than ought to be naturally produced by the irrita-
tion


58 Of Suppuration. Part I.
tion of the cord, it may be altogether taken out; and
gentle pressure being continued upon the parts by a
roller for a few days longer, a pretty certain and last-
ing cure may generally be expected.
In the introduction of the seton it was expressly
said, that it ought to be made from above downwards;
that is, by an opening made in the superior part of
the abscess. The reason for such a restriction is this,
that when the first opening is made in the depending
part of a swelling, a considerable quantity of matter
immediately runs out, which, as it causes the sides of
the upper part of it to collapse, renders it more diffi-
cult to introduce the director through the whole course
of the abscess, than when done in the manner directed:
when properly executed, the bottom as well as every
other part of the tumor is kept distended to the last,
very little of the matter escaping by the upper orifice.
By being introduced in this way, too, the quantity of
cord that still remains to be used is kept clean and dry;
which it cannot possibly be when inserted in the con-
trary manner.
To some these circumstances may perhaps appear
too trifling to deserve such particular notice; but too
much, it is imagined, can never be said in rendering
the account of a beneficial practice clear and evident.
All that has hitherto been said with respect to the
use of setons in cases of abscess from recent inflamma-
tion, applies with equal propriety, it must be under-
stood, to tumors of very long continuance, when the
matter contained in them is either of a purulent na-
ture, or of a consistence not much thicker than pus. 
All encysted tumors of the thinner melicerous kind
are as successfully treated in this manner as recent ab-
scesses: so that the practice is by no means confined
to 


Sect. III. Of Suppuration. 59
to one set of tumors only; and it may even probably
be employed in others, for which it has not as yet been
advised.
It answers particularly well in all collections of mat-
ter in glandular parts, where the admission of air is at-
tended with even worse consequences than in other
parts. Thus, when it is thought advisable to open
scrophulous soft swellings, they commonly heal much
sooner and easier with the seton than by a large inci-
sion. Venereal buboes, too, when fully maturated,
and when the teguments are not become very thin by
being long overstretched, heal much more readily and
kindly by this management than with any other.
From the practice answering so remarkably well in
every case of abscess, it was at last, a good many years
ago, employed by Mr. Rae in the Infirmary here, in
the hydrocele, or collection of water in the tunica va-
ginalis testis; and it has since that time been frequent-
ly used in, similar cases. I must acknowledge, howev-
er, that from the several instances I have yet seen of
its effects in this disorder, I am not altogether certain
whether it ought to be preferred to the simple incision
or not. For, though I never knew an instance, when
the operation was properly done, of its failing to pro-
duce a radical cure; yet the friction of the cord upon
the body of the testis, to which in this operation it is
immediately applied, generally occasions a very high
degree of inflammation; fully more, I have often
thought, than is commonly observed from the simple
incision: Farther experience, however, is necessary, in
order to determine a question of such importance.
This was my opinion in the year 1778, when the
first edition of this book was published. Since that
period I have had no other reason to alter it, than to
be




60 Of Suppuration. Part I.
be more and more convinced that the treatment of hy-
drocele by seton, is productive of more pain than any
other method of cure now in use; while, at the same
time, it is not more certain in its effects than the sim-
ple incision. And, accordingly, although I could not
at that time speak with precision of the merits of this
operation, I am now satisfied that the cure by incision
ought in every instance to be preferred.
But when, in such cases, it is resolved to employ the
seton, the method of introducing it, as we have direct-
ed for abscesses, with a curved director of a proper size,
seems more simple, though in other respects perhaps
not better, than that lately recommended by Mr. Pott,
which being with the help of a common trocar, ap-
pears to be neither safe nor easily performed. For in-
stances have occurred, even with very able surgeons
now living, where, in cases of hydrocele, the body of
the testis has been wounded by puncturing with that
instrument; which, from its round form, is introduced
with much difficulty. Whenever it is agreed upon,
however, to make use of a trocar, either with a view to
a palliative or a radical cure, one with a lancet point,
as is represented in the plate, answers the purpose with
much more ease than that in common use. A large
instrument of this kind was made, by my direction
some years ago, for the paracentesis of the abdomen;
and, as it answered the purpose exceedingly well, it
has since been often used, and is now very generally
employed*.
Of
* Mr. Thomas Hay, surgeon in this place, some years ago invented
a curved director, such as is here recommended, which has since that
time been used for the introduction of a cord in cases of hydrocele, and
is found to answer the purpose very conveniently.


Sect. IV. Of Mortification. 61
SECTION IV.
Of MORTIFICATION.
§ 1. General Remarks on Gangrene.
THE termination of inflammation, both by Reso-
lution and Suppuration, having now been fully
treated of, we come next in order to the consideration
of Gangrene or Mortification.
The several appearances of Gangrene having been
already particularly enumerated, it is not now necessa-
ry to make a full recapitulation of them. Only, it may
be remarked, that a thorough mortification, or the last
stage of gangrene, is known only by the diseased part
becoming totally black, by its losing all pain and se-
nsation, at the same time that it emits a considerable se-
tor; at last, too, a softness or flaccidity in general takes
place, together with an entire dissolution of the differ-
ent parts of which the organ is composed.
I have said only in general: for although the sever-
al appearances, as above related, do most frequently
occur; yet there are some instances of what is called
Dry Gangrene, in which the parts continue totally
mortified for a great length of time, without either
turning very flaccid, or running into dissolution.
Such cases, however, never occur from inflamma-
tion. They happen commonly from the flow of blood
to such parts being put a stop to by compression of one
kind or another, as tumors, ligatures, or other similar
causes, obstructing the principal arteries that used to
supply them; which, when the stoppage of the circu-
lation is complete, always occasion a very slow morti-
fication: and as the parts, in such instances, are no
longer 


62 Of Mortification. Part I.
longer supplied with fresh quantities of fluids, while a
considerable evaporation must still be going on; such a
degree of humidity cannot therefore possibly occur, as
in other cases of gangrene. Thus, that species of the
disorder has, perhaps with propriety enough, been
termed the Dry Gangrene.
There are other varieties of the disease enumerated
by authors, as the White Gangrene*; in which the
parts supposed to be mortified do not turn black, but
retain nearly their former colour, &c. Whether such
complaints, however, can with propriety be denomin-
ated Gangrene or not, may probably be doubted: but
as it is chiefly that species of the disorder which suc-
ceeds to inflammation, that is now particularly to be
treated of, and in which no such varieties are ever ob-
served, it is not here necessary to carry the inquiry far-
ther; and especially as nearly the whole mode of
treatment, to be afterwards recommended, applies, with
almost equal propriety, to every variety of the disease.
Of all the inflammatory complaints to which the
system is liable, that species of the disorder termed Ery-
sipelas, is observed most frequently to terminate in
gangrene; and whenever phlegmon is in any degree
conjoined with an erysipelatous affection, which it not
unfrequently is, it seems thereby to acquire the same
tendency, by being, as was already remarked, more dif-
ficult to bring to suppuration than the true phlegmon;
and by going on more frequently to the mortified state.
The best and most effectual means of preventing
mortification in every case of inflammation, is to en-
deavour either to obtain its resolution or suppuration;
the different remedies for both which purposes have
already been fully pointed out. But, in some cases, the
disorder
* Quesnay, Traité de la Gangrene, p. 337. 


Sect. IV. Of Mortification. 63
disorder is far advanced, and gangrene is already be-
gun, before the surgeon's assistance is called in; and,
in others, the inflammation runs so high, and proceeds
so quickly, that gangrene occurs notwithstanding the
use of all the remedies that can be applied: In some
instances so quickly even, that the inflammatory state
is scarcely thoroughly discerned till mortification ap-
pears to be beginning.
§ 2. Observations on Carbuncles as a Species of
Gangrene.
This rapid progress of the disorder occurs most fre-
quently in cases of Carbuncles, what by the French
are termed Charbons; in which the inflammation
proceeds so quickly to mortification, that there is sel-
dom any evident tumor raised, the parts turning black,
and ending in real gangrene, often in the course of
twenty four hours from the first attack.
The quick progress usually made by this disorder,
renders it the worst and perhaps the most dangerous
species of inflammation. For when it occurs inter-
nally upon any of the viscera, as it sometimes does, it
must, probably in every instance, prove fatal; as no
remedies with which we are acquainted can ever pre-
vent its progress towards the last stage of mortification:
Externally, indeed, when they are not very extensive,
and not seated on any of the large blood vessels and
nerves, carbuncles are frequently got the better of;
that is, with the loss of the affected parts.
As carbuncles commonly appear without any evi-
dent external cause, they are in general most probably
owing to a scorbutic or putrid state of the fluids; for,
when putrescence prevails in the system, every inflam-
matory affection that occurs, proceeds much more read-
ily


64 Of Mortification. Part I. 
ily to the mortified state than inflammation in other
circumstances ever does.
This opinion with respect to the cause of carbuncles
depending upon a putrescent state of the system, is
particularly confirmed by their occurring most fre-
quently as a symptom in pestilential disorders; for,
although they are sometimes met with even in this
country, where the plague is now never known, yet
the real carbuncle is far from being a common occur-
rence;
In such instances gangrene is very easily accounted
for, from the predisposition in the system to putrid dis-
orders: but in what manner is it produced by inflam-
mation in other cases, and where no such disposition
can be supposed to take place? This we shall proceed
to investigate.
§ 3. Of the Causes of Gangrene.
An increased action in the vessels of a part, we have
already endeavoured to establish as the immediate or
proximate cause of inflammation; and the same cause,
it is presumed, will, in many instances, account for the
rise of mortification.
One evident effect of an increased action in the ves-
sels, in every case of inflammation, is a propulsion, in-
to the smaller capillaries, of a greater quantity of the
more dense parts of the blood than naturally they were
intended to transmit. When this is not considerable,
a due circulation is frequently restored in a short time,
without any bad consequence whatever; nay, when
an actual extravasation of the serous part of the blood
into the cellular membrane has taken place in some
degree, the fluid is often reabsorbed, and a cure is thus
obtained by resolution. But when such extravasation 
from 


Sect. IV. Of Mortification. 65
from a farther increase of this undue action of the ves-
sels has taken place to a still greater degree, suppuration
is then most frequently the consequence.
When, again; a strong exciting cause is applied to a
Constitution already predisposed to inflammatory com-
plaints; as a lacerated wound, for instance, in a young
healthy man; the violent irritation, and consequent
increased action of the vessels that ensues, occasions the
red particles of the blood to be likewise poured forth
together with the serum. In this manner a collection
of an extravasated fluid is produced, and the great de-
gree of preternatural heat kept up by the disorder very
readily excites in it some degree of fermentation;
which, from the nature of the matter it has to act up-
on, not being able to effect a suppuration,* and the
crassamentum of blood being particularly liable to run
into the putrid fermentation,† mortification, which we
may here consider as the ultimate stage of putrefaction,
comes in course to be produced.
The disorder being, in this manner, once raised in
a part, the progress which it afterwards usually makes,
does not appear very difficult to account for. The
putrescent particles of the tumor, by insinuating them-
selves into the cellular membrane of the neighbouring
sound parts, as in this manner they extend the conta-
gion, so they very soon bring these likewise to suffer.
In this way, the mortification continues to advance;
till meeting with a part, perhaps, naturally more irrit-
able
* Mr. Gaber, when speaking of his experiments upon the crassamen-
tum of blood, says, that he could never obtain genuine pus from it; and
farther adds, " Vero similius ergo sanguinem cæteris puris principiis ad-
mixtum, ipsum magis fœtidum et deterius reddere, &c."  Loc. cit. p. 87.
† For some animal substances, such as urine, the bile, and the crassa-
mentum of blood, soon putrefy. Sir John Pringle's Experiments, Ap-
pendix, p. vi. 
E


66 Of Mortification. Part I.
able than the others, or which by this time has been
rendered so by the different remedies to be pointed
out, a certain degree of new inflammation comes to be
easily induced, in consequence of the stimulus which
putrid particles must always occasion: This, as it ren-
ders the parts more firm and compact, makes them less
easily penetrable by the putrescent contagion; and a
suppuration of course ensuing as a consequence of the
preceding inflammation, a complete separation of the
diseased from the sound parts is thereby, in general,
very soon effected.
At least, that such an inflammation, with a conse-
quent suppuration, does, in cases of real gangrene, al-
ways happen before a separation of the diseased parts
takes place, is a fact well known to every practitioner;
and that the cause assigned for these appearances is the
true one, I think, from the different circumstances tak-
en notice of, is at least exceedingly probable.
Thus the local symptoms of gangrene appear to be
pretty certainly accounted for: and the finking of the
pulse, which, in extensive mortifications, always oc-
curs, and which is by much the most remarkable
change that takes place in the general system, is a very
natural consequence of that debility, which seems to
be a constant and necessary attendant on a putrescent
state of the fluids, from whatever cause this may have
arisen; a circumstance we have particularly demon-
strated in putrid fever, and in scurvy, where a languid
pulse and general debility are always considered as the
most characteristic symptoms.
§ 4. Of the Prognosis in Gangrene.
In every case of gangrene, the prognosis should at
first be exceedingly doubtful; for even in the slightest
affections 


Sect. IV. Of Mortification. 67
affections of this nature, the system, from the contagion
it receives by the absorption of putrid matter, is, in
some instances, so much affected, that the patients are
suddenly carried off, without appearing previously to
have been in any imminent danger.
In such cases, however, as succeed to inflammation
from an external cause, where the gangrene is neither
very deep nor extensive, and where it does not seem
to spread, the prognostic ought to be much more fa-
vourable than in those which arise suddenly from an
internal cause, where the mortification runs deep, and
more especially when it is still continuing to advance;
in which circumstance the greatest danger is always to
be apprehended.
Indeed, no person whatever, with any considerable
mortification, even from an external cause, can be said
to be free from risk, till the diseased parts are not only
separated, but even entirely cast off from the found;
the poison of putrid miasmata being of such a pene-
trating and destructive nature, that many instances
have occurred of patients being very quickly carried
off, seemingly from this circumstance alone, long after
the progress of the mortification had ceased. In such
cases we presume, that the putrescent miasmata prove
destructive, chiefly by their deleterious influence on
the nervous system. In long continued cases of mor-
tification, the general mass of fluids may sometimes
suffer merely from, the absorption of putrid effluvia;
but as patients, labouring under mortification, fre-
quently die suddenly, and before any putrescency has
appeared in the system at large, we conclude that this
most probably happens from some effect produced ei-
ther upon the nerves or on the sensorium from whence
they originate. But in whatever manner the putrid
E 2 fomes  





68 Of Mortification. Part I.
fomes of a mortified spot may operate, their influence
is frequently found to be so pernicious as to warrant
the conclusion we have formed; namely, that no per-
son, labouring under a real mortification, can be said
to be free from danger till all the diseased parts are en-
tirely removed.
§ 5. Of the necessary Remedies in Gangrene.
In the treatment of Gangrene, when no blood let-
ting or other evacuation has been prescribed during
the preceding inflammatory state of the disorder; and
when the general symptoms of inflammation, particu-
larly a quick, full, or hard pulse, still continue violent;
and especially when the patient is young and pletho-
ric; it then becomes absolutely necessary, even al-
though mortification may have commenced, to empty
the vessels a little by one general blood letting.
Which, by moderating the fever, and abating the uni-
versal heat, proves often a sure means of preventing
the progress of the disorder: and, in this view, blood
letting, in such cases, may, in reality, be considered as
an antiseptic; and it does often, indeed, in this partic-
ular situation of mortification, prove more powerful-
ly so than all the different articles in general enumer-
ated as such.
For the same reasons that blood letting is recom-
mended, gentle laxatives, and a free use of acidulated
cooling drink, become necessary. But, as in the far-
ther progress and continuance of mortification, the pa-
tient is very apt to sink and the pulse to turn languid,
every evacuation, especially of blood, should be direct-
ed with much caution, never to a greater degree than
may seem to be absolutely necessary for moderating
such symptoms as at the time appear to be too violent.
When, 


Sect. IV. Of Mortification. 69
When, again, as is most frequently the case when
the disorder has made any considerable progress, the
patient is much reduced, either by fevered evacuations,
or merely by the effects of the complaint; when the
pulse is low, and the other symptoms of fever not con-
siderable; in these circumstances a very contrary treat-
ment becomes necessary: the principal indication now
being to prevent the system from sinking too much, by
a proper use of cordials, and especially by those of the
tonic kind; while, by the same means, we enable it to
free itself from, or to cast off, the mortified parts.
For, as we have already observed, the separation of
gangrenous from healthy sound parts, being always ef-
fected by the intervention of inflammation, it should
be our chief care to assist nature as much as possible, in
exciting the system, by every proper means, to that dis-
position which, from experience we know to be most
favourable for the production of inflammation; which,
when speaking of the general predisposing causes of
inflammatory complaints, we have endeavoured to
show, is a full plethoric state of the vessels, which at
the same time is generally conjoined with a more in-
vigorated tone of the vessels themselves.
It may, perhaps, be imagined, that this indication
proves, in some measure, contradictory to what we
lately advised with respect to the propriety of blood
letting in some cases of gangrene. When properly
considered, however, it will by no means appear to be
so. For we well know, that, in every disorder to
which the system is liable, an over dose of the most
effectual remedy will often prove just as detrimental
as a medicine of the most opposite tendency: and, in
the same manner, though a certain degree of inflam-
mation is, perhaps, absolutely necessary for the cure of
E3 every 


70 Of Mortification. Part I.
every gangrene; yet, in a very high degree, it becomes
always exceedingly hurtful.
With a view to fulfil the intention of this indica-
tion, a good nourishing diet becomes necessary, with
such a proportion of generous wine as the patient's,
strength and symptoms of the disorder may seem to
require.
By a due attention to this circumstance of regimen,
particularly by a proper allowance of wine, much more
real advantage is commonly obtained than ever occurs
from the use of the whole tribe of stimulating warm
cordials. When, however, the patient is much re-
duced, and very languid, some of these, such as the
volatile alkali, and confectio cardiaca, may, at the
same time, and in such quantities, be prescribed, as the
patient's immediate situation appears to render nec-
essary.
But of all the medicines hitherto used in mortifica-
tion, none proves so certainly efficacious as the Cortex
Peruvianus, which has often a very evident and pow-
erful influence in putting a stop to the disorder. As
it is a very powerful tonic remedy, it may probably
act by invigorating the general system; and thus, by
rendering it more susceptible of that inflammatory
tendency, which we have shown to be so necessary for
effecting a separation of mortified parts, it may in this
manner enable it to free itself from them. It may
likewise, perhaps, in some instances, act as an antisep-
tic, merely by correcting putrefaction; though, in
the former mode of operating, its effects, we appre-
hend, are generally much more considerable than in
the latter.
In whatever manner the bark operates, however, it
can in no case of mortification be ever, with propriety
omitted, 


Sect. IV. Of Mortification. 71 
omitted, excepting in the first stage of the disorder,
while several of the inflammatory symptoms yet re-
main violent; but, as soon as these are tolerably a-
bated, it may always, both with safety and advantage,
be employed.
The best rule with respect to the quantity of the
medicine to be exhibited, is to give it always in as large
doses, and these to be as frequently repeated, as the
stomach can easily bear. It is a great inconvenience,
however, which is found to attend almost every case
of gangrene, that the stomach can seldom bear a suf-
ficient quantity of the bark in substance, which is al-
ways, we may remark, the best mode of using it; but
particularly in this disorder, when none of the finer
preparations of the medicine are ever so much to be
depended on.
Of all the different forms employed for exhibiting
bark, I have generally found it sit easiest on the stom-
ach when conjoined with some of the spirituous wa-
ters; and to the use of which, in such cases of gan-
grene as bark itself is proper in, there can never be any
objection. The following formula is far from being
disagreeable, and I have known it answer with patients
whose stomachs rejected every other,
R. Aq. alexiter. simp.
cinnamon, fort, aa unc. iii.
aromatic, unc. ii.
Pulv. cort. Peruv. subtil. unc. ss. misce; coch. ii.
omni semihora sumendis, agitata phiala.
In this manner a drachm of the bark comes to be
taken every hour, which, in general, in less than twen-
ty four hours, has a considerable influence in produc-
ing a change on the disorder. A great deal depends
upon the medicine being in a fine powder, as patients
E4 often 


72 Of Mortification. Part I.
often bear considerable quantities of it in that state,
when they reject even very small doses of a coarse
powder.
As a species of bark has lately been much employed,
of a more deep red colour than the kind in ordinary
use, r think it right to mention the result of my own
experience of it. I cannot pretend to form any
judgment of the effects of this remedy in the cure of
intermittents, as, in Edinburgh and its environs, agues 
are very rarely met with. But, so far as I have yet
seen, its influence, in cases of gangrene, and in cor-
recting the thin fetid discharge of putrid ulcers, is far
inferior to that of the best ordinary bark of a brown
or cinnamon colour. One very remarkable instance
of this it may not be improper to mention: A gentle-
man, for several years, had laboured under a sinuous
ulcer, the discharge of which, once in two or three
months, always became thin, putrid, and very acrid.
The influence of common bark, in correcting this, was
so remarkable, that a few doses of it commonly had a
considerable effect in rendering the matter thick and
much less offensive. From the taste, and other sensi-
ble qualities of the red bark, being stronger than those
of the ordinary kind, I was at first inclined to think
favourably of it; and among others I prescribed it to
this patient. But although he continued for several
days to take it in the same doses he had always used of
the other, he did not experience any advantage from
it; while, on the other hand, on the common bark.
being again employed, the matter from being thin and
fetid, was quickly converted into pus of a proper con-
sistence.
One trial, however, is by no means sufficient for en-
abling us to form a just opinion of any medicine:
And 


Sect. IV. Of Mortification. 73
And accordingly I was resolved to put it to the same
test in future occurrences of a similar nature. It has
now been three times tried in the same manner, and
the result has been always the same. The red bark
has never produced any change on the nature of the
discharge, while the influence of the other has been
uniformly the same. Indeed, our patient is now so
much convinced of the inefficacy of the former, that it
is with reluctance he is induced to take it; although,
at first, his expectations from it were raised very high,
not only from the opinion I had endeavoured to give
of it, but from the high panegyrics bestowed on it by
others.
This is the most remarkable case I have met with
for comparing the effects of the different kinds of
bark: but I have likewise seen the red bark fail in
other cases, where the common kind of it proved evi-
dently useful; so that, although I cannot with cer-
tainty say that the red bark will never prove useful in
cases of mortification, and in such ulcers as we have
described, yet from the result of all the experience I
have yet had of it, I am inclined to consider it as of a
very inferior nature to the other. Farther observa-
tion, however, is necessary to determine a matter of
such importance.
Together with bark, the vitriolic acid is frequently
employed with advantage; and the best form of using
it is, by acidulating all the patient's drink with elixir
of vitriol.
These are almost the only internal remedies to be
depended on in cases of gangrene. Many others, in-
deed, have been recommended; but all the advantages
to be obtained from any of them, may be procured
with more certainty from some or all of those we have
already enumerated. 
Indeed


74 Of Mortification. Part I.
In the way of external application, we find a variety
of remedies pointed out by authors, and particularly
those of the antiseptic kind; such as all the warm gums
and balsams, ardent spirits, and even alcohol: and to
admit of their nearer application to the sound parts
with a view to the preservation of these from putre-
faction, deep scarification through the diseased and
into the sound parts have been generally recom-
mended.
But although such articles may be of use in pre-
serving dead animal substances from corruption; yet
that they will always prove serviceable, in the same
manner, in living bodies, is probably very much to be
doubted. And it is even apprehended, by the strong
irritation they always occasion when applied to a liv-
ing fibre, that, in such cases as the present, they may
rather do mischief; it being only, as we already ob-
served, a very slight degree of inflammation that is re-
quired. The incisions too, when carried into the
sound parts, with a view to facilitate the operation of
such remedies, may likewise do harm; not only from
the risk of wounding the blood vessels, nerves, and
tendons, that lie in the way; but also, by allowing a
free and farther entrance of the putrescent fluids into
the parts not yet affected: And unless they are car-
ried so deep as freely to reach the sound parts, appli-
cations of the antiseptic kind can never have any effect
in answering the purpose for which they are intended,
For these reasons, and from never having observed
any advantages to accrue from scarification, I have
long thought that they might be entirely laid aside.*
Theriac
* Although I was convinced from experience of what is here advanc-
ed against the use of scarification, as well as of the impropriety and in-
efficacy of very warm stimulating applications in cases of mortification;
it 


Sect. IV. Of Mortification. 75
Theriac was, in former times, and still is with some
practitioners, a very common application in every case
of gangrene; but from any opportunities I have had
of seeing it used, I cannot say that it ever seemed to
produce any evident good effects.
All the advantages commonly derived from the great
variety of applications recommended for gangrene,
are obtained with more ease, and generally too with
more certainty, from the use of any gently stimulating
embrocation; which, by exciting a slight irritation
upon the surface, and especially when assisted by a
free use of the bark, as was already directed, at last
commonly produces, such a degree of inflammation as
is wished for. With this view, I have frequently
known a weak solution of fal ammoniac in vinegar and
water answer exceedingly well; a drachm of the salt
to two ounces of vinegar and six of water, form a mix-
ture of a very proper strength for every purpose of
this kind; but the degree of stimulus can be easily
either increased or diminished according to circum- 
stances, by using a larger or smaller proportion of the
salt.
Although, for the reasons we have already advanc-
ed, incisions may not, in general, be proper; yet,
whenever the mortification runs very deep, it is of ser-
vice to make scarification into the diseased parts, so as
to remove a portion of them, which, by taking off a
considerable
it was not without diffidence that I first ventured to assert it, the opinion
at that time being, in this place at least, in a great measure new. I am
now happy to find, however, in a late publication, the same practice rec-
ommended from the best authority. Vide Chirurgical Observations by
Percival Pott, F. R. S. &c.
In the same publication is given a particular description of a species of
mortification incident to the toes and feet, in which Peruvian bark has
little or no influence, and in which opium, given in large doses, fre-
quently repeated, proves a very effectual remedy. 


76 Of Mortification. Part I.
considerable load, perhaps, of putrid dead matter, not
only lessens the fetor, which in such cases is always
considerable; but often renders it more easy for the
sound parts to free themselves from the remainder:
When with this view, however, incisions are employ-
ed, care should always be taken that they be not carri-
ed the length of the sound parts. 
Whenever, either by the means we have recom-
mended. Or by the effects of a natural exertion of the
system, a slight inflammation begins to arise between
the diseased and sound parts, we may in general, with
tolerable certainty, expect, that, in due time, a thor-
ough separation will take place: and, when a full
suppuration has fairly commenced, there then can be
little doubt but that the mortified parts will be very
soon and easily removed.
A separation being completely effected, the remain-
ing sore, which is then to be considered merely as a
simple purulent ulcer, may be treated in the same man-
ner as such fores generally are, with very slight easy
dressings; at the same time that proper attention must
always be paid to support the strength of the system, by
the continuance of a nourishing diet, the bark, and
such quantities of wine as may seem to be necessary.
Although such ulcers, however, as remain after gan-
grenous affections that have not been very extensive,
may, in general, be healed in the manner now men-
tioned; yet, in mortificatiohns seated on the extremi-
ties, and which have penetrated to the bones, it some-
times happens that the whole surrounding soft parts
come to be destroyed, so that amputation of the mem-
ber is thereby rendered necessary. But we should
never have recourse to amputation till a full and
thorough separation of the mortified parts has taken
place; 


Sect. IV. Of Mortification. 77
place: so that it ought, in every case of gangrene, to
be held as an established maxim, never to amputate a
member till a full stop has been put to the disease, or
even till a complete separation of the mortification
from the sound parts has been produced. For al-
though the parts immediately contiguous to those ev-
idently diseased, may outwardly appear to be sound,
yet there can never be any certainty of those, even di-
rectly below, remaining so till a separation occurs; so
till this has evidently taken place, we can never have
any security for the disorder not returning, and per-
haps immediately too, upon the remaining stump.
It must be observed, however, that as soon as an en-
tire separation of the gangrene has occurred, no time
should be unnecessarily lost in putting the operation
in practice; for, as long as any of the corrupted parts
remain in contact with the sound, the system must still
be suffering considerably, by the constant absorption
of putrescent particles, that so long will undoubtedly
take place. 




CHIRURGICAL
ESSAYS.
PART II.
On the THEORY and TREATMENT of ULCERS.
SECTION I.
Observations on Ulcers in general.
BY different authors very different definitions have
been given of the term Ulcer: But what in gen-
eral seems to be understood by it is, a solution of con-
tinuity in any of the softer parts of the body, dis-
charging either pus, sanies, or any other vitiated mat-
ter; and this, whether the complaint may have orig-
inally proceeded from an internal or an external cause.
Many writers, indeed, have confined the term to
such sores as are the consequence of some internal dis-
order of the system. But in this they have certainly
erred: for even the most simple wound, not in the
least connected with any other disease, if it does not
heal by what is called the first intention, without the
formation of matter, must, in its progress towards a
cure, always end in an ulcer.
Although, 


80 Observations on Part II.
Although, in compliance with custom, we have, in
the definition, confined the seat of ulcers to the soft
parts only, yet that ulcers of the bones do likewise oc-
cur, is certain. Thus every species of caries attended
with loss of substance, may, with propriety, be termed
an ulcer; and it is so in reality, both in its appear-
ances and effects.
But, in order to prevent such confusion as common-
ly occurs from the introduction of more destinctions
than are absolutely necessary, I mean to consider ca-
ries as an accidental symptom of ulcers, and to speak of
it under the general denomination of Carious Ulcer.
Ulcers have been commonly distinguished by differ-
ent appellations, according to some particular circum-
stance attending them; and different methods of cure
have accordingly been pointed out for each. And if
these had been taken from characteristics sufficiently
distinct, and of any real consequence either in the the-
ory or treatment of the different disorders, they would
certainly have been material, and ought to be retain-
ed. But as it is evident, that many of them have been
formed from circumstances either not very obvious, or
from such as are merely accidental, and that do not,
therefore, afford any real distinction, to adhere to
these could never be productive of any advantage; and
might even, it is presumed, frequently do mischief, by
leading to a more complicated practice, when a much
more simple treatment would probably answer the
purpose.
The different circumstances from which ulcers have
received their denominations, are, 
1. From the general appearances of the solids in
the parts diseased: as the Callous, Fungous, Fistu-
lous, &c.
2. From 


Sect. I. Ulcers in general. 81
2. From the nature of the matter discharged: as
the Ichorous, Sordid, and Purulent; from their dis-
charging a thin ichor, a more viscid glutinous kind of
matter, termed sordes, and purulent matter.
3. From their duration; as the Recent, and Ha-
bitual.
4. From the attendant symptoms being mild or vi-
olent, they are denominated Benign or Malignant.
And,
5. They have been termed Venereal, Scorbutic, or
Scrophulous, according as they have been supposed
to be connected with the Lues Venerea, the Scurvy,
or Scrophula.
Though it may be proper for practitioners to be
acquainted with these and other terms that have been
used, in order more accurately to understand the
meaning of authors, and to explain to one another the
appearances of diseases; yet it is exceedingly obvious,
that many of the distinctions we meet with in books,
have been taken from circumstances quite too trivial
to have any real influence on the disorders, and which
consequently can have no other effect than to embar-
rass and perplex all such as enter upon the study of
this branch of practice.
§ 1. Of the Arrangement of Ulcers.
The following arrangement of ulcers, at the same
time that it appears to be exceedingly simple and nat-
ural, comprehends every species of the complaint that
can occur; and if duly attended to, will, we hope,
render the method of treating them more effectual,
and at the same time more certain than in general it is
found to be.
F Ulcers, 


82 Observations on Part II.
Ulcers, then, may be divided into two general class-
es. In the first we mean to comprehend all such as
are merely local, and that do not depend upon any
disorder of the system.
In the second class all such ulcers are included as
are the consequence of, or that are connected with,
any disorder of the constitution.
The importance of such a classification appears evi-
dent from the very great difference in the treatment,
which undoubtedly should take place, between ulcers
that are only topical affections, and such as are con-
nected with any disorder of the system. It is fre-
quently, indeed, from want of due attention to a distinc-
tion of this nature, that the treatment of ulcers is ren-
dered so tedious and uncertain as it very often is.
For, by forming a diagnosis too hastily, and by treating
an ulcer that is merely a topical affection, with reme-
dies directed to some disorder of the general system,
many are forced to undergo very unnecessary courses
of medicine, and may thereby have their constitutions
irreparably hurt.
A contrary error, again, not unfrequently happens,
which is sometimes attended with very disagreeable
consequences, namely, the treating, as simple local af-
fections, those ulcers which are certainly owing to
some general disorder of the habit; and which it is,
therefore, in vain to expect to cure by topical reme-
dies only, unless the disease of the constitution be at
the same time attended to. Sometimes, too, an ulcer
is treated as a disorder of the constitution; but, by
mistaking the nature of the complaint, which of course
must occasion a misapplication of remedies, the cure
of the fore is thereby not only greatly retarded, but
the


Sect. I. Ulcers in general. 83
the system in other respects is often brought to suffer
very materially.
Thus, an ulcer connected with a scorbutic habit of
body, is not unfrequently mistaken for, and treated as,
a leprous, or perhaps a venereal affection; a circum-
stance which must undoubtedly lead to a kind of prac-
tice that will frequently be attended with disagreeable
consequences.
The only cause that can occur, to occasion such
mistakes in practice, is the want of a proper set of di-
agnostic symptoms for the several species of ulcers.
This, in the ensuing sections, we have in some meas-
ure endeavoured to remedy, by enumerating, as clear-
ly and concisely as possible, the different characteristic
symptoms of each: the several varieties we have men-
tioned contain every distinction of importance; but
as they are not near so numerous as those commonly
enumerated by authors, the means of distinction we
have proposed will probably characterise them with
more precision than ulcers in general have hitherto
been.
But before going on to the particular consideration
of the different species of the disorder, it will not be
improper, in the first place, to make a few observations
upon ulcers in general; and first with respect to their
causes.
§ 2. Of the Causes of Ulcers in general.
The causes which, in different circumstances, may
give occasion to ulcers, are exceedingly various; but
in general they are found, on examination, to arise
from one or other of the following nature.
1. From such as may be termed Occasional or Ex-
citing Causes: Of which kinds are wounds in
F 2 general— 


84 Observations on Part II.
general—bruises ending in suppuration—burns—-and
inflammation, from whatever cause it may have arisen,
when it terminates either in gangrene or suppuration.
2. From such as with propriety may be termed
Predisposing Causes; of which kind are considered,
all disorders of the system in general, attended with
determinations to, or affections of, particular parts:
such as fevers of all kinds that terminate in what are
called Critical Abscesses—also lues venerea—scrophu-
la—and scurvy.
3. Ulcers may proceed from a combination of the
two foregoing causes. Thus a slight scratch, or exco-
riation, that in a sound constitution would heal with-
out any trouble, in a habit tainted with any of the a-
bove mentioned disorders, will frequently produce a
very disagreeable and tedious ulcer. 
§ 3. Of the Prognosis of Ulcers in general.
The causes of ulcers being so very various both in
their nature and effects, the prognosis to be given in
all such complaints must, it is evident, be no less so.
1. It must depend upon the nature of the differ-
ent exciting causes that may have given rise to the
disorder.
2. Upon the situation of the sores; and,
3. On the time of life and habit of body of the
patient at the time.                                
With respect to the first of these, it is evident, that 
the occasional cause must have a very considerable in-
fluence on the nature of the complaint. Thus an ul-
cer proceeding from a simple wound, inflicted with a
clean cutting instrument, will, cæteris paribus, always
heal more easily, than one that has been the conse-
quence, 


Sect. I. Ulcers in general. 85 
quence, either of a severe bruise, or of a wound from
a foul ragged instrument.
It is likewise found, that punctured wounds are
much more difficult of cure, than such as have large
free openings; and this again may be owing to two
different reasons.
1. To the want of a free exit to the matter; which,
in punctured wounds, is very apt to insinuate itself
between the common teguments and muscles, and even
between the interstices of the different muscles them-
selves: a circumstance that frequently lays the foun-
dation of very troublesome sinuses.
2. Pain and inflammation are always much more
troublesome in wounds occasioned by punctures, than
in those where the parts have been freely and exten-
sively divided. For it is found by experience, that
the irritation occasioned by the partial division, either
of a nerve or of a tendon, proves always much more
considerable than when the parts have been thorough-
ly cut in two: And hence has arisen the practice of
enlarging all such wounds; which often carries off the
pain and inflammatory symptoms more effectually,
than all the applications and remedies that in such
cases are generally recommended.
Secondly, The cure of ulcers, it was observed, is
considerably influenced by their situation; and this,
we may remark, is the case in two different respects.
1. With respect to the nature and organization of
the parts on which they are seated; and,
2. As to their situation on the trunk of the body,
or on the upper or lower extremities.
Thus it was long ago remarked, and it has since been
confirmed by experience, that ulcers in the soft fleshy
parts heal much more easily, than when the tendons,
F 3 aponeuroses 


86 Observations on Part II.
aponeuroses of muscles, glands, periosteum, or bones,
are affected.
The pain occasioned by sores in the soft muscular
parts is not so considerable, the charged is generally
better conditioned, and the cure commonly advances
more quickly, than when any of the other parts are
the seats of the disorder: And, on the other hand,
whether ulcers are seated in the cellular membrane, in
the tendons, periosteum, or bones, their cure is always
observed to go on much more easily when seated in
the trunk of the body, than on any of the extremities;
and of these, again, the legs and feet are found by ev-
ery practitioner to be the most troublesome situation
for sores of every kind.
The depending situation of the latter seems to be
the principal cause of such a difference: for the fluids
having, in them, to proceed in a direction quite con-
trary to their own gravity; and this too at such a con-
siderable distance from the heart, where the influence
of that organ cannot be material; whenever any of the
parts happen to lose their tone, or by any accident suf-
fer in their arrangement, swellings,, especially those of
the serous kinds, very naturally occur. And, when
such swelling do arise in the neighbourhood of ulcers,
by occasioning too great an afflux of matter to the
sores, the discharge at last becomes vitiated in its qual-
ity likewise; and thus the cure is protracted, till the
parts, by rest and proper management, have again re-
covered their natural tone.
It is from this circumstance chiefly, that a material
part of the cure in ulcers of the legs is found to be ob-
tained from rest, and in keeping the limb in an hori-
zontal posture. One great advantage too of the laced
stocking, in such cases, consists in its tendency to pre-
vent 


Sect. I. Ulcers in general. 87
vent these kinds of swellings: This will hereafter, how-
ever, be more particularly taken notice of.
The situation of ulcers, with respect to the neigh-
bourhood of large blood vessels and nerves, from the
danger of these at last becoming affected, must, like-
wise, have a considerable influence on the prognosis;
as ought also their being seated upon, or very near to,
any of the large joints; or there being any risk, from
their situation, of the matter penetrating into either of
the cavities of the chest or abdomen.
It was, in the third place, observed, that the prog-
nosis, in every case of ulcer, should be much influenc-
ed by the age and habit of the patient.
Thus, in young healthy people, all the secretions
are commonly better proportioned, both in quantity
and quality, than in the old and unhealthy, in whom
the secreting organs are seldom capable of performing
rightly their different functions: And, as the different
discharges from ulcers are to be considered almost en-
tirely as secretions from the general mass of fluids,
their being of a good or of a bad quality, must of
course depend so much on a healthy state of the solids,
that it cannot appear surprising, their being so much
influenced by the general health of the patient.
The cure of ulcers depending, therefore, upon such
a number of circumstances, a just prognosis, it is evi-
dent, can only be obtained from a due attention to all
their varieties.
§ 4. The Cure of every Ulcer may, with certain Cautions,
be safely attempted.
With respect to the treatment of ulcers, the first cir-
cumstance to be determined, is the propriety of at- 
tempting a cure or not. That it is proper to endeav-
F 4 our


88 Observations on Part II.
our to heal every recent sore, is universally allowed;
but when ulcers have been of long continuance, or
when they appear to have had any effect either in car-
rying off or in preventing any disorder to which the
constitution may have formerly been liable, it has al-
ways been considered as dangerous to attempt their
cure: And, accordingly, almost every author who has
written upon the subject, has expressly determined
against it, as being a hazardous, and even a dangerous
practice.
Such ulcers as have afforded a copious discharge,
and have been of very long standing, it would no doubt
be exceedingly imprudent all at once to heal up, as
the system might very probably suffer from the sudden
retention of a considerable quantity of fluids, which it
had been accustomed for a long while to throw off by
means of such drains. Many cases, indeed, have
ended fatally upon such ulcers drying up suddenly,
either of their own accord, or by the imprudent use of
astringent applications.
On the other hand, however, the trouble arising
from a foul extensive sore, disagreeably situated, and
which is probably to continue for life, is an inconve-
nience which none but very old or inactive people can
be supposed willingly to submit to: and, therefore, the
discovery of such a course as can render it safe for pa-
tients to attempt the removal of such disorders, be-
comes at once a most important object.
With a small degree of caution, the cure of every
ulcer, we think, may be attempted; the only requi-
site precaution, before entering upon the means neces-
sary for this purpose in habitual sores, being the intro-
duction of some other drain, by means of a pea issue
or of a cord: The former of these is managed with the
greatest 


Sect. I. Ulcers in general. 89
greatest ease; and, by increasing or diminishing the
size and number of peas made use of, the quantity of
matter may be increased or diminished at pleasure.
§ 5. Of the Effects of Issues in the Cure of Ulcers.
An issue of this kind being introduced, and having
come to discharge properly, and in quantity nearly
equal to what the ulcer afforded, the cure of the latter
may be then carried on with the greatest freedom;
and if the sore has not been of very long standing, the
size of the issue may be gradually lessened, till it is
brought to contain a single pea only, which will pro-
duce a constant discharge, with very little trouble.
But when, on the contrary, the ulcer has been of
very long continuance, and especially if it seems to
have been instrumental in preventing any other for-
midable complaint; in this case, the issue should un-
doubtedly be continued of the same size for life: but
even this may be done with no great inconvenience, at
least in comparison with the trouble attending a large
ulcer.
This practice might, we think, from reasoning alone,
be considered at least as safe. For, if a drain equally
copious is first introduced, and is afterwards kept run-
ning, the healing of the ulcer for which it was substi-
tuted, however old it may have been, cannot, proba-
bly, in these circumstances, be productive of any harm
to the constitution. And I can say, from much ex-
perience in this branch of surgery, that nothing com-
monly proves more effectual in the cure of old ulcers
than issues; and I never knew an instance of their be-
ing, attended with any material inconvenience.
The objections that have been made to the practice
here recommended, are,
1. That 


90 Observations on Part II.
1. That an artificial issue, to be continued for life,
is almost as troublesome and disagreeable in its man-
agement as a natural ulcer. And,
2. That nature having been for a long time accus-
tomed to the discharge of a particular kind of morbid
matter afforded by the ulcer, we ought not therefore,
by innovations, to run any risk of diverting her stated
and usual operations.
The first of these arguments is very easily, and has
already, indeed, been partly answered; for it cannot
be readily admitted, that a simple issue, for which we
can choose the most convenient situation, will ever
prove so troublesome as a large ulcer, and which is
probably, too, very inconveniently situated. Of this,
indeed, we have evident demonstration, from daily ex-
perience; there being few complaints more perplex-
ing to patients than extensive ulcers; especially when
the discharge is so thin and acrid as to fret the neigh-
bouring parts, and which is not unfrequently the case.
§ 6. The Effects of Ulcers on the Constitution depend
more on the Quantity than on the Quality of the Mat-
ter discharged.
The other objection alledged against the practice of
healing old ulcers, is, as was already observed, the sup-
posed danger arising to the constitution, from the re-
tention of a particular kind of morbid matter, which
by their means it had been accustomed to throw off.
By the supporters of this objection it is said too,
that although the matter of an issue may be equal in
quantity to that afforded by an ulcer; yet that its being
of a different quality must render the discharge much
less salutary.
And 


Sect. I. Ulcers in general. 91
And it must be acknowledged, that we do almost
universally observe the greatest difference between the
matter of an issue, and that which is discharged from
an ulcer; from the latter it being frequently thin,
sharp, and acrid, whereas a mild bland pus is the most
common discharge from issues.
The foregoing argument, at first sight, appears ve-
ry conclusive; and it has probably, with many, been
the principal reason for rejecting the practice in ques-
tion. Upon due consideration, however, it will not,
it is presumed, be found to be of much importance;
and that it is more owing to the quantity discharged by
ulcers, than to the quality of the matter, that they
prove useful to the constitution or otherwise, will, with
very little reflection be rendered exceedingly evident.
Thus it is observed, that the stoppage of even a pea
issue, though it may never have discharged any thing
farther than the mildest and most simple pus, if it has
been of long continuance, proves equally dangerous
to the constitution as the stoppage of an ulcer that has
discharged nothing but matter of the most acrid kind:
a circumstance which could by no means be the case,
if the common opinion was well founded, namely, that
the bad effects of drying up old sores are to be attri-
buted solely to the retention of a noxious matter,
which had formerly been discharged by them.
And, that the quantity merely of matter discharged,
should, independently of every other circumstance,
have a considerable influence on the system, cannot
appear in the least surprising, when we reflect on the
very considerable proportion of fluids requisite for the
supply of an issue, of even a moderate size, with pus.
For, independent of the quantity that appears and is
discharged at the different dressings, a large exhalation 
and










92 Observations on Part II.
and absorption likewise of the more thin serous parts
is constantly and at all times going on; which circum-
stance alone accounts for the debilitating effects fre-
quently produced by issues, which in point of size ap-
pear very inconsiderable.*
Were we, indeed, certain that such acrid and putres-
cent matters, as are frequently discharged by ulcers,
previously existed in the mass of blood, and that such
sores served merely as drains for these; this would, no
doubt, prove a very weighty argument: but as it is
probable, and indeed, I may say, certain, that it is by
the ulcer only that such kinds of matter are formed,
and that none of them previously existed in the blood,
we are induced therefore to consider this argument as
of little or no importance.
Very little consideration, indeed, will make it ap-
pear, that no such varieties of matter, as are frequently
observed to flow from ulcers, ever existed in the blood.
No analysis of the blood has ever been able to discov-
er them: Nor can it be conceived, how fluids so acrid,
and so different from the blood of a healthy person,
can circulate in the delicate and irritable vessels of the
human frame, without producing dangerous or even
fatal effects. Now it is well known, that the discharge
from some kinds of ulcers, especially from those gener-
ally termed Phagedenic, is often so acrid, as not only
to excoriate the surrounding parts, but even sometimes
to render it dangerous for a surgeon to apply the nec-
essary dressings.
The
* Upon this subject Sir John Pringle remarks: " As near as I could
guess, an ounce of serum, upon standing some days, did not furnish more
of this matter, viz. Pus, than what might be produced by the daily run-
ning of a pea issue, or of a seton." Vid. Exper. xlv. Appendix to the
Diseases of the Army. 


Sect. I. Ulcers in general. 93
The discharge which occurs from the eyes, in some
instances of ophthalmia, has been known too to be so
acrid as to corrode the neighbouring parts; and the
serous evacuation produced by blisters, although com-
monly inoffensive, is sometimes possessed of a great
deal of acrimony.
In some cases of scurvy, indeed, a considerable de-
gree of putrescency, even of the blood itself, does, no
doubt, frequently take place: but it is not in such ul-
cers as occur in this disease, that such very acrid corro-
sive humours, as we are now describing, are ever ob-
served; the phagedenic ulcer of authors, being a very
different disorder from the true putrid ulcer, as des-
cribed by Lind and other writers on scurvy.
Besides, though it were really proved that these
kinds of matter actually did exist in the blood, even in
a completely formed state, how is it possible, that by
means of such ulcers, or any other drains, the morbid
fluids chiefly should be evacuated, and such only left
behind as are mild and innoxious? A circumstance
which, however improbable it may appear, has always
been asserted by the supporters of the opinion in ques-
tion.
The obvious insufficiency of this theory should in-
duce us to reject it, though we could not propose a
more satisfactory opinion in its place. But, as the va-
rious appearances and alterations which take place in
the discharge of ulcers, seem evidently to depend in a
great measure on some peculiarity of the solids or secre-
tory organs connected with them, we are therefore
more easily induced to conclude, that other supposi-
tions do not merit our attention.
The general seat of ulcers is in the cellular mem-
brane. Now it is well known, that naturally there is
secreted


94 Observations on Part II.
secreted into the cells of this membrane, as there is in-
to every cavity of the body, a thin transparent serum,
the principal intention of which is to keep these moist,
and to facilitate the actions of such muscles as are con-
nected with it. It is this chiefly, with a greater pro-
portion of the coagulable part of the blood, which,
with a due degree of heat, as was elsewhere remarked,
forms that matter which we call pus; and which we
suppose, and indeed find, to be the natural discharge
of ulcers in a sound healty state of the body; and it
is some change induced upon the nature of this fluid
which occasions the varieties in the discharges from
ulcers, and from the same ulcer at different times.
Such changes, though they may frequently be, in
some degree, influenced by different circumstances, as
will hereafter be observed, must yet, in a great meas-
ure, depend upon some particular affection of the ves-
sels that separate such fluids from the blood: for, by
means of an external topical application merely, we
can often change the appearance entirely of the mat-
ter of an ulcer; which in that manner we could never
do; if the change produced upon it depended on an
alteration effected on the general mass of blood.
According to the nature of the exciting and other
causes of ulcers, it is not unreasonable to suppose, that
very considerable differences will occur in their effects
upon the secreting organs to which they are applied.
Thus, it may readily be presumed, that a burn will
produce a very different effect from a cut, a bruise
from a puncture, &c. and that likewise, according to
the particular state of the patient's health at the time,
very considerable differences will in the same manner
take place.
In 


Sect. I. Ulcers in general. 95
In what manner these different causes operate in
producing such various effects upon the solids or se-
creting vessels of ulcers, is not, perhaps, to be so easily
explained, nor can we determine precisely what the
particular changes they induce upon such parts really
are. But, as all the causes of ulcers, with which we
are acquainted, are of an irritating or stimulating na-
ture, it is probable they all act by producing some in-
flammatory affection on the extremities of such vessels
as empty into the sores; and therefore, that the na-
ture of the discharge will in every respect depend
much upon the degree of inflammation thus raised;
We have endeavoured to show in the preceding part
of this work, that one certain effect of inflammation is
to propel a greater quantity of the red globules of the
blood into the smaller sets of vessels than naturally
they are intended to transmit. This, when it occurs
in vessels discharging their contents into ulcers, and
especially when the inflammation is considerable, will
render the matter very different, both in colour, smell,
and acrimony, from genuine pus, which we have al-
ready demonstrated to be produced from pure serum
only.
Upon this principle it is evident, that many of the
varieties of matter which we meet with in sores may
be accounted for: But other circumstances likewise
occur, which have some influence in producing many
of the alterations that are observed. The degree of
heat especially, in which the part is kept, as will after-
wards be more particularly remarked, and the remora
of the fluids for a longer or shorter time in the cavities
of fores, must have no small influence in many respects,
but especially on the degrees of consistency observed
in them. 
From 


96 Observations on Part II.
From one or other of these circumstances, or from
different modifications of all of them, the various ap-
pearances in matter afforded by wounds and ulcers,
are very clearly explained, without having recourse to
that inexplicable doctrine of their preexisting in the
system. But although the case were otherwise, and
that the several differences observed could not be so
easily accounted for; yet that they depend in a great
measure on some peculiar action or confirmation of the
vessels in the part affected, seems to be still more evi-
dent and probable than any other opinion hitherto ad-
vanced; and is just as certain as a great many circum-
stances under our daily observation, that we cannot in
any manner account for, and yet have no sort of doubt
as to their reality.
Thus, in what manner the nerves, which in their
structure are all so similar, act in the production of
hearing, vision, taste, and all the different senses, is,
perhaps, impossible ever to determine; as is also the
action of the liver, secretory organs of the mouth, ear,
&c. in producing fluids of such different natures from
the same mass of blood, and which did not previously
seem to exist in it: Only that the facts are so, nobody
pretends to doubt: And till the contrary is evidently
demonstrated, we have the same reason to believe,
that the different appearances of ulcers with respect to
the varieties of matter afforded by them, are at least
more frequently owing to some of the local causes we
have enumerated, than to any indisposition of the gen-
eral mass of blood.
I have said more frequently only, because there are,
no doubt, some particular cases of scurvy and of other
putrid diseases, as we have formerly remarked, in which
the blood is so much dissolved, as to run off by ulcers
and


Sect. I. Ulcers in general. 97
and other drains in the form of a bloody ichor: such
cases, however, occur very rarely, except in high de-
grees of the true scurvy, which are not often met with
in any country; and, although they were more fre-
quent than they really are, they could never account
for all the varieties of matter afforded by ulcers.
The principal objection, therefore, that has been
made to the healing of long continued ulcers, seems,
on being examined into, to be no better founded in
theory, than it is, as we have formerly remarked, on
real experience. For, although it has been strongly
inculcated by the generality of authors never to at-
tempt the cure of such sores, yet all of them have prob-
ably been either biassed by that favourite opinion of
morbid matter in the system; or, a few having led the
way and laid down principles, the rest have indiscrim-
inately copied from them, without having recourse to
experience.
Nay, we even imagine, and indeed it is pretty evi-
dent, that long continued ulcers, instead of proving
serviceable to the constitution, are not unfrequently
attended with a good deal of risk and danger. Thus,
it is very common for ulcers on the shin and other
parts immediately above the bones, to penetrate so
deep as to affect the periosteum, and sometimes even
the substance of the bones themselves; which always
produce very troublesome and often dangerous carios-
ities; every risk of which is avoided by having recourse
to an issue in a proper situation, at the same time that
every advantage is obtained from it as a drain.
The constitution must likewise, in another respect,
suffer much more from the long continuance of an
ulcer, than it ever can do from the substitution of an
issue: For it will surely be acknowledged, that a very
G considerable


98 Observations on Part II.
considerable part of the matter secreted by ulcers, must
be again taken into the system by the lymphatics; and
when it happens to be of a corrosive irritating nature,
which in old sores it frequently is, not only the gener-
al mass of fluids, but even the solids themselves, must
thereby in time become greatly vitiated.
Accordingly, there is nothing more common, than
very troublesome and even dangerous obstructions of
such external glands as are situated in the course of the
lymphatics leading from such ulcers; and as the
glands seated internally are undoubtedly, from the
same cause, liable to the same sort of affections, it
surely cannot be denied, but that, from this circum-
stance alone, considerable danger may attend a long
continued ulcer.
Thus it appears, that from every consideration, both
with respect to convenience and safety, the cure of ev-
ery ulcer ought to be attempted; and, with the pre-
vious caution of inserting an adequate drain, it may
always be done without any kind of risk.
This much it was thought necessary to say in gen-
eral, with respect to the propriety of attempting the
cure of ulcers; and I have insisted the longer upon
this, part of the subject, as the opinion generally re-
ceived of it appears to be very ill founded, and not a-
dopted from experience, but from hypothetical reas-
oning alone.
When the healing of an ulcer, then, is to be at-
tempted, the method to be pursued for its accomplish-
ment must next be attended to. By almost every au-
thor who has given directions on this subject, four
different states, as they are termed, are enumerated, as
being necessary for an ulcer to go through in its prog-
ress towards a cure, namely, those of digestion, deter-
sion, 


Sect I. Ulcers in general. 99
sion, incarnation, and cicatrisation; and various rem-
edies have been recommended as proper for the differ-
ent states, and for these only: And, upon this part of
the subject, it may be observed, authors have spoken
with as much certainty and precision, as if every cir-
cumstance in the treatment of ulcers could be regulat-
ed at discretion.
Thus all the different kinds of turpentines, as like-
wise the unguentum Ægyptiacum, powders and tinc-
tures of myrrh, euphorbium, aloes, &c. are pointed
out as digestives: as detergents, unguentum basilicon,
linimentum Arcæi, mercurius precipitatus ruber, &c.
with a view to promote incarnation, or the growth of
new granulations, powders of mastich, thus, &c. and
as cicatrisers to accomplish the cure, we find rec-
ommended a variety both of simple and compound
applications, particularly all the astringent boles,
earths, lime water, &c.
Such a number of divisions, however, in the several
states or stages of ulcers, with the consequent indica-
tions of cure, and remedies recommended for the ac-
complishment of these, has had a considerable tenden-
cy to render the treatment of such disorders more com-
plicated than we find from more late observation to be
in any degree necessary. The indications pointed out
in the following sections, we hope, will appear to be
just and simple ; and the effects of the methods of cure
we have recommendeded, will probably be found
much more considerable than those which commonly
result from a more complex treatment.
We now proceed to a particular consideration of
the different classes and species of ulcers; and in
pointing out the several distinctions, it will be observ-
ed, as we formerly hinted, that they are obvious cir-
G 2 cumstances


100 Observations on the Part II.
cumstances only, and such as at the same time indicate
and require some peculiarity in the method of treat-
ment, that are allowed to have any influence in char-
acterising a species.
Thus, those of the first class, will all of them, in their
appearances, be found very different from one ano-
ther; and all of them will likewise require something
peculiar in the method of cure: And again, those of
the second class, it is presumed, are equally well distin-
guished, and by similar circumstances, not only from
one another, but from every one that with propriety
could be considered as belonging to the preceding class.
In the first division of ulcers we comprehend, as
was formerly remarked, all such as are merely local;
and that are not connected with any disorder of the
constitution; and, in this view, we mean to consider
the following different species, viz.
1. The simple purulent ulcer.
2. The simple vitiated ulcer.
3. The fungous ulcer.
4. The sinuous ulcer.
5. The callous ulcer.
6. The carious ulcer.
7. The cancerous; and,
8. The cutaneous ulcer.
In the second class of ulcers all such sores are meant
to be included as are the consequence of, or that are
connected with, any disorder of the system. The
different species of which are, the venereal—the scor-
butic—and scrophulous ulcers.
It is proposed, as being first in order, to go through
the consideration of the several species of sores con-
tained in the first class; and to proceed afterwards, in
course, to those enumerated in the second division.
SECTION 

Sect. II. Simple Purulent Ulcer. 101
SECTION II.
Observations on the SIMPLE PURULENT ULCER.
§ 1. Of the Symptoms, Causes, and Prognosis, of the
Simple Purulent Ulcer.
BY the simple purulent ulcer, is meant, that species
of sore, which is entirely a local affection, and is
attended with a very inconsiderable degree of pain and
inflammation, whilst the discharge afforded by it is
always of a mild purulent nature, and of a proper con-
sistence.
This species of ulcer is fixed upon as the first to be
treated of, from its being the most simple that can oc-
cur, both in its symptoms and method of cure. And,
as it is to the state of such an ulcer that every other
species of the disorder must be reduced before a per-
manent cure can be obtained, we shall be more par-
ticular in our observations with respect to it than oth-
erwise might be necessary: When we come too to treat
of the different varieties of ulcers, if the treatment of
these shall at any time coincide with that which we are
now considering, proper references, in order to pre-
vent repetitions, will always be made to what may be
here advanced.
Together with the circumstances already mention-
ed in the definition of this species of ulcer, it is not
improper here to remark, that the granulations which
arise in it are of a firm, fresh, red, healthy appearance;
and, if no unforeseen accident occurs, the cure, in gen-
G 3 eral,


102 Observations on the Part II.
eral, goes on regularly, and without interruption, till a
cicatrix is produced.
In considering the origin of the disorder, it may
be observed, that even this, the most simple species of
ulcer, may be produced by a great variety of causes;
but, from the definition we have given of it, it will be
understood, that they must all be such as act merely
by producing a local affection, without in the least
disordering the system.
In this view we are to consider wounds of all kinds
that do not immediately unite without the formation
of matter; and this whether they may have been at-
tended with loss of substance or not. Under this head
we may rank all chirurgical operations attended with
incision into any part of the body
Among other causes of such ulcers, must be men-
tioned, burns, in whatever manner they may be pro-
duced, whether by fire, aquasortis, scalding liquids,   
&c. also bruises; and in short, every external accident
that terminates in suppuration, with an opening as a     
consequence of it.
We do not, however, by any means intend to assert,
that a simple purulent ulcer is always a necessary and
an immediate consequence of the different circum- 
stances we have enumerated; for the very reverse of
this is frequently found to take place. Thus burns,
especially, are sometimes known to produce very trou-
blesome vitiated ulcers; and bruises, as well as all the
other causes we have mentioned, are not unfrequently
attended with the same effect. It is only contended,
that some one or other of them may in general be con-
sidered as the primary or original cause of such ul-
cers, independent of any appearances they may exhibit
before they are brought into the simple purulent state.  
With 

Sect. II. Simple Purulent Ulcer. 103        
With respect to the prognosis in this species of ul-
cer, it should almost in every instance be exceedingly
favourable; more or less so, according as there is a
less or a greater loss of substance, and according to the
situation of the sore and habit of body of the patient.
These circumstances being attended to, together with
what has already been mentioned upon ulcers in gen-
eral, there will never remain any doubt with respect to
the prognostic.
Before we proceed to a particular investigation of
the means to be employed in the cure of a simple ul-
cer, it will not be improper to offer a few general ob-
servations upon the manner in which nature seems to
operate in accomplishing the cure of sores, as also on
the effects of such assistance as may be afforded by art
for effecting the same purpose.
§ 2. Remarks on the Growth of new Parts in Sores.
There is evidently in every ulcer, in its progress to-
wards a cure, a growth of parts that tends considerably
to diminish any vacancy the complaint or accident
may have occasioned. This substance, from the gra-
nulated form it assumes, has been generally termed
Granulations; and it appears, in every wound, in
larger or smaller proportions, according as the patient
is young or old, healthy or otherwise; in so much that,
in young plethoric people, the increase of parts is of-
ten so considerable, as to rise above the level of the
neighbouring teguments, and to require the use of dif-
ferent caustic applications with a view to repress it.
When any loss of substance that may have been
produced, is thus, as far as possible, supplied, the re-
maining part of the cure consists in the formation of a
cicatrix. This is effected, either when nature alone
G 4 produces


104 Observations on the Part II.
produces an exsiccation, as it were, of the surface of
such granulations as had been previously raised, and
in that manner forms a kind of cuticle or scarf skin;
or, it is obtained by art from the use of drying astrin-
gent applications.
By the formation of new parts, or granulations, it is
not here, or wherever the term may be made use of,
meant to insinuate, that we suppose real muscular or
other organised parts are ever regenerated in those
wounds or ulcers wherein they have been destroyed;
but merely to express that production, which, if the
constitution be sound, always takes place to a certain
degree in ulcers, attended with loss of substance.
The real nature of this production is not, perhaps,
easily to be determined: but, from its several appear-
ances, it is obviously very vascular; from which it is
probable, that it consists in an elongation or extension
of the small blood vessels that have been divided, with
a considerable proportion of inorganic cellular sub-
stance; which, again, is most probably formed by a
matter secreted from the mouths of such vessels, and
which serves chiefly as their support or means of con-
nection.
We are not to imagine, however, that any very ex-
tensive loss of substance is ever to be entirely filled up
in this manner: for although, in particular circum-
stances, nature does effect the repair of very consider-
able accidental losses; yet, in general, her operations
of this kind are very limited. In youth, indeed, be-
fore the different parts have arrived at their full
growth, and while the several vessels are yet daily ex-
tending themselves, considerable losses are, often, al-
most completely repaired: but we ought not, even at
this period of life, to attribute, as practitioners com- 
monly

Sect. II. Simple Purulent Ulcer. 105         
monly do, such cures entirely to the growth of new
parts; for on reflection it appears very evident, that a
circumstance of a quite opposite nature always con-
tributes in a considerable degree to their accomplish-
ment.
§ 3. The Decay of the contiguous Sound Parts, is a nec-
essary Circumstance in the Cure of Ulcers.
Thus, though in the healing of every ulcer, whether
it be attended with loss of substance or not, a growth
of new parts, as we have already remarked, generally
takes place to a certain degree; yet the greatest part
of the vacancies, which in these cases always occur, is
evidently more diminished by the decay or decrease of
the divided parts that remain, than by any other cause.
Indeed, the effect with respect to a cure is ultimately
the same as if all such deficiencies were actually sup-
plied with a new substance: for, if the cavity of an
ulcer be diminished, or even entirely annihilated, by
the subsiding or wasting away of the parts with which
it is surrounded, there is then no kind of necessity for
the formation of others: and, in effect, cures are often
obtained, especially in old people, without any evident
growth of parts whatever, and this too in very consid-
erable and extensive ulcers.
This part of nature's process in the cure of ulcers,
is to a certain degree obvious even in the smallest sores:
but the larger the ulcer, the more evident always it
appears; and particularly it becomes exceedingly re-
markable in the cure of that very extensive ulcer,
which commonly remains after the amputation of any
of the extremities, especially of the thigh.
In these instances, indeed, there is never any con-
siderable formation of new parts observed to take place;
and 

106 Observations on the Part II.      
and the cure always advances, just in proportion as the
skin is allowed to contract by the wasting away or de-
crease of the parts which it surrounds: and such a
decay, or diminution of bulk, is not, in any of these
cases, confined to one set of parts only; but extends
equally to all, the bones perhaps only excepted.
Thus, after the cure of a stump, every vessel, even
the largest, is almost entirely obliterated for a consid-
erable extent: at least nothing is found to remain of
them but the thin membranes that composed their
coats, now shrunk into very small inconsiderable
cords; the fibres of the different muscles are, in the
same manner, greatly diminished; and the cellular
substance seems frequently to be almost entirely anni-
hilated. I have happened to meet with several op-
portunities of dissecting the stumps of patients after
death, and the appearances were uniformly as is here
related.
There is yet another case of ulcer, in which the cure
seems with still greater probability to be chiefly effect-
ed by the influence of the same cause. In a large in-
cised wound, with little or no loss of substance, its
edges, in the course of twenty four hours, become
greatly swelled and tumefied; they are thereby kept
at a considerable distance from each other, and the
whole exhibits the appearance of a large foul ulcer.
In this situation it would remain for a considerable
length of time, if it should either be neglected, or treat-
ed with acrid irritating applications: As soon, how-
ever, as by warm emollient poultices, and other proper
dressings, a free discharge of pus is obtained, the in-
flammation diminishes—the swelling of the sides of
the ulcer subsides—and the sore gradually contracts
to such a degree, that its edges, which before were
much 

Sect. II. Simple Purulent Ulcer. 107
much separated, are now brought near to one ano-
ther.
The same phenomenon is observable in a remarka-
ble degree, in the cure of every ulcer attended with
much inflammation; where a great part of the treat-
ment consists in removing the pain, irritation, and
swelling, which, in such cases, always takes place.
Every small bile is found to exhibit the same appear-
ances: On a bile being laid open, an ulcer is always
left, and the cure depends chiefly on the removal of
the inflammation and swelling of the surrounding
parts.
These, however, it may be said, are only instances
of preternatural swellings, perhaps originally excited
by the presence of some acrid irritating cause; upon
the removal of which, they may be expected to subside,
and the ulcers occasioned by them to contract and
heal. The same circumstance, however, has been shown
to take place even with respect to the substance of sound
parts; particularly, as we have already remarked, af-
ter the amputation of a member; the blood vessels,
nerves, and muscles, in all such cases, being constantly
found to suffer a very considerable decay.
The same thing is likewise known to happen in all
deep transverse wounds that penetrate through the dif-
ferent muscles, so as to reach the bone: for a cure, in
these cases, is seldom to be obtained by the first inten-
tion, especially when any loss of substance has been
produced. In the cure of ulcers which remain after
such wounds, an evident decay of the extremities of
the divided parts always takes place: and what shows
it in a remarkable manner is, that in all such cases, the
vacancies occasioned by the wounds are never so large
and conspicuous immediately after the cure, while the
patient 
 

108 Observations on the Part II.      
patient yet remains lean and emaciated, as they after-
wards become, when in the course of time, by the re-
covery of health and appetite, all the parts of the body,
and, among others, those which have been divided,
come in a great measure to regain their former bulk;
and when, accordingly, all vacancies that have been
occasioned by such wounds appear to be more consid-
erable.
When, indeed, a wound penetrates only into the cel-
lular membrane, or does not entirely divide the mus-
cles, the cavity produced by it, does, no doubt, in the
course of time, gradually diminish, so as sometimes to
disappear altogether. This, however, is in conse-
quence of the parts below extending in their diameters;
which, in the other case we have supposed, of a wound
with loss of substance penetrating to the bone, never
can happen.
This opinion, with respect to the cure of wounds
depending in a great measure upon the decay of the
surrounding parts, was first introduced by a very in-
genious French practitioner, Mr. Fabre: and, like ev-
ery new doctrine, it has by some been denied to have
any sort of influence; whilst, by others, much more
remarkable effects have been attributed to it, than, on
examination, it will be found entitled to.
Thus Mr. Fabre, and Mr. Louis, another surgeon
of eminence in Paris, assert, that wounds of every kind
which do not heal by the first intention, are cured en-
tirely by an affaisement, as they term it, or a wasting
away of the extremities of such parts as have been di-
vided; and they absolutely affirm, that there never
does occur any lasting production of new parts in the
healing of sores.*
Such
* Vid. Memoires de l'Academie de Chirurgie, tom. 4.


Sect. II. Simple Purulent Ulcer. 109
Such an assertion, however, is entirely contradicto-
ry to daily experience; and seems to be merely the
consequence of a lively imagination entering keenly
into the support of a favourite doctrine: for, although
it will readily be allowed, that a very considerable part
of the cure in every ulcer, especially in old people, is
effected by the cause we have assigned; yet few prac-
titioners will, probably, deny, that in many instances,
particularly in young people, very considerable pro-
ductions occur of that vascular substance we have for-
merly described; insomuch that it is sometimes a very
troublesome matter to suppress such excrescences, so
as to keep them within proper limits.
As a farther confirmation that a growth of new parts
does, to a certain degree, frequently occur, many very
remarkable instances might be mentioned from differ-
ent authors, of deep and extensive losses being almost
entirely repaired by nature. It would here, however,
be very foreign to our purpose, and especially as it does
not appear to be in the least necessary; for by every
candid practitioner it must be acknowledged, that such
occurrences are by no means uncommon.
Though the opinion, however, cannot be admitted
in such an extensive latitude as those who introduced
it might incline; yet, from the several arguments we
have advanced, it will appear to have at least a consid-
erable share in the cure of every ulcer; and from all
that has been said with respect to it, this inference, we
think, may be drawn, that although the generality of
ulcers are supplied with a species of new production,
yet to a certain extent the cure of all such disorders de-
pends very much upon the contraction of the sur-
rounding skin, in consequence of the parts lying be-
low it subsiding or diminishing in bulk.
This, 


110 Observations on the Part II.
This, when there has been any preternatural tume-
faction induced, as frequently happens in a particular
manner in scrophulous sores, is effected merely by the
discussion of such swellings; but in others that are at-
tended with a real loss of substance, the extremities
of even the found remaining parts, must, as we have
already remarked, undergo very considerable diminu-
tions.
§ 4. Of the Effects of Compression in the Cure of Ulcers.
From this view of the matter, a very material piece
of practice, which we find to have been long ago
known to practitioners, but which of late has, for no
evident reason, however, been almost entirely laid
aside, comes to be clearly accounted for: I mean, the
use of the laced stocking in ulcers of the legs; which,
by Wiseman and many other old writers, is much re-
commended, with a view to prevent those œdematous
swellings to which patients with such disorders are
commonly liable.
With this view, the laced stocking is no doubt to be
considered as the most effectual remedy; but it has,
in all such cases, I am persuaded, been much more
frequently of service, by serving to promote that dimi-
nution of the adjoining parts, which we have already
shown to be so necessary for the cure of every ulcer:
As in this respect it acts merely by the degree of com-
pression afforded, it must evidently prove equally serv-
iceable in whatever part of the body sores may be sit-
uated; and accordingly, I have constantly found, that
ulcers in the arm, and wherever a continued gentle
pressure could be applied, have received more benefit
from an application of this kind, than from all the oth-
er remedies usually employed.
As 


Sect. II. Simple Purulent Ulcer. 111
As it is the pressure therefore only, which in such
cases is wanted, it is most conveniently made, both in
the legs and elsewhere, by means of a pretty broad
roller applied spirally, if necessary from the extremity
of the member, to a little above the diseased part; but
when no œdematous swellings occur, it generally
proves sufficient to make the roller pass from about
three inches below the sore, to two or three inches
above it. In ulcers of the legs the roller should com-
mence at the toes, and should be carried to the knee joint,
or at least to two inches above the sores: and, even in
ulcers of the thighs, if any œdematous swelling occurs
in the leg, as is often the case, the bandage should com-
mence at the toes; but when the leg is altogether free
from swelling, this is seldom found to be necessary.
By means of a roller, compression can be made more
directly on any particular part, than with the laced
stocking; it is more conveniently applied too, and it
generally gives less uneasiness to the patient. It is
likewise more easily obtained: for the difficulty of fit-
ting a laced stocking, with that exactness which this
application requires, is so great, that very few trades-
men are capable of making it; whereas a roller may
at all times be easily procured.
Rollers, for this purpose, ought to be about two
inches and a half broad; and on experience it is found,
that they answer better when made of thin flannel of
the Spanish or Welsh kind, than of any other article.
This not only keeps the parts warmer than linen,
which, in ulcers of every kind, proves commonly serv-
iceable; but the softness and elasticity of the flannel
prevents it from fretting and galling the parts to which
it is applied; an inconvenience frequently experienc-
ed from linen bandages.
In 

112 Observations on the Part II.
In the application of such a bandage, it will readily
be understood, that it should always be done in such
a manner as particularly to support the skin, so as to
occasion as near a conjunction as possible of the edges
of the sore. For as it is well known, that there never
occurs any production of new skin, or even elongation
of the old, as much as can be easily saved should al-
ways be brought to cover such parts as by its retrac-
tion may have been denuded; for all such as remain
uncovered, have afterwards for their protection a thin
scarf skin only, which in strength, as well as in every
other circumstance, is greatly inferior to the cutis vera.
From a due attention to this point, much more as-
sistance is to be obtained in the cure of wounds and ul-
cers than is commonly imagined: for, in by far the
greatest number of situations, every wound not attend-
ed with much loss of substance may be brought to heal
by the reunion of the divided parts; which, in every
case that can occur, is by much the most eligible meth-
od of cure. When this can be properly accomplished
immediately upon a wound being inflicted, it should
always be done: but very often, when that precaution
has either at first been neglected, or when it has not
then been practicable from a too great retraction of
the parts, it may frequently be effected afterwards in a
later period of the disorder.
For, in large wounds, when in the space of about
fourteen days a full suppuration has come on, and the
inflammation which originally took place has in a
great measure subsided, the sides of such wounds, or
ulcers as they then are, may by proper compression be
either entirely united, or at least brought so far to ap-
proach one another, as greatly to diminish any vacancy
that at first took place; a circumstance which renders
the 


Sect. II. Simple Purulent Ulcer. 113        
the cure of such complaints much more short and ea-
sy than it is otherwise found to be.
In the application of compression, for the purpose
we have mentioned, it will be understood, from what
we have said already, that it is not to be employed in
any species of ulcer while any considerable degree of
inflammation remains; but as soon as that symptom
is pretty much removed, it may always be put in prac-
tice with the greatest safety.
The remedy of which we are now speaking, name-
ly, compression, proves so generally useful in the cure
of ulcers, that after the inflammatory stage of sores is
over, it ought in, perhaps, every instance to be em-
ployed: Cures may no doubt be effected by other
methods; but I will venture to say, that in the most
troublesome of all sores, habitual ulcers of the legs,
more lasting cures may in general be obtained by a
proper application, of pressure, than by any other
means with which practitioners are as yet acquainted.
The other most remarkable part of the process of
nature in the cure of ulcers, consists, as we have alrea-
dy observed, in the formation of a certain kind of new
substance; the production of which we in some meas-
ure attempted to explain, by supposing it to consist in
an extension of the divided vessels, with a considera-
ble increase of cellular substance. This, in a sound
healthy state, appears, in every sore, in the form of an
infinite number of very small tubercles, of a bright,
fresh red complexion, and in general of a tolerably
firm organisation.
As, in diseased states of the body, these tubercles or
granulations put on very different appearances, ac-
cording to the particular nature of the complaint with
which they happen to be connected, such peculiarities
H as


114 Observations on the Part II.
as are thereby occasioned in the several species of ul-
cer enumerated in the ensuing sections will be all par-
ticularly taken notice of; as will likewise the various
methods of assisting nature, not only in the correction
of the diseased states of such productions, but in pro-
moting a firm and healthy growth; for although this
is chiefly to be considered as the work of nature, yet
art in different circumstances is frequently able to af-
ford her very considerable assistance.
Though the means necessary for this purpose will
be afterwards particularly pointed out, it will not be
improper, in the first place, to make a few observations
with respect to their general tendency, so that the op-
eration of all of them may be then more readily un-
derstood.
§ 5. Of the Advantages to be obtained from Art, in the
Production of Granulations in Sores.
The principal advantage which in this respect ac-
crues from art in the cure of sores, is the removal of
such causes as tend to retard the natural exertions of
the system; and although the different obstructions
which nature meets with in her progress are exceed-
ingly various, yet they may all with propriety enough
be reduced to two general heads, namely, to such as
may be considered entirely as of an internal nature,
and to those again which operate merely as external or
local causes.
Of the former kind are, every general disorder to
which the constitution is liable; as it is by experience
found, that a found healthy state of the system only,
is capable of producing proper granulations.
Thus the cure of such ulcers as occur in lues vene-
rea, scrophula, and scurvy, can never be properly ef-
fectted 

Sect. II. Simple Purulent Ulcer. 115
fected unless the general affection of the habit be first
corrected.
A low emaciated state of the system too, proceeding
either from a very poor diet or from immoderate evac-
uations; is found to be very prejudicial to the growth
of new parts: for, as the supply of such accidental loss-
es as occur in sores, must render it necessary to supply
the system with a larger proportion of nutritious mat-
ter than is requisite when there are no losses or defic-
iencies to be repaired, if a patient in such a situation
be kept upon a low allowance in point of diet; and es-
pecially if at the same time the discharge from the ul-
cer is considerable, the repair of any deficiencies must,
in such circumstances, it is evident, go on much more
slowly than when the contrary of these occur. And
in fact we find, though a very plethoric habit of body,
with a full allowance of heating nourishing diet; is not
proper for the cure of any kind of sores; yet that an
emaciated state, and a low debilitating regimen, prove
equally prejudicial.
A middle course, therefore, should in all such cases
be observed, and the patient ought to be kept in a sit-
uation at least not much more reduced than that of his
ordinary or natural health. But this circumstance must
in a great measure be regulated by the particular exi-
gencies of every case: for, in some patients of a high-
ly inflammatory diathesis, every scratch almsot is apt
to inflame and become troublesome; so that, when ul-
cers of any magnitude occur in this state of the system,
it is often necessary to keep the patient on a very low
allowance.                   
Others, again, of a contrary habit of body, who have
been much reduced, and who have no particular ten-
dency to inflammatory complaints, very frequently
H 2 bear


116 Observations on the Part II.
bear, and receive much benefit from, more nourishing
foods than they were formerly accustomed to; so that
it must always depend on the judgment of the practi-
tioner, to point out such a regimen as may seem best
suited to the particular situation of every patient.
The local obstructions, again, which occur to the
formation of new parts in ulcers, are of various kinds:
but they may all be reduced to two general divisions;
namely, to such as act solely in a mechanical manner
by exciting irritation; and those that are evidently of
a corrosive nature.
From daily experience, it is found, that granula-
tions in sores, are, cæteris paribus, always most quick-
ly formed when the part is kept entirely free from
pain; and, when duly attended to, the reason of this
appears sufficiently obvious. For whatever proves
the cause of much uneasiness, must excite in the ex-
tremities of the divided vessels, as irritation does in ev-
ery sensitive part to which it is applied, a preternatu-
ral degree of action or stricture; which is a state en-
tirely opposite to what we have shown to be the most
favourable for the production of new part ; for as this
very probably depends, as we have elsewhere remark-
ed, on an elongation of the divided vessels, the more
easy and lax these are preserved, the more readily al-
ways will such an extension advance.
And we do accordingly find, that whatever tends to
keep up any considerable inflammation in sores, has a
certain effect in putting a total stop to the production
of granulations.
Hence the necessity of removing from wounds and
ulcers, every extraneous body, or whatever tends to
produce irritation; and from the same circumstance is
accounted for the great advantage of dressing seldom,
and

Sect. II. Simple Purulent Ulcer. 117
and of using mild simple applications, instead of fol-
lowing the practice which formerly prevailed, of dress-
ing much more frequently, and that too with very
complex irritating ointments and washes.
The other set of local causes that tend to obstruct
the formation of new granulations, and which were
said to be of a corrosive nature, are chiefly all those vi-
tiated discharges, which, by neglect or improper man-
agement, are so apt to occur in every ulcer. For, al-
most every kind of matter afforded by sores, that dif-
fers much in its nature, either in colour or consistence,
from mild and good pus, possesses constantly a greater
or less degree of acrimony or causticity; which in some
cases is so very remarkable, that not only the granula-
tions are corroded and prevented by it from rising, but
even the neighbouring sound parts are often greatly
injured.
In all such disorders, the principal intention to be
kept in view, is the correction of this acrid state of the
matter, whilst at the same time we attempt to convert
it into what is termed laudable pus; the several means
for effecting which will afterwards in the different sec-
tions be particularly enumerated.
These different obstacles to the formation of granu-
lations being at last removed, nature will always, as
far as possible, carry on their formation; and when, in
due time, such vacancies as occur in sores, are, either
by their means, or by the effect of compression, or by
both, as much as may be, supplied, the only remain-
ing part of the cure, as we formerly remarked, is the
formation of a cicatrix. This, too, is frequently, in a
great measure, effected by nature; but it can often be
considerably promoted by the use of proper applica- 
tions.
H 3 Whilst


118 Observations on the Part II.        
Whilst any deficiencies in sores remain to be filled
up, and whilst the parts are for this purpose still shoot-
ing and extending, the very mildest applications, it
was remarked, are the most proper; but, when the loss
of substance has either been repaired entirely, or to
such a degree as the strength and other circumstances
of the patient will permit, those applications, which in
the extending state of the vessels would have been pre-
judicial, now become proper and necessary.
Thus, all the mild styptic powders and washes, by
contracting or corrugating the extremities of such ves-
sels as have been divided, and by producing an exsic-
cation of that inorganic cellular substance in which
these are enveloped, tend to induce over the surface of
sores that delicate thin covering termed Cicatrix;
which, though it is at first always very tender, yet in
course of time it commonly acquires greater strength,
by a farther addition of thickness, from that same cel-
lular membrane which at first contributed to form it.
Having premised these general observations with
respect to the manner in which the cure of sores seems
to be effected, and which apply in a great measure to
every species of the disorder, we now proceed to the
more particular treatment of the simple purulent ulcer.
§ 6. Remarks on the Indications of Cure, and on the
Remedies necessary in the Treatment of the Simple
Purulent Ulcer.
In the cure of this species of ulcer, as there is very
little inflammation, and no preternatural swelling sup-
posed to take place, but merely a vacuity, either from
a real loss of substance, or from a retraction of parts
simply divided, the discharge at the same time being
of 


Sect. II. Simple Purulent Ulcer. 119
of a mild purulent nature; the only indications that
occur, are,
1st, To diminish, as much as possible, any vacancy
the ulcer may have occasioned; and,
2d, To promote the formation of a cicatrix.
For the more effectual accomplishment of the first
of these, the concurrence of two different circumstances
is requisite; namely, the formation, to a certain ex-
tent, of new ganulations; and the diminution or de-
cay of such parts as lie immediately contiguous to the
ulcer.
We have formerly shown, that either a considerable
degree of inflammation, or the prefence of any acrid
corrosive matter, are both exceedingly detrimental to
the production of new parts; so that this part of the
cure ought to consist entirely, or at least chiefly, in
such a treatment as tends most effectually to the pre-
vention of these causes.
With this view, the first circumstance to be attend-
ed to, is, to avoid the use of the several warm gums,
balsams, and spirituous tinaures, as we find recom-
mended in every case of ulcer, by all the older writers,
and as is still continued by many of the modern for-
eign practitioners.
For although, in some species of ulcers, different ar-
ticles of this kind may be used without much incon-
venience, and in certain circumstances may sometimes
even be of service; yet, in every case of simple ulcer,
they always do mischief, and in the treatment of such
sores should certainly be laid aside; as ought also ev-
ery application that can occasion much pain or irrita-
tion: for whatever has this effect, must always increase
the inflammation; and, consequently, for the reasons
we have formerly given, must necessarily retard the
H 4 cure
 
  

120 Observations on the Part II.
cure. Even the common basilicon and linimentum
Arcæi of the shops, are, for the same reasons, improp-
er; for every ointment with any large proportion of
rosin or turpentine, always irritates very considerably.
The only advantages which, in such cases, ought to
to be looked for from the use of any ointment, should
be, its allowing the different dressings to be renewed
with less pain than they otherwise could be; and
hence a composition of the blandest materials, is, for
such purposes, preferable to every other.
In this view, any ointment similar to the unguen-
tum cereum of the Edinburgh Dispensatory, answers
exceedingly well: It is prepared with pure white wax,
spermaceti, and fresh olive oil, without any other ad-
dition.
The quantities of each of the articles, as there pre-
scribed, are, four ounces of wax, three ounces of sper-
maceti, and a pound of oil; a composition which
forms an ointment of a very proper consistence, and
which ought to be kept in every shop, as the most
useful dressing for all the more simple kinds of ulcers.
In such sores as we are now treating of, an ointment
containing a proportion of any of the saturnine rem-
edies, is sometimes found to prove useful; and as
Goulard's cerate is a very neat preparation of this
kind, we think it right to communicate the prescrip-
tion he gives for it.
Take four ounces of refined wax and one pound of
oil; and keep them over a slow fire till the wax is
melted, taking care to stir them gently. Having pre-
viously mixed four ounces of the extractum saturni
with six pounds of water, add it by little and little to
the wax and oil, now cooled in a vessel of a proper
size. 


Sect. II. Simple Purulent Ulcer. 121
size.* Let them be well incorporated together with
a wooden spatula, always taking care to let the quan-
tity of water first put in be thoroughly absorbed before
any more is added: This cerate may be made stronger
or weaker, by adding more or less of the extract.
This, as well as every ointment, should always be pre-
pared in small quantities, as it is of much importance
in the treatment of sores to employ such dressings only
as are perfectly fresh and free from rancidity.
Pledgits of lint, spread thin with either of these oint-
ments, are in general applied without occasioning the
least pain; and the use of them in this manner, in-
deed, is never attended with any kind of inconveni-
ence: for, though all oily applications to sores have
been condemned by some, from an apprehension of
their turning rancid; yet I can say from experience,
that under proper management they never become so.
Nor is it easy to suppose that any such preparation, as
these we have mentioned, when composed of fresh
materials, can ever become putrid between the differ-
ent dressings of sores, which very rarely ought to be
more distant than twenty four hours from one ano-
ther.
The frequent dressing of sores is now very gener-
ally, and very properly, condemned; but, as prac-
titioners are apt to run into opposite extremes, we find
that by some it is recommended to renew applications
of this kind not oftener than once in five, six, or eight
days. It rarely, if ever, happens, however, that this
can be proper. It affords no advantage to the sore:
for we can assert from frequent evidence of both meth-
ods, that an ulcer, except in the latest stages of it when
the cicatrix is nearly forming, will in general cure
more
* For the preparation of the extractum saturni, see page 32. 


122 Observations on the Part II.
more easily by the dressings being changed daily, than
when not renewed so frequently; and it is attended
with this advantage, that the patient is kept clean, and
the air of the apartment in which he lies is preserved
in a more pure state than it ever is by a contrary man-
agement. We are therefore clearly of opinion, that
although the dressings of sores ought not to be very
frequently renewed, yet that the contrary extreme
would prove still more prejudicial: In hospitals es-
pecially, where it is so difficult to preserve the air pure
and untainted, this is a circumstance which merits the
greatest attention; more indeed than practitioners
commonly bestow upon it. The leading circumstance
which ought to direct us in the frequency of dressing
is, the quantity of matter afforded by sores: No ap-
plication should be removed till it can be done with
perfect ease; but whenever there is any considerable
quantity of matter in the cavity of an ulcer, the dress-
ings ought to be renewed daily.
One principal inconvenience supposed to arise from
the frequent dressings of sores, is the influence produc-
ed upon them by exposure to the air; but if new
dressings are so prepared as to be immediately applied
on the others being removed, every inconvenience from
this cause may be avoided. This we must remark,
however, is a point of such importance as to deserve
very serious attention; for a too free admission of air
to sores always interrupts the cure, not only by acting
as a powerful irritating cause, but by tending to viti-
ate the nature of the matter discharged by them.
Another objection too has been made by different
practitioners, to the use of unctuous applications in
the treatment of sores, namely, that they are apt to
render the parts lax and slabby, so as to prevent the
new 


Sect. II. Simple Purulent Ulcer. 123
new granulations from being so firm as they otherwise
would be.
This, I know, indeed, to be the consequence of a
long continued use of warm emollient applications,
especially of fomentations and poultices: but an oint-
ment of the kind we have recommended, very thinly
spread, never does produce that effect, and it always
proves a more agreeable application than dry charpee
alone; which, unless the sores to which it is applied
are covered with large quantities of matter, always oc-
casions a good deal of irritation, and in some degree
is attended with the same effects as gentle escharotic
applications; a circumstance that seems to have been
well known to many of the old writers on surgery,
who frequently recommend dry charpee for suppress-
ing the undue growth of parts, when, in the cure of
sores it happens to be too considerable.
I have long been an enemy to the indiscriminate
use of dry charpee or lint in sores. This will appear
from the contents of the preceding paragraph, which
was published six years ago, and I never had any rea-
fon to alter my opinion. The effect of custom, how-
ever, is so powerful, that it may be long before the use
of dry lint is so universally laid aside as it ought to be:
but, from much experience in matters of this kind, I
am clearly of opinion, that a general use of it as a
dressing tends much to retard the cure of ulcers; and
whoever will have the resolution of deviating from the
established practice, and will employ, any mild oint-
ment as a common application sores, will receive
much satisfaction from doing so. When speaking of
mild dressings, I would wish to have it understood,
that it is in the simple purulent state of an ulcer only,
in which much utility is to be expected from them. 
After

124 Observations on the Part II.
After all that has yet appeared to the contrary, not
only in the writings of many of the ancient authors,
but even in those of some modern practitioners, I am
perfectly convinced, that in this state of an ulcer a cure
will be more easily and more quickly obtained by mild
dressings than by any other means: but in the sloughy
foul state of some sores, applications of this kind, it
must be owned, have little or no effect; and in such
circumstances some of the warm irritating dressings,
to be afterwards pointed out, are the only means from
which relief is to be expected.
In all such ulcers, therefore, as we are now speaking
of, those pledgits, which, at the different dressings, are
applied immediately to the sores, should be spread
with some such ointment as those we have recom-
mended.
The next circumstance requiring attention in this
part of the cure, is to employ such means as may pre-
serve the matter discharged from sores in its proper
purulent state, both with respect to colour and consist-
ence; for, unless very particular attention be given to
this point, the best conditioned matter always degen-
erates sooner or later into a worse kind; and as mat-
ter of a real purulent nature is the mildest and least
acrid discharge that ulcers ever afford, every precau-
tion should be taken to preserve a continuance of it in
this state.
In the simple species of ulcer now under considera-
tion, the principal attention which for this purpose is
requisite, is the preservation of a due degree of heat in
the part affected. This, in whatever part of the body
the disorder is situated, is exceedingly necessary: but
it is more particularly so in the extremities than any
where else; for the natural heat of these parts is not
near

Sect. II. Simple Purulent Ulcer. 125
near so considerable as it is in the trunk and other sit-
uations where the action of the heart has more influ-
ence.
We have formerly shown in the treatise on inflamma-
tion, how necessary a proper degree of heat is for the
formation of pus in every case of abscess: and as it is
no less so in the treatment of ulcers, it should always
be very particularly attended to; for the want of a due
regard to this circumstance alone, very often occasions
the degeneracy of simple ulcers into those of much
more inveterate dispositions.
Whilst any degree of inflammation remains in ul-
cers, the easiest and best mode of applying heat is by
the use of warm emollient cataplasms; but, as soon as
the inflammatory symptoms are much abated, these
should be immediately laid aside: For, in consequence
of the very powerful relaxing properties of warm emol-
lients, a too frequent and long continued use of them,
as we have already observed, is apt to induce too much
laxity or want of tone in the parts to which they are
applied. And the same purpose may be then answer-
ed equally well, by applying over the dressings thick
quilted coverings of wool, cotton, or of any such sub-
stances as most effectually retain heat.
The good effects resulting from a proper attention
to this kind of management, I have on many occa-
sions experienced; and although it may not be of so
much importance in cases of simple ulcers merely, as
in those of a worse kind, yet even in the slightest that
occurs it should never be omitted.
In almost every species of ulcer, poultices are found
to be very useful applications in one part, or other of
the cure: and although in such as are attended with
much inflammation, they may no doubt prove ser-
viceable 

126 Observations on the Part II.
viceable by their emollient properties; yet the degree
of heat they afford, by its effects in promoting a good
suppuration, is, I am persuaded, independently of ev-
ery other circumstance, the greatest advantage they
ever produce.
But poultices, when used with this intention, unless
they are much more frequently renewed than they
generally are, rather do harm than good; for, in order
to obtain all the advantages that may be derived from
them, they should be renewed at least every three
hours. But this subject having been more fully treat-
ed of in the essay on inflammation, it is not now nec-
essary to enlarge farther upon it; for the same obser-
vations we had then occasion to make respecting the
effects of heat in promoting suppuration, apply with
equal force and propriety here.
These different circumstances, namely, the preven-
tion of irritation by very mild dressings, and the pres-
ervation of a proper degree of heat in the part affec-
ed, are the most certain means both of promoting the
growth of new parts, and for obtaining and keeping up
a discharge of good matter. They should both, there-
fore, be all along particularly attended to; either till
there does not seem any farther deficiency to fill up;
or till nature appears to have effected as much in the
production of a new growth of parts as the circum-
stances of the case will permit.
The other most material part of the first indication
in the cure of ulcers, is to be obtained, as we already
observed, by means of gentle compression: and this,
it may be remarked, is to be employed at the same
time, and to be used along with the several applica-
tions we have already mentioned; for as soon as the
inflammatory state of an ulcer is over, and a discharge
of 

Sect. II. Simple Purulent Ulcer. 127
of good matter is induced, slight compression by means
of a roller, as we formerly recommended, may be im-
mediately applied, and should be continued during all
the remainder of the cure. It should be applied too,
as was then directed, in such a way as not only to pro-
duce a gentle pressure upon the parts immediately
surrounding the ulcer, but likewise to serve as a sup-
port to the skin and other teguments, so as to prevent
their retraction, which otherwise, in large ulcers espec-
ially, is very ready to happen.
When, by a proper attention to the most material
circumstances in the treatment, and on the necessary
remedies being continued for a longer or shorter peri-
od according to the size of the sores and habit of the
patient, any loss of substance which occurred is at last
as far as possible supplied, the next indication of cure
comes then to be attended to; and that is, the form-
ation of a cicatrix.
We have formerly observed, that a cicatrix is fre-
quently effected by nature alone; but, in many cases,
when every deficiency appears to be even thoroughly
supplied, yet still a cure is difficult to accomplish: The
surface of the sores remains raw, and at the same time
discharges considerable quantities of matter. In such
cases, it becomes necessary to lay aside the ointment
recommended for the preceding part of the cure, and
to use one of a more styptic drying nature.
In this view, the unguentum album prepared with
ceruss, as is ordered in different dispensatories, an-
swers exceedingly well; better, indeed, I have often
thought, than the ceratum e lapide calaminare, so com-
monly employed as a dry application. Lime water,
too, often proves a very effectual application in this
situation of ulcers: By bathing the sores with it once
or 

128 Observations on the Part II.
or twice daily, and using the ceruss ointment or com-
mon cerate as a dressing, a cure will frequently be ef-
fected, when it cannot possibly be obtained by emol-
lients: Ardent spirits, too, will often answer the same
purpose, of putting a stop to the discharge afforded by
sores in this state, and of drying or corrugating the soft
cellular substance upon their surface into a firm cica-
trix.
On some occasions, again, a proper cicatrix is pre-
vented from forming, by the growth of new granula-
tions being so considerable as to rise above the surface
of the neighbouring sound parts. In such cases, it
becomes necessary to have recourse to different astrin-
gent or even escharotic applications, of which the most
effectual among the milder caustics is blue vitriol;
which, unless in very obstinate cases, almost always
proves sufficient; and when it happens to fail, noth-
ing weaker than the common caustic stone is ever
found to prove effectual.
In slight cases of this kind, indeed, a cure is often
effected by the use of dry charpee alone; a pretty
tight bandage being at the same time applied over all.
This, we must observe, however, is a situation of a
sore which frequently proves more perplexing and
troublesome than any other part of the cure: for it
often happens, even in the most healthy constitution,
and when the preceding part of the cure has gone very
properly on, that a cicatrix cannot be induced, and the
granulations newly formed continue raw, and do not
show any tendency to heal: In this situation, when
the means we have already advised do not prove ef-
fectual, compresses moistened in strong ardent spirits,
as we have mentioned above, particularly in French
brandy, being applied under the roller, will often ac-
complish 

Sect. II. Simple Purulent Ulcer. 129
complish a cure: or spirits used in this manner, may be
alternated with tincture of myrrh, or with a solution
of blue vitriol in water; a practice which in different
instances I have found to succeed, when the means
usually employed in such cases have all failed.
In the preceding observations we have enumerated
such local applications as have been found to be most
effectual in the cure of ulcers; but there are some cir-
cumstances, which, though of a more general nature,
are yet equally necessary to be attended to.
In every species of ulcer, even in those of the most
simple nature, rest of body, especially of the part af-
fected, is particularly requisite; insomuch, that, un-
lets this circumstance be attended to, all the applica-
tions that can be used, prove commonly of little im-
portance. In disorders of this kind, too, occurring in
the lower extremities, the affected limbs should be al-
ways kept, as much as possible, in a horizontal posi-
tion, as being the posture which proves most favoura-
ble for the circulation of the fluids.
Rest and an horizontal posture, have by almost all
practitioners, both ancient and modern, been looked
upon as absolutely necessary for the cure of ulcers in
the lower extremities. In some late publications,
however, it is asserted, that rest is so far from being
necessary in such cases, that a cure is just as easily and
certainly performed whilst patients are going abroad,
as whilst they are under the strictest confinement.
In some very slight ulcerations, this may sometimes
be the case; and with the assistance of a pretty tight
bandage or laced stocking, applied so as to support the
parts properly, even sores of a worse kind may be fre-
quently cured, and the patients at the same time be
allowed to take gentle exercise. But, in general, so
I far


130 Observations on the Part II.
far at least as my experience goes, the regulations up-
on this point, enjoining strict confinement in every
ulcer of the extremities, as handed down to us by all
the ancient writers, appears to be very well founded;
for, according as they are more strictly attended to or
not, the cure commonly advances quickly or other-
wise.
It does often happen, indeed, as we have said above,
that ulcers of even a bad nature are cured without any
assistance from confinement or a horizontal posture of
the limb. This I have frequently met with; and at
this time I have different cases under my care, of ul-
cers going on towards a cure, whilst the patients are
daily going abroad. But their being allowed to take
this liberty, has always proceeded from necessity; as
there is nothing of which I am more perfectly con-
vinced, than that ulcers on the lower extremities will
cure sooner, more easily, and to more real advantage,
whilst the limb is preserved in a horizontal posture,
than they will do whilst the patient continues to take
exercise. But when the circumstances of patients
prevent us from receiving the advantages to be derived
from confinement, we are reduced to the necessity of
attempting the cure of ulcers by other means; and, in
such circumstances, nothing answers so well as press-
ure applied by a roller in the manner we have uni-
formly mentioned in this as well as in the former edi-
tions of this work.
As confinement, during the cure of ulcers on the
legs, proves always inconvenient, various means have
been proposed for rendering it unnecessary; and it
has not only been said, that cures may be performed
without any assistance from confinement or a horizon-
tal 

Sect. II. Simple Purulent Ulcer. 131
tal posture, but by some it is alledged, that they are
even prejudicial.*
We have already remarked, that ulcers of the legs
may be healed while patients are daily going abroad;
and especially if a due compression be continued:
But; notwithstanding all the arguments adduced in fa-
vour of the practice, I have not yet heard of any which
ought to set aside the opinion we have endeavoured
to inculcate upon this point, and which, indeed, has
in all ages been allowed to be well founded; namely,
that a horizontal posture is highly proper in the cure
of every ulcer of the lower extremities. The means
proposed by Mr. Underwood, I have tried on various
occasions; they have sometimes proved successful;
but whatever may have been the case with others,
they have never, in the course of my experience, ef-
fected cures so easily and speedily, or which have prov-
ed so permanent, as the means we have recommended,
of employing mild dressings to simple sores, together
with a horizontal posture in every ulcer of the leg.
In almost every case of ulcer, particular directions
have been given by practitioners, with respect to regi-
men; and, in general, a low spare diet has been pre-
scribed. Such regulations, however, when carried to
a great length, most constantly do mischief: for they
seldom fail to relax the habit considerably, and to pro-
duce other disagreeable effects, particularly on the na-
ture of the matter discharged from sores.
The only attention, which, in this respect, seems to
be necessary, is to guard against all excess in eating or
drinking; for whatever has the effect of producing
merely
* This has been asserted by other writers; but it has been more fully
enlarged upon of late, in a Treatise upon ulcers of the legs, by Mr.
Underwood, of London.
I 2 

132 Observations on the Part II.
merely a slight temporary fever with any additional
inflammation, proves, in such cases, always very prej-
udicial: But, in place of a diet much lower than usu-
al, as is most frequently recommended, a more full
and nourishing regimen, than the patient even in a
state of health has been accustomed to, is often found
to prove serviceable.
For the discharge of purulent matter proves always
so very debilitating, that in large ulcers, when great
quantities of it are afforded, this circumstance alone
generally weakens the patient too much, if the consti-
tution be not at the same time enabled to support it by
a proper diet. Indeed, it is constantly found, that
the cure of such sores goes on much more easily when
the patient is kept in his usual habit of body, than
when his system is much reduced by a very low allow-
ance: nay, I have had many opportunities of observ-
jng, that ulcers even of the worst kinds, are soon
brought to heal by the use of a nourishing diet alone,
after they have obstinately refilled all the usual appli-
cations and remedies.
For the same reasons that a low regimen is con-
demned, the use of purgatives, and in general what-
ever tends to weaken the constitution, is improper.
Nor does it ever happen, if proper attention be paid
to the different circumstances we have pointed out,
that internal medicines of any kind are necessary in
this species of ulcer: I know that it is a frequent prac-
tice to give medicines of different kinds, particularly
bark, nitre, and cooling purgative salts, in this as well
as in every variety of ulcer. But in the simple puru-
lent ulcer, of which we are now treating, I never find
it necessary to employ any remedy directed to the sys-
tem at large: The disorder is merely local, and local
applications 

Sect. III. Simple Vitiated Ulcer. 133
applications ought to be solely depended on for the
cure. When, indeed, the matter of a sore is in too
great quantity, and especially if it be thin and acrid,
bark, steel, and other tonics are frequently employed
with advantage: But when the local applications we
have already recommended do not prove effectual in
correcting this, it will commonly be found to originate
from some general disease of the constitution; a dif-
ferent species of ulcer will be therefore produced, and
other remedies will consequently be necessary.
SECTION III.
Observations on the SIMPLE VITIATED ULCER.
THE simple purulent ulcer we have described in
the preceding section being the mildest, and, if
the expression may be used, the most natural species of
the disorder that can occur on a healthy body, every
deviation from it might be considered as a vitiated
state. But those we mean to comprehend under the
denomination of Vitiated Ulcers, are such as differ
from it chiefly in the appearance and nature of the
discharge which they afford. All those which are dis-
tinguished by any remarkable peculiarity of the solid
parts, as they require each of them a distinct and sep-
arate method of treatment, so they are allowed, as we
have formerly remarked, to constitute so many distinct
species of the disorder; and they will, accordingly, be
all taken notice of separately.
I 3 Whereas,


134 Observations on the Part II.
Whereas, those which differ from the more simple
ulcer, only or chiefly in the nature of the discharge,
as they require all nearly the same method of cure,
and as these differences are merely accidental, they
have not, for these and other reasons, as we have al-
ready remarked, been allowed to have any influence
in forming distinctions.
§ 1. Of the Symptoms, Causes, and Prognosis of the
Simple Vitiated Ulcer.
The most common appearances in the matter af-
forded by ulcers, when it deviates from the more nat-
ural state of purulent matter, are,
l. A thin, limpid, sometimes greenish discharge,
termed Sanies.
2. A somewhat red coloured, thin, and generally
very acrid matter, termed Ichor. And,
3. A more viscid glutinous kind of matter, called
Sordes.
This last, too, is frequently of a brownish red ap-
pearance, somewhat resembling the grounds of coffee,
or grumous blood mixed with water. They are all of
them much more fetid than purulent matter, and none
of them are altogether free from acrimony; but that
which has generally been termed Ichor, is by much the
most acrid of any of them, being frequently so sharp
and corrosive as to destroy large quantities of the
neighbouring parts.
In consequence of the acrimony of the different
matters we have mentioned, the ulcers discharging
them do not fill up with fresh granulations, but waste
away more and more; and, instead of a red healthy
complexion, they have either a dark brown, or some-
times a black sloughy appearance. The pain in all of
them 

Sect. III. Simple Vitiated Ulcer. 135
them is considerable; and is generally more or less
so, according as the matter afforded is more or less
corrosive.
As causes of this species of ulcer may be mentioned,
all such as we have taken notice of in the preceding
section, namely, wounds in general, burns, bruises,
and in short all those which were enumerated as causes
of the simple purulent ulcer; for even that species of
the disorder, however mild it may have been; if it hap-
pens to be either neglected, or to be dressed with im-
proper irritating applications, very readily degener-
ates into the vitiated ulcer of which we are now speak-
ing.
It is not improper here to observe, too, that such
changes in ulcers, from the simple to those of a more
inveterate kind, happen much more frequently in par-
ticular parts than in others: thus from the tendons
and aponeurotic expansions of muscles not affording
that species of serum necessary for the formation of
good pus, such ulcers as are seated in these parts com-
monly prove much more troublesome and inveterate
than those which are seated in the cellular membrane,
where a plentiful secretion of a fluid proper for this
purpose generally takes place.
In ulcers of the kind which we are now considering,
that are merely local, and that are not connected with
any disorder of the system, when they have not been
of long duration, and more especially when they oc-
cur in young healthy patients, the prognosis should
always be favourable. But, when the opposite cir-
cumstances take place; when the patient is very old;
the ulcer extensive, inveterate, and of long standing;
the prognostic should always be very doubtful.
I 4 § 2. Of 


136 Observations on the Part II.
§ 2. Of the Cure of the Simple Vitiated Ulcer.
We have already remarked, that the bad qualities
of the matter afforded by ulcers, proceed, in general,
from some particular affection of the solids or secret-
ing organs in the parts diseased, whereby such kinds of
fluids are separated from the blood as cannot be con-
verted into good pus. The nature of this affection,
too, we have endeavoured to explain; and, from the
several arguments formerly advanced, it appears evi-
dently to consist in different degrees of inflammation,
or of increased action in the vessels of the parts diseas-
ed, occasioned by one or other of the several exciting
causes which give rise to ulcers.
Independently too, of what was formerly advanced
in support of this opinion, it seems to be farther con-
firmed by the nature of the different remedies found
to be most effectual in the cure of such dorders, which
are chiefly of that kind which have evidently very
powerful effects in easing pain and abating irritation.
Thus warm emollient fomentations and cataplasms,
in a very short space, sometimes even in the course of
twenty four hours, will frequently not only give the
patient a great deal of relief from pain, but will even
produce a considerable amendment in the nature of
the discharge; and, by being continued for a longer
time, till the tendency to inflammation is thoroughly
removed, they will, very frequently, without any far-
ther assistance, convert the matter, however bad it may
have been, into a natural and good pus.
The most proper method of proceeding, therefore,
in the treatment of all such ulcers, is to foment the
parts three or four times a day, for half an hour at least
each time, with an emollient decoction; and then to
apply 

Sect. III. Simple Vitiated Ulcer. 137
apply pledgits of the wax ointment, as was formerly
recommended, with warm poultices over all, to be re-
newed as frequently as they turn cold.
In sores of this nature, when the pain is considera-
ble, as nothing more quickly promotes the cure of
such disorders than the removal of pain, it frequently
becomes necessary to have recourse to opiates, which,
in such circumstances, are often used with much ad-
vantage: and when they are employed, they should
always be given in such doses, and these should be as
frequently repeated, as the violence of the pain may
indicate.
The habit of body must, in the mean time, be also
attended to, and particular directions given with re-
spect to it, according to the immediate situation of the
patient. Thus, when from a long continuance of an
ulcer, or from any other cause, the constitution has
been much reduced, we ought, by a full allowance of
diet, to endeavour to repair it; and when, on the con-
trary, the patient is of a full plethoric habit, and has
formerly been liable to inflammatory affections, it
then becomes proper to keep him rather upon a low
regimen.
In ulcers of this kind, which occur in the former of
these circumstances, namely, in low reduced habits,
the Peruvian bark proves often efficacious: in such
sores, indeed, it acts frequently as a very powerful
remedy, and particularly in effecting a change for the
better in the nature of the discharge.
The bark, however, in order to produce such an ef-
fect, requires to be given in much larger quantities
than are commonly exhibited: It is seldom given in
any complaint of this kind to a greater extent than
three or four doses in the day, of a scruple or half a
drachm 

138 Observations on the Part II.
drachm each; whereas, when any remarkable advan-
tages are expected from it, six or eight doses of a
drachm each should always be given in this space of
time; and, in such quantities, it seldom fails of prov-
ing a very effectual remedy.
It must be observed too, that, in the manner we have
directed, very little more of the remedy ever becomes
necessary, than what, upon the whole, is commonly
exhibited in the usual way of giving it in small doses;
for with large doses, and these being frequently re-
peated, more real advantages are in general obtained
in the course of twelve or fourteen days, than are usu-
ally experienced from its being continued a great num-
ber of weeks in small doses.
In such cases of ulcers, however, as occur in inflam-
matory constitutions, and in plethoric habits, the bark
must be used with greater caution; and, in these cir-
cumstances, indeed, it should seldom be given to any
extent, till the tendency to inflammation has in a good
measure disappeared.
The several circumstances in the cure which we have
enumerated being all duly attended to, whilst at the
same time the part affected is kept act rest and in a
proper posture, it rarely or never happens that the
discharge is not soon converted into good pus; and
when once this is accomplished, every other appear-
ance of the sore, in a very short time, generally changes
for the better. At least this is commonly the case,
unless the ulcer happens to be connected with some
general disorder of the system; a circumstance we do
not here suppose to occur, and which would constitute,
indeed, a species of sore different from that which we
are now considering.
As 


Sect. III. Simple Vitiated Ulcer. 139
As soon as the discharge is converted into a proper
suppuration, the most material part of the cure is thus,
in a great measure, effected: for the  parts being no
longer corroded by a constant immersion in an acrid 
matter, but, on the contrary, being covered by the
most natural balsam that can be applied to them, they
commonly soon put on a red healthy appearance; and
new granulations being now at liberty to form, any loss
of substance which occurred, comes as far as possible to
be supplied, and this in a longer or shorter space of
time, according to the depth and size of the ulcer, sit-
uation of the part affected, and the age and habit of
the patient.
Sores of this kind being by these means reduced to
the state of simple purulent ulcers, are to be treated
during the remainder of the cure exacty in the man-
ner we have directed in the preceding section: that is,
with very mild dressings; at the same time that due
attention is paid to the preservation of a proper degree
of heat in the parts, together with the use of a gentle
compression from the time of the inflammatory symp-
toms having been thoroughly removed.
It frequently happens, however, in this as in every
species of ulcer of long standing, that although the
parts, by proper management, may have been brought
to put on a very healthy appearance; and although
the discharge has, from a very bad sort of matter, been
converted into the best kind of pus; yet still the sore
cannot be got to cicatrise, but continues to discharge
as plentifully as ever.
When, in such a situation, the different directions
we have given in the last section with respect to the
cicatrisation of sores, do not succeed, as may frequent-
ly be the case, an issue of a proper size, inserted in any
convenient 

140 Observations on the Part II.
convenient situation, will often contribute more to-
wards the accomplishment of a cure, than all the ap-
plications which are generally used in such cases.
And, indeed, in old habitual ulcers of every kind,
nothing but the introduction of adequate drains will
ever produce permanent cures: for although, by the
use of drying astringent applications, the sores may be
covered with a thin cicatrix or scarf skin; yet in cases
of this nature, such cures are seldom of any long du-
ration.
For, independently of the danger which arises from
the practice of healing old drains before new ones are
inserted in their place, any cicatrix obtained by means
of astringent applications, being very weak, generally
soon bursts open, in consequence of that redundancy
of fluids which must always be induced in the system
by the retention of that considerable quantity of serum,
which for a long time the constitution had been accus-
tomed to throw off, for a supply of pus to the ulcers.
In all such ulcers, therefore, and indeed in every
species of the disorder that has been of long standing,
the first part of the cure ought to consist in the intro-
duction of an issue of such a size as may afford a quan-
tity of matter in some degree proportioned to that
which the sore has generally yielded. And although
the situation of such drains has commonly been chos-
en as near to the part affected as possible; yet, provid-
ed the same quantity of matter be discharged, the sit-
uation of the issue is not probably of much conse-
quence; and therefore, that which is most convenient
for the patient may be always fixed upon.
The issue having discharged for some time, and the
different remedies formerly recommended being still
continued, 


Sect. III. Simple Vitiated Ulcer. 141 
continued, the cure of such ulcers will at last be com-
monly completed.
Since the first edition of this work was published,
the good effects to be obtained from issues in the cure
of old habitual ulcers have in various instances been
experienced. In some of these, cures were obtained
by issues, when every other means of relief had been
found to fail: And in others, the sores broke out again
upon allowing the issues to dry up, and were again cur-
ed by having recourse to the same means.
Various instances might likewise be given from au-
thors, not only of the difficulty of curing habitual ul-
cers unless an issue be previously inserted, but of very
pernicious consequences resulting from it. But as the
experience of every practitioner must have furnished
instances of this, we do not think it necessary to refer
to books for authorities.
In sores which have not been of long duration, how-
ever extensive they may be, it would be highly improp-
er to put the patient to the trouble of an issue for their
cure. In recent ulcers, the system has not been so
long accustomed to the discharge, as to induce any risk
from a stop being put to it; we wish, therefore, to have
it understood, that it is not in such sores they are meant
to be recommended: But in ulcers of long continu-
ance, we must again say, that a cure can never be at-
tempted with safety, unless an issue of an adequate size
be previously inserted.
As issues of every kind are attended with some in-
convenience, they seldom prove agreeable to patients;
and from this consideration, practitioners are frequent-
ly induced to dispense with them: The least atten-
tion, however, must render it evident that no consid-
eration of this nature ought to have any influence. 
It


142 Observations on the Part II.
It is in the species of ulcer we are now considering
that the internal use of nitre has been so much recom-
mended; but, although I have given it, in this as well
as in other kinds of sores, in very considerable quanti-
ties, and with every necessary precaution, I cannot say
that I ever observed any evident effects produced by
it. Sores, indeed, have been cured in which nitre was
used; but unless the roller and other local applications
were employed at the same time, this remedy, in any
of the trials I have made of it, has never of itself been
able to effect a cure.
SECTION IV.
Observations on the FUNGOUS ULCER.
FUNGOUS excrescences frequently occur in dif-
ferent species of ulcers; and very often increase
to such a degree as to constitute sores extremely dif-
ferent in their appearances and effects, as well as in
their treatment, from the sores which originally induc-
ed them: and this is the reason for our allotting a sep-
arate section for their consideration.
§ 1. Symptoms and Causes of the Fungous Ulcer.
By the term fungus is understood such preternatu-
ral risings of the parts in sores, as are commonly more
soft and spongy than found healthy granulations;
which, though they do not in general acquire any
great degree of bulk, yet by very long continuance and
neglect, 

Sect. IV. Fungous Ulcer 143
neglect, they do, in some instances, arrive at very con-
siderable sizes: And although, as we have observed,
they are generally at first lax and soft, yet, when of
long duration, they likewise, in some cases, acquire
very great degrees of hardness.
The pain attending them is not commonly consid-
erable; though, in some instances, it is otherwise; and
the discharge afforded by them varies according to the
species of ulcer they happen to be connected with.
Thus, when a hypersarcosis, the term commonly
used for such risings in sores, occurs merely from ne-
glect in a simple purulent ulcer, the discharge fre-
quently continues all along tolerably good; and, on
the contrary, when it is connected with an ulcer dis-
charging any of the more acrid vitiated matters, as in
some instances is the case, the discharge usually contin-
ues to be of the same nature.
With respect to the causes of the disorder; when
speaking of simple purulent ulcers, it was observed,
that in a healthy state of body, and especially in young
people, the new granulations that form in such sores
are very apt to push forward too much, so as to rise
above the surface of the neighbouring parts. This, by
attending to the directions which were then given,
may very often be effectually prevented; but if, in
such circumstances, the sore be neglected, and the
parts are allowed to advance much further, the disor-
der of which we are now speaking comes then to take
place. And if it is not attended to for yet a still long-
er time, as with poor people especially is frequently
the case, even this, the most simple secies of fungus,
degenerates into a very troublesome disorder; it be-
ing in this manner that the very hardest excrescences
are commonly produced.
Another 

144 Observations on the Part II.
Another variety of the disorder is sometimes met
with in the cure of wounds and ulcers of different
kinds, from not attending to their being sound at bot-
tom before the new granulations are allowed to pro-
ceed any length. In this manner, whether from any
sinus not being filled up, or from any corrupted parts,
that may not have been thrown out, continuing to
act as extraneous bodies, the granulations that first ap-
peared still continue to advance; but, instead of cica-
trising when they are on a level with the neighbour-
ing sound parts, they go on rising considerably be-
yond them, till the disease we are now considering is
of some duration.
And, when in this way a fungus has once commenc-
ed, it continues to increase from day to day, till the
cause which originally produced it is discovered, and
removed, either by art or nature, in consequence of a
plentiful suppuration being formed below and bursting
out; which, by laying open the seat of the disorder,
gives room for a proper treatment to take place.
§ 2. Of the Cure of the Fungous Ulcer.
By a proper attention to the case, and to the differ-
ent causes we have mentioned, it will, in general, be
easily discovered from which of the two the disease has
originally proceeded: and, as soon as the cause is dis-
tinctly known, the method of cure to be pursued is
just as certainly determined; which, till then, could
not with propriety be undertaken, as, in the two differ-
ent cases, the remedies found to be necessary are of
very opposite natures.
When it is found that the fungus has been induced
merely by an overgrowth of parts, and that there is no
disease lurking at the bottom of the sore; when the
tumor 

Sect. IV. Fungous Ulcer. 145
tumor is of a considerable breadth, and especially when
it does not rise to any great height; we should have
recourse immediately to the use of escharotics.
Of such applications, a great variety has been re-
commended: by many; even the actual cautery has
been proposed; and by others, we are directed to re-
move at once all fungous parts by the scalpel.
Either of these methods would, no doubt, prove in
every case very effectual, and a great deal more expe-
ditious than any other that can be recommended: But
they have such an appearance of severity, as to deter
almost every one from submitting to them; especially
as it is well known, that the disorder we are treating
of can be just as certainly, though perhaps not so
quickly, removed by means of much more gentle rem-
edies.
Of all the artificial caustic preparations enumerated
by authors, the lunar caustic is, for such purposes es-
pecially, by much the best. It acts more quickly, and
does not produce more pain, than many of the mild-
er sorts; it never fails to produce the proper effect,
which is not the case with any of the others; and it is
not near so apt to run and to spread over the neigh-
bouring parts, as some of the other compound forms of
caustic, which is frequently a very troublesome circum-
stance attending their use.
The caustic should be liquefied; and a small brush
or pencil being dipt in it, it is in this manner to be ap-
plied to such parts as are to be destroyed: And this
eing done either daily or every second day, the fun-
gus will be removed in a longer or shorter time, ac-
cording to the size and firmness of the tumor. A
strong solution of verdigrise in water, of crude sal am-
moniac, or of blue or white vitriol, being applied in a
K similar 


146 Observations on the Part II.
similar manner, will commonly prove effectual too, in
removing such excrescences.
In the course of practice, cases occur in which some
variety of such applications is found to be necessary:
I have made trial of a great number; but none ever
proves so generally useful, as we said above, as the lu-
nar caustic. For purposes of this kind, I have some-
times used a strong solution of silver or of crude mer-
cury in spirit of nitre; and the effects of it, as may
readily be imagined, are always very powerful: they
are nearly the same, indeed, being only somewhat more
powerful than those we commonly experience from lu-
nar caustic; this kind of caustic being merely a solu-
tion of silver in the nitrous acid evaporated to dry-
ness.
One ounce of pure quicksilver will disolve in an
ounce and a half of strong spirit of nitre; and this
forms, perhaps, as strong a caustic as can be prepared.
For other purpofes, where milder applications of this
kind are necessary, the strength of the remedy may be
reduced by using a smaller proportion of mercury and
a weak nitrous spirit: But for the removal of a hard
callous excrescence, the strongest solution ought to be
employed; it gives no more pain than those of a weak-
er nature, and it always proves more effectual. We
may here remark, too, that a strong solution of this
kind is perhaps the most effectual of any caustic appli-
cation in the removal of warts of every kind, and partic-
uarly for those which originate from a venereal cause.
But in using it, either for warts, or for such fungous ex-
crescences as we are now describing, it ought never to
be applied to an extensive surface at once. When the
fungus is inconsiderable, a small quantity of the solu-
tion may be applied over the whole of it without any
risk: 


Sect. IV. Fungous Ulcer. 147
risk: But, in extensive affections of this nature, it an-
swers better to apply it to a small portion of them on-
ly; and if different parts of an excrescence be touch-
ed with it daily, the whole will in general be soon re-
moved. After the application of any of these articles,
the parts should be covered with dry lint; and not,
as is commonly done, with any kind of ointment,
which always tends to destroy the activity of every
caustic remedy.
We have hitherto been supposing, that the surface
of the fungus is of a considerable extent, and that it is
not raised to any great height above the contiguous
sound parts: But whenever the reverse of these cir-
cumstances takes place, that is, when there is a narrow
base, and the height of the excrescence is considerable,
the most expeditious and easiest method always is, to
take it off by a ligature; which being applied at its
root tolerably tight, and straightened a little every
day, soon destroys the circulation in the swelling so
entirely, as to cause it in a short time to drop off.
When the rising is, as we have observed, narrow at
the base, and especially when it is in the least pendu-
lous, a ligature can be applied and kept on with the
greatest ease; but when the tumor is broader below
than above, it is not possible, without some assistance,
to prevent it from slipping off. It may always, how-
ever, be certainly and very easily effected in the fol-
lowing manner.
A strong straight needle, fixed in a handle with an
eye near to its point, being pushed through from one
side of the tumor to the other at its base, and two
strong waxed threads being introduced at its eye, it is
to be again drawn back, leaving the threads with their
ends hanging out at each side of the swelling. In this
K 2 situation, 


148 Observations on the Part II.
situation, a firm ligature is to be formed round one
half of the tumor by the two extremities of one of the
threads; and with the other two, the other half is in
like manner to be comprehended; and each of them
being from time to time properly tightened, both
halves of the swelling will for the most part very soon
fall off. The hint of the practice we have here re-
commended, was taken from the description of a curv-
ed needle of this kind, recommended by Mr. Chesel-
den, for the extirpation, by ligature, of diseased ton-
sils, which, without some such contrivance, could nev-
er with propriety be attempted.
The fungus being by either of these methods remove
ed, the sore is then to be treated in the manner we have
already directed for the management of simple purulent
ulcers.
The other species of fungus we have mentioned,
that proceeds, as we observed, from the new granula-
tions in ulcers not being raised on a sure foundation, by
purulent matter or some other extraneous body being
lodged at the bottom of the sore, is in general, very
easily distinguished from the preceding species. It
rises with much greater rapidity, and is not near so
firm; on the contrary, indeed, it is always more soft
and flabby even than healthy granulations.
By attending to these, and all the other circumstanc-
es of the ulcer, the cause will seldom remain long in
doubt; and as soon as it is discovered, the first thing
to be done, is to give free vent to the confined matter,
by making a proper opening into it. After which, by
taking care that the sore fills properly up from the
bottom, the cure will go easily on in the ordinary way.
Nor, unless when the fungus is very considerable, can
there ever be any occasion for the use of escharotics;
for, 


Sect. V. Sinuous Ulcer. 149
for, in such cases, the granulations are commonly so
soft and spongy, as to waste away of themselves in the
course of the cure, without any assistance whatever
from caustics.
These are the only cases of fungus, which, in gener-
al, in local ulcers, ever prove troublesome; excepting,
perhaps, that which occurs as a symptom in carious ul-
cers, and which in its proper section will be taken no-
tice of. It may be alleged, indeed, that the varieties
we have now described may be considered as symptom-
atic; and for this reason, it may be said, that they
should not be allowed to constitute distinct complaints:
For the reasons we have formerly given, however, and
particularly from their treatment being very different
from that which is necessary in any other symptom of
ulcer, it was thought proper to allot a separate section
for their consideration.
SECTION V.
Observations on the SINUOUS ULCER.
§ 1. Of the Symptoms and Causes of the Sinuous Ulcer.
BY the term sinuous ulcer, is meant that species of
sore communicating with one or more openings or
cavities of various sizes and dimensions, which are gen-
erally seated in the cellular membrane, between the
common teguments and muscles, or between the inter-
stices of the muscles themselves.
K 3 These 

150 Observations on the Part II.
These different sinuses serving as reservoirs both for
the matter formed in the body of the sore, and for that
which is afforded by the sides of their own cavities,
make the discharge of all such ulcers, when the matter
of the sinuses is pressed into them, appear to be much
more considerable than their extent of surface would
give cause to expect.
A sinus, as thus described, is the most simple state of
the disorder: but by long continuance, or by the use
of drying astringent applications, it is liable to become
hard and callous in its internal surface; and, in such
a state, from its supposed resemblance to a pipe, it is
termed a fistula; of which nature is the fistula in ano,
a well known and troublesome disorder.
The most frequent cause of the formation of sinuses
in ulcers and abscesses, is the want of a free vent to the
discharge; which, naturally falling to the most depend-
ing situation of the part, if it does not there find an
easy and ready passage by an opening being made into
it, it very readily insinuates itself into the soft yielding
substance of the cellular membrane, and proceeds on
gradually till it somewhere or other makes an opening
for itself, either upon the surface of the body, or into
some of the neighbouring cavities.
Very tight bandages, too, when applied directly up-
on ulcers, if they are not made to act likewise upon
the neighbouring sound parts, for some way both
above and below the sores, are not unfrequently at-
tended with the same effect: and should never, there-
fore, be applied in this manner.
In every case of recent sinus, and even, in general,
in those of longer standing, when these are so far ac-
cessible as to admit of proper applications being made
to them; and when the constitution in other respects
is

Sect. V. Sinuous Ulcer. 151
is healthy, we may almost always venture to make a
favourable prognosis. But when the complaint has
been of very long continuance, and especially when
the different sinuses open into any of the joints, or are
beyond the reach of an operation, a cure, in such cases,
becomes both very difficult and doubtful. Nor is
there, indeed, any disorder that more frequently baf-
fles the ingenuity of surgeons, than some species of this
disorder, particularly the fistula in ano.
§ 2. Of the Cure of the Sinuous Ulcer.
In recent affections of this nature, we are directed
by all the old writers, as likewise by many of the mod-
erns, to make use of what they call vulnerary or heal-
ing injections. And, in the more advanced states of
the disorder, when bylong continuance the sides of
the different sinuses have become callous, escharotic
injections and powders have been recommended: But
none of these have ever been found to produce any
permanent good effects, and the too frequent use of
them has often rendered hard and callous such sinuses
as before were of the most simple nature.
Others again have advised, in every case of this
kind, especially when the complaint is in any degree
of a fistulous nature, to lay the different sinuses open
from one end to the other, and, by cutting out all the
hardened parts, to convert the whole into one common
ulcer, and to proceed afterwards with the cure in the
ordinary manner.
This method will, no doubt, very frequently effect
a cure; but, independently of the great pain, and very
large unseemly cicatrix, which it never fails to pro-
duce, it cannot, in every case, with safety, be put in
practice,
K 4 Thus, 


152 Observations on the Part II.
Thus, when sinuses run very far up the rectum, it
can never conveniently be practised; and when, as is
frequently the case, they penetrate deep, and run be-
low either large blood vessels, tendons, or nerves, it
would never surely, in these cases, be advisable to have
recourse to such treatment.
But although the practice was even altogether free
from danger, it ought in almost every instance to be
laid aside; since we can, by a much more simple and
less painful operation, be always as certain of obtain-
ing a cure, as we ever could be, either by a simple in-
cision, or by an entire destruction of the parts.
The intention of cure in every cafe of sinus, is to
produce a coalescence of its sides, so as to destroy any
vacuity that may have been occasioned.
The most effectual means for accomplishing this, is,
first to make a depending orifice for a free exit to the
matter; and then, by a gentle irritation, to induce, on
the internal surface of the sinus, a slight degree of in-
flammation, which by experience is known to be the
state which proves most favourable to the production
of adhesion between any two parts; so that a firm
union of the sides of the sinus to one another may in
due time be obtained.
Now both these intentions are fully answered by the
introduction of a seton, from the orifice in the ulcer,
along the course of the sinus, to its other extremity;
where an opening, large enough for the discharge,
ought to be made in the manner we formerly directed
in cases of abscess.
The cord of cotton or silk ought at first to be pretty
large, more or less so according to the capacity of the
sinus; and it should be diminished gradually, as the
cure advances, by taking away a thread or two from its
thickness 

Sect. V. Sinuous Ulcer. 153
thickness every second or third day. And at last,
when the discharge is greatly lessened by the filling up
of the vacuity occasioned by the sinus, the seton should
be totally withdrawn; and a bandage being applied
with some tightness over the part, and being continu-
ed a sufficient length of time, a complete cure will for
the most part be effected.
The first step to be taken then, in all cases of this
kind, is to discover the direction in which the sinuses
run; which commonly we can easily do, either by the
introduction of a probe, or by observing where the
matter points on being allowed to collect for some
time, and from whence it comes, on the part being
pressed. And into every sinus that opens into the
ulcer, a seton, as we have above directed, should be
introduced.
This method of curing sinuses, by the use of the se-
ton, is free from all manner of danger, and is admissi-
ble in almost every case that can occur. Even when
sinuses run deep among the muscles and blood vessels;
and when it would be unsafe, therefore, to use either
the scalpel or acrid injections; a seton, introduced by
means of the director, as we formerly recommended
in the treatment of abscesses, may be always employed
with much safety and advantage.
The practice we have here recommended is seldom
found to fail in any case of simple sinus; and, in gen-
eral, it answers even in those which are considered as
real fistulæ.
Although it would be very inconvenient in such a
situation, yet I am much persuaded, from its general
utility in similar cases in other parts, that the seton
would prove a much more effectual remedy in cases
of the fistula in ano, than any other that has as yet
been 

154 Observations on the Part II.
been employed. In similar cases of this kind that oc-
cur in the perineum, I have known it used with the
greatest advantage: And it is in this situation, indeed,
particularly proper; as the cicatrix formed after the
opening of a long sinus in the common method, with
a scalpel, proves in these parts frequently more trou-
blesome and painful to the patient, than even the o-
riginal disease it was intended to remove.
The sinuses, by these means, being at last filled up,
the ulcers with which they have been connected are
then to be cured in the ordinary manner, as we have
directed in one or other of the different sections, for
the species of sore to which they may happen to be-
long.
This part of surgery, it may be observed, is much
indebted to the ingenious Mr. Pott, for the simplicity
he has been in a great measure the means of introduc-
ing in the treatment of fistulous complaints in ano and
in perineo. In all of which, as we have already re-
marked, it used formerly to be, and with many indeed
still is, the practice to cut out the affected parts en-
tirely, whether they are much hardened or not: which
not only occasions a great deal of unnecessary pain, but
very seldom produces such an agreeable or speedy cure
as is obtained by merely laying the parts open with a
simple incision; and which is all that, even in the
most obstinate cases, should be ever attempted. For,
if a cure cannot be obtained by such an operation a-
lone, or by the seton when it can be used, as we have
lately advised, cutting out the parts never will effect
it, unless they are all evidently in a very hard callous
state; in which case, extirpation of the diseased parts
may no doubt in some cases, be necessary. Even
when a very considerable degree of hardness prevails,
much 

Sect. VI. Callous Ulcer. 155
much advantage is often derived merely from laying
the sinuses open by a simple incision along the course
of each of them: The free vent which is thus given
to the discharge, together with the new suppuration
induced by the incisions, proves frequently a very cer-
tain means of removing the callosities; and this being
accomplished, a complete cure is commonly obtained.
SECTION VI.
Observations on the CALLOUS ULCER
§ 1. Of the Symptoms and Causes of the Callous Ulcer.
AN ulcer is said to be callous, when its edges, in-
stead of contracting, and diminishing the size of
the sore, keep at a stand, turn ragged, and at last, by
acquiring a preternatural thickness, often rise consid-
erably above the level of the neighbouring parts:
And, as it is generally from neglect, or improper treat-
ment, that ulcers do turn callous, the discharge afford-
ed by them is commonly a thin vitiated matter.
It is in this species of ulcer chiefly too, that varicose
veins occur as a symptom, especially when the com-
plaint is seated in the lower extremities. This seems
to be owing, not only to the difficulty the blood, in
such situations, meets with in its return to the heart;
but, in a great measure, to the stricture occasioned by
the callosities on the course of the different veins; a
circumstance which, in extensive sores of this kind,
must, no doubt, have a considerable influence.
By 

156 Observations on the Part II.  
By many, and even by late writers, this species of
ulcer has been commonly termed varicose; from their
supposing such sores to proceed from, and to be as it
were fed by matter furnished to them from these swell-
ed veins, which frequently have the appearance of
opening into them.*
This error, however, it is evident, must have pro-
ceeded from want of attention to the cause of such
swellings in the veins; together with the mistaken no-
tion which has hitherto prevailed respecting the form-
ation of pus and other kinds of matter; which were
formerly, in general, supposed to circulate with, and
to be deposited from the blood; but which, in the
preceding essay, we have endeavoured to demonstrate
to be an opinion entirely void of any real founda-
tion.
With respect to the causes of callosities in ulcers, it
may be remarked, that they may all be reduced to the
general head of neglect and improper management
When sores are injudiciously treated, either by irri-
tating or by very relaxing applications; or when they
are entirely neglected, so that fungous excrescences
are either allowed to arise, or different dressings and
other extraneous bodies are permitted to remain too
long in their cavities; such substances come at last to
act as impediments to the farther diminution or con-
traction of the ulcers. And, the small vessels of their
edges being thus prevented from proceeding farther in
a proper direction, are forced to push upwards, and
sometimes even backwards, till, in consequence of the
usual pressure from the necessary bandages, they nat-
urally come to acquire a morbid hardness or callosity;
which, as long as it is allowed to remain, very effectu-
* See Turner's Art of Surgery, vol. II, p. 3. 

Sect. VI. Callous Ulcer. 157
ally prevents the accomplishment of a cure, however
judiciously the sores may in other respects be treated.
§ 2. Of the Cure of the Callous Ulcer.
From the consideration of the above mentioned
cause of the disorder, the first step towards a cure, it is
evident, should consist in its total removal.
Thus every improper application, which, till now,
may have been used, should be immediately laid aside;
and if any fungous or other extraneous body appears
to be doing mischief, these and every other obstruc-
tion to a cure ought as soon as possible to be removed.
This being too thoroughly accomplished, and the sore
being brought to a clean healing condition, the differ-
ent callosities are then to be destroyed; for, till they
are effectually removed, it is in vain by any kind of
application to expect a cure.
In very recent instances of such complaints, warm
emollient cataplasms, when continued for a proper
length of time, by softening the callosities, will fre-
quently, without any other application, answer every
intention of cure. But it is in the earliest periods of
the disorder only that these ever prove effectual; for
when it has been of long duration, so that the edges of
the sore have acquired much preternatural hardness,
neither the use of emollients nor of gum plasters, as
we find in such cases recommended by many authors,
are ever attended with any remarkable advantages.
The only remedy then we can have recourse to, is
the scalpel or caustic: And as this last, when properly
managed, is equally certain with the other, it should,
as the easiest method, be always employed; and, for
reasons we have mentioned in a former section, the lu-
nar caustic should be here likewise preferred. The
solution 

158 Observations on the Part II.
solution of silver or of mercury, of which we gave a
description when treating of the fungous ulcer, may
be used with equal propriety here too: Either this, or
the lunar caustic, should be applied every two days to
the callous edges of the sores, which in this manner
will be soon destroyed. By this means, together with
a continuation of the poultices so long as any degree
of foulness remains in the sores, they will soon be re-
duced to the state of simple purulent ulcers, when the
treatment we have recommended for that species of
sore will seldom fail in accomplishing a cure.
In the list of symptoms which we formerly enumer-
ated, varicose veins were mentioned as one. These,
it might be imagined, when the cause which produced
them was removed, would likewise disappear. This,
however, is very seldom the case; for blood vessels,
which have once suffered such a distention as to be
deprived entirely of their tone, do not often soon re-
cover it. In the treatment, therefore, of this species
of ulcer, it is not merely necessary to remove the cause
which originally produced these swellings in the veins:
some support must be afforded to the weakened parts
in order to enable them the more easily to recover
their usual strength.
For this purpose, nothing has hitherto proved so
effectual as the laced stocking, or spiral bandage,
which we have already recommended so frequently
for different circumstances in the cure of sores. In
order to have a proper effect, however, in every case
of varix of long duration, it ought to be continued for
a very considerable time: And it rarely happens, we
may remark, that any instance occurs of the disorder
being so bad, in which a cure may not be obtained
merely by the means we have recommended; or at
least, 

Sect. VI. Callous Ulcer. 159
least, that the inconvenience produced by the swelling
of the veins may not be so far palliated as to render
quite unnecessary that painful operation so frequently
recommended of extirpating, as in cases of aneurism,
the diseased or swelled parts.
The effects of pressure in the cure of sores we have
already taken different opportunities of mentioning;
but they are particularly remarkable in ulcers with
callous edges. In sores of this kind, this hardness or
callosity of their edges, is not the only impediment to
a cure: the contiguous parts are always much tumefi-
ed; an occurrence which must be entirely removed
before any permanent cure can be obtained.
This swelling of the neighbouring parts originates
most probably from obstructions taking place in the
smaller vessels of the edges of the sores, in consequence
of pressure produced by the callosities which surround
them: And accordingly it will sometimes subside
merely by the effects of emollient poultices in remov-
ing this hardness by which the tumefaction was in-
duced. But when these do not prove altogether ef-
fectual, pressure obtained by a proper and continued
use of a flannel roller, will in almost every instance
complete the cure.
SECTION 

160 Observations on the Part II.
SECTION VII.
Observations on the CARIOUS ULCER.
§ 1. Of the Symptoms and Diagnosis of the Carious
Ulcer.
BY the term Carious Ulcer, is here understood that
species of the disorder only, which is connected
with a local affection of a bone. For although the
spina ventosa, rickets, and some other disorders of the
bones, may, in particular circumstances, perhaps, come
under the same denomination; yet as it is probable,
that such affections of the bones as occur in these dis-
eases, are connected with, and depend upon, some
general disorder of the system, and which with more
propriety comes under the province of medicine than
of surgery, to enter upon their consideration at pres-
ent would evidently be deviating very much from our
plan: All that is now intended is, to give as clear and
concise a description as possible of that species of caries
in which surgery is more particularly concerned, and
in which, by proper attention, we often have it in our
power to be of more real service, than in almost any
other chronic disorder that comes under the manage-
ment of a surgeon.
It may likewise be observed, that so far as those dis-
eases of the bones above mentioned are to be consider-
ed as local affections, which, after the removal of the
general diathesis which produced them, they frequent-
ly are, the different directions we are afterwards to
give 

Sect. VII. Carious Ulcer. 161
give will be found to apply with equal propriety to
them as to the most simple cases that occur.
The most clear and simple idea that can be given of
a caries, is, that it is a disorder of the bones exactly
of the same nature with a sphacelus or gangrene of the
soft parts; a circumstance which, we think, is very
clearly demonstrated both from the symptoms, causes,
and method of cure.
As the blood vessels in bones are not near so nu-
merous in proportion as they are in the softer parts of
the body, the anastomosing of different vessels cannot
occur in them so frequently; so that, when any con-
siderable artery of a bone happens to be destroyed, the
parts supplied by it naturally suffer much more than
any of the softer organs would do from a similar cause.
And, as all the blood vessels of bones are known to
pass to them through their surrounding membrane
the periosteum, upon which they generally run for a
considerable way before penetrating deeper, it is not
very uncommon for a caries to occur in a bone which
has suffered no other apparent injury than that of
having a very small portion of its membrane de-
stroyed.
We do not, however, mean to say, that a caries
must always necessarily follow a destruction of a part
of the periosteum; for the contrary of this is frequent-
ly known to happen: And unless the injury has been
so considerable, as at the same time either to affect the
structure of the bone itself, or to occasion as we have
already observed, the destruction of some principal ar-
tery, a caries will never occur merely from an abrasion
of the periosteum; but whenever an accident has pro-
duced either of these effects, the other will almost con-
stantly be found to follow.
L From


162 Observations on the Part II.
From the first appearance of a bone after it is laid
bare, unless its substance has been evidently affected,
we can never at once determine precisely, whether a
caries will succeed or not. In mere abrasions of the
periosteum from ordinary accidents, I would, from a
number of observations, conclude, that there is at least
an equal chance that it will not: a short time, how-
ever, will commonly resolve the uncertainty.
For if, at the end of the fourth day at farthest, a
bone that has been denuded still retains its natural ap-
pearance, we may in general conclude, with tolerable
certainty, that no carious affection is to succeed; and
may accordingly proceed with safety in the treatment,
as if the case were that of a simple wound only; which
can never with propriety be done, whilst any uncer-
tainty remains with respect to the state of the bone:
And hence the great consequence of being able soon
to determine whether a bone laid bare is to be attacked
with caries or not.
For if, from want of attention, a cure should be at-
tempted in a case where caries is to follow, and if the
sore should be made to cicatrise, all the new growth
would be again to destroy, much unnecessary pain
would be given to the patient, and a permanent cure
would be much longer protracted than if proper meas-
ures had been taken at the beginning.
In general, however, as we have already remarked,
if a denuded bone is to become carious, it usually
shows itself in a very short time. By the end of the
third or fourth day at farthest, the bone begins to lose
its natural healthy appearance, turns first of a pale
white, and then gets a slight tinge of a yellow com-
plexion; and whenever this begins to appear, there
can be no longer a doubt of what will be the conse-
quence.                                      
It

Sect. VII. Carious Ulcer. 163
It sometimes remains, however, in this state for a
good many days, and by degrees gets a more deep tal-
low like appearance; in which state it commonly con-
tinues for a longer or shorter time, according to the
degree of violence with which the injury has been
done; and afterwards goes through the different stages
of brown and dark, till it has acquired a black of the
deepest dye, a period at which we may suppose this
portion of the bone is arrived at, perhaps, the highest
degree of mortification.
The discharge from ulcers of this kind, is never of
the consistence of good pus: it is generally consider-
ably thinner; and from the first appearance of a ca-
ries, it acquires a most disagreeable fetor, which al-
ways turns more considerable as the different stages of
the disorder advance; and at last, too, it acquires a
blackish hue, at the same time that it frequently be-
comes exceedingly acrid.
As the several degrees of blackness or mortification
go on, small foramina or holes seem as it were to form
in the diseased parts; and by degrees increase consid-
erably, till even the most solid bones acquire a kind of
spongy appearance. In this situation, the mortified
portion generally becomes loose, and, when pressed
upon, a considerable quantity of a fattish like matter,
with an intolerable fetor, can commonly be forced out
from the different openings; which so taints the whole
discharge from the ulcer, and gives it such a very pe-
culiar smell, as to render it scarcely possible for any
practitioner who has once known thoroughly what it
is, ever to be deceived with respect to the existence of
a caries. Indeed this circumstance alone affords al-
most as certain a distinction in cases of latent caries, as
any that can be pointed out.
L 2 In


164 Observations on the Part II.
In ulcers attended with a carious bone, the fleshy
parts never have a healthy appearance; they are soft
and more flabby than natural; and, instead of a florid
red, they have rather a dark brown, together with
somewhat of a glassy complexion.
The granulations, however, commonly advance
quickly enough; and they would frequently proceed
too far, if they were not prevented by art; which it is
always necessary that they should be till the diseased
parts of the bone are either cast off by the efforts of
nature, or are cut out by art, so as that the healing of
the sore may take place with certainty from the bot-
tom. And, when neglected for any considerable time,
these soft productions in carious ulcers frequently in-
crease so remarkably, as to form very large and trou-
blesome excrescences.
We have hitherto been supposing, that only a por-
tion of the substance of a bone has been affected; in
which case a cure is sometimes obtained by a single
lamina only casting off. But the same phenomena
likewise occur when the caries has been so considera-
ble, as to affect a bone through its whole circumser-
ence. Only, in this case, the caries generally advan-
ces more quickly; and, in the treatment of it, it is of-
ten necessary that the whole substance of the bone, in
the diseased part of it, should be taken out.
Such are the different appearances of caries pro-
ceeding from an external accident that has laid the
bone fairly open to view: But the same kind of dis-
ease occurs frequently in a more latent manner; and,
in such cases, it proves always, in every respect, a great
deal more troublesome.
Ulcers of long continuance above the tibia, or any
other bone not thickly covered with soft parts, merely
by 


Sect. VII. Carious Ulcer. 165
by the matter insinuating itself to the periosteum, and
there producing an inflammation and suppuration of
that membrane, by which the bone itself is apt to be
eroded, very often prove the origin of troublesome
cariosities; which again, as long as they remain, pre-
vent effectually the proper cure of all such sores, not-
withstanding the use of every remedy that can be em-
ployed. For when, by the application of very drying
astringent remedies, a cicatrix happens in such cir-
cumstances to be induced, it proves constantly a tem-
porary cure only; for the disease, in the course of a
short time, always breaks out again.
In such cases as we are describing, when the exter-
nal ulceration is not attended with a great destruction
of parts, so that the bone still remains with a tolerably
thick covering, a caries is not always easily discovered;
so that practitioners are frequently, for some time, at a
loss how to proceed in the cure: With a little atten-
tion, however, and especially with the assistance of
experience in former similar circumstances, a carious
bone may, in general, be easily enough detected.
When by the introduction of a probe at any open-
ing that may have been formed, if a roughness is dis-
covered on the surface of the bone, the case becomes
altogether evident.
Such information, however, is not always to be ob-
tained: for frequently there is no evident opening in
the surface of the sore; and, if there are any, they are
often so small that no instrument proper for the pur-
pose can get admission. And on other occasions, a-
gain, when an opening even tolerably large is met
with, and when a caries does certainly exist, yet the
diseased part cannot be reached with the probe on ac-
L 3 count


166 Observations on the Part II. 
count of the obliquity or winding direction of the
sinus which leads to it.
Although in such case, however, the bone itself
cannot be immediately reached; yet if sufficient at-
tention be given to the appearance of the sore and to
the nature of the discharge, we will not often be at
any great loss.
If a caries of the bone does take place, any new
parts which may have appeared in the sore, are com-
monly, as we formerly remarked, soft and flabby; and,
instead of forming a regular surface, the new gra-
nulations sprout up in different clusters, of the size of
small nuts or the like; and, instead of a healthy red
appearance, they have usually a dark brown com-
plexion.
These circumstances, when they take place, togeth-
er with the discharge from the ulcer being thin, dark,
and of a greasy appearance, and especially the peculiar
and very offensive fetor which a caries always affords,
point out the real state of a bone in every case of this
kind, with almost as much precision as if the bone it-
self were exposed to view.
§ 2. Of the Causes and Prognosis of the Carious Ulcer.
All such accidents as can occasion either denuda-
tion, loss of substance, or erosion of a bone, have com-
monly been enumerated by authors as the causes of
caries. But it is a circumstance well known to every
practitioner, that the common teguments and perios-
teum are very frequently destroyed, without any cari-
ous affection ensuing: and that even a very consider-
able loss of substance in a bone may, and frequently
does, occur, without being followed by any such ap-
pearance.
The


Sect. VII. Carious Ulcer. 167
The causes, therefore, of caries may, in general, be
said to be, whatever can, by erosion or otherwise, de-
stroy the circulation in the whole or in any part of a
bone.
As such, may be mentioned, wounds in general,
which affect either the periosteum or bones; violent
contusions, and inflammation of the periosteum, from
whatever cause it may proceed, when it ends either in
abscess or gangrene; the acrid matter of ulcers pene-
trating to and destroying the periosteum; and, lastly,
the improper application of sharp acrid spirits and
powders to bones merely laid bare; a practice we find
recommended very universally by almost all the an-
cient writers on this part of surgery.
We have observed above, that loss of substance in a
bone does not always produce caries. Thus, very
considerable portions of the cranium, it is well known,
are frequently taken out when fractured, without any
caries of the remaining part of the bone ensuing; and
that the same circumstance likewise happens, in many
instances, in other parts of the body, I have had va-
rious opportunities of being convinced of.
That such occurrences, however, do not so frequent-
ly take place in other bones as in those of the crani-
um, cannot be denied: and the reason of it very pro-
bably is, that by a greater proportion of blood vessels
being sent to the bones of the skull than to any of the
long ones; any accident which might otherwise be
sufficient for separating one part of a bone from ano-
ther, will, by this mechanism, be prevented from ef-
fecting a stoppage of circulation in the contiguous re-
maining parts with so much ease as in the hard bones
of the extremities, in which the blood vessels are much
more sparingly distributed: And to such a stoppage
L 4 we


168 Observations on the Part II.  
we have already endeavoured to show that every case
of caries is to be attributed.
In every instance of caries, the prognosis to be form-
ed must depend upon a variety of circumstances: The
principal of which are,
The situation of the diseased parts; the nature and
organisation of the affected bone; the nature and de-
gree of the inflicting cause; the size of the caries; the
age and habit of the patient.
Thus it will be readily allowed, that a caries in any
of the bones of the skull, ribs, or vertebræe, by these
parts being situated above or upon organs so immedi-
ately necessary for life, must be attended with more
risk, than a disease, in every other respect of a similar
nature, in any of the bones of the extremities.
For a similar reason, too, a caries seated near to any
of the joints, from the danger of these becoming af-
fected, is always attended with more risk than when
the disease is confined to the middle of a bone.
The consistence or texture of a bone, too, has no
small influence in every case of caries; exfoliations
being much more tedious, in the hard and compact,
than in the more soft vascular bones. Thus, although
as we have already remarked, disorders of this kind are
attended with more risk on the skull than elsewhere;
yet a caries of any of the bones of the cranium, if it
admits of a cure at all, never proves near so tedious as
when the hard substance of the humerus, femur, or
tibia, is affected.
The nature of the cause which produced the disor-
der, has likewise a considerable effect in determining
the prognosis. Thus a wound with a sharp cutting
instrument, that may have destroyed not only some of
the periosteum, but even part of the bone itself, does
not 

Sect. VII. Carious Ulcer. 169
not generally produce either such a deep or extensive
caries as what commonly succeeds to violent contu-
sions of bones, with perhaps no immediate loss of sub-
stance.
The extent of the diseased part, too, we have already
observed, is a circumstance which influences the cure
considerably. This is, no doubt, the case in every
species of ulcer, but it is more particularly so in all
cases of caries; for it is constantly found, that much
more time, in proportion, is requisite for the separa-
tion of a large piece of spoiled bone, than what in gen-
eral proves sufficient for the removal of one of a less
extent.
And, lastly, as in every species of sore, the patient's
being young or old, healthy or otherwise, are circum-
stances which occasion very considerable differences in
the progress of the cure. This, we may remark, is the
case in every variety of ulcer; but it is particularly so
in those attended with carious bones, which always
render the cure of sores so extremely tedious, that few
constitutions are able to support the discharge which
they produce, if they have not previously been per-
fectly firm and healthy.
These are the leading circumstances requiring our
attention, in the treatment of ulcers attended with ca-
rious bones; and it is from a due attention to all of
them that a just prognosis is to be formed.
§ 3. Of the Cure of the Carious Ulcer.
Caries being a disease of the same nature in the
bones, as  mortification is in the soft parts, no cure, it
is evident, can with propriety be attempted, till the
removal of all the diseased parts is accomplished.
For, 

170 Observations on the Part II. 
For if, either by accident or design, an union of the
parts above such a caries should be obtained, the dead
portion of the bone not having any connection with
the living or sound parts, and by thus acting as an ex-
traneous irritating body, would soon produce an ab-
scess or collection of matter, and in this manner would
force open the parts already united.
In a healthy constitution, the separation of diseased
mortified parts from such as remain sound, is, in gen-
eral, accomplished by a natural exertion of the system.
The course which nature follows in effecting this,
seems, as we formerly remarked when treating of gan-
grene, to be through the intervention of a slight de-
gree of inflammation excited upon the extremities of
the remaining sound parts, which forms, as it were, a
boundary between these and such as are diseased.
In consequence of such an inflammation, a serous
exsudation from the mouths of the sound vessels is
produced; a suppuration is accordingly brought
about, with a consequent production of new granula-
tions, which, together, soon effectually detach all the
diseased from the living parts.
This is evidently the process, in such cases of morti-
fication as occur in the softer parts of the body; and,
with a very little attention, the same phenomena will
be observed in every case of caries. Only in the lat-
ter, from their being in the bones, as we have former-
ly remarked, a more sparing distribution of blood ves-
sels, and consequently not such a disposition to in-
flammation, the exertions of nature, for the removal
of the disease, are seldom so quickly accomplished.
It is from a due attention to this process of nature,
in freeing herself from such disorders, that the greatest
advantages in the treatment of caries are to be obtain-
ed: 

Sect. VII. Carious Ulcer. 171
ed: And if we be directed by this in the choice and
order of our applications, we may have it frequently
in our power to accomplish in a few weeks, what na-
ture, if left to herself, would require many more months
to effect.
From the foregoing considerations, the principal in-
dication, it is evident, in every case of caries, should
be, by proper applications frequently reiterated, to
excite, and continue as long as may be necessary, such
a degree of inflammation in the adjoining sound parts
of the bone, as may be requisite for the total separation
of the mortified parts.
In this state of the disorder, the diseased part of the
bone we suppose to be laid quite bare; which in the
case of caries, as we first described, is the case from the
beginning; and which must, in the other, be brought
about, by destroying the corrupted and other parts that
cover it, as soon as the caries from the different symp-
toms is known to exist.
So far at least it must be laid open, as is necessary
for getting freely at the disease of the bone in its full
extent. This, by a mere incision along the course of
the caries, may in general be done; but when the dis-
ease occupies any considerable extent of surface, it be-
comes necessary to make a crucial incision, or even to
take away part of the teguments altogether. And till
the disease of the bone is entirely removed, it is neces-
sary, by a due attention from time to time, to prevent
the formation of new parts, at least so far as might in
any degree obstruct the separation of the caries.
Whether authors have ever had in view such an in-
dication as the one we have mentioned, for the cure of
caries, I know not: but the remedies employed, in
such cases, have, in general, been very different from
those 

172 Observations on the Part II.
those which reason evidently points out, and from
those means which have been used with much success
by many modern practitioners.                
The directions given by all the older writers on
this subject, and which are still attended to by some
of the moderns, are, in every case of caries, or even
only of a denuded bone, to apply immediately, to the
bone itself, powders and tinctures of aloes, euphorbi-
um, myrrh, and other warm gums. This, it is proba-
ble, they were originally led into, with a view to cor-
rect the great degree of fetor and putrefaction that, in
cases of carious bones, always takes place: and from
custom only the practise has been continued, without
any other satisfactory reason for the only effects
which these applications can ever produce, farther
than that of correcting the smell, is to irritate and in-
flame the soft parts of the sore, without having the
least influence on the more material disease of the
bone.
For, when the caries is of any considerable depth,
such substances can never penetrate to or affect the
sound parts of the bone, where alone, by the irritation
they would occasion, some benefit might be expected
from them.
And again, when no caries or affection of this na-
ture has appeared, such applications to bones merely
denuded of their periosteum, can never, in any respect,
be necessary; and may, on the contrary be frequently
a means of inducing a real caries, the very disorder
they have intended to prevent.
Another remedy which we find frequently recom-
mended by almost every author, in the more advanced
stages of caries especially, is the actual cautery. This,
however, independently of the many objections made
to 


Sect. VII. Carious Ulcer. 173
to it by patients, from the pain and seeming cruelty
attending it, is evidently, from its nature, a very inju-
dicious application in all such disorders: and al-
though many have no doubt recovered When the cau-
tery has been made use of, there can be little doubt,
but that the same complaints would have been more
quickly removed, although no such remedy had been
employed; for, in whatever way we suppose it to be
applied, its effects must evidently be pernicious.
If the cautery be applied in such a manner as en-
tirely to destroy the diseased parts of the bone, as is
commonly recommended, the sound parts underneath,
from the degree of heat necessary for that purpose,
must undoubtedly always suffer so much, as to be
soon rendered equally carious with those intended to
be removed.
And, on the contrary, when it is used in a more
sparing manner, the diseased part of the bone will not
be removed, whilst at the same time there will be a
considerable risk incurred of retarding the natural ex-
ertion of the system for the removal of the disease:
for even a very moderate heat will effect the destruc-
tion of such granulations as nature may for this pur-
pose have already formed; and the just degree of heat,
it may be remarked, necessary for destroying the mor-
bid, without affecting the sound parts, it is scarcely
possible to determine.
When, for any particular reason, the actual cautery
may not be judged proper, it has been recommended,
by the same authors, to make use of different artificial
caustic preparations; and by others, it is advised, as
the shortest process, to strike off at once all the diseased
parts with a chisel and mallet.
But 
 

174 Observations on the Part II.
But the objections to the use of the cautery, which
we have already slated, hold equally strong with re-
spect to these: so that, in every case of caries, every
application of such a precarious nature should be en-
tirely laid aside; especially as we have it in our pow-
er to accomplish the same indication in a much more
safe and certain manner.
For the purpose of exciting a necessary degree of in-
flammation, the most effectual and safest method, and
which, in slight cases of caries, proves always suffic-
ient, is to make a number of small perforations all over
the surface of the diseased bone, to such a depth as to
give the patient a very little pain, and no farther.
This operation being, in different parts, renewed
every third or fourth day, the diseased portion of the
bone, in the course of a short time, not only loses the
cohesion of its own parts, but a gentle inflammation
being, by the same means, raised and kept up till a free
suppuration is produced, the whole mortified mass is
generally, in a short time thereafter, entirely thrown
off.
These perforations are very conveniently and effect-
ually made by a pin or perforator, such as is used for
fixing the head of the trepan; which being fixed in
the handle of that instrument, not the one in common
use, but that which resembles the tool made use of by
coopers for perforating casks, it is thereby wrought
with a great deal of ease and expedition.
Although the operation, as now described, in gener-
al answers very effectually in slight cases of caries,
which are not of great extent, and which do not pen-
etrate deeper than the first or second lamella of a
bone; yet when the disease is very extensive, and es-
pecially when it goes deep into the substance of a bone,
it 

Sect. VII. Carious Ulcer. 175
it shortens the process considerably, if, instead of the
perforator, a very small head of a trepan be employed.
This instrument being applied at proper distances
over the surface of the caries, and being carried just as
deep as to give the patient a very little pain, as we for-
merly directed, the production of that degree of in-
flammation which we have shown to be so necessary in
all such cases is thus very considerably promoted.
And at the same time, by converting, as it were, a very
large caries into so many smaller diseased parts, their
separation from the sound bone below comes to be
much more easily effected, than if the whole surface
had still remained in one continued piece.
As soon as any of the parts loosen at the edges, their
final separation may be always greatly hastened, by
daily insinuating below them the end of a common
spatula or levator, so as to press their edges a very lit-
tle upwards.
The head of a common trepan is frequently made
use of for taking out a piece entirely when bones hap-
pen to be carious through the whole substance of their
differeut lamellæ; but, in the state of the disease, of
which we are now speaking, the caries is not supposed
to have advanced so far, and consequently such a prac-
tice cannot with propriety be recommended.
After the use of either of the above mentioned in-
struments, the ulcer is to be dressed in the usual man-
ner. Only, as long as any of the carious bone re-
mains, the putrescency and fetor of the matter are com-
monly so considerable, that it becomes necessary to
employ some remedies merely with a view so correct
it. or which purpose, a strong decoction of Jesuit's
bark and walnut tree leaves is frequently used with
advantage: and a solution of camphor in weak brandy
is 

176 Observations on the Part II.
is also an application by which this fetor of morbid
bones is very effectually corrected. The carious part
of the bone should be daily dressed with pieces of soft
lint soaked in either of these, whilst the rest of the
sore is treated in the manner we have directed for cas-
es of simple purulent ulcers.
This putrescent state of the discharge afforded by 
carious ulcers is likewise much corrected by the appli-
cation of lime water: If the sores be daily moistened
with soft cloths dipt in it, the matter seldom becomes
very offensive; and as this remedy seems to have some
influence in destroying the cohesion of osseous matter,
it ought never to be omitted in any case of this kind.
Since I first employed lime water in ulcers attended
with carious bones, I have met with different instan-
ces of exfoliations being much promoted by it.
As soon as the carious parts are all entirely remov-
ed, the whole being then in the state of a simple pu- 
rulent sore, it ought to be treated accordingly: For,
although we are particularly directed by authors in
general, never, in any case of caries, or of denuded
bone, to make use of ointments, or of any kind of
greasy application; yet as there was never any just
reason given for such a prohibition, I long ago made
trial of applications of this kind in cases of caries; and,
no inconvenience arising from the practice, I have
since that time been in the daily custom of applying
them just as freely to bones as to other parts.
Of the great variety of books I have had occasion
to consult upon this subject, none have afforded me
more satisfaction than a treatise on carious bones, by
the late celebrated Dr. Monro; and I am happy to
find, that the practice we have ventured to recom-
mend is supported by the authority of such an emi-
nent 
 

Sect. VII. Carious Ulcer. 177
nent practitioner; who, after speaking of the applica-
tion of unctuous medicines to bones, not only admits
of it as safe, but recommends the practice as exceed-
ingly useful; and says, "I can now, after a great ma-
ny trials, assure you that no medicines so effectually
prevent the corruption of bones laid bare, and assist to
cover them so soon with flesh, as ointments."*
We have hitherto been supposing, as was already
observed, that the disease does not penetrate far into
the substance of a bone: but when this is found to be
the case, and a considerable portion, perhaps, of its
whole circumference is affected; or when the disease
extends even round the whole bone, which in many
instances is the case; the shortest process then is, to
take out at once all the diseased parts, either with the
head of a trepan frequently applied, or by means of a
small spring saw.
Many inventions have been proposed for cutting
out portions of carious bones which lie deep: With a
view to protect the contiguous parts from being injur-
ed by the saw, it has been advised to cover them with
thin plates of steel; and saws of various forms have
been supposed to be necessary for dividing the bone.
Almost every part of surgery is already too much
loaded with machinery; but no operation with which
we are acquainted, seems to require less aid from new
instruments than the removal of a portion of a carious
bone. In whatever part of the body the disease is
seated, the teguments and muscles which cover the ca-
ries
* In the same ingenious Dissertation may be seen a particular account
of the several species of caries; with a list of authors in different ages,
from Hippocrates downwards, who have wrote upon it, with the sever-
al methods of cure proposed by each of them Vid. Monro's Works,
410. Edin. 1781, p. 283, &c.
M. 

178 Observations on the Part II.
ries should be freely divided: and, when the bones of
any of the extremities are affected, if this be done to a
proper extent, so as to admit of a piece of firm leather
being inserted below the bone, for the purpose of pro-
tecting the soft parts on the opposite side of the limb,
a common straight saw will answer, in almost every
case, better than any other instrument. But when the
bone lies very deep, a small spring saw of a circular
form may be employed for dividing such parts of it as
cannot be easily reached by the common saw.
Thus either by the use of the trepan, or by a saw,
any portion of a diseased bone may be removed; a
practice which may frequently be employed to much
advantage in the skull, in the bones of the hands and
feet, as also in those of the legs and arms, when the ca-
ries does not run into the necks and heads of the bones,
so as to affect the joints: In which event, if an anchy-
losis does not ensue, or if nature dees not by some
means or other affect a cure, amputation of the limb
must almost always be had recourse to at last; a caries
of the extremities of large bones being one of the ma-
ny complaints for which art has not as yet discovered a
remedy.
But, whenever a caries is confined to the middle of
any of the bones of the extremities, excepting, per-
haps, in the thigh, where the thickness of parts is very
considerable, amputation of the member should never
be advised for it: for, with a little patience and attention,
if the patient's health is not much injured, nature may,
in general, be so far assisted by removing the diseased
parts, that a complete cure may at last be most fre-
quently obtained. And in no case whatever ought we
to despair, when the carious part can, with safety, be
removed: For, however extensive the disease may be,
if

Sect. VII. Carious Ulcer. 179
if we can properly accomplish its removal, nature will
seldom fail on her part, in filling up the vacancy;
there being many instances to be met with, in different
chirurgical publications, of even whole bones being re-
generated.
We have observed above, that in carious affections
of the larger joints, amputation of the diseased limb
is almost the only remedy to be depended on. It has,
however, been proposed, and has even been attempted,
to save limbs affected in this manner, by cutting out
the ends of the carious bones. Mr. Park, a very in-
genious surgeon of Liverpool, has published a trea-
tise upon this subject, in which he gives the history of
a diseased knee joint where this operation succeeded.
Although much merit, however, is due to whoever
makes any probable attempt for saving limbs which
otherwise would be amputated, and although the pub-
lic is much indebed to Mr. Park for the trouble he
has taken in promoting the success of the operation we
have now mentioned, yet, from various circumstances
there is much reason to think, that it will never be
found to be of much general utility: Independent of
other objections which occur to it, the risk which at-
tends it is evidently much greater than what common-
ly results from the amputation of limbs: the extent of
sore induced by it is greater; the suppuration is of
course more plentiful; and the matter is not so freely
discharged. We do not here, however, think it nec-
essary to enter more fully into the discussion of this
point, as we shall have occasion to treat more particu-
larly of it in another work in which we are at present
engaged.
During the treatment of a caries, it must be under-
stood that the same attention is requisite to the pa-
M 2 tient's 


180 Observations on the Part II.
tient's habit of body, diet, and regimen in general, as
we have recommended in other species of ulcers.
Thus, if he is of a full inflammatory constitution,
all heating and very nourishing articles of diet should
be abstained from; and if, on the contrary, the system
is low and emaciated, as from the long continuance of
such disorders is most frequently the case, a nourish-
ing generous regimen should always be allowed. In
such cases, too, as tonic remedies are much wanted,
Jesuit's bark is often found to be very serviceable,
and it should always be used in considerable quan-
tities.
The bark is almost the only medicine which, in
cases of caries, should ever be given internally: but in
some instances the soft parts which cover a carious
bone, become so swelled and painful, that opiates are
found to be necessary. And as it appears, that in
such cases the pain proceeds in a great measure from
the distention of the periosteum, in consequence of the
bone becoming enlarged, I have frequently been in-
duced to try the effects of slight scarifications, or of
bleeding with leeches directly on the pained parts;
by which means relief is frequently obtained when it
cannot be procured by any other means. I may here
remark, too, that in every species of ulcer, attended
with much pain, leeches applied either upon the edg-
es of the sores, or directly upon the affected parts, are
often attended with the best effects, insomuch that I
am now in the daily habit of using them whenever a
sore becomes so inflamed and painful as to resist the
influence of poultices and the other means we have
recommended.
In every ulcer of this kind, as soon as the diseased
part of the bone is extracted, the sore which remains is
to

Sect. VIII. Cancerous Ulcer. 181
to be treated in the manner we have already directed
for the management of that species of ulcer, to which,
at the time, it may appear to belong.
SECTION VIII.
Observations on the CANCEROUS ULCER.
§ 1. Of the Symptoms and Diagnosis of the Cancerous
Ulcer.
CANCERS have been generally divided into oc-
cult and open. By the former are meant such
hard scirrhous swellings as are attended with frequent
shooting pains, and which at last generally terminate
in the latter.
By the open cancerous ulcer, we understand that
species of sore, which commonly succeeds to hard
swellings of the glands; although in some instances, it
occurs without any previous hardness. The edges of
the ulcer are hard, ragged, and unequal, very painful,
and reversed in different ways, being sometimes turn-
ed upwards and backwards, and on other occasions
inwards. The whole surface of the sore is com-
monly very unequal: in some parts there are consid-
erable risings, whilst in others there are deep excava-
tions. The discharge for the most part is a thin, dark
coloured, setid ichor; and is often possessed of such a
degree of acrimony as to excoriate, and even to des-
troy the neighbouring parts. In the more advanced
stages of the disease, too, by the erosion; of blood ves-
M 3 sels


182 Observations on the Part II.
sels which occurs, considerable quantities of pure
blood are sometimes discharged.
Patients labouring under real cancerous affections,
universally complain of what they term a burning heat
over the whole ulcerated surface; which, in general,
it may be remarked, is the most tormenting symptom
that attends the disorder; and those shooting lancinat-
ing pains, which were very distressing even in the more
occult state of the complaint, become now a great deal
more so.
These are the most frequent symptoms which attend
an ulcerated cancer; but the appearances of such sores
are so various, that it is almost impossible in any des-
cription to comprehend every one. When two, three,
or more, however, of those we have enumerated, con-
cur together in the same ulcer, we may always be pret-
ty certain of its being of the cancerous kind.
The situation too of such sores, affords some assist-
ance in the diagnosis: for though cancers do no
doubt occur in every part of the body, yet by far the
greatest proportion happen, either evidently in the
substance of one or more glands, or in those situations
where glands are known to be most numerous. Thus
six times the number of cancerous affections, we im-
agine, occur in the lips and in the breasts of women,
than in all the rest of the body besides.
§ 2. Of the Causes of Cancerous Disorders.
Various circumstances have been mentioned by au-
thors as tending to produce cancer, and an equal num-
ber of remedies have been recommended for the cure
of it: But the little success which still attends our
treatment of the disease, shows evidently, that the ideas
which have been adopted, and the remedies proposed,
have 

Sect. VIII. Cancerous Ulcer. 183
have been more founded on theory alone than on
practice and observation; for there is no disease to
which the human frame is liable, that has baffled the
power of art more than that which we are now consid-
ering.
Although a thorough acquaintance with the theory
of the disorder might probably throw some light upon
the method of cure; yet as any thing that has hitherto
been offered, or perhaps as yet discovered upon this
subject, seems to be merely speculative, and not sup-
ported by experience, any account we could give of it
here, would not prove either entertaining or instruc-
tive. Before going farther, however, it would seem
to be of consequence, to examine with accuracy the
different opinions of practitioners, with respect to can-
cers being a general disorder of the system, or merely
a local affection.
This is a point, we may remark, of much import-
ance in practice: for if it were once established, that
cancers are originally local affections only, no objec-
tion could then be made to their cure by extirpation,
as at present there is by many, who contend, that can-
cers, in every instance, proceed originally from some
disorder in the general system; and consequently,
that their removal can never have any other effect
than to make the disease again break out in the same
or in some other part of the body. And this they are
much confirmed in, from attending to the little success
which is commonly derived from the extirpation of
cancers; the disorder, as is alledged, generally return-
ing, in by far the greatest proportion of all that are
cut.                                    
If this argument were founded in fact, it would no
doubt merit some attention; though even in this case
M 4 it


184 Observations on the Part II.
it ought not to be considered as conclusive against the
operation, as will hereafter more evidently appear. It
will soon, however, be demonstrated, and to many in-
deed is already known, that a much greater propor-
tion than what we have mentioned, recover and do
well after the extirpation of cancers; and it is proba-
bly the fault of surgeons, or of patients, only, who
generally delay the operation too long, that the num-
ber of those who recover is not much larger than hith-
erto it has ever been.
It is of the more importance to have the point in
question determined, as the only account of the suc-
cess from extirpation, which, till lately, has appeared
in this country, gives so bad a prospect of recovery,
that I make no doubt of its having been the means of
deterring many patients from undergoing a timely op-
eration; which for cancerous complaints, is the only
remedy to be depended on with which we are as yet
acquainted.
It is very probable, too, that the same publication,
as coming from great authority, has had no inconsider-
able influence even with practitioners, in making them
much more backward in undertaking the extirpation
of cancers, than they otherwise probably would have
been.
The publication alluded to, is that of the late justly
esteemed Dr. ALEX. MONRO, in vol. v. of Edin-
burgh Medical Essays; where the Doctor says, "Of
near sixty cancers which I have been present at the
extirpation of only four patients remained free of the
disease at the end of two years: three of these lucky
people had occult cancers in the breast, and the fourth
had an ulcerated cancer on the lip."
The

Sect. VIII. Cancerous Ulcer. 185
The Doctor likewise observes, that of the few he
had an opportunity of seeing the disease relapse in, it
was always more violent, and made a quicker progress,
than it commonly did in others on whom no opera-
tion had been performed. He therefore proposes by
way of question, "Whether ought cancerous tumors
to be extirpated, or ought the palliative method only
to be followed when they cannot be resolved?" and
upon the whole, he concludes against their extirpa-
tion, except in such as are of the occult kind, in young
healthy people, and that have been occasioned by
bruises or some other external causes. In all other
cases, the doctor observes, it should be the patient's
earnest intreaty only, after the danger of a relapse has
been explained, that should make a surgeon undertake
the operation.
That Dr. Monro, from observing the disease to re-
turn so very frequently, should be of this opinion, is
not in the least surprising: and if no better success
should, in general, be found to attend the extirpation
of cancers, it would no doubt be an objection to the
practice; and this especially, if all the cases which re-
lapse should be found to be attended with more invet-
erate and more painful symptoms, than they either
were previous to the operation, or than they probably
ever would have been if the tumors had not been ex-
tirpated.
But the experience of many practitioners since Dr.
Monro's publication, has been attended with much
greater success; and one late publication upon the
subject, of which we shall afterwards take notice, puts
it beyond a doubt, that a much greater proportion
have recovered from cancers by means of extirpation,
than of those which were treated in the same manner
in

186 Observations on the Part II.
in the course of his experience. It will not therefore
appear to be improper, to attempt to discover the rea-
son of the Professor's great want of success in such
cases, in comparison with what others have met with:
and this, it is presumed, will not be difficult to do.
It may, I think, be considered as certain, that the
sooner cancerous cases are operated upon after their
appearance, the greater is the chance of the extirpa-
tion's proving effectual, and vice versa.
Now, it is exceedingly probable, that the high rank
which Dr. Monro bore in his profession, both as an
anatomist and surgeon, would be the means of his be-
ing applied to for more bad and old cases of cancer, as
well as of other complaints, than perhaps any other
practitioner of his time. Patients in the country,
with slight cases of cancer, have them generally taken
off by their own surgeons: but whenever they become
of a more inveterate nature, by long standing or oth-
erwise, patients always resort to a town; to the capi-
tal, when they can conveniently do so; and there the
most eminent in his profession is naturally applied to.
This being the case, it is not surprising that very little
success attended many of the operations performed in
such cancerous cases as occurred to Dr. Monro.
From the cause we have mentioned, a great propor-
tion of these would be of the worst kind; so that we
need not wonder either at the bad success of any ope-
rations which were advised, or at the opinion which
the Doctor afterwards adopted on the subject.
Such unfavourable cases as those we have repre-
sented, it is probable, for the reasons alledged, would
most frequently occur in Dr. Monro's private prac-
tice; and in his attendance on the infirmary, he would
in general, meet with very similar ones. For, in ev-
ery 

Sect. VIII. Cancerous Ulcer. 187
ery hospital, it is commonly the worst cases chiefly
that are to be met with; as, before application is made
there, private surgeons are always consulted, who,
when an operation is to take place, if the case does not
appear to be desperate, and if any reputation is likely
to be got from it, generally retain the patient under
their own management. And, on the contrary, when
the disease is evidently of an inveterate nature, and
when an operation therefore would probably be at-
tended with much risk, the patient is always recom-
mended to a public hospital. So that no fair judg-
ment, from the result of such experience, in cancerous
cases especially, can ever be formed, unless at the same
time these different circumstances be properly attend-
ed to, and due allowance be made for them.
This, in my opinion, is the only way in which the
great want of success which attended the extirpation
of cancers in the course of Dr. Monro's experience,
can be properly accounted for; and it explains it, I
think, in a very satisfactory manner: so that all the
conclusion which can be drawn from this part of the a-
bove mentioned paper is, that there is very little chance
of success from extirpation in the more advanced states
of cancer; a circumstance which ought, therefore, to
make us have recourse to that operation in the earliest
stages of the disease, when in general there would not,
probably, be much chance of its frequently failing.
Such expectations will probably, by many, be con-
sidered as by much too sanguine; and they no doubt
would be so, if the success which in general attends
the operation, was all that could be attained: but its
proving, for the most part, so unsuccessful, should by
no means be imputed either to the nature of the dis-
ease or to the fault of the remedy; but entirely to its
being, 

188 Observations on the Part II.
being, in by much the greatest number of cases, delay-
ed too long, till the system has become so much infect-
ed, that we should rather wonder at the operation's
succeeding so frequently, as it is, even in the general
course of practice, found to do.
In confirmation of the opinion we have endeavour-
ed to support, it is not thought improper here to in-
troduce a very short abstract from a late publication
on cancers formerly alluded to, by the late Mr. James
Hill, an eminent surgeon in Dumfries, who, in the
course of a very extensive practice, had more experi-
ence in cancerous cases than often falls to the share of
one man: So that to such as have not yet perused Mr.
Hill's book, it will not probably appear to be super-
fluous that we should insert here a short extract from
his observations on these complaints.
In the year 1772, the date of this publication, Mr.
Hill had extirpated from different parts of the body,
eighty eight genuine cancers, which were all ulcerated
except four; and all the patients, except two, recov-
ered of the operation.
Of the first forty five cases, only one proved unsuc-
cessful; in three more, the cancer broke out again in
different parts; and in a fifth, there were threaten-
ings of some tumors at a distance from the original dis-
ease. These tumors, however, did not appear till
three years after the operation, and the woman was
carried off by a fever before they had made any prog-
ress. All the rest of the forty five continued well as
long as they lived; or are so, says Mr. Hill, at this
day. One of them survived the operation above thir-
ty years; and fifteen were then alive, although the
last of them was cured in March 1761.
Of

Sect. VIII. Cancerous Ulcer. 189
Of the next thirty three, one lived only four
months; and in five more the cancer broke out afresh,
after having been once healed. The reason why, out
of forty five cases, only four or five proved unsuccess-
ful, and six out of thirty three, was as follows.
"The extraordinary success I met with," continues
our author, " made cancerous patients resort to me
from all corners of the country, several of whom, after
delaying till there was little probability of a cure by
extirpation or any other means, forced me to perform
the operation contrary both to my judgment and in-
clination."
Upon a survey in April 1764, made with a view to
publication, the numbers stood thus: Total cured of
different ages from eighty downwards, sixty three; of
whom there were then living in all thirty nine. In
twenty eight of that number the operation had been
performed more than two years before, and in eleven
it had been done in the course of the two last years.
So that, upon the whole, after a course of thirty
years practice, thirty nine of sixty three patients were
alive and sound; which gives Mr. Hill occasion to
observe, that the different patients lived as long after
the extirpation of the cancers, as, according to the bills
of mortality, they would have done, had they never
had any cancers, or undergone any operation.
The remaining twenty five, which completes the
eighty eight, were cured since the year 1764. Twenty
two of these had been cured, at least, two years; and
some of them, it may be remarked, were seventy years,
and one ninety years old.
In the year 1770, the sum of the whole stood thus.
Of eighty eight cancers, extirpated at least two years
before; not cured, two; broke out afresh, nine;
threatened 

190 Observations on the Part II.
threatened with a relapse, one; in all, twelve, which
is less than a seventh part of the whole number. At
that time there were about forty patients alive and
sound, whose cancers had been extirpated above two
years before.
I have been the more particular in giving this ac-
count of Mr. Hill's success in cancerous cases, as it is
the latest, and perhaps the most considerable, even in
point of number, that the public was ever favoured
with: and I am the more readily induced to it, from
having been present at a considerable number of the
operations; and from knowing that no fallacy or mis-
take could occur in the relation, Mr. Hill having been
so exact, as to keep a register of every case of much
importance that came under his management.
From these and many other authenticated facts,
which if necessary might be adduced, of the success at-
tending the extirpation of cancers, there is, it is pre-
sumed, very great reason for considering this disease,
in general, as a local complaint, not originally con-
neaed with any disorder of the system; and that a
general cancerous taint seldom, or perhaps never, oc-
curs, but in consequence of the cancerous virus being
absorbed into the constitution from some local affec-
tion. This, in every case of real cancer, or rather in
such scirrhosities as from their nature are known gen-
erally to terminate in cancer, should certainly deter-
mine us to have recourse to extirpation as early as
possible; and is this was done soon after the appear-
ance of such affections, or before the formation of mat-
ter takes place, their return, as was already observed,
would probably be a very rare occurrence.
The particular nature of the cancerous virus, I do
not pretend to know; nor will it perhaps be ever dis-
covered: 

Sect. VIII. Cancerous Ulcer. 191
covered: but it is not unreasonable to suppose, that
external accidents merely may produce such an ef-
fect upon particular parts, as to induce the formation
of a matter, even as acrid as that of cancers appears
to be.
Thus we have daily instances in which vitiated sores
produce very acrid and even corrosive matters, which,
from what we have already remarked in some of the
preceding sections, could not probably have existed
previously in the blood: And, if that is the case, why
may not some peculiar affection of a part contribute
to the formation of a cancerous matter? The one may
be conceived, à priori, just as probably to occur as
the other; and it does, we apprehend, as certainly
happen.
The ordinary situation of cancers, too, may in some
measure account for the discharge afforded by them
being even of a more acrid and virulent nature, than
that of any other kind of ulcers. For as they are in
general seated in the glands, which are known, even in
much more simple affections, never to produce good
matter, it is not at all improbable, but, by some pecu-
liar irritation applied to a gland, such a disposition in
it may be induced, as to cause the formation of the
worst and most inveterate of all matters, namely, the
cancerous: Which being allowed to remain, and ab-
sorption to take place, the whole system comes, in
course of time, to be as it were saturated with it; and,
thus a general affection, or what may be termed the
Cancerous Diathesis, is at length produced, from what
at first was only a local ulcer.
We have thus endeavoured to show, that, by an ex-
ternal accident merely, cancer may be produced, with-
out having recourse to the suppofition of any internal
affection. 

192 Observations on the Part II.
affection. But, say those who assert that the latter in
such cases always takes place, " Although external vio-
lence does sometimes seemingly end in cancer; yet
that disorder would never be produced in this man-
ner, unless a predisposition to such complaints subsist-
ed in the habit at the same time; and besides, although
cancers do, from that circumstance, on some occasions,
succeed to external accidents, yet by far the greatest
number of cancerous disorders occur without the in-
tervention of any seeming violence whatever."
That this is the case, will not by any practitioner be
denied: but it may, however, be explained upon very
different principles from what it commonly has been;
and in a manner, too, that will rather tend to confirm
the opinion of cancers proceeding, in general, from a
local affection.
In by much the greatest number of cancerous cases,
as we have already observed, the glands appear evi-
dently to be the seat of the disease: which renders it
probable, that, in all, they are the parts originally af-
fected; and that the neighbouring soft parts come on-
ly to suffer in consequence of their vicinity to these:
or perhaps, in some few cases, cancerous ulcers may
break out in parts not glandular, from the whole sys-
tem being much infected by the absorption of diseased
matter from the long continuance of a cancerous gland
in any one part.
This being the case, we may very easily conceive
how single glands may frequently become affected,
without any evident, external cause intervening: for
the circulation in the glands, being carried on by a set
of vessels much more minute than those with which
other parts of the body are supplied, obstructions will
much more readily and easily occur in them than in
other 

Sect. VIII. Cancerous Ulcer. 193
other parts; and a gland being once obstructed, the
stimulus and irritation thereby occasioned, may, it is
probable, have nearly the same effects and be attend-
ed with the same consequences, as are commonly ex-
perienced from a blow or a bruise.
In this manner, too, may be accounted for, without
having recourse to any peculiar cancerous disposition
in the system, all those cases of cancer that occur from
the improper management of imposthumes in the
breasts of nurses and of lying in women; as likewise
those which so frequently happen to women about
that period at which the menses leave them; and also
such as sometimes succeed to severs and other disor-
ders, and of which they seem, as it were, to be the ter-
minations.
In every affection originating from any of these
causes, there is always a determination of blood, or of
some other fluid, to the affected part: which, when it
happens to be the cellular substance, an abscess is pro-
duced; when to the pleura, to the membranes of the
eye, or any such parts as from their firmness of texture
do not favour the extravasation of fluids, violent in-
flammations are the consequence; and, when the sub-
stance of a gland happens to be the part a determina-
tion is made to, it being neither, as is found from ex-
perience, so proper as the cellular membrane for the
formation of pus, nor from its softness so susceptible of
inflammation as a membrane, an indolent hard swell-
ing called Scirrhus, comes, merely by the obstruction
and distention of its different vessels, very naturally to
be produced. And a tumor of this kind having once
taken place, it generally remains for some time in its
original indolent state, till by increase of bulk, or per-
haps from external violence, an irritation sufficient to
N excite.


194 Observations on the Part II.
excite some considerable degree of inflammation is
applied; which, from the nature of the affected part,
not being able to produce suppuration, generally at
last terminates in what we call Cancer, as in other soft
parts of the body it would in gangrene, if not previ-
ously resolved or brought to suppuration.
This objection, therefore, of cancers appearing more
frequently without than with the intervention of any
external accident, does not, when properly examined
into, appear to be of any importance: and from the
whole of what has been said, this conclusion, I think,
may be drawn, that cancers, in very few instances,
perhaps in none, ever arise from a general affection
of the system; but, on the contrary, are, at their first
appearance, almost always local affections only.
Such a conclusion, were we better acquainted with
the nature of the disorder than as yet we are, would, it
is probable, appear to be founded in fact. The rea-
sons for adopting it appear to be stronger than any
that have been adduced in support of the contrary o-
pinion: And, at any rate, its being admitted can nev-
er prove so detrimental to mankind, as if the contrary
opinion was universally to prevail; which, by having
the effect of preventing patients with cancerous disor-
ders from having recourse to extirpation, would, as
long as it prevailed, be always the means of their
neglecting the only remedy which, so far as we know,
ought ever to be trusted.
With respect to that circumstance, taken notice of
in the paper lately quoted from Dr. Monro, of can-
cerous disorders being always more violent and mak-
ing a quicker progress upon returning after extirpa-
tion, than in patients on whom no operation had been
performed, this may in some instances be the case; but
I know 

Sect. VIII. Cancerous Ulcer. 195
I know from experience, that it is not always so: and
although it should in reality be found to be so on ma-
ny occasions, yet still it is no valid objection to the
practice of extirpation; and would appear only to be
an additional reason for having recourse to the opera-
tion at an early period of the disease, in order to guard
as much as possible against the possibility of a return.
§ 3. Of the Treatment of Cancerous Disorders.
From all that has been hitherto said, it is evident,
that very little is to be expected in the treatment of
cancerous disorders from internal medicines: Nor are
external applications, farther than with a view to pal-
liate particular symptoms, ever to be depended on.
A great many remedies have at different times been
recommended to the public as cures for cancer: but
none, it is probable, was ever more depended on than
cicuta; a remedy, however, which, in this country,
has by no means answered the expectations that were
formed of it.
Its want of efficacy, indeed, has now proved so uni-
versal, that there seems little occasion here to say any
thing with respect to it: I shall only just observe,
therefore, that although, in a great number of in-
stances, I have known it exhibited with all the atten-
tion to its preparation that could possibly be given;
yet, in real cancers, I never knew it, nor indeed any
other remedy, produce a cure.
In simple cases of indurated glands, I have fre-
quently, indeed, known the use of cicuta attended with
very good effects; and in the advanced stages of can-
cer, when excision was determined against, I have, on
different occasions, seen it useful, both by relieving
pain, and by procuring from the sores a better and
N 2 less 


196 Observations on the Part II.
less acrid discharge than could otherwise be obtained.
But whenever there is no valid objection to it, the ex-
tirpation of a cancer, as being the most certain reme-
dy, is that which we should have recourse to as soon
almost as the disease is discovered.
With respect to the mode of operating in extirpat-
ing cancerous affections, very full information may be
obtained from the several systematic writers on surge-
ry: it may not be improper, however, in this place,
to introduce a few general observations on the sub-
ject. And,
1. The removal of cancerous disorders, even in the
slightest and most trivial cases, should be always ef-
fected with the scalpel in preference to caustic; the
use of which, though formerly much recommended by
some authors, and still by same practitioners adhered
to, ought, for very obvious reasons, to be entirely laid
aside.
The irritation generally occasioned by every appli-
cation of the caustic kind, together with the pain and
inflammation which commonly ensue, are, in cancer-
ous cases especially, very strong objections against their
ever being used. Plunket's remedy, which is evi-
dently of a caustic nature, and which we have much
reason to think consists chiefly of arsenic, has no doubt,
like every other medical secret, been greatly extolled;
but it is not probable, if the different cases it has been
used in were all fairly examined into, that it would be
found to have ever produced any advantages which
might not more speedily, and with more certainty,
have been obtained from the scalpel.
2. In whatever part of the body the disorder is sit-
uated, every part that has the least appearance of dis-
ease should be always taken off; and if, even in the
course 


Sect. VIII. Cancerous Ulcer. 197
course of the subsequent dressings, any cancerous por-
tions may appear to have been left, these should al-
so be directly extirpated, otherwise the disorder will
just as certainly return as if no part of it had been re-
moved; and, from want of proper attention to this
circumstance, the want of success in this operation, I
have no doubt, may, on many occasions, have arisen.
Even every indurated gland which appears in the
neighbourhood of a cancerous sore, should just as cer-
tainly be taken away as the ulcer itself; for if it be
allowed to remain, there will seldom be much chance
of success from the operation.
When the complaint is seated in the breast, although
perhaps part of the mamma only may be affected, the
whole of it should be always taken off: for leaving
part of it is not only attended with no advantage, but
proves afterwards, as I have often seen, very inconve-
nient to the patient.
Although it is always proper, however, to extirpate
every part that is really diseased, none of the external
teguments should be ever unnecessarily destroyed, nor
should more of them be taken away than is altogether
requisite: for the smaller the cicatrix that remains af-
ter the part is cured, the less will be the consequent ir-
ritation; and perhaps from this circumstance, too, the
chance of the disease returning may be in some meas-
ure lessened.
At least, in the Infirmary of this place, much great-
er success has of late attended the extirpation of can-
cerous lips, than was ever formerly experienced; and
the only evident reason for it is, that during that pe-
riod, in the greatest number of cases, the operation
has been performed in the manner commonly practis-
ed for the cure of the hare lip. Whereby not only a
N 3 very


198 Observations on the Part II.  
very narrow cicatrix is left, but the deformity attend-
ing it is very inconsiderable: and another very agree-
able circumstance to the patient, is, that he can always
retain his spittle, or any other liquid, just as well as
before the operation; which never can be the case
when any considerable portion of the under lip has
been extirpated in the ordinary manner.
It is proper in this place to observe, too, that very
extensive cancers in these parts admit of being treated
in this manner; for the lip being composed of parts
which yield very considerably, it cannot, but from ex-
perience, be imagined, how far they may be brought
to stretch. In some instances, where more than the
half of the under lip was taken away, I have brought
the remaining parts to stretch so far, as to admit of a
cure being effected in the hare lip form, and with very
little deformity being produced. And, in the same
manner, in cancers of the mamma, when the external
teguments are not wholly diseased, so much of them
may, in general, be preserved, as will be sufficient for
covering a great part of the wound occasioned by the
operation; a circumstance which always renders the
cure both more quick and more certain than it other-
wise would be.
When the skin and teguments which have been
preserved, can be retained in their situation by the
proper application either of the uniting bandage, or of
pieces of adhesive plaster, it ought always to be done;
but in general it answers better to secure any loose
portions of the parts which have been divided, by
means either of the interrupted or twisted sutures.
The difference of pain produced by this method is in-
considerable; and we are always more certain of se-
curing the skin by ligatures, than by any other means.
In 

Sect. VIII. Cancerous Ulcer. 199
In the ordinary method of extirpating cancerous
breasts, a very extensive sore is always left : by the
retraction of the divided skin it frequently appears to
be at least twice the size of the diameter of the tumor
newly removed ; by this means a very copious sup-
puration takes place, which in weakly constitutions
proves always yery prejudicial; a cure is tedious in
accomplishing ; and the cicatrix which remains being
of a considerable extent, the parts are afterwards very
liable to injuries. Instead of this, no more skin should
be removed than is really diseased ; and if a simple
incision be afterwards made through the skin and cel-
lular substance along the course of the swelling, all the
sound teguments which cover it may thus be separat-
ed from it; and on the tumor being extirpated, and
the teguments being again replaced, they may be re-
tained in their situation in the manner we have men-
tioned, either by ligatures, by the uniting bandage,
or by the assistance of adhesive plasters. In this
manner I have on different occasions accomplished
the cure of sores remaining after the extirpation
of cancerous breasts, in the space of three weeks or
a month ; which in the usual method of performing
this operation, would not have healed in less than
eight or ten weeks.
3. After all the cancerous parts have been removed,
if the sore cannot be entirely covered by such portions
of the skin as have been saved, and if any considerable
quantity of blood is discharged by the smaller vessels,
the remaining wound should be dressed in the usual
manner with dry lint; but when this does not hap-
pen, no dressing answers so well as pledgits of one or
other of the mild ointments we have already recom-
mended : and when the dressings can be easily remov-
N 4 ed, 

200 Observations on the Part II.
ed, by a free suppuration coming on, the sore being
now in a state exactly similar to a simple ulcer from
any other cause, is to be treated accordingly, and a
cure to be promoted as quickly as possible.
4. But some little time before the sore heals up, an
issue should be introduced, so as that it may come to
discharge freely before the cicatrix is quite formed.
This, when the complaint has been of long standing,
is particularly requisite ; as also, when it seems to have
been occasioned by any particular determination, in
consequence of a redundancy of fluids in the system,
either from suppressed menses, or from any other
cause. And in this way I have no doubt but an issue
may be, and frequently has been, a means of prevent-
ing the return of cancers after extirpation.
It has been sometimes advised, as the best method
of forming such a drain, to keep the part open from
whence a cancerous tumor has been extirpated. I
should strongly suspect, however, that the irritation
produced by an issue, directly upon the old seat of a
cancer, might sometimes do mischief: and as all the
advantages attending the practice are probably to be
obtained from an issue on whatever part it is situated,
I would therefore always advise, that the sore itself
should be immediately healed up ; and that an issue
should be introduced, in the manner we have men-
tioned, in some other convenient situation. After
cancers of the breast, it has been a frequent practice in
the Royal Infirmary here, to put a seton into the side,
near to the original seat of the disorder ; and as it has
been thought to produce considerable advantages, and
as the side is perhaps as convenient a situation for a
drain as any other, it may therefore be always pre-
ferred.
These 

Sect. VIII. Cancerous Ulcer. 201
These are the different circumstances, in general, to
be attended to in the extirpation of cancers ; and as,
from what has already been said, the removal of the
diseased parts seems to be the only effectual remedy in
every case of cancer, there are very few circumstances
only, which should ever prevent its being put in prac-
tice. And these, in general, are,
1. When, by a long continuance of the disorder,
cancerous ulcers, and scirrhous glands, have appear-
ed in several different parts of the body, the removal
of one, or even all of these, as it would not probably
prove effectual, so, in such circumstances, the opera-
tion, it is presumed, ought not to be recommended.
2. When a cancerous tumor adheres so firmly to the
parts beneath, that the whole of it cannot be removed,
whilst at the same time it might be dangerous to ex-
tirpate along with it those parts with which it is con-
nected, extirpation can never be advisable. Thus
cancers adhering to the trachea arteria, or to the coats
of a large artery, can never, without the greatest risk,
be extirpated.
One instance of the rashness of a surgeon, in at-
tempting an operation in such circumstances, and
which was attended with effects which proved imme-
diately fatal, came within my own knowledge. In an
attempt to cut out a large scirrhous tumor seated upon,
and lying immediately contiguous to, the femoral ar-
tery, and so high in the thigh that a tourniquet could
not be applied, the artery was unfortunately opened,
and the patient died among the surgeon's hands.
But the attachment of cancerous tumors to the cir-
cumjacent muscles or tendons, should never entirely
prevent their extirpation; for considerable portions of
these, it is well known, may, without much inconve-
nience, 

202 Observations on the Part II.
nience, be taken away along with them. I have, on
many occasions, been reduced to the necessity of tak-
ing away large portions of the pectoral muscle along
with cancerous tumors of the mamma, without any in-
convenience ensuing from it.
There is a paper upon cancers by the celebrated
Monsieur le Cat of Rouen, inserted in the first volume
of Memoirs of the Academy of Surgery at Paris ; in
which the author is clearly of opinion, that extirpation
is the only remedy to be depended on, and advises it
in the most desperate cases. But on the subject of
which we are now treating, he goes a much greater
length than I could from experience venture to do :
although, independently of the authority of such a res-
pectable author, and of the instances he mentions of
the success of his practice, I think there cannot be the
least doubt of its being better to follow his advice, than
to allow a patient, labouring under a cancer, to remain
with the certain prospect of suffering a miserable
death, and without making trial of the only remedy
which art can afford. For, however fixed a cancer-
ous tumor may appear, if the parts to which it ad-
heres, can without much danger be removed, and if
the case is otherwise favourable, the operation ought
undoubtedly to be always advised,*
This was my opinion several years ago, when the
first edition of this work was published : Since that
period, I have met with many instances of very bad
cancers, particularly of the mamma ; in some of
which, attachments occurred to the periosteum of the
ribs ; and in others, the disease was found to extend to
the
* Upon this subject M. le Cat expresses himself thus , ** L'adherance
d'un cancer aux muscles pecteraux, aux cotes meme, ne fera pas un excuse
valable, si ces muscles si ces attaches de la tumeur aux cotes peuvent etre
emportes, de facon qu'il ne reste, que de sain au-dela." Loco citato. 


Sect VIII. Cancerous Ulcer. 203
the corresponding clavicile, and frequently by a chain
of indurated glands to the very bottom of the arm-
pit. Very few cases, however, have occurred, in
which, by cautious dissection, the diseased parts were
not totally extirpated ; and in every instance where
this was found to be practicable, much advantage was
evidently derived from it: In most of them, no return
of the disease has been as yet experienced ; and, even
in those which have relapsed, much relief has been
derived from the operation, by the pain and misery of
the patient having been for some time removed by it;
whilst in no instance, were the symptoms which ensued
from a return of the disease, more severe, than those
to which the patient had been liable before any oper-
ation was advised.
3. But, an operation can never be advisable, where
the diseased parts are so situated as to prevent their be-
ing totally extirpated ; as is the case in cancers of the
uterus, of the liver, rectum, &c.
When, from the existence of one or all of these
causes, a cancer cannot with propriety be extirpated,
the next consideration is, to palliate the different
symptoms, so that the disease may be rendered as tol-
erable to the patient as possible.
As, for this purpoSe, the great object to be kept in
view, is the abatement or prevention of pain, nothing
should be either exhibited internally, or applied out-
wardly, that can have the least effect in raising irrita-
tion or inflammation. So that, for diet, the lightest
vegetables and milk should be preferred to every thing
else; no animal food should be allowed, nor spirits,
wine, or any fermented liquors ; all violent exercise,
and whatever, in short, can heat, or as it is termed, in-
flame the blood, should be carefully avoided. 
The

204 Observations on the Part II.
The fetor attending cancerous ulcers being com-
monly very disagreeable, and the matter afforded by
them being usually very thin and acrid, it becomes al-
ways a consideration of importance to have these cir-
cumstances changed, and a discharge of a better na-
ture induced. In this view, hemlock frequently
proves serviceable, both as an internal medicine and as
an external application. For internal use, there are
two preparations of the remedy commonly used ; the
powder, and the extract ; But as the former, when
properly prepared, seems to possess all the virtues of
the latter, and as it is not liable to so many accidents
in the preparation, it should for that reason be in gen-
eral preferred. The extent of the dose, and number
of repetitions, can never be determined but by trial;
some patients being able to bear three times the quan-
tity that others can admit of : so that these circum-
stances must always be regulated by the strength of the
patient, and by the state of the stomach at the time.
When recent hemlock can be procured, a quantity
of the juice being mixed with the common emollient
poultice, makes a very convenient and effectual appli-
cation for cancerous sores ; and in the winter season,
when the juice cannot be obtained, the dry powder
made into a poultice in the same manner, answers the
purpose tolerably well.
The external use of cicuta proves generally more
expeditious than its internal exhibition, in procuring
a discharge of good matter; and, in this respect, it
commonly proves more effectual too, even than the
carrot poultice, so much recommended for this pur-
pose in different kinds of sores.
A good discharge being once obtained, the common
unguentum cereum is the mildest and most simple ap-
plication 
 

Sect. VIII. Cancerous Ulcer. 205
plication that can be used ; and the parts should be
dressed with it more or less frequently, as the dis-
charge is more or less copious : But the several dres-
sings should be performed so quickly as to prevent as
much as possible the admission of the air, which in
every ulcer, but more especially in the cancerous, al-
ways produces disagreeable effects, both in causing ir-
ritation, and in vitiating the nature of the discharge.
The violent shooting pains which prove always so
tormenting in cancerous cases, are frequently moder-
ated by a continued use of cicuta ; but when this ef-
fect is not obtained from it, it becomes necessary to
have recourse to opiates in large doses, which ought to
be repeated at such intervals as the violence and re-
turns of the pain may indicate. These pains, too, are
sometimes relieved by the use of warm emollient fo-
mentations.
By a proper attention to the different circumstanc-
es we have taken notice of, particularly to the preserv-
ation of a well conditioned discharge, and by a well 
timed use of opiates, very bad cases of cancer may be
sometimes so far palliated, as to render them, in some
measure, tolerable ; though never to such a degree as to
prevent the sufferers from regretting daily their not
having, in due time, had recourse to extirpation.
Various remedies have at different times been pro-
posed for the cure of cancers, of which, in the course
of this treatise, we have taken little or no notice. Of
these the cicuta which we have just now spoken of, bel-
ladona, and different preparations of arsenic, have
been most frequently employed. But although the
cicuta, as we have said above, has, in some instances,
been a means of producing a good discharge from can-
cerous sores, yet neither this nor either of the others
have 


206 Observations on the Part II.
have ever, so far as I know, produced any permanent
advantages in cases of real cancer. We have heard of
arsenic proving useful in cancers, not only as an ex-
ternal application, but as an internal remedy : but al-
though I have employed it in a variety of cases, the
result of these trials has never proved in any degree
adequate to the accounts which have been given of it.
In a late publication on cancerous disorders by Mr.
Justamond of London, we find an escharotic applica-
tion much recommended. It was long employed in
Vienna and other parts of Germany ; and as Mr. Jus-
tamond, whose experience in cancerous diseases has
been extensive, speaks favourably of it, it therefore
merits the attention of practitioners : Although I have
used it, however, in different cases, I have not as yet
observed any real advantages to ensue from it; but
as no remedy should be hastily rejected, which has
been recommended by an author of reputation, I am
resolved to give it a fair and impartial trial. This ap-
plication is a composition of steel and sal ammoniac
infused in spirit of wine, with a certain proportion of
oil of tartar and spirit of vitriol. The edges of can-
cerous sores, as well as the hard tumors or excrescen-
ces which frequently occur in ulcers of this kind, are by
Mr. Justamond's method, kept constantly moist with
this liquid ; and during the use of it, he likewise re-
commends an internal use of steel and sal ammoniac
in the form of flores martiales.
In other species of ulcers attended with a discharge
of thin fetid matter, and in which tonic remedies seem
to be indicated, I have in different instances used the
flores martiales with advantage ; but, as I have al-
ready observed, neither this, nor any other medicine,
has ever, in the course of my experience, produced
any material benefit in cases of cancer.
The

Sect. VIII Cancerous Ulcer. 207
The flores martiales, may be given either in the
form of pills, or in powders. It seldom produces
sickness, and may therefore be given in much larger
doses than are commonly employed. The first doses
should not exceed twelve or fifteen grains ; but they
may be increased, in a gradual manner, to half a
drachm or more, to be repeated three, four, or five
times daily. In every case where steel medicines are
found to be proper, the flores martiales, by conveying
the remedy in a very subtile form, is perhaps prefera-
ble to any other preparation of it.*
SECTION
* To such as have not an opportunity of perusing Mr. Justamond's
treatise upon this subject, it may prove acceptable to have the prescrip-
tion for the liquid which he recommends so warmly as an application in
cancerous affections. It is as follows.
R. Ramentor. ferri lotor. et supra ignem in vase aperto siccatorum &
minutissimme contusorum, salis armoniaci in pulveram redacti, āā unc.
iv. Mixta dentur in retortam terream optime in fundo et circumferen-
tia lege artis minutam, imponatur hæc capellæ, admoveatur vas vitreum
recipiens, quod bene lutetur : detur ignis in gradu digestionis ; & dum
retorta calefieri incipit, augeatur successive ad sublimationis, sinitaque sub-
limatione ad calcinationis, gradum. Hoc facto successivæ refrigeratione
committatur retorta, et ex refrigerata fractaque accipiatur calcinatum
in fundo hærens, caput mortuum teratur, et subigatur minutissime in
mortario lapideo; dein subactum imponatur in vas vitreum, et affundan-
tur spiritus vini rectificatissimi Empyreumaticum odorem non redolentis
lb. ij. Agitentur sæpius primis octo horis : post viginti quatuor horas
agitatis denuo instilletur tribus quatuorve interstitiis observatis, acerrimi,
ut vulgo vocatur, olei vitrioli nigri unc. i.—ad quamvis instillationem
semper mixta agitando ; deinde in quiete permittantur per viginti qua-
tuor horas, his elapsis decantetur tinctura, residuo vero in sundo affun-
dantur prioris spiritus vini lb. ij. Agitentur iterum pluries, dein extrac-
tio de novo relinquatur per viginti quatuor horas ; his transactis instil-
letur iterum, ut prius, olei vitrioli supradicti unc. i. Effervescentia fi-
nita vero infundantur spiritus tartari simplicis unc. iv. Agitentur, et
finita agitatione aliquoties repetita relinquantur in vase per viginti qua-
tuor horas ; his elapsis secunda hæc solutio misceatur priori decantatæ
et optime simul agitentur, tunc parata est ad usum PANACEA NOSTRA
ANTI-CANCROSA.
This was originally published by Dr. Francis Xaverius de Mare, in a
treatise which he published some years ago at Vienna.— He had long
kept this liquid a secret, but at last made it public in the year 1767. 


208 Observations on the Part II.
SECTION IX.
Observations on the CUTANEOUS ULCER.
§ 1. General Remarks on Cutaneous Affections.
THERE are few complaints, which are less under-
stood by practitioners, than the different disor-
ders to which the skin is liable. This, indeed, is in
some measure the case, both with respect to such as
are attended with fever, and those that are not : it is
however, more especially so with the latter, which only
are to be here taken notice of ; those of the exanthe-
matous kind, as they are termed, belonging more prop-
erly to the province of medicine.
The appearances of such complaints are so various,
and the descriptions given of them by different au-
thors are so confused and intricate, that it is scarcely
possible, from the several writings on the subject, to
collect any thing satisfactory. By different writers,
different names have been given to the same appear-
ances ; many complaints of this kind are enumerated
by old writers, which are now never to be met with ;
and diseases of a similar nature, though still, in some
respects, different, have been regularly described by
modern authors, which do not appear, in ancient
times, to have been at all known. It is much to be
wished, therefore, that, by some practitioner, a
thorough investigation of the subject was attempted,
as there does not appear to be any part of medicine
more defective than that which relates to the history
and 


Sect. IX. Cutaneous Ulcer. 209
and theory, as well as to the treatment, of cutaneous
disorders.
To give a particular detail of all the varieties of
these complaints, would of itself require a pretty ex-
tensive volume, and it would also be entirely foreign
to our purpose ; all that is here proposed, being to
give a few general observations upon such eruptions
of this kind, as, when neglected or improperly treated,
are apt to give rise to troublesome ulcers.
A great many complaints of the eruptive kind, have,
by different authors, been described under the term
Herpes, from their being very apt to spread, or to creep,
as it were, from one part to another; and by this ap-
pellation have been distinguished by late writers, sev-
eral disorders which, though not entirely the same, yet
bear a considerable resemblance to the lepra of the
Greeks, and to the several species of impetigo enu-
merated by Celsus. As none of these, however, are
now in their true form ever to be met with, at least in
these climates, it is not here necessary to enter into a
particular enumeration of them ; and this more es-
pecially, as very minute descriptions of them can be
found in many of the old writers, and nothing new, it
is probable, can now be offered on the subject.
§ 2. Of the different species of Herpes.
There have commonly been comprehended, it was
remarked, under the term Herpes, a variety of erup-
tive disorders : but many of the distinctions in these
are taken from very trivial circumstances, and such as
do not in any respect influence the treatment; and on
examination it will be found, that all the varieties of
importance may be comprehended in the four follow-
O ing 

210 Observations on the Part II.
ing species, viz. the Herpes Farinosus, Pustulosus,
Miliaris, and Exedens.
The first of these, viz. the Herpes Farinosus, or
what may be termed the dry Tetter, is the most sim-
ple, both in its nature and treatment, of all the several
species. It appears indiscriminately in different parts
of the body ; but most commonly on the face, neck,
arms, and wrists, in pretty broad spots of exceeding
small red pimples. These are generally very itchy,
though not otherwise troublesome : and after contin-
uing a certain time, they at last fall off in the form
of a white powder similar to fine bran, leaving the
skin below perfectly sound ; and again returning in
the form of a red efflorescence, they fall off and are
renewed as before.
The second species of the disorder, viz. the Herpes
Pustulosus, appears in the form of pustules, which
originally are separate and distinct, but which after-
wards run together in clusters. At first they seem to
contain nothing but a thin watery serum, which after-
wards turns yellow ; and, exsuding over the whole
surface of the part affected, it at last dries into a thick
crust or scab : When this sails off, the skin below fre-
quently appears entire, with only a slight degree of
redness on its surface; but, on some occasions, when
the matter has probably been more acrid, upon the
scab falling off, the skin is sound slightly excoriated.
Eruptions of this kind appear most frequently on the
face, behind the ears, and on other parts of the head;
and they occur most commonly in children.
The third species of Herpes, viz. the Miliaris,
breaks out indiscriminately over the whole body ; but
more frequently about the, loins, breast, perinæum,
scrotum, and inguina, than in other parts. It gener-
ally 


Sect. IX. Cutaneous Ulcer. 211
ally appears in clusters, though sometimes in distinct
rings or circles, of very minute pimples, which, from
their resemblance to the millet seed, has given rise to
the denomination of the species. The pimples are at
first, though small, perfectly separate ; and contain
nothing but a clear lymph, which, in the course of the
disease, is excreted upon the surface, and there forms
into small distinct scales : these at last fall of, and
leave a considerable degree of inflammation below,
that still continues to exsude fresh matter, which like-
wise forms into cakes, and so falls off as before.
The itching in this species of the complaint is al-
ways very troublesome ; and the matter discharged
from the pimples is so tough and viscid, that every
thing applied to the part adheres in such a manner, as
to occasion a great deal of trouble and uneasiness on
its being removed.
The different species of herpes are commonly, in
England, distinguished by the names of Tetter, shin-
gles, and Ringworm, but the last is most frequent-
ly applied to the variety of the disorder which we are
now considering.
The Herpes Exedens, so called from its destroying
or corroding the parts which it attacks, appears com-
monly at first in the form of several small painful ul-
cerations, all collected into larger spots of different siz-
es and of various figures, with always more or less of
an erysipelatous-like inflammation. These ulcera-
tions discharge large quantities of a thin, sharp, serous
matter; which sometimes forms into small crusts, that
in a short time fall off; but most frequently the dis-
charge is so thin and acrid, as to spread along the neigh-
bouring parts, where it soon produces the same kind
of sores.
O 2 Though 

212 Observations on the Part II.
Though these excoriations or ulcers do not, in gen-
eral, proceed farther than the cutis vera ; yet some-
times the discharge is so very penetrating and corro-
sive, as to destroy the skin, cellular substance, and, on
some occasions, even the muscles themselves. It is
this species of the disorder which should properly be
termed the Depascent or Phagedenic ulcer, from the
great destruction of parts which it very frequently oc-
casions : but, by a piece of very great impropiety, ul-
cers of the herpetic kind, have most commonly been
supposed to be connected with scurvy ; and have,
therefore, by practitioners in general, been usually
distinguished by the appellation of Scorbutic. Where-
as, there is nothing more certain, than that herpes is a
complaint which is generally, if not always, connect-
ed with that state of the system, probably the most op-
posite of any to that which takes place in true scurvy
I mean the plethoric and inflammatory ; whilst in scur-
vy a high degree of putrescency is well known to consti-
tute the very existence of the disease.
And besides, the real scorbutic ulcer, hereafter to
be described, exhibits appearances perfectly different
from the disorder now under consideration ; insomuch
that there is scarcely a possibility of mistaking the one
for the other ; and the remedies necessary in the two
diseases are just as opposite as their several symptoms
and appearances are different.
This species of herpes appears, at times, in every
part of the body, but most frequently about the loins,
where it often spreads to such a degree as to surround
the whole circumference of the waist. It seems to be
easily communicated by contagion, that is, by the ap-
plication of the virus either through the intervention
of clothes, spoons, or other table utensils. This is
indeed 

Sect. IX. Cutaneous Ulcer. 213
indeed the case, in some degree, with every species of
herpes ; I have known instances even of the first or
dry species of the disorder proving so, which would
not a priori be so readily suspected.
§ 3. Of the cure of the Cutaneous Ulcer.
It was already remarked, that, in the descriptions
given of these disorders, there is very little accuracy
to be met with amongst authors. The same confusion
and uncertainty likewise occur in the method of cure.
It was always, till lately, believed, that eruptive
diseases of this nature could never appear but in con-
sequence of some general morbid affection of the sys-
tem ; and accordingly, a great variety of internal rem-
edies have been recommended by almost every au-
thor who has written upon the subject. It has even
been commonly considered as an unsafe and danger-
ous practice to attempt the cure of such eruptions in
any other way than by correcting the original disor-
der of the fluids, which at first was supposed to have
produced them.
It is somewhat singular, however, that the opinion
should have remained so long uncontroverted by reg-
ular practitioners ; as, from the writings of many old au-
thors, it appears that complaints of this kind were con-
stantly and easily cured, as they still are by every itine-
rant practitioner, with local external applications only.
This, we should imagine, ought very soon to have
overturned the general notion which prevailed with
respect to the nature of these disorders, and which
seemed all along to have no other foundation than an-
tiquity for its support. Modern practitioners, how-
ever, not being shackled by such authority, have, in
many instances, ventured to dispute, and boldly to
O 3 deviate 

214 Observations on the Part II.
deviate from, the opinions of their predecessors ; and
the improvements which have universally resulted
from such a free spirit of inquiry, have never yet giv-
en them reason to repent their having done so.
This, in no instance, has been more remarkable, nor
attended with better effects, than in the treatment of
cutaneous disorders, which, from having been very
perplexed and intricate, will soon, it is hoped, become
a very simple and easy part of the pracitioner's em-
ployment.
Instead of the tedious and debilitating courses of
medicines which patients went through formerly, and
which, perhaps, they are still too frequently obliged to
undergo, it is now found, that the greatest number of
these complaints are more certainly and speedily re-
moved by the use of local remedies merely, than they
ever are by a contrary course. This, probably, is one
reason, amongst others, why all complaints of this na-
ture are classed among local disorders, in the Genera
Morborum of our justly celebrated professor, Dr.
CULLEN : and which, without any other sanction,
would of itself, be sufficient authority for their being
here inserted among such affections.*
That internal remedies may sometimes be of use,
and even necessary, in many instances of cutaneous
eruptions, will not, probably ever be doubted ; but
that they ever prove serviceable in the way common-
ly imagined, namely, by correcting particular kinds of
acrimony supposed to exist in the mass of fluids, does
not appear in the least probable : Nor do the good ef-
fects which are sometimes produced by internal med-
icines
* The character given by Dr. Cullen of the class Locales, is,
" Partis, non totius corporis, affectio." Vid. Synop. Nosolog. Meth-
od. Edinburgi. 


Sect. IX. Cutaneous Ulcer. 215
icines render it less certain that cutaneous affections;
are in general only local disorders.
Thus, in many diseases of the skin antimonials are
frequently exhibited with considerable advantage.
But the principal advantages attending them seem to
depend entirely upon their producing a determina-
tion to the skin, and keeping up a free discharge of
the matter of perspiration ; which frequently, from
want of cleanliness, and sometimes from other causes,
being long retained on the surface of the body, and
there turning acrid, may often, it is probable, give rise
to many of our cutaneous affections. And accord-
ingly we find, that all such remedies prove constantly
more or less effectual, according as they are more or
less powerful in keeping up a free perspiration.
By those who maintain, that an acrimony of the
fluids is the most common cause of such disorders, it is
supposed, that the beneficial effects of antimonials and
other diaphoretic medicines depend entirely on their
evacuating or carrying off the morbid matter, with
which the fluids, in these disorders, are imagined to
abound.
Many arguments, however, occur against the prob-
ability of this opinion ; and in particular the diffi-
culty, or rather impossibility, of showing how these
morbid matters, supposing that they really existed,
should be more readily evacuated by sudorifics, than
the other parts of the blood with which they must in
the course of the circulation be intimately mixed : but
what puts it beyond a doubt that all such medicines
act entirely in consequence of their preserving a free
perspiration, and not by evacuating any fluids partic-
ularly morbid, is, that the very same advantages, in
all such complaints, are frequently to be obtained,
O 4 merely 


216 Observations on the Part II.
merely by the use of repeated warm bathing, with a
due attention in other respects to cleanliness.
From this view of the theory of such complaints,
many circumstances with respect to them can be much
more clearly accounted for, than on any other supposi-
tion. Of these, however, we cannot here enter into a
full consideration ; and shall only observe, that by it
may be explained the reason why such eruptions ap-
pear very frequently in a partial way only, which they
often do, by breaking out in a single spot, without af-
fecting any other part of the surface. This we cannot
Suppose would frequently happen if these disorders al-
ways proceeded from a general affection of the syst-
tem ; but it may very readily occur from a local stop-
page of perspiration, occasioned by the application of
such causes to particular parts as we know to be gen-
erally followed with that effect. And upon this prin-
ciple, as was already remarked, is accounted for, much
more obviously, the operation of the several remedies,
than on any other.
In the treatment of every disorder of this kind, the
first and principal circumstance to be attended to, is,
that not only the parts affected, but even the whole
surface of the body, be kept as clean and perspirable
as possible : for which purpose nothing is of so much
importance as the frequent use of warm bathing, to-
gether with gentle frictions with clean linen cloths ;
which, in the dry species of the complaint, may be ap-
plied over even the diseased parts; but in the others,
especially where considerable ulcerations occur, the
frictions can be applied to such parts of the body only
as are not, at the time, affected. When due attention
is paid to this article of cleanliness, few or no internal
remedies 

Sect.IX. Cutaneous Ulcer. 217
remedies are ever necessary in the slighter species of
herpes. 
Of all the external applications, usually employed
both in the mild and in the more inveterate species of
these disorders, the several drying and astringent rem-
edies are most to be depended on : Of these, the most:
simple of all is lime water; which, in slight cases of
dry tetter, often answers the purpose, but it seldom
proves effectual in any of the others.
The different solutions of lead in the vegetable acid,
prove often, in affections of this nature, very effectual;
and of these the watery of saccharum saturni,
as directed in the treatise on inflammation, is always
most to be depended on. It may either be applied in
the form of cataplasms, or on soft linen rags laid di-
rectly upon the parts. The latter is perhaps the most
convenient method ; and in such affections, from its
being more cleanly than poultices, should always be
preferred.
Although this, in general, is found to be a very use-
ful application in the milder eruptions of this kind ;
yet, in such cases as prove to be inveterate, I have fre-
quently found, that weak solutions of corrosive sub-
limate in water, have proved more beneficial. About
ten grains of the former, to a pound of the latter,
makes, for all such affections, a very easy and effica-
cious wash.
Decoctions of the different kinds of boles, and of
the astringent earths, are sometimes, too, used with
advantage in slight cases of this kind ; but in general,
the preparations of lead, as we have directed above,
with the watery solution of corrosive sublimate, prove
a great deal more effectual ; and do indeed, in a great
measure, 

218 Observations on the Part II.
measure, render every other application unneces-
sary.
Ointments prepared with saccharum saturni and
corrosive sublimate, have frequently too, in these dis-
orders, been used with advantage : but as, in such
forms, they must necessarily be combined with unctu-
ous substances, they cannot of course prove so cleanly
as the watery solutions of the remedies ; and as they
do not in that way prove in any respect more effica-
cious, they ought never therefore to be preferred.
By proper attention to the different circumstances
We have mentioned, many of the milder complaints of
the herpetic kind are often removed : but when the
disorder is of a more inveterate nature ; when it is of
long standing ; and especially when it is accustomed
to discharge large quantities of matter, as in the herpes
exedens frequently happens, other remedies come like-
wise to be necessary.
The more obstinate and virulent such complaints
are, the greater attention becomes requisite to the pro-
moting of a free discharge by the skin ; for which pur-
pose, together with warm bathing, as we formerly
recommended, warm diluent drinks should be plenti-
fully allowed. New whey answers in this view very
well, and it is likewise of use as a gentle laxative.
Decoctions of sarsaparilla and of mezereon, both sep-
arately and combined, have, in different forms, been
recommended for the same purpose. Although I
have known them used, however, in a variety of cases,
I cannot say they ever seemed to be attended with any
superior advantages to those which are produced by
the decoctum lignorum of the shops ; which, when
properly exhibited, proves always a powerful diapho-
retic. And we have it always our power to in-
crease 


Sect. IX. Cutaneous Ulcer. 219
crease the diaphoretic powers of this remedy by add-
ing to each cupful of the decoction, fifteen or twenty
drops of tincture of antimony.
When, in this manner, two or three pounds of the
remedy are taken at proper intervals every twenty four
hours, it seldom fails to keep up a very free perspira-
tion.
As a gentle diaphoretic too, I have often known
crude antimony prove useful, when duly prepared,
and given to the quantity of about two drachms in the
day, either in powder or in the form of an electuary.
It commonly answers tolerably well by itself; but
when conjoined with a small proportion of gum gua-
iac, it seems not only to prove more certainly sudorif-
ic, but more readily goes off by stool, which in some
cases renders the combination of the two remedies of
service.
In patients of plethoric habits, in whom complaints
of this nature frequently occur, laxatives prove often
serviceable ; but those of the cooling kind only should
be used. Sea water is very commonly prescribed in
these disorders as a purgative, and it frequently an-
swers exceedingly well ; but to many patients it proves
so nauseous and disagreeable, that it cannot be exhib-
ited in proper quantities. When this is found to be
the case, cream of tartar, which is a much more agree-
able medicine, may be used instead of it: and as it
cannot be conveniently given in solution, on account
of the large proportion of water necessary for dissolving
it, the most commodious way of using it is in the form
of an electuary ; six or eight drachms of the remedy
in powder, with an equal quantity of sugar, being
made into the consistence of a linctus, or of an electu-
ary 
 

220 Observations on the Part II.
ary with the mucilage of gum arabic, makes an easy
dose of a very agreeable laxative.
Together with these internal remedies, an issue, in
the more inveterate species of herpes, becomes always
necessary ; and it should indeed be among the reme-
dies first prescribed ; for here, as in the treatment of
all old ulcers which have served as issues to the consti-
tution, the cure of the disorder is rendered more cer-
tain and easy, by establishing proper drains for the
superfluous fluids ; without which the sores, although
they may be healed, are very apt soon to break out
again.
In different eruptions of this kind, especially in the
herpes exedens, very considerable degrees of inflam-
mation often occur ; for the removal of which, warm
poultices and fomentations, are generally employed,
but seldom or never with any advantage. And in no
case whatever does the superiority of saturnine appli-
cations over the whole tribe of emollients, in inflam-
matory affections, appear more evident than in this.
For the latter almost constantly seem to encourage the
spreading of the secreted acrid humour ; and thus,
instead of removing inflammation, in such instances,
they rather tend to promote it: whereas the different
saturnine applications appear not only to correct the
acrimony of such humours, but tend greatly to pre-
vent their spreading so far as they otherwise would
do.
In all superficial ulcerations of the herpetic kind,
the saturnine and sublimate solutions, as we have al-
ready recommended, in general prove effectual; but
whenever the ulcers have penetrated deep into the
substance of the muscles and other parts, as they fre-
quently enough do, an ointment prepared with cal-
cined 

Sect. IX. Cutaneous Ulcer. 221
cined zinc I have sometimes found to answer better :
about two drachms of zinc in fine powder, to fix
drachms of axunge, seems to be in general a proper
proportion. It lessens the inflammation which com-
monly takes place ; and it has often a considerable ef-
fect in altering the nature of the discharge from a thin
acrid sanies to a thick purulent matter.
The common unguentum saturninum is also, when
newly prepared, a very proper application for the
same purpose. But it ought never to be made use of
after being long kept: for the lead seems thereby not
only to lose its activity, which it in some measure, in
unctuous preparations, always does ; but that oint-
ment, probably from its being prepared chiefly of ax-
unge, or of wax and oil, without any addition of the
antiseptic gums and resins, is much more apt to turn
rancid than almost any other ointment in common
use.
In such cases, too, an ointment prepared with ax-
unge and mercurius precipitatus albus, I have some-
times known of use ; but as it commonly occasions a
good deal of pain and irritation, it is not in every case
admissible.
By a due continuance of the several remedies we
have pointed out, whilst proper attention is at the same
time given to cleanliness, the most troublesome species
of herpes will in general be entirely removed. But in
some instances, notwithstanding the use of all these,
and of every other ordinary remedy, complaints of this
nature still continue obstinate ; they do not seem to
yield in the least, and frequently even turn more in-
veterate*
In such cases, there is commonly much reason to
suspect that some other disease subsists at the same
time; 

222 Observations on the Part II.
time ; which, on inquiry, is frequently found to be of
the venereal kind, for herpes often appears as a symp-
tom of that disease. This, however, may commonly
be known from the history of the complaint, and like-
wise from the situation of the eruptions. For all erup-
tions of this kind which appear in lues venerea, are con-
stantly above some of the hard and thinly covered
bones, as those of the cranium, sternum, and tibia : at
least in the beginning of the disorder, these are the
parts chiefly affected ; though, no doubt, in its more
advanced stages, the whole surface comes to be more
or less affected.
As soon as the complaint is discovered to be of the
venereal kind, its cure must depend in a great measure
upon the general treatment necessary in that disor-
der ; so that, by a proper use of mercury, with a con-
tinuance of the different remedies already enumerated
for herpes, all affections of this nature may in due
time be expected to be eradicated.
On other occasions, again, and when there is no
cause for suspecting a venereal taint, it sometimes hap-
pens, that even the slightest species of tetter resists all
the common remedies both internal and external, and
perhaps, too, becomes more inveterate. In such cases,
there is frequently conjoined with the disorder which
we are now considering, the common scabies or itch :
and when it happens to be so, as I have sometimes
seen, a very disagreeable and troublesome disease comes
to be produced ; what may be considered as a tertium
quid, or a production of the two ; which, in its ap-
pearance, is exceedingly loathsome ; little less so, in-
deed, than the descriptions that are given of the lepra
of the ancients; and, when it is allowed to remain
long, it proves sometimes almost as inveterate.
The 


Sect. IX. Cutaneous Ulcer. 223
The itch being such a well known disorder, its con-
junction with herpes is commonly very easily detect-
ed : and when once it is known to take place, the cure
must consist in the several remedies already recom-
mended for herpes, together with such as are more
particularly active in the cure of scabies ; and of
which, though there are many recommended by au-
thors, yet none ever prove so certainly efficacious as
sulphur. Mercury, too, does, no doubt, often cure
complaints of this kind; as it does, indeed, the itch in
all its stages : yet as it fails in many instances, which
sulphur, when properly directed, very seldom does,
the latter should in general be preferred.
In every eruption of the herpetic kind to which
children are liable, sulphur, in one form or other,
proves commonly more effectual than any other rem-
edy : When in these complaints, therefore, the usual
remedies are found to sail, sulphur should always be
employed ; and, to practitioners of experience, it is
scarcely necessary to remark, that the Sulphur Vivum,
as it is termed, in fine powder, proves always much
more effectual than the flowers of sulphur. As this
remedy evidently loses much of its strength by the
process of sublimation, this preparation of it should
never be employed for any cutaneous eruption.
There is a species of herpes to which, in some con-
stitutions, especially in females, the face is particularly
liable ; and no variety of the disorder proves either
more distressing to patients, or more perplexing to
practitioners. All the common preparations of sul-
phur, as well as different ointments and washes of the
mercurial kind, are commonly employed here without
any advantage ; but the following combination of
sulphur with saccharum saturni, I have found to suc-
ceed 

224 Observations on the Part II.
ceed in many instances of the most obstinate species of
this disorder.
R. Lac. sulphuris - - 3ij.
Sacch. faturni - - ej.
Aq. rosarum - - 3viij.m.
The eruption to be bathed with this morning and
evening, care being taken to shake the vial when
used. 
In what manner this remedy acts, I know not ; but
I have known different instances of complete cures
being effected in very obstinate cases by a frequent
use of it.
When, however, in cases of this kind, as well as in
every species of herpes, it may for some reason or oth-
er be thought proper to make use of mercury instead
of sulphur, an ointment similar to what in the dispen-
satories is termed Unguentum Citrinum, has on many
occasions been found to answer exceedingly well. 
But as this ointment has commonly been ordered with
too great a proportion of mercury, it frequently acts
as a caustic, and occasions a great deal of irritation.
That effect, however, is easily prevented, whilst at the
same time all the advantages of the remedy are pre-
served, by diminishing the quantity of mercury : Half
an ounce of mercury dissolved in an ounce of strong
spirit of nitre, and a pound either of axunge or of fresh
butter, have, upon trial, been found to be very good
proportions : or, as this ointment is very apt to turn
too hard, it may at first be made with a double pro-
portion of mercury and spirit of nitre ; and, by adding
an equal quantity of axunge at the time of using it,
the same strength of the remedy is preserved, whilst at
the same time an ointment is obtained of a better con-
sistence.
This 

Sect. IX. Cutaneous Ulcer. 225
This makes a very effectual and perfectly safe oint-
ment for all such eruptions as partake either of a ve-
nereal taint, or that are in the least connected with
common itch ; and may be used for the latter disor-
der, in preference to all other mercurial applications,
by those who, on account of its offensive smell, or for
other reasons, do not incline to make use of sulphur.
Indeed no preparation of mercury, in the course of
my experience, has ever proved so useful as this oint-
ment ; not only in cases of real herpes, but even in
common itch. It only indeed requires to be more
generally knOwn, in order to be very universally em-
ployed in every affection of this kind.
By a proper and continued use of the several rem-
edies recommended, but above all by a due attention
to cleanliness, almost every herpetic complaint may at
last be removed;
After these Several observations on Such disorders, it
may not be improper to remark, that there are many
complaints of the eruptive kind, to which children es-
pecially are liable, which may all be reduced to one or
other of the species of herpes we have enumerated,
and which of course may be all cured by the same
general method of treatment.
Thus the tinea capitis, and crusta lactea, are com-
monly described as distinct and unconnected diseases :
but both of these affections, it is presumed, may, with
propriety enough, be reduced to the same species of
herpes ; and they seem evidently, indeed, to belong
to the second, or what we have termed Pustulosus, as
they appear to be exactly of the same nature, and to
differ only in situation ; the tinea being on the hairy
scalp, what the crusta lactea and other such eruptions
are upon the face.
P The

226 Observations on the Part II.
The several means of cure we have enumerated for
herpes in general, apply, as was observed, with equal
propriety to any of these ; but in the tinea capitis a
peculiarity occurs from the situation of the disorder,
which, in the treatment, it has been frequently found
necessary to attend to. In this complaint, the hair,
by occasioning a more considerable remora of the ex-
suded matter than what occurs in any other species
of herpes, produces in it a greater degree of acrimony,
which sometimes gives rise to bulbous swellings, by
being roots of the hair ; and hence it has been sup-
posed, that these swellings, by being perhaps the first
parts affected, tend to produce and to keep up all the
other symptoms of the disorder : So that it is common-
ly recommended as the first step in the cure of tinea,
to extract entirely all the hairs by the roots, either
with pitch plasters, or with some other adhesive appli-
cation.
This, however, is always attended with a great deal
of pain ; it sometimes produces very troublesome in-
flammations ; and besides, it is never in any respect
necessary in the first stages of the disorder : for though
in very long continued cases of tinea, these tuberosities
at the roots of the hair do sometimes become so con-
siderable as to render the cure of such affections more
tedious than they otherwise would be ; yet, merely by
keeping the hair very short, and the parts affected as
clean as possible, the different remedies already enu-
merated almost always effect a cure, without having
recourse to the extraction of the hair.
The watery solution of corrosive sublimate Was al-
ready recommended as an external application for
different herpetic eruptions; but in no species of the
disorder does it produce such remarkably good effects
as 

Sect. IX. Cutaneous Ulcer. 227
as in tinea capitis ; insomuch that, except in very in-
veterate cases, a cure may generally be obtained by the
use of this remedy alone.
Issues have already been mentioned as being very
useful in all eruptive disorders of this kind ; but in
these complaints, which, in childhood especially, are
so common, they seem to be still more necessary and
more useful, than in the advanced periods of life ; for,
as those children that are particularly liable to such
eruptions, are commonly of very gross full habits, it
is scarcely possible often to obtain, at least, lasting
cures, without in the first place introducing adequate
drains.
Indeed issues alone, with a proper attention to clean-
liness, will very frequently, in the first years of child-
hood get the better of all such complaints, without the
assistance of any other remedy ; and they do not by
any means prove so prejudicial to the constitution as
the frequent use of purgative medicines, which in such
cases are so commonly employed. Purgatives do, no
doubt, frequently prove serviceable, by carrying off
such superabundances of fluids as the system happens
to be loaded with, but never in such an easy gradual
manner as is done by issues.
There has an objection been commonly made to the
use of issues in general, that they are very apt to be-
come so far habitual as to prevent them from being
afterwards healed up, without considerable risk.
This, in children, however, should never be any ma-
terial objection to them : for, about the fifth or sixth
year, when children are able to take more regular and
fatiguing exercise ; when the system, having acquired
a firmer tone, is rendered more capable of preserving a
due balance between the solids and different contained
P 2 fluids; 


228 Observations on the Part II.
fluids ; and when, in fact, the latter are never observ-
ed to be so abundant as in the preceding years of
childhood ; there is not then the same necessity for
such drains, and it might even in some instances be
prejudicial to continue them longer. We do accord-
ingly observe, about this period of life, that many of
the eruptive disorders, which had prevailed before,
now disappear entirely : nature then requiring a great-
er supply of fluids for all the different secretions,
throws off, by their means, what had formerly been
discharged by different eruptions upon the surface.
SECTION X.
Observations on the VENEREAL ULCER.
HAVING, in the several preceding sections, gone
through the consideration of all such ulcers as
can with propriety be looked upon as local affections
merely, those of an opposite nature come next in course
to be treated of; and they are, as was formerly re-
marked, to be comprehended in the second class.
The general character of this class has been already
given. It includes, as was formerly remarked, all
such ulcers as are connected with, or that depend up-
on, some general disorder of the system ; and the sev-
eral species of it are, the Venereal, the Scrobutic, and
Scrophulous.
Having 

Sect. X. Venereal Ulcer. 229
Having spoken so sully upon the different species of
local ulcers, all that is necessary upon those of the sec-
ond class, is to point out, as concisely and distinctly as
possible, the different characteristics by which they
may be distinguished ; together with such remedies as
may be peculiar to or proper for each ; referring al-
ways to what may have been remarked in the preced-
ing sections, for whatever may, in common, occur be-
tween any two species of the different classes.
§ 1. Varieties of the Venereal Ulcer.
By venereal ulcers, in general, are meant such as
are connected with an universal syphilitic affection of
the system. But as chancres, and some other species
of sores which occur in that disorder, may with equal
propriety be termed Venereal Ulcers, although they
are not always connected with a general infection, yet,
in order to prevent any sort of ambiguity, it will be
proper here to comprehend the consideration of these
also.
Venereal ulcers, then, may be divided into two va-
rieties ; namely, those which appear as primary symp-
toms of the disease, and such as may more properly be
considered as symptomatic.
Of the former kind are chancres in general, whether
upon the parts of generation, communicated by vene-
real intercourse ; upon the nipples and breasts of wom-
en, by nursing infected children ; or on the lips and
parts adjacent, communicated by salutation : for all
such sores, though seated on different parts, are of one
and the same nature. Those ulcers, too, may some-
times be reckoned primary, which remain after the
opening or bursting of such buboes as appear to have
arisen from an infection lately communicated, and be-
P 3 fore 


230 Observations on the Part II.
fore there is any probability that the whole system is
affected.
Such ulcers, again, are considered as symptomatic,
which arise in consequence of a general taint of the
habit. Of this kind are all those which succeed to old
buboes, and such as appear along with other venereal
symptoms a considerable time after infection ; the
most ordinary situations for which are, the throat, pal-
ate, nose, the parts immediately above the bones of
the cranium, tibia, humerus, and other hard bones
thinly covered with flesh.
Although, in many cases, it is not easy to make this
distinction in venereal sores, yet it may frequently be
done, and should be always strictly attended to ; the
treatment of the two different species being in some
respects exceedingly different, as will be afterwards
particularly taken notice of.
In such cases, the principal means of distinction are
obtained either by information from the patient, or
from the appearances of the different sores them-
selves.
If, soon after exposure to infection, an ulceration
appears upon the part to which the virus was immedi-
ately applied, together with swellings of any of the
glands in the course of the lymphatics, we may be al-
most convinced that these are only local affections, and
ought to be considered accordingly as primary symp-
toms. Ulcerations thus occurring from the immedi-
ate application of the venereal virus, are in general
termed Chancres : they appear, at first, as small mili-
ary spots, which soon rise and form little vesicles, that,
upon bursting, discharge sometimes a thin watery flu-
id, and, on other occasions, a more thick yellow mat-
ter. The edges of such sores are generally hard and
painful; 

Sect. X. Venereal Ulcer. 231
painful ; and are, together with the glandular swell-
ings already described, commonly attended with more
or less inflammation.
These are the common appearances of venereal sores
from a recent infection ; but the ulcers which appear
as symptoms of a long continued affection, in general
prove most troublesome. They are distinguished from
those already described, as likewise from every other 
species of ulcer. 1. By information from the pa-
tient. 2. By their situation. And, 3. By their ap-
pearances.
Whenever an ulcer is suspected to be of a vene-
real kind, the real nature of it may frequently be learn-
ed from the patient. Thus, if a person, who has long
had other symptoms of infection in his constitution,
is attacked with one or more ulcers, whether in conse-
quence of external injuries or not, and if they resist the
common methods of cure, there can be very little
doubt of their being infected with the general taint of
the habit.
It sometimes happens, however, that such informa-
tion is not to be obtained : for patients infected with
disorders of this kind, very often conceal, and, when
questioned, even refuse to acknowledge it; and, on
other occasions, patients cannot even themselves be
certain whether they are infected or not, having per-
haps no other symptoms at the time than these ulcers,
and which they may not probably have considered to
be of the venereal kind.
When this happens to be the case, we must endeav-
our to obtain our information from the situation and
appearances of the ulcer itself.
By far the greatest part of venereal ulcers from an
old infection, appear, as was already remarked, imme-
P 4 diately 

232 Observations on the Part II.
diately above the bones, and such of these especially as
are most thinly covered with muscles. They first ap-
pear in the form of a red, and somewhat purplish, ef-
florescence, not circumscribed, but in general rather
considerably diffused. This soon comes to rise into a
number of very small pustules, which ooze out a thin
fretting serum. At first, these pustules, when observed
through a glass, appear perfectly distinct ; but they
at last run together, and form one large ulcer, whose
edges are commonly ragged and somewhat callous ;
and there is generally a light red appearance, which
extends a considerable space beyond the sore, over the
skin that does not seem to be otherwise diseased.
Sores of this kind have frequently a very remarka-
ble appearance, being hollowed as it were into the
form of a cup, generally narrow and contracted at the
bottom, with the edges extending gradually till they
reach the outward circumference. This at least is
commonly the case, except when carious bones happen
to lie at the bottom of the sores, and then they are
generally filled up with troublesome fungous excres-
cences.
Venereal ulcers are not commonly attended with
much pain; at least, seldom so much as from their ap-
pearances might be expected. In some instances,
however, it is otherwise : and the discharge of all such
sores, though at first thin, comes at last to put on a
very particular and characteristic appearance, being of
a consistence rather more tough and viscid than good
pus ; with a very loathsome, though not the ordinary
fetid, putrid smell ; and a very singular greenish yel-
low colour.
These are the most common appearances of old ve-
nereal ulcers, and when all or any of them occur
upon 

Sect. X. Venereal Ulcer. 233
upon any of the situations enumerated, we may almost
always determine, with certainty, the complaint to be
of the syphilitic kind.
The distinction we have proposed of venereal ulcers
into primary and symptomatic, is in the treatment of
the disease found to be a matter of considerable im-
portance ; for those of the former kind, if attended to
immediately on their first appearance, and before any
absorption of matter has taken place, might undoubt-
edly be frequently removed without the assistance of
any internal medicine, merely by converting an insip-
ient chancre into the state of a simple ulcer, by burn-
ing or destroying the venereal matter contained in it
with caustic.*
But although a cure might in this manner be some-
times effected with sufficient safety, yet as we have no
means of becoming absolutely certain whether some of
the virus may not have entered the system, the cure of
even the slightest chancre should never be trusted to
any other remedy than the internal use of mercury ;
with this material difference, however, that in incipi-
ent sores of this kind it commonly proves sufficient to
administer a very small quantity of the remedy only,
in proportion to what is requisite in such ulcers as ap-
pear in consequence of an old general infection.
The distinction proposed points out likewise another
circumstance of consequence in the cure. In ulcers
from an old pox, we ought never to make use of mer-
curial and other dressings with a view to heal and dry
them up soon ; but should rather trust entirely to
mercury given internally, and in the mean time con-
tinue to apply such remedies only as are necessary for
keeping the sores clean and easy.
Thus
* Dr. MONRO'S Prelections. 

234 Observations on the Part II.
Thus the healing of the different ulcers merely by
the use of internal remedies, affords the best, and in-
deed the only convincing proof of the disease being
eradicated ; and it proves indeed the surest index by
which a Surgeon can be directed, as it plainly shows,
that little more mercury can be necessary ; a circum-
stance, of which a practitioner cannot by any other
means be convinced.
With many practitioners, it has been the common
method to treat in this manner chancres, and all those
venereal ulcers we have termed Primary ; whilst, at
the same time, they have not thought proper to apply
the practice to those of long standing, or that proceed
from a general infection of the system. But, with very
little attention, it must appear, that directly the re-
verse of this should be followed ; and the advantages 
attending it would commonly be found considerable.
The reasons for keeping old venereal ulcers open
during the internal exhibition of medicines, have been
already explained. But in recent chancres, produced
merely by a local application of a corroding matter,
as they are entirely topical, and not connected with
any disorder of the system, mercury given inwardly has 
not near such a chance of effecting a cure ; and ac-
cordingly we often find, that after very considerable
quantities of the medicine have been used, we are at
last, after all, obliged to have recourse to some exter-
nal application.
This, however, is far from being the greatest incon-
venience attending the practice : for as long as a
chancre or ulceration continues open, there is much
more reason to suspect that the system may be gener-
ally infected, than if the chancre or source of that mat-
ter had been healed Soon after its appearance.
By

Sect. Venereal Ulcer. 235
By some it may be alledged, that it is not of much
consequence whether a small or a larger portion of
the venereal matter be taken into the system, as the
least particle may just as certainly produce all the
symptoms of the disease, as if a much larger quantity
had been admitted.
This, in some respects, may probably be the case, as
the syphilitic matter is known to be of a very penetrat-
ing and assimilating nature ; but there is surely much
more reason to hope, that a very small portion of such
matter may be prevented from infecting the system,
either by being stopped in its course ; by occasioning,
as it frequently does, obstructions of one or more
glands ; or even by being afterwards thrown out at
some of the emunaories ; than that the danger of a
general infection, arising from a constant absorption
and diffusion of the same sort of matter, can by any
means be obviated or removed.
That the opinion we have ventured to give on this
point is at least very probable, will not readily be con-
troverted. But it is likewise said, that the practice of
treating chancres, by the use of internal remedies on-
ly, can never occasion any kind of risk, as the mercury
which is, or ought always in such cases to be exhibit-
ed, by acting as a certain antidote to the venereal vi-
rus, must soon exert its influence on the system, in
such a manner as to prevent the latter from having
any farther influence.
Such reasoning, however, is, in practice, by no
means to be depended on. For, in the first place,
though mercury in general proves a very certain cure
for venereal complaints already subsisting in the con-
stitution ; yet, even where it has been previously ex-
hibited in considerable quantities, it does not prevent
a new 

236 Observations on the Part II.
a new infection from taking place : Of this I have
known many instances ; and it would probably, if at-
tended to, be found to occur very frequently.
But again, although we were even certain, if a
proper quantity of mercury was present in the fluids,
that no farther infection could take place from the in-
troduction of a larger portion of venereal matter ; yet,
in cases of chancre, we can never be sure that the
medicine will so soon enter the circulation as to pro-
duce this prophylactic effect. For when we consider
how frequently practitioners are disappointed in at-
tempting to introduce a sufficient quantity of mercury,
either from the fault of the preparation, from its run-
ning off by stool, from its flying too quickly to the
mouth, or from some other cause, no dependence, it is
evident, is to be placed upon this matter.
Upon the whole, therefore, the cure of chancres, and
of all venereal ulcers of the same kind, should be has-
tened as much as possible, not only by internal medi-
cines, but by exterhal applications likewise.
§ 2. Of the Cure of the Venereal Ulcer.
The most effectual method in every case of chan-
cre, as we have already hinted, would probably be, to
touch the part affected with some strong caustic as
soon as the disease is observed ; and, by thus destroy-
ing at once all the venereal matter, the sore being now
nearly in the state of a simple ulcer from any other
cause, would, with ordinary dressings, be very easily
cured. Practitioners, however, are seldom called in
so early, and frequently not till the different ulcera-
tions are considerably enlarged, when the practice
could not readily prove effectual and when it might
sometimes even be dangerous to apply, so extensively
to 

Sect. X. Venereal Ulcer. 237
to those tender parts on which chancres are common-
ly seated, such irritating remedies as any of the more
active caustics.
What I have generally found to answer in every
case of ulcerated chancre not attended with much in-
flammation, is, after wiping the sores as free from mat-
ter as possible, to sprinkle them well with mercurius
precipitatus ruber finely prepared, and to apply a
pledgit of any common ointment over all. This does
not commonly occasion much pain or iritation ; and it
has the effect of producing a kind of slough over the
sore, which, in the course of a dressing or two, general-
ly comes away, and leaves the ulcer perfectly clean.
Chancres being reduced to this state, would proba-
bly soon heal, although no other dressing should be
used than common cerate ; but, left any venereal mat-
ter should remain, I have commonly, after removing
the dressings with the precipitate, been in the way of
using the strong mercurial ointment of the Edinburgh
Dispensatory, and to dress with it till the sores heal
up. 
In this manner all such ulcerations are in general
easily cured, and with much less mercury given in-
wardly than if allowed for any considerable time to
remain open.
By long continuance, however, and from neglect
of proper remedies, even these, at first, seemingly sim-
ple sores, come to put on all the appearances of such
ulcers as depend upon a general infection ; and as
they are then really such in every respect, their treat-
ment must vary accordingly.
Ulcers of this kind, upon the penis especially, when
of long duration, are very apt to become inflamed :
and then, by the pain they occasion, they prove fre-
quently 

238 Observations on the Part II.
quently exceedingly troublesome. When the inflam-
mation comes any considerable length, blood letting it
sometimes requisite; but in general, that symptom is
easily enough kept moderate, merely by a continued
and proper use of the saturnine poultice. 
The inflammation being once thoroughly removed,
the best application, in all such cases, is simple wax
ointment, as we have formerly mentioned, till a prop-
er quantity of mercury has been exhibited, and then
the sores commonly heal without any farther appli-
cation.
There are two different modes in use of throwing
mercury into the system ; the one by giving it inter-
nally by the mouth, and the other by introducing it
into the body through the absorbents on the skin by
means of friction : But, as the last of these methods is
by much the most troublesome and inconvenient, and
as it does not, upon trial, appear to be attended with
any superior advantages, the former is now, I believe,
very commonly preferred.
Various forms of mercury have been contrived for
internal exhibition ; but those in which it has under-
gone no other preparation than simple triture, such as
the quicksilver pill of the Edinburgh Pharmacopœia, 
are, in general, the best. They prove commonly
more effectual, and are seldom attended with any of
the inconveniencies which often occur from the use of
the different mercurial calces.
But whatever preparation of mercury be employed,
it should always be continued till a soreness of the
mouth be induced, that being the only certain indica-
tion of the medicine having entered the system : and
it should never be carried further than is merely nec-
essary to produce a moderate affection of the mouth,
which 

Sect. X. Venereal Ulcer. 239
which is now found from experience to be productive
of all the advantages, and none of the inconveniences
which commonly attend a considerable salivation : it
is not the quantity of salivary matter discharged that
has any influence in the cure of venereal complaints,
but the quantity of active mercury really introduced
into the course of the circulation.
It is not always easy, however, to prevent mercury
from running off too quickly by the mouth, so as
sometimes to occasion very troublesome salivations.
To guard against this circumstance by determining the
medicine more particularly to the skin, the warm bath
has been frequently recommended, both as a necessa-
ry preparation, and as a remedy which ought to be
used along with the mercury. The same effects, we
may remark, may in some degree be obtained, and
with less risk to the patient from cold, by the use of a
flannel shirt next the skin, and by drinking plentifully
of decoction of sarsaparilla or of the woods ; care at
the same time being taken to keep the body in a prop-
er temperature, and that it be never exposed to any
considerable degree of cold. But whenever the warm
bath can be conveniently and properly procured, it
ought to be employed ; for it commonly proves an use-
ful assistant to a mercurial course : By preserving a soft
skin and a free perspiration, it prevents the mercury
from running with too much violence to the mouth ;
and nothing tends so certainly to prevent this med-
icine from affecting the bowels with gripes and other
symptoms of colic.
A course of this kind being continued for a longer
or shorter period, according to the degree of infection
and violence of the symptoms, a cure of all such com-
plaints is at last very commonly obtained.
In 

240 Observations on the Part II.
In some instances, however, the quicksilver pill
above recommended, either does not produce all the
desired effects, or even fails altogether. On such oc-
casions, the corrosive sublimate is frequently found to
answer ; and may be given either in the form of pills,
or in the spirituous solution : the former, however,
never proves so nauseous as the latter, so that a larger
quantity of the medicine may in that manner be com-
monly exhibited. The mercurius calcinatus ruber,
is often found to answer in old venereal sores, when
the usual forms of employing mercury have failed.
In large doses, of three, four, or five grains, it operates
briskly both as an emetic and purgative : but small
doses, especially when conjoined with opiates, are sel-
dom productive of any inconvenience ; and may, in
general, be continued for a considerable length of
time, without inducing salivation.
In very obstinate venereal ulcers, it becomes some-
times necessary to make trial of all the variety of mer-
curial preparations ; and, on particular occasions, one
will be found to prove very serviceable, though none
of the others may appear to have had any influence.
The most certain rule for determining the quantity
of the medicine to be exhibited, is, that it should be
always continued for some time after every symptom
of the disease has disappeared ; and that for a longer
or shorter period, as the disorder may have been of
long or short standing, and as the symptoms may have
been inveterate or otherwise : but this very material
circumstance in the cure of every venereal complaint,
must be ultimately determined by the judgment of
the practitioner in attendance.
Though by such a course of mercury given inward-
ly, with the necessary external treatment formerly
pointed


Sect. X. Venereal Ulcer. 241
pointed out, almost every ulcer of this nature may, as
was observed, be in general removed, yet in some few
instances it is otherwise ; and the sores cannot be
brought to heal, even though the mercury be contin-
ued very long after every other symptom has disap-
peared, and when, from this circumstance, and from
the quantity of the medicine exhibited, there is every
reason to think that the venereal taint in the system is
altogether eradicated.
As an ulcer, in this situation, cannot with proprie-
ty be considered as a venereal affection, it would be
in vain to expect a cure from the use of any prepara-
tion of mercury whatever. Whenever such sores,
therefore, show a greater obstinacy than what from
their appearances might be expected, and especially
when they do not yield in any degree to mercury, it
gives great reason to suspect, that some other disease
may probably have subsisted in the constitution togeth-
er with lues venerea, and that both may have had
some share in the production of the ulcers.
As soon as the nature of this conjoined disorder is
discovered, proper remedies must be employed in or-
der to correct it ; and this being accomplished, the
cure of the sores will, in general, go easily on.
On some occasions, however, venereal ulcers prove
obstinate when the system appears to be perfectly free
from every other disorder. In such cases, when the
sores are seated upon or near to any of the bones, es-
pecially when fungous excrescences arise, there will
commonly be reason to suspect that the cure is pro-
tracted by a latent caries ; and if this is found on ex-
amination to be the case, and if the patient is in other
respects healthy, there will seldom be reason to doubt,
but that, by following the directions already given re-
Q specting 


242 Obervations on the Part II
specting the treatment of carious bones, and by a con-
tinuance of the mercurial course, a cure will at last be
effected.
In some instances, again, when there is no reason,
from the situation of the sores, to imagine that a caries
can be the cause of their inveteracy ; and although
there is no appearance either of scrophula, scurvy, or
of any other disease of the constitution; yet still they
go on without showing any disposition to heal, and
perhaps even become worse.
In such cases, when the system is much reduced by
long confinement and a tedious course of mercury,
which frequently indeed happens when a violent sali-
vation has been long kept up, the best and most effect-
ual remedy, in general, is a light nourishing diet, with
the assistance of fresh air and moderate exercise ; which,
by invigorating the constitution, tend more certainly
to promote a cure than all the medicines and applica-
tions commonly employed.
In all such circumstances, indeed, the effects of a
change of this nature are often surprising; for the most
obstinate ulcers, which have resisted every usual rem-
edy, I have in various instances seen entirely cured,
merely by such means as we have now mentioned.
In this situation of these sores, too, the Peruvian bark,
when taken in proper quantities, frequently proves
very serviceable.
With respect to the external treatment of old sores
of this kind, as the sloughs with which they are com-
monly covered render some degree of stimulus always
necessary, common basilicon, with a large proportion
of red precipitate, answers for this purpose exceeding-
ly well. Two drachms of the mercury to an ounce
of ointment, make very good proportions, and afford
one 

Sect. X. Venereal Ulcer. 243
one of the best dressings for every ulcer of this nature :
and when, by the use of such an ointment, the sloughs
have all cast off, and a discharge of proper matter has
been induced, the treatment must afterwards be regu-
lated according to the several circumstances already
pointed out in the different preceding sections on local
ulcers.
When any of the glands happen to be the seats of
venereal ulcers, as it is always difficult to induce a
kindly suppuration in them, it is sometimes necessary,
before a cure can be obtained, to destroy the whole,
or a considerable portion of such as are very much
hardened. This is most conveniently and most easily
done by reiterated applications of caustic : If the sur-
face of the affected glands be rubbed over every third
or fourth day with lunar caustic, so much of them as
has been greatly diseased, may, in this manner, be
soon destroyed ; and the remainder, by proper atten-
tion to every other circumstance of the cure, being
brought to furnish healthy granulations, the sores,
without any farther difficulty, will soon be brought to
heal.
Although, in general, by attending to all these dif-
ferent circumstances as appearances may indicate, al-
most every ulcer of the venereal kind may at last be
removed ; yet, in long habitual and reiterated poxes,
which have never been properly cured, the whole
frame comes to be so contaminated with the infection,
as, in some instances, to produce such an inveteracy in
ulcers, as does indeed baffle all the efforts both of na-
ture and art, and at last carries off the patients in very
great misery. Some such instances I have seen in dif-
ferent hospitals, where probably such very obstinate
cases are only met with.
Q2 SECTION 


244 Observations on the Part II.
SECTION XI.
Observations on the SCORBUTIC ULCER.
§ 1. General Remarks on Scurvy.
IT was remarked in a former section, that, under the
appellation of Scorbutic Ulcer, there have in gen-
eral been ranked a great many of those eruptive dis-
eases to which the skin is liable, as the itch, several
species of lepra, &c. But the real nature of true scur-
vy being now much better understood, and it being
known that no such symptoms as eruptions of that
kind ever occur in it, the impropriety either of apply-
ing the term Scorbutic to such, or of treating them as
symptoms of that disease, must appear exceedingly
evident.
We have already remarked, that ulcers which pro-
ceed from any of the above mentioned eruptive disor-
ders, are probably connected with a very opposite
state of the system to that which takes place in those
really scorbutic : The former generally, if not always,
we suppose to depend upon an inflammatory diathe-
sis ; whereas, in true scurvy, the fluids arrive at prob-
ably the highest degree of dissolution and putrefaction
of which in the living body they are susceptible. We
know that doubts have been entertained of this point ;
but they will not be readily admitted by those who
have had opportunities of attending cases of real
scurvy.
From 

Sect. XI Scorbutic Ulcer. 245
From the writings of several old authors, it ap-
pears, that scurvy was a well known disorder some
ages ago ; but the true causes, symptoms, and meth-
od of treatment of the disease, were never very accu-
rately understood till Dr. Lind's publication on the
subject appeared.
The several species of scurvy enumerated by au-
thors, viz. the Muriatic, the Alkaline, &c. so named
from the nature of the causes supposed to produce
them, are now known to be very false and improper
distinctions ; the true scurvy being always of the same
nature, and always produced by the same causes,
wherever these occur, in whatever climate, and wheth-
er at sea or land.
§ 2. Symptoms and Causes of the Scorbutic Ulcer.
Among other symptoms of scurvy enumerated by
Dr. Lind in his ingenious treatise on this subject, the
ulcers which are so common in that disease are partic-
ularly described; and as he gives a very clear and dis-
tinct idea of them ; we shall here transcribe verbatim
the Doctor's description of them.
" The distinguishing characteristics of scorbutic ul-
cers are as follow : They afford no good digestion ;
but a thin fetid sanious stuff, mixed with blood;
which at length has the true appearance of coagulated
gore lying caked on the surface of the ulcer, and is
with great difficulty wiped off or separated from the
parts below.
"The flesh underneath these sloughs feels to the
probe Soft or spongy, and is very putrid. No deter-
gents or escharotics are here of any service; for though
such sloughs be with great pains taken away, they are
found again at next dressing, where the same sanguin-
Q3 ious 

246 Observations on the Part II.
ious putrid appearance always presents itself: Their
edges are generally of a livid colour, and puffed up
with excrescences of proud flesh arising from below un-
der the skin.
"When too tight a compression is made in order to
keep the fungus from rising, they are apt to leave a
gangrenous disposition ; and the member never fails
to become œdematous, painful, and for the most part
spotted.
"As the disease increases, they at length come to
shoot out a soft bloody fungus, which the sailors ex-
press by the name of Bullock's Liver ; and indeed it
has a near resemblance to that substance when boiled,
both in colour and consistence. It often rises in a
night's time to a monstrous size ; and, although des-
troyed by cauteries, actual or potential, or cut smooth
with a bistoury, in which case a plentiful hæmorrhagy
generally ensues, it is found at next dressing as large as
ever. They continue, however, in this condition a
considerable time, without affecting the bones.
"The slightest bruises and wounds of scorbutic
persons degenerate into such ulcers : Their appear-
ance, on whatever part of the body, is so singular and
uniform ; and they are so easily distinguished from all
others, by being so remarkably putrid, bloody and fun-
gous ; that we cannot here but take notice of the im-
propriety of referring most of the inveterate and ob-
stinate ulcers in the legs, with very different appear-
ances, to the scurvy."*
This accurate description of the scorbutic ulcer
comprehends almost the whole appearances ever ob-
served in such affections. Only it may be remarked,
that at land, unless in very particular situations, and
from
* See Lind's Treatise on the Scurvy. 

Sect. XI. Scorbutic Ulcer. 247
from a constant exposure to all the more active causes
of scurvy, such inveteracy as is described by Dr. Lind
is not often met with : But in every country, and
none, perhaps, more frequently than in some parts of
this kingdom, slighter degrees of the same kinds of
sores very often occur, forming what by practitioners
in general are termed Foul or Malignant Ulcers.
In the Royal Infirmary of this place, sores of this
kind are frequently met with, accompanied sometimes
with even the most characteristic symptom of scurvy,
soft spongy gums. In the worst cases, however, that
I ever met with here, there never was the appearance
of such a high degree of putrescency in the system as
we are told happens frequently in long voyages at
sea.
The reason of this may be, that such complaints of
the scorbutic kind as occur in this country, appear
generally among the lowest class of people, and pro-
ceed rather from the want of a sufficient supply of
food, than from confinement to any one kind that can
be at all considered as particularly septic, or as predis-
posing to scurvy.
In such patients, the putrid diathesis seldom ever
prevails to such a degree as to produce ulcers in parts
previously sound ; but it never fails to show itself in
ulcers either already formed, or in such wounds as hap-
pen to be inflicted while such a state of the fluids sub-
sists. Indeed very many of the ulcers upon the legs,
and other parts of the generality of our poor people,
frequently partake, more or less, of the real scorbutic
taint ; as is evident both from their appearances,
causes, and particularly from the method of cure that
is found to succeed best ; a good nourishing diet con-
tributing 
Q 4

248 Observations on the Part II.
tributing more towards a cure than all the applica-
tions usually employed.
The immediate or proximate cause of such ulcers,
as of every other scorbutic symptom, may be referred
to a certain degree of putrescency in the fluids; which
again may be induced by a variety of causes, but of
which the most material are, living constantly upon
salt provisions ; a total want of vegetables ; with ex-
posure to a cold moist atmosphere. Many other ex-
citing causes of the disorder might be mentioned ; but
as this would lead to a more extensive discussion of
the subject than is here intended, for farther informa-
tion, Dr. Lind, Sir John Pringle, Huxham, and other
authors, who treat more directly on the subject, may
be consulted.
§ 3. Of the Cure of the Scorbutic Ulcer.
The cure of the scorbutic ulcers, it is evident, must 
depend much upon the correction of the putrid dia-
thesiss in the system ; for which purpose vegetables of
all kinds, but especially those of an acescent nature,
with milk and whey, are found to be almost certain
remedies. The different secretions, especially those
by the skin and kidneys, should be gently promoted:
and as the former in a particular manner is almost en-
tirely obstructed in every case of scurvy, the restoring
of a due perspiration is found to have a considerable
influence in the cure; probably by carrying off many
of the putrid particles with which the fluids in such
cases always abound. Gentle laxatives too, for the
same reasons, are of use and, as such, Tamarinds and
Cream of Tartar with Manna answer well.
These, together with a total abstinence from salted
food, and a proper attention to avoid all the other ex-
citing 

Sect. XI. Scorbutic Ulcer. 249
citing causes of the disease, very commonly effect a
cure of every scorbutic symptom, and among others,
of such ulcers; the best external applications for which
are antiseptics of the most powerful kinds. Lind rec-
ommends Unguentum Ægyptiacum, and Mel Rosa-
rum acidulated with Spiritus Vitrioli.
These in general are the remedies found most ef-
fectual, and which are commonly employed in very
bad cases of scurvy ; but in such putrid ulcers as oc-
cur most frequently in this country, the septic state of
the fluids, as we have observed above, seldom advances
to such a high degree, as to render it particularly nec-
essary to confine patients to what may properly be
called an antiscorbutic course.
The common malignant or scorbutic ulcer of this
climate seeming, as was already remarked, to proceed
more frequently from a real deficiency of food, than
from any other circumstance ; putting the patients by
degrees upon a full allowance, with  a daily, though
moderate, proportion of some generous wine, has al-
ways a powerful effect in promoting their recovery.
This, we must observe, is a point of more import-
ance in the treatment of these ulcers than is common-
ly imagined, and the attention of practitioners ought
to be more directed to it than is generally the case.
Instead of prescribing medicines for the cure of such
ulcers, much more advantage would be derived from
a well regulated nourishing diet; and especially when
to this is conjoined, as we have said, a moderate pro-
portion of wine, or, what I have frequently imagined
has answered better, a proper allowance of porter or
strong beer. The foul old ulcers of poor people in
every country are most frequently induced by indi-
gence, and are kept up by a real want of nourishment. 
In

250 Observations on the Part II.
In all such cases, therefore, the practice of hospitals
would probably prove more beneficial, by laying the
use of internal medicines almost totally aside ; and by
employing the savings thus produced, in furnishing
such a diet as we have been here recommending.
The Jesuits bark, however, is a remedy which, in
ulcers of this kind, proves frequently useful : it com-
monly indeed proves more serviceable here than in
any other species of sore. When given in proper
quantities, which are always to be determined by the
state of the stomach, it seldom fails of producing, in
the course of a few days, a considerable change for the
better. For such scorbutic ulcers as occur in this
country, the bark indeed is almost the only internal
medicine that is ever necessary.
With respect to the use of mercury in these kind of
sores, it ought always to be kept in view, that in ul-
cers really scorbutic, instead of acting as a remedy, if
given in any considerable quantities, it proves always
extremely hurtful. Lind, from a great deal of expe-
rience, says, with respect to this point: "Mercury, in
a truly scorbutic ulcer, is the most pernicious medi-
cine that can be used."* So that a proper distinction
between sores of this nature, and the several eruptive
disorders commonly termed Scorbutic, appears in the
treatment to be a matter of considerable importance :
in the latter, mercury may not only be generally given
with impunity, but in some instances with advantage;
whereas, in the former, it can never be administered
but with very great hazard.
Peruvian bark, as an external application, too, an-
swers exceedingly well in all such ulcers ; pledgits
dipped in a strong decoction of it, and applied to the
sores,
Vide Treatise on the Scurvy, Part II. chap. ii. 


Sect. XI. Scorbutic Ulcer. 251
sores, have generally a considerable effect in correcting
the fetor and putrescency of the discharge : But the
best application for that purpose, in these ulcers, is the
carrot poultice, which when conjoined with the inter-
nal use of bark, and a proper regimen, in the course of
a short time, generally corrects the putrescency which
prevails, so effectually, that the sores being dressed for
a few days longer with pledgits of basilicon and red
precipitate, with a view to procure the removal of any
sloughs that remain, a cure is afterwards commonly
easily obtained, merely by attending to the directions
formerly laid down for the management of ulcers in
general, and particularly to the introduction of an is-
sue, along with moderate compression by means of a
roller.
What has hitherto been said with regard to the treat-
ment of scorbutic ulcers, applies, in a great measure,
with equal propriety, to all such sores as are in the
least connected with a putrescency of the fluids, from
whatever causes this may have been induced. Thus,
such fores, as remain after critical abscesses that succeed
to putrid fevers, require the same general method of
treatment: and the same may very probably be found
to be the most effectual in those produced by pestilen-
tial disorders ; though, as I never had an opportunity
of seeing the real plague, I cannot from experience
venture to assert it.
SECTION 


252 Observations on the Part II.
SECTION XII.
Observations on the SCROPHULOUS ULCER.
§ 1. Of the Symptoms and Causes of the Scrophulous
Ulcer.
BY scrophulous ulcers, are meant those sores which
remain after the opening or bursting of such
swellings as appear in different parts of the body as
symptoms of the scrophula or evil.
From the frequent occurrence of scrophula, it is
such a well known disease, that it is almost unnecessary
here to give any description of it. It begins with in-
dolent, somewhat hard, colourless tumors ; which at
first chiefly affect the conglobate glands of the neck ;
but, in process of time, the cellular substance, ligaments
of the joints, and even the bones themselves, come to
suffer.
In scrophula, the swellings are much more movea-
ble than those of the scirrhous kind; they are generally
softer, and seldom attended with much pain : They
are tedious in coming to suppuration ; are very apt
to disappear suddenly; and again to rise in some other
part of the body. We may likewise mention, as char-
acteristic circumstances of this disease, a remarkable
softness of the skin, a kind of fulness of the face, with
generally large eyes, and a very delicate complexion.
Ulcers which appear in scrophula seldom yield a
good discharge ; affording,  upon their first appear-
ance, a viscid, glairy, and Sometimes a whitish curdled
matter, that afterwards changes into a more thin wa-
tery 

Sect. XII. Scrophulous Ulcer. 253
tery fanies. The edges of the sores are frequently,
though not always, painful; and are constantly very
much raised or tumefied. As long as the scrophulous
diathesis subsists in the constitution, such ulcers very
often remain for a great length of time, without show-
ing any disposition either to heal or to turn worse; at
other times they heal very quickly, and again break
out in some other part of the body.
A variety of causes have been mentioned as tending
to produce scrophula; namely, a crude indigestible
food, bad water, living in damp low situations, its be-
ing an hereditary disease, and in some countries en-
demic.
Many other causes, too, have been enumerated by
authors ; but we cannot propose to enter into a full
consideration of them here. This, however, may be
observed, that whatever may, in different circum-
stances, be the exciting, or predisposing causes of scro-
phula, the disease itself either depends upon, or is at
least much connected with, a debility of the constitu-
tion in general, and  probably of the lymphatic system
in particular ; the complaint always first shewing itself
by some affections of the latter. And that debility has
at least a considerable influence in its production, is
probable, not only from the evident nature of many
of the causes which are known to be productive of
scrophula, but likewise from such remedies as are found
to prove most serviceable in the cure, which are all of
a tonic invigorating nature.
§ 2. Of the Cure of the Scrophulous Ulcer.
It was long supposed, that scrophula depended upon
an acid acrimony of the fluids ; and this, it is proba-
ble, gave rise to the use of burnt sponge, different kinds
of


254 Observations on the Part II.
of soap, and other alkaline substances, as being the best
correctors of acidity. But although a sourness of the
stomach and primæ viæ is a frequent symptom in scro-
phula ; yet this ought not by any means to be imput-
ed to a general acescency of the fluids, but merely to
that relaxation which so universally prevails in this
disease, and this especially as it often occurs in other
diseases where no such acrimony has been ever sus-
pected.
There is another circumstance, too, which renders it
still more probable that no kind of acrimony whatever
exists in scrophula, namely, the very long continuance
of matter collected in the different swellings which oc-
cur in this disease, without occasioning either much
pain, or showing any tendency to corrode the sur-
rounding parts ; there being many instances of such
collections subsisting, even for years, without exciting
any kind of uneasiness : And in fact, the several rem-
edies recommended for the correction of such an acri-
mony as has been supposed to exist in scrophulous
complaints, never have, at least so far as I have seen,
any influence in the cure.
Gentle mercurials are sometimes of use, as resolv-
ents, in scrophulous swellings ; but nothing has ever
such a considerable influence as a frequent and copi-
ous use of Peruvian bark. Chalybeate and sulphure-
ous waters, too, have frequently proved serviceable in
scrophula ; and a long and continued use of mild
aperients of the saline kind has likewise had some in-
fluence in resolving such tumors as occur in it. Cold
bathing, too, especially in the sea, together with fre-
quent moderate exercise, is often of singular service ;
as is likewise change of air, particularly to a dry cli-
mate.
With

Sect. XII. Scrophulous Ulcer. 255
With respect to the treatment of scrophulous ul-
cers, as long as the general morbid diathesis continues
in the system, it is commonly in vain to attempt their
cure: Nor would it, indeed, be always safe ; as the
sores, when dried up in one part, very commonly
break out somewhere else ; and they just as readily
fall upon the lungs, or some organ essential to life, as
on any other part.
Such instances, indeed, are very frequently met
with, whether the sores heal up naturally or by the as-
sistance of art: We should therefore be very cau-
tious in the application either of repellent or of drying
remedies ; and should chiefly endeavour to correct
the general disease of the habit, by the use of such
strengthening remedies as are commonly found to
prove most useful.
Till the disease is eradicated from the habit, all that
should in general be done to the sores, is to give as free
and open vents to the matter as possible, so as to pre-
vent effectually the formation of sinuses.
The best applications for scrophulous ulcers, are
the different saturnine preparations : of which the
watery solution of Saccharum Saturni, Goulard's
Cerate, and Unguentum Saturninum, answer exceed-
ingly well; for they tend greatly to prevent the spread-
ing of scrophulous sores, which is otherwise very apt
to occur, and to remove that inflammatory complex-
ion which they so frequently put on when relaxing
applications are much employed.
A continuation of such simple dressings as these we
have recommended, is all that, in general, should be
attempted, so long as any disorder of the constitution
is found to remain. But, in some cases, the ulcers be-
come swelled and painful ; they discharge an acrid
and 

256 Observations on the Part II.
and corrosive matter ; and grow otherwise so inveter-
ate, as to render other resources necessary.
When these circumstances occur, a carious bone
may frequently be suspected to be at the bottom of the
sore ; and then nature must be assisted, as much as
possible, in throwing off such parts of it as are most
diseased, and that are become loose. This, in many
situations, may be easily done : but when the com-
plaint fixes on any of the large joints, art can seldom
afford much assistance ; and as amputation of the
member is not, in these circumstances, always advise-
able, from the great risk of the disease returning in
some other part, nature alone must generally be trust-
ed to for a cure.
In such a situation, therefore, as no operation can
be expected to contribute much to the removal of the
disorder, the most effectual means should be adopted
for assisting nature in getting the better of it. With
this view, a continued use of sea bathing often proves
very serviceable : but this remedy, in order to have
any considerable effect, should be continued, with
proper intervals, for a number of years, instead of a
few weeks annually, which is all that is commonly
thought necessary.
The bark, as formerly directed, should still be con-
tinued ; and I have sometimes observed very good ef-
fects from a conjunction of it with cicuta, particularly
in procuring a proper discharge from scrophulous
sores.
When, in course of time, and by proper attention
to the different circumstances we have mentioned,
there is reason, from the sores showing a tendency to
heal, to hope that the general morbid disposition of
the system is pretty much eradicated, nature is always
greatly 

Sect. XIII. Management of Ulcers. 257
greatly assisted in the cure, and that too is rendered
much more safe, by the introduction of an issue some-
what proportioned to the discharge yielded by the dif-
ferent sores, and which, when the ulcers have been of
long duration, should certainly be continued for life.
Gentle compression has, in the several preceding
sections, been recommended for different kinds of ul-
cers ; but in no species of sore is it either so evidently
indicated, or of so much real utility, as in scrophulous
ulcers : in which that swelling and tumefaction, which
frequently raise their edges to very considerable
heights, often prove a greater hindrance to the cure
than any other circumstance ; and which, when no
considerable inflammation occurs, may always, by
gentle compression, be easily and safely removed.
Such, in general, is the treatment which answers
best in scrophulous ulcers : but as the scrophula is
one of those diseases for which art has not as yet dis-
covered any effectual remedy, I have not attempted
more than to point out as concisely as possible those
means by which nature is best assisted in her efforts
towards a cure.
SECTION XIII.
General Corollaries relating to the Management of
Ulcers.
HAVING endeavoured, in the preceding sections,
to investigate every point of importance relating
to the different species of ulcers, it will not in this
R place


258 Observations on the Part II.
place be considered as improper, our exhibiting, by
way of conclusion, such general corollaries as naturally
result from what has been said.
1. It appears, that, except in a few instances,
namely, in Lues Venerea, Scrophula, and Scurvy,
that ulcers are always to be considered merely as lo-
cal affections.
2. That, excepting in one or other of the above-
mentioned disorders, the varieties in the matters dis-
charged by ulcers depend always on some particular
affection of the solids in the part diseased, and not on
any morbid state of the blood or other fluids.
3. That ulcers appear to be useful or prejudicial
to the constitution, not by the quality of the matter
afforded by them, but by the quantity : And accord-
ingly, that the cure of even the oldest sore is rendered
perfectly safe by the introduction and preservation of
such an issue as will yield the same quantity of fluids
which the system has, by means of the ulcer, been ac-
customed to throw off.
4. That, in the cure of ulcers, the first circum-
stance to be determined, is, whether they are to be con-
sidered as general or topical complaints. If they ap-
pear to be of the former kind, such remedies must be
administered as are known to be most effectual for the
correction of the disease with which they happen to
be connected ; in other respects, the treatment of such
sores is nearly the same with those originally of an un-
mixed simple nature.
5. That, in the topical treatment of ulcers of ev-
ery kind, the principal object to be kept in view, is, to
reduce them as nearly as possible to the state of simple
purulent sores ; for which purpose the different rem-
edies


Sect. XIII. Management of Ulcers. 259
edies have been pointed out in the several preceding
sections.
6. That when ulcers are once reduced to the simple
state abovementioned, their farther treatment, in gen-
eral, becomes a very easy matter ; as the cure is then
to be entirely effected by a proper attention to the
three following circumstances.
lst. To the introduction of an issue, as was lately
observed, of such a size as may carry off nearly the
same quantity of fluids which the system has, by means
of the sore, been accustomed to throw off.
2d. To the preservation of the matter in a purulent
form, the several means for which have been already
fully pointed Out; but the principal of these, it may
be remarked, are, the avoiding every kind of irritation
by using the mildest dressings only ; and preserving,
in the parts affected, a proper degree of heat.
3d. To the application of gentle compression, not
only upon the ulcer itself, but on the neighbouring
sound parts also.
We have taken various opportunities, in the course
of this work, to recommend the application of pressure
in the cure of ulcers. In addition to what we have
already said upon this point, we think it necessary to
observe, that this remedy is not as yet sufficiently
known, otherwise it would be more generally employ-
ed. Those who have not seen it used, would scarcely
give credit to the accounts we could give of its uni-
versal utility in the cure of sores; but from much ex-
perience of its effects in almost every species of sore,
we can venture to assert, that those who have not em-
ployed it, have deprived their patients of the most
powerful application which has hitherto been invent-
ed for the cure of ulcers.
R 2 These


260 Corollaries. Part II
These are, in short, the principal circumstances to
be kept in view in the management of ulcers ; and
which, in different parts of the preceding sections,
have been more fully explained.


CHIRURGICAL
ESSAYS.
PART III.
Observations on WHITE SWELLINGS of
the JOINTS.
SECTION I.
Of the Symptoms and Causes of White Swellings.
§ 1. General Remarks on White Swellings.
THERE are not, probably, many disorders to
which the human body is liable, which prove
either of worse consequences to patients, or that are
less understood by practitioners, than white swellings
of the joints ; insomuch that, whenever the disease is
thoroughly formed, it is in general considered as in-
curable.
This ought certainly to be a very strong induce-
ment with every practitioner for carrying his researches
with respect to it as far as possible ; and will, it is
R3 hoped,



262 Of the Symptoms and Part III.
hoped, be a sufficient apology for the following obser-
vations ; which, merely by pointing out defects, al-
though no material improvement should be suggested,
may excite others to more successful inquiries. If
this should, in any degree, be the result of the follow-
ing remarks, I shall always consider the time bestowed
on them as having been usefully employed.
The term White Swelling has commonly been ap-
plied to such enlargements of the joints as are not at-
tended with external inflammation or discolouration
of the skin and common teguments ; the only Symp-
toms which at first commonly take place, being a
greater or less degree of swelling, with a deep seated
pain. In the progress of the disease, indeed, the whole
surrounding parts come to be so much affected, that
inflammation is at last communicated to the skin it-
self; and when this terminates in abscesses and conse-
quent ulcerations, it is not at all uncommon to find a
great many openings surrounding the whole joints
that are so diseased.
Though there are, by different writers, several de-
tached observations upon this complaint,* yet no reg-
ular account has ever been given of it, farther than
what may be met with in general dissertations on dis-
eases of the bones, which have always been considered
as the principal feat of such disorders.
§ 2. Different Species of White Swellings.
There seem evidently to be two different species of
white swellings, entirely distinct from one another ;
and
* See Monro's works, 4to Edin. 1781, p. 460, and a paper by Dr.
Simpson, in Vol. IV. of Edinburgh Medical Essays. See also a paper
on this subject, inserted in a Collection of Pathological Inquiries and
Observations in Surgery, by Richard Brown Cheston, Surgeon to the
Glocester Infirmary.


Sect. Causes of White Swellings. 263
and as the one is of a much milder nature than the
other, and very frequently admits of palliation, and
sometimes even of complete cures, which the other
never does, it would seem to be a matter of import-
ance so to characterise the different varieties, that the
one may be easily and certainly distinguished from
the other.
In this, however, as in many other diseases, the
complaint has frequently been of considerable stand-
ing before practitioners are called in : So that al-
though, if seen from the beginning, and through all its
different stages, it might generally be easily enough
known of what particular nature the disorder in real-
ity is; yet, when it is far advanced, and when an ex-
act history of the symptoms cannot be obtained from
patients themselves, it is often impossible to make any
accurate or certain distinction ; the symptoms of both
species being in the latter stages of the disease com-
monly very similar.
When this, however, is not the case, and a practi-
tioner is called in before the symptoms have made any
great progress, he may commonly, with a little atten-
tion, form almost a certain judgment of the nature of
the complaint. And, as I have had many opportuni-
ties of seeing every species of the disorder, in all its
stages, I propose, first, to give as exact an account as
possible of the rise and progress of the different Symp-
toms in each species ; then to mention the several ap-
pearances of the joints, which in each of them are ob-
served on dissection, with the most common exciting
and predisposing causes of the disorder; and, lastly,
I shall enumerate the different remedies that I have
known used for it, with their several effects.
R 4 Swellings	


264 Of the Symptoms and Part III.
Swellings of this nature, it may be remarked, occur
in every joint of the body; but much more frequent-
ly in the large than in the smaller joints : Thus, at
least, twice as many are met with in the knee and an-
cle joints, as in all the rest of the body besides.
§ 3- Of the Symptoms of the first, or Rheumatic Species
of White Swelling.
The first, and what may be considered as the most
simple, species of the disease, begins with an acute 
pain, which seems to be diffused over the whole joint,
and frequently even extends along the tendinous apo-
neurotic expansions of such muscles as are connected
with it. There is, from the beginning, an uniform
swelling of the whole surrounding teguments, which
in different patients is in very different degrees ; but
it is always so considerable as to occasion an evident
difference in point of size between the diseased and
found joint of the opposite side: A considerable ten-
sion generally prevails ; but there is seldom, in this
period of the disorder, any external discolouration.
The patient, from the commencement of the dis-
ease, suffers much pain from the motion of the joint ;
and always finding it easiest in a relaxed posture, keeps
it accordingly constantly bent ; which generally in
every situation, but more especially in the knee, pro-
duces a stiffness or kind of rigidity in all the flexor
tendons of the limb.
This rigidity of the tendons has by many been con-
sidered as an original symptom of the disorder; but
when duly attended to, it will always be found to be
rather a consequence of the disease, and to have arisen
from the abovementioned cause. In consequence,
too, of the total want of motion, which from this cir-
cumstance


Sect I. Causes of White Swellings. 265
cumstance is always produced, such joints in a very
short time generally become quite stiff and immovea-
ble, and seem frequently to be in a state of complete
and real anchyloses.
If the disorder, either by nature or by the effects of
proper remedies, is not now carried off, the swelling,
which originally was not perhaps very considerable,
begins gradually to augment, and goes on till it some-
times increases to twice, or even thrice the natural size
of the part.
The cuticular veins become turgid and varicose ;
the limb below the swelling decays considerably in its
fleshy muscular substance, at the same time that it fre-
quently acquires an equality in point of thickness, by
becoming œdematous ; the pain turns more intolera-
ble, especially when the patient is warm in bed or is
otherwise heated ; and abscesses form in different parts
of the swelling, and run in all different directions,
whilst at the same time they frequently do not appear
to communicate with one another.
In all these abscesses, a fluctuation of a fluid, upon
pressure, is generally evident, as is the case in every
collection of matter not very deep seated ; but, inde-
pendently of the fluctuation, all such swellings afford
a very peculiar elastic feel; yielding to pressure, at
the same time that they do not, like œdematous swell-
ings, retain the mark, but instantly rise again as soon
as the pressure is removed.
These different collections, either upon breaking of
themselves, or on being laid open, discharge consider-
able quantities of matter, which at first is generally pu-
rulent, and of a pretty good consistence : it soon, how-
ever, degenerates into a thin fetid ill digested sanies ;
and has never, at least in proportion to the quantity
discharged,


266 Of the Symptoms and Part III.
discharged, any remarkable influence in reducing the
size of the swellings, which still retain nearly their
former dimensions.
If the orifices from whence such matters slow are
not by art kept open, they very soon heal up ; and
new collections forming in different parts, again break
out and heal as before: So that, in long continued
disorders of this kind, the whole surrounding tegu-
ments are often entirely covered with cicatrices that
remain after such ulcers.
Long before the disorder has arrived at this state,
the patient's health has generally suffered considera-.
bly ; first, from the violence of the pain, which is oft-
en so great, as to take away entirely both sleep and ap-
petite ; and then, from the absorption of matter into
the system, which always takes place in some degree
from its first formation in the different abscesses ; but
which, indeed, never appears so evidently, till the sev-
eral collections either burst of themselves or are by in-
cision laid open ; when a quick pulse, night sweats,
and a weakening diarrhaœ, always certainly occur ;
and generally, at last, carry off the patient, if the
member be not amputated or if a cure of the disorder
be not otherwise effected.
These are the several symptoms of this species of
white swelling, in all its different stages. We shall
now, as was proposed, enumerate the appearances
which in general are observed on dissecting such swell-
ed joints after amputation of the member.
§4. Appearances observed on Dissection, in the Rheu-
matic Species of White Swelling.
In some cases, the pain, even in this species of the
complaint, is from the beginning so violent, that prac-
titioners


Sect. I. Causes of White Swellings. 267
titioners are led at once to conclude it to be of the
worst and most incurable kind: And patients, rather
than suffer a long continuance of such a torment, as it
is often attended with, and after all remain uncertain
whether a cure is to be obtained, frequently prefer the
immediate amputation of the member.
Several such instances I have seen, where the opera-
tion has been performed in very early periods of the
disorder. In all of these, the only preternatural af-
fection observed on laying open the swellings, was, a
considerable morbid thickness of the surrounding lig-
aments, without any disease of the joint whatever;
the bones and cartilages always remaining perfectly
sound, and the synovia in a natural condition both as
to quantity and consistence.
This thickening of the ligaments, though in general
it appears in a greater or less degree according as the
complaint has been of longer or shorter duration,
yet we do not find that it always does so ; for in some
recent instances, the ligaments have appeared more
diseased than in others where the disorder had contin-
ued longer : In the former, indeed, the symptoms
were always found to have been very violent.
In the more advanced stages of the disorder, when
abscesses have formed in different parts; when the
pain has been long very violent, with great addition of
swelling; on laying open the parts, the thickening of
the ligaments is then found to be more considerable,
and is generally, if not always, attended with an effu-
sion, into the surrounding cellular substance, of a thick
glairy matter, which appears to be the cause of that
elastic feel peculiar to such fwellings, formerly taken
notice of in the description. 
The 
 

268 Of the Symptoms and Part III.
The different abscesses or collections of matter are
found to run in various directions through this glairy
albuminous congestion, without, however, seeming to
mix with it. In some few instances, again, together
with collections of pus, a great many small hydatides
are observed ; and in the farther progress of the disor-
der, all these together form such a confused mass of
different matters and substances, that it is almost im-
possible, by dissection, to procure a more distinct view
of them, than what presents itself on their first being
laid open.
Even all these appearances I have met with, with-
out any affection of the bones of the joint; which,
together with the surrounding cartilages, upon cutting
through  the capsular ligaments, remained perfectly
sound.
When, however, by a very long continuance of the
complaint, these ligaments come to be corroded by the
different collections of matter, the cartilages, and in
consequence the bones, are very soon brought to suf-
fer ; the latter becoming carious, as soon as the form-
er, by the acrimony of the matter, have been abraded.
The tendons of the flexor muscles, which are always
in this disease, as was already mentioned very stiff
and much contracted, do not, upon dissecton, exhib-
it any evidenty morbid appearances, either with re-
spect to hardness or enlargement. We shall now, as
was proposed, give a description of the other species of
the disorder.
§ 5. Of the Symptoms of the more inveterate or Scrophu-
lous Species of White Swelling.
In this species of the disease, the pain is generally 
more acute than in the other; and, instead of being
diffused,

Sect. I. Causes of White Swellings. 269
diffused, it is more confined to a particular spot, most
frequently to the very middle of the joint. In some
instances I have known the patients say, they could
cover the whole pained part with a crown piece or less.
The swelling is at first commonly very inconsidera-
ble ; in so much that, on some occasions, even when
the pain has been very violent, little difference, in
point of size, could be observed between the diseased
joint and the opposite sound one.
In this, as in the other species of the disease, the
least degree of motion always gives very great pain :
so that the joint being here too constantly kept in a
bent position, stiffness and rigidity of the tendons
come likewise soon to be produced.
As the disorder advances, the pain turns more vio-
lent, and the swelling becomes more considerable, with
an evident enlargement of the ends of such bones as
compose the joints.
In process of time, the tumor acquires that elastic
feel formerly taken notice of, varicose veins appear
over its surface, and collections of matter occur in dif-
ferent parts of it: These, upon bursting or being laid
open, discharge considerable quantities sometimes of a
purulent like matter, but most frequently of a thin fe-
tid sanies ; and if a probe be introduced, and can be
passed to the bottom of the sores, the bones are found
carious, and pieces of them are often discharged at the
openings.
On the farther continuance of the disorder, the con-
stitution comes here likewise to suffer as in the first
species of the disease ; and a diarrhœa with night
sweats commencing, the patient, though naturally per-
haps of the fullest habit, is reduced by loss of flesh to
the most extreme weakness.
§ 6.

270 Of the Symptoms and Part III.
§ 6. Appearances observed on Dissection, in the Scrophu-
lous Species of White Swelling.
When such joints are dissected, either after death,
or after amputation of the member in the first stages
of the disorder, the soft parts seem to be very little af-
fected : but in all, even the slightest that I had ever 
opportunity of seeing, there was constantly observed,
an enlargement either of the whole ends of the bones,
Or of their epiphyses; frequently of those on one side
of the joint only ; in others, again, the bones on both
sides have been affected.
This enlargement sometimes occurs without any
other evident disease : but in general, and always in a
more advanced state of the complaint, the soft spongy
parts of such  bones are found to be dissolved into a
thin, fluid, fetid matter; and that too, in some cases,
without the cartilages which surround them seeming
to be much affected. In process of time, however,
the cartilages come likewise to be dissolved ; and then
the different matters, namely, the dissolved bones and
softer parts, mixed all together, exhibit, when such
swellings are laid open, a still more confused collection
than is generally observed even in the worse stages of
the other species of the disorder.
Although it was remarked, that in the early periods
of the complaint, the Surrounding soft parts do not
always appear to be much affected ; yet, in its farther
progress, they likewise are generally brought to suffer.
The ligaments become thickened, and the contiguous
cellular membrane filled with that viscid glairy kind
of matter we mentioned when speaking of the other
species of the disorder.
§ 7.

Sect. I. Causes of White Swellings. 271
§ 7. Of the Causes of White Swellings of the Joints.
Having thus given a particular account of the dif-
ferent appearances generally observed in both species
of white swelling, we come now, in course, to the con-
sideration of the different causes which tend to pro-
duce them : And, to go on in the same order with the
descriptions that have been given, we shall first enu-
merate those that are particularly connected with that
which we termed the first or rheumatic species of the
disorder.
All such strains may be mentioned as causes, as par-
ticularly affect the ligaments of the joints, so as to
produce inflammation; likewise bruises, luxations of
the bones, and in short every derangement which can
in any degree be attended with that effect.
A rheumatic disposition, or Diathesis, as it is termed,
may here too be taken notice of as a principal cause of
this species of white swelling; for, in every rheumatic
affection, the parts most liable to be attacked are the
ligaments of the joints, and other deep seated mem-
branes. The disorders occurring most frequently in
the large joints, especially in the knee, is a strong ar-
gument too for supposing that the rheumatic disposi-
tion has a considerable influence in its production ;
for it is well known, that rheumatism, in its most evi-
dent form, does really more frequently attack the larg-
er joints than any of the smaller : And, in fact, we
find this species of white swelling occurs more fre-
quently in young plethoric people, in whom the rheu-
matic diathesis most frequently prevails, than it ever
does in those of an opposite temperament.
That it is the ligaments of the joints only which
are first affected in this disorder, is from the history
of the dissections rendered evident; these, in the first
stages 

272 Of the Symptoms and Part III.
stages of the complaint, being almost the only parts
that are found diseased. The effusions, into the cel-
lular membrane, of that thick glairy matter we have
taken notice of, are probably occasioned by an exfu-
dation from the vessels of those ligaments that have
been originally inflamed, as it is known that such parts
never furnish a proper fluid for the formation of pu-
rulent matter : In the course of the disease, indeed,
abscesses containing real pus do always appear ; but
never till inflammation has been communicated to the
surrounding parts, which more readily afford a fluid
proper for this purpose.
I would therefore, upon the whole, conclude, that
this species of white swelling is at first always occasion-
ed by an inflammatory or rheumatic affection of the
ligaments of such joints as it attacks, from whatever
cause such inflammation may originally have pro-
ceeded.
The other species of the disorder, from all the
symptoms enumerated, and from the different ap-
pearances on dissection, seems evidently to be origin-
ally an affection of the bones ; the surrounding soft
parts coming only to suffer in the progress of the dis-
ease, from their connection with and vicinity to these.
This species of white swelling very seldom occurs
as the consequence of any external accident. It gen-
erally begins without the patient's being in the least
able to account for it. From the effects usually pro-
duced on the bones which it attacks, it would appear
to be a species of the real spina ventosa ; and which,
again, is very probably a disease of the same nature in
the bones that scrophula is of the soft parts. Indeed,
the appearances of the two disorders, after making al-
lowances for their different situations, are exceedingly
similar; 
 

Sect. I. Causes of White Swellings. 273
similar : they both begin with considerable enlarge-
ments or swellings of the parts they invade; which,
afterwards in both, too, generally end in evident ul-
cerations; and they both likewise frequently occur in
the same person, and at the same time.
It is likewise observed, that this species of white
swelling is generally either attended with other evi-
dent symptoms of scrophula subsisting at the time ; 
or that the patient in an earlier period of life has been
subject to that disease ; or, what is nearly the same,
that he is descended from scrophulous parents, and
consequently most probably has the seeds of that dis-
ease lurking in his constitution. *
From all these circumstances, it may I think with
probability be concluded, that this species of white
swelling is commonly, if not always, of a scrophulous
nature : And as it has already been shown, that the
other species of the disorder is to be considered as an
inflammatory, or what we have termed a Rheumatic,
affection ; and a thorough distinction of the two differ-
ent species being, in the treatment, a matter of much
importance ; it will not here be improper to give a
short enumeration of the several diagnostic or most
characteristic symptoms of each.
§ 8. Diagnosis.
he pain in the white swelling from a rheumatic
disposition, is always, as was formerly remarked, from
the beginning, diffused over the whole joint, and on
some occasions extends even a a considerable way along
the muscles that are attached to it: Whereas, in the
other species of the disorder, the pain is not only al-
ways at first, but sometimes even when the complaint
S has


274 Of the Symptoms, &c. Part III.
has been of considerable standing, confined to a very
small circumscribed space.
In the former, the swelling is always confined to the
soft parts, and is from the beginning exceedingly evi-
dent: but, in the latter, there is seldom for some time
any perceptible swelling ; and when it does more sen-
sibly appear, the bones are found evidently to be the
parts chiefly affected, the surrounding teguments
coming only to suffer on the further progress of the
disease.
These are the chief local differences of the two spe-
cies of this disorder ; but some assistance in the dis-
tinction may likewise be obtained, from considering
the general habit of the patient, and the manner in
which the complaint may seem to have been pro-
duced.
Thus, when such swellings occur in young, strong,
plethoric people, and especially in those who have
formerly been subject to rheumatism ; whether they
have been the immediate consequences of external ac-
cidents or not, they will most probably always prove
to be of the mildest or rheumatic species of the dis-
order.
Whereas, when swellings of this nature appear in
such patients as are otherwise evidently of scrophulous
dispositions; where, together with a fine skin and del-
icate complexion, there are either, on examination,
found to be hardened glands in the neck, arm pits, or
inguina ; or it is discovered that the patient may be
liable to such complaints from inheritance; when ei-
ther any or all of these circumstances occur, and if the
disorder has begun in the manner formerly described,
without any evident external cause, we need be under
very


Sect. II. Treatment of White Swellings. 275
very little doubt in concluding it to be of a scrophu-
lous nature.
The great utility of properly distinguishing the two
different species of white swelling appears in no cir-
cumstance so evident as in the treatment: In the one,
there is some chance, by proper remedies, of being
serviceable to the patient; whereas in the other, viz.
in the scrophulous, it is not probable that art will ev-
er be able to afford much assistance.
SECTION II.
Of the Treatment of White Swellings.
§ 1. Of the Effects of an Antiphlogistic Course in
the Rheumatic Species of White Swelling.
IN the rheumatic white swelling, as it is always at
first evidently of an inflammatory nature, consid-
erable advantages are commonly obtained by a due
attention to a proper antiphlogistic course.
The first remedy which, with this view, should be
employed, is blood letting; but, instead of general
evacuations from the arm or elsewhere, it proves al-
ways more effectual to take the blood immediately
from the part affected. Cupping and scarifying is
here a principal remedy. The instrument should be
applied to each side of the diseased joint; on each side
of the rotula, for instance, when the knee is the part
affected ; at least eight or ten ounces of blood should
be discharged; and this should be repeated at proper
intervals, once, twice, or oftener, according to the vi-
S 2 olence


276 Of the Treatment Part III.
olence of the symptoms and state of the patient's
strength at the time.
In the ordinary way of discharging only an ounce
or two of blood by this operation, it has, in general,
very little or no influence; but in the quantities men-
tioned, which, by those accustomed to the practice,
are commonly easily obtained, it is most frequently
attended with very considerable effects.
It must here be observed, that cupping is in these
cases much superior to the application of leeches;
which is not only a more tedious method of procur-
ing the same quantity of blood, but the swelling oc-
casioned by the application of any considerable num-
ber of them proves frequently very troublesome ; and,
what is often of worse consequence, it frequently gives
an interruption, for a time, to the use of other reme-
dies. In some instances, however, when the swelling
of the joint is considerable, it proves difficult, or even
impracticable, to procure a sufficient quantity of blood
by cupping : In such cases, we are under the ne-
cessity of applying leeches, which seldom fail of ob-
taining as much blood as is required.
Upon the anterior part of the joint, where the cup-
ping glasses or leeches have not been placed, a small
blister should be directly applied; and the part should
be kept open with issue ointment, till the wounds
from whence the blood was discharged are so far heal-
ed, that a vesicatory may likewise be laid on one side
of the joint; and as soon as this is nearly healed, the
other side should be also blistered.
By thus alternately applying them, first to the one
side, and then to the other, almost a constant stimulus
is kept up ; which, in deep seated inflammations,
seems


Sect. II. of White Swellings. 277
seems to have fully a more powerful influence than all
the discharge occasioned by blisters.
Gentle cooling laxatives, at proper intervals, are
here of use too : and the patient should, in every re-
spect, be kept upon a strict antiphlogistic course, both
as to diet and every other circumstance : From a due
attention to which, with a continuance of the topical
treatment already recommended, I have frequently
observed very considerable advantages, more indeed,
than from any other remedies I had ever an opportu-
nity of using in this complaint.
It is in the first stages only, however, of the disease,
that such a course can probably be of much service ;
and in these, I am, from experience, convinced, that
it has frequently effected cures in cases which other-
wise would probably have proceeded to the last stages
of white swelling.
The original inflammatory affection being removed,
drains of this kind seem to have little or no influence ;
and ought not now to be long persisted in, as they
tend to prevent the use of other remedies, which, in
an advanced state of the disease, prove commonly
more efficacious.
S2. Of the Effects of Mercury, Friction, and other
Remedies, in the more advanced Stages of White
Swelling.
The inflammation being mostly gone, and while
there are yet no appearances of the formation of mat-
ter, mercury I have sometimes known of use ; not
given so as to salivate, but merely to affect the mouth
gently, and to keep it somewhat sore for a few weeks.
The best form of using mercury, in such cases, is
certainly by way of unction ; as it allows, at the same
S3 time,


278 Of the Treatment Part III.
time, of the application of friction, which in all such
swellings may of itself in some measure be considered
as a remedy. For this purpose, an ointment of quick-
silver and hog's lard should be prepared; but with so
small a proportion of the former, that two drachms of
the ointment may be safely rubbed in, three times a-
day. In order to rub in that quantity of the medi-
cine with gentle friction, and so as to receive all the
advantages that attend the practice, an hour at least
should be spent each time in rubbing ; for, however
useful friction in such cases may be when properly
applied, in the ordinary way of continuing the reme-
dy for a few minutes only, it is not probable it ever
can have much influence.
Gentle mercurials, given internally, are here some-
times of service too ; but, as all the advantages to be
derived from them in this form are obtained from the
unction, together with any benefit that may ensue from
the friction used in applying it, the latter should cer-
tainly be preferred.
By Le Dran, and other French writers, falls of
warm water, on swellings of this nature, are much rec-
ommended ; and there is much reason to think, that
a long continued and reiterated application of this
remedy, may, in the first stages of these complaints, be
often attended with very good effects. Of this, in-
deed, I have now had many opportunities of being
convinced ; and, from the well known relaxing prop-
erty of moisture when conjoined with heat, there is
the greatest reason to imagine, that a proper applica-
tion, especially of warm emollient steams, will, if it is
ever generally employed, be found to prove more ser-
viceable in disorders of this kind than perhaps any oth-
er remedy.
In


Sect. II. of White Swellings. 279
In the use of warm water in cases of white swelling,
the friction occasioned by its fall on the part, indepen-
dent of every other circumstance, may probably have
a very considerable influence ; At least this, I think,
is the principal effect which cold water can, in this
way produce ; I have known it frequently used, and,
on some occasions, with advantage.
By a proper use of these different applications,
namely, of the several topical remedies in the first or
inflammatory state of the disease, and afterwards, but
still before the formation of matter, of mercurials,
friction &c. many affections of this nature have been
entirely removed : But, in many instances, when, either
ther by the use of medicines, or by an effort of nature,
the swelling and pain are almost entirely, or even
wholly removed, it frequently happens, by the bent
position in which the limb has for a long time been
kept, that the use of the joint comes to be entirely lost,
as it often contracts such a degree of stiffness, that any
attempts to move it are commonly attended with very
great pain.
Unluckily, in all such cases, these affections of the
joints have been constantly attributed to one or other
of two different causes, which are both in their nature
incurable ; namely, either to the ends of such bones
as compose the joints having run into one another, so
as to become firmly conjoined in consequence of the
surrounding cartilages being abraded ; or to the in-
spissation, as it is termed, of the synovia of the joints,
whereby their cavities are supposed to be entirely fill-
ed up, and no space thereby left for the motion of the
different bones.
Both of these opinions, however, I can, from a great
number of facts, assert to be, in general at least very
S 4 ill


280 Of the Treatment Part III.
ill founded ; for although, by an abrasion of the car-
tilages which surround the different bones at the joints,
an union of their extremities may very readily be oc-
casioned, and is no doubt on some occasions the cause
of such affections ; yet, from a variety of dissections,
I am convinced that it is an exceeding rare occurrence,
and in cases of white swelling never happens but in
the most advanced stages of the disorder: the only
cause almost of the stiffness of the joints, in such cases,
being that contracted state of the flexor tendons, for-
merly taken notice of in the description ; at least in
nineteen cases out of twenty it seems to be so.
There is nothing indeed more deceiving than the
feel on such occasions ; for when the disorder has been
of long duration, the stiffness and immobility of the
joint are generally so considerable, as, at first sight, to
make it seem very probable, or almost certain, that a
real conjunction of the bones had taken place ; Many
instances of this I have known, which had been all
along considered as real anchyloses of the worst kind ;
but which, on dissection, were constantly found to
proceed merely from a contracted state of the flexor
muscles and tendons.
With respect to the other opinion, which formerly
prevailed so universally, and which is still held by
many, that affections of this kind generally proceed
from an inspissated state of the synovial fluid, it has
for some time been much doubted by many anato-
mists, whether or not such a state of that fluid ever
occurs ; and from all the opportunities I have had of
dissecting such diseased joints, I am much convinced,
that it either never does take place, or at least that it is
an exceeding rare occurrence. For, in every case of
this kind I have met with, even when the disease had
been


Sect. II. of White Swellings. 281
been of very long continuance, if the capsular liga-
ment of the joint remained undivided, so that no mat-
ter from the surrounding soft parts got admittance,
and when the ends of the bones were not become ca-
rious, the synovia always retained its natural colour
and consistence : So that it is very probable, the ma-
ny causes of diseased joints, which have been attribut-
ed to affections of this fluid, have been more founded
on mere hypotheses, than on facts and experience.
As this stiffness of the joint, therefore, which to a
certain degree always occurs in white swellings, pro-
ceeds seldom or never from either of the causes men-
tioned, which might probably both be considered as
incurable, but merely from a preternatural contraction
of the muscles and tendons, we have from this circum-
stance great reason to expect, that, in many situations,
a good deal may be done towards its removal. And
in fact, there is no doubt but that complaints of this
kind, which often remain after every other symptom
of white swelling has disappeared, may, on many oc-
casions, be removed, merely by a long continued use
of emollients : several instances, indeed, of this, I have
seen, some of which had been thought to be of the
worst species of anchylosis.
The best, and probably the least offensive, emollient
that can be used, is pure olive oil applied warm. As
much of it as can be easily consumed by an hour's gen-
tle friction, should be regularly rubbed in at least three
times a day : and instead of confining the friction en-
tirely to the rigid tendons, which is the common prac-
tice, it should be extended over the whole muscles,
even to the insertions of their other extremities ; but
more especially on their fleshy muscular parts, where
the principal cause of the continuance of such com-
plaints


282 Of the Treatment Part III.
plaints is probably seated ; these parts being chiefly,
if not altogether, possessed of the contractile, and con-
sequently of the resisting, powers.
I have known used, too, in this complaint, as an e-
mollient, and often with advantage, an oil extracted
from animal substances, known by the name of Neat's
foot Oil: but as it is more apt to turn rancid than ol-
ive oil, it is not such a pleasant application ; and as it
is not possessed of any superior relaxing properties, the
other will probably, for that reason, be commonly pre-
ferred.
The disorder now under consideration, namely, a
stiff joint, is so evidently one of those which particu-
larly require the use of emollients, that almost every
old woman has some particular form or other of rec-
ommending them ; one of which I cannot avoid men-
tioning, as I have frequently known it used, and in two
cases particularly, with very evident advantages, viz.
the web or omentum of a new killed sheep, or of any
other animal, to be applied over all the diseased parts
directly on being cut out of the animal.
In the two cases alluded to, one was in the knee, and
the other in the hand ; and the motion of the joints,
after having been totally lost, was almost perfectly re-
stored. The application should be renewed as fre-
quently as possible, once a day at least, or oftener when
it can be done : for on being more than four or five
hours applied, it becomes disagreeable ; and, after that
time, indeed, as it commonly turns stiff, it cannot then
probably be of much service. The same kind of rem-
edy, used in somewhat a different manner, I find rec-
ommended by LIEUTAUD, a celebrated French prac-
titioner.* I have
* Mr. Lieutaud says, when speaking of such affections, " Obvolvi-
tur etiam pars affecta pelle calida vervecis, vituli, alteriusve pecudis,
recens


Sect. II. of White Swellings. 283
I have been the more particular on this part of the
subject, as I have often thought, that with a little at-
tention, the use of many joints might be recovered,
which, from a mistaken notion concerning their causes,
have generally from the first been considered as in-
curable.
The disorder has hitherto been supposed not to be
so far advanced as to have occasioned the formation
of matter ; for, when it is come that length, no con-
siderable advantages can be expected from any of the
remedies we have recommended : but, even in this
state of the complaint, if the patient's health does not
absolutely require it, amputation of the member should
by no means be performed immediately, as it most
frequently is. For, by paying attention to open the
different abscesses soon after their formation, the mat-
ter may be pretty certainly prevented from affecting,
or essentially injuring, the capsular ligaments of the
joints ; the destruction of which would no doubt ren-
der amputation necessary.
By the use of the seton, as was formerly directed in
other cases of imposthume, the discharge of such col-
lections is certainly and easily effected ; is never at-
tended with any inconvenience ; and has sometimes
been, and may frequently be, a means of saving many
such diseased joints. At least, when a limb is at stake,
the practice recommended is on all occasions worth
trying : and there never, it is probable, can be any
well grounded objection made to it, unless the pa-
tient's constitution be so much reduced as to produce
much risk from any farther delay ; in which case, am-
putation
recens mactati, vel immittitur in imum ventrem bovis, vitali calore
haud defraudate." Synopsis Universae Praxeos Medicæ, vol. I. p.
400.


284 Of the Treatment Part III.
putation is, no doubt, to be immediately performed :
though, if such abscesses as occur be opened soon after
their first formation, there will always be sufficient
time for observing what advantages are to be obtained
from the discharge which is thus produced.
It is necessary, however, to remark, that it is in col-
lections of matter only for which we here mean to rec-
ommend the use of setons ; for it frequently happens,
in rheumatic affections of the larger joints, that effu-
sions of serum take place in very considerable quanti-
ties ; which, merely by the application of moderate
friction to the parts affected, are frequently altogether
absorbed. This, however, happens rarely in abscesses
of real purulent matter: so that whenever collections
of this nature occur upon a joint, they ought to be
discharged; and the safest method of effecting  it, is
undoubtedly by the introduction of a seton.
With respect to the most proper period of the dis-
ease for amputating limbs diseased in this manner,  it
may be observed, that, even in point of success from 
the operation, it ought never to be advised the
complaint is pretty far advanced. For though, a pri-
ori, it might be imagined, that the more early, in the
disease, amputation of the member is employed, the
more successful it should prove ; and although this,
indeed, has been made use of as a common argument
for amputating very early in every case of white swell-
ing ; yet, however plausible the observation may ap-
pear, it will not, from experience, I am persuaded, be
found to hold good. For, in this disorder especially,
I have constantly observed, that amputation has more
frequently succeeded, that is, a greater proportion of
such patients have recovered from it, who have previ-
ously been considerably reduced, by diarrhœas and
other


Sect. II of White Swellings. 285
other weakening symptoms, than of such as have still
remained in a full plethoric habit of body.
In the former, when the constitution has not been
too much broken, and we have it always in our power
to guard against its being so, the several symptoms of
hectic fever, which previously took place, are com-
monly removed in a very few days after the limb is
taken off: No high inflammatory affections are ever
produced ; the patient daily improves in his health ;
and a complete cure, if he has not been too much re-
duced, is generally very soon obtained. In the latter
again, the very reverse of all these circumstances oc-
curs : The patient, from being in high health at the
time of the operation, is generally thrown into a smart
inflammatory fever ; which is, no doubt, very often
removed, but which frequently either carries off the
patient immediately, or produces such effects as he
never thoroughly recovers from.
So that in no case whatever is it proper to have re-
course to amputation, until every probable means for
saving the limb has been tried in vain.
All the means we have hitherto recommended, re-
late particularly to the rheumatic species of the disor-
der ; and when employed in time, and duly persisted
in, they will frequently be found of service : but when
the disease is so far advanced as to have destroyed the
capsular ligaments of the joint, and perhaps even the
cartilages and bones themselves, amputation of the
member is then no doubt the only resource.
In the more fatal species of white swelling, namely, 
the scrophulous, as I know no certain remedy for scro-
phula, even in its milder form in the soft parts of the
body, I cannot here pretend to offer any thing satis-
factory upon the subject.
In 

286 Of the Treatment, &c. Part III.
In the small joints, when the diseased parts of the
bone begin to cast off, a cure may be sometimes pro-
moted by assisting the efforts of nature ; but in all the
large joints, particularly in the knee and ancle, it is
not probable that any other resource than amputation
will ever afford much relief. And even the effects of
this operation can seldom be depended on as lasting:
for when the general scrophulous disposition still sub-
sists in the constitution, the disorder will most proba-
bly appear again in some other part; which, however,
in the advanced stages of the disease, it is sometimes
necessary to run the risk of, the pain being often so
tormenting as to make it more eligible to submit to
any hazard rather than to bear it longer.
When, however, for some reason or other, amputa-
tion is determined against, by there being almost a cer-
tainty that the complaint will soon return, from the
scrophulous disposition's appearing very strong in the
System, it then becomes necessary to have recourse to
palliatives, so as to render the complaint as tolera-
ble as possible ; and, with this view, opiates in large
doses, by moderating the pain and procuring rest, will,
in general, be found to be the principal remedy.
In other respects, all such medicines and articles of
regimen, as are found to prove beneficial in scrophula,
are advisable ; but for these, as it would be foreign to
the intention of this treatise to enumerate them, a
former section of the second part of this work, together
with such authors as have written more fully on the
subject, may be consulted.
INDEX. 

287
INDEX.
Page.
ABSCESS, a case of, which ended fatally from improper 
treatment, - 50
Abscesses, when they ought to be opened, - 49
- always injured by the access of air, - 53
- different methods of opening, - 51
- method of opening by caustic, - ibid.
- opening by incision, - 52
- opening by the introduction of a cord, 55
Acid, vegetable, its sedative powers, 30
- vitriolic, its use in gangrene, - 73
Alkaline substances, their effects in scrophulous ulcers, 254
Alcohol, its effects in gangrene, - 74
Amputation, the most certain remedy in cancer, - 195
- circumstances which render it improper in
cancer, - 201
- observations on, in cases of white swellings, 284
Antimony, its use in cutaneous affections, - 219
Antiseptics, their effects in scorbutic ulcers, - 249
Aperients, their use in scrophulous ulcers, - 255
Applications, mild, their general utility in ulcers, 116
Arsenic, observations on, in cancerous disorders, 205
Arteries, increased action of, - 21
Astringents, their use in cutaneous affections, - 217
- their utility in the cure of ulcers, - 128
B
BANDAGE, spiral, its use in callous ulcers, - 158
Bark, Peruvian, its effects in gangrene, - 70
- best mode of exhibiting it, - 71
- red, an account of its effects, - 72
- Peruvian, useful in carious ulcers, - 175
- often necessary in the simple vitiated ulcer, 137
- its utility in venereal ulcers, - 242
- its use in scorbutic ulcers, - 250
- an external application in scorbutic ulcers, ibid.
- its use in scrophulous ulcers, - 254
Bath, warm, proper to be used in a course of mercury, 239
Bathing, 


288 INDEX.
Bathing, warm, its use in cutaneous ulcers, - 216
Belladona, observations on, in cancerous ulcers, 205
Blisters, their effects in white swellings, - 276
Blood letting, local, its utility in cases of phlegmon, 35
- its effects in white swelling, - 275
Boles, useful in cutaneous affections, - 217
Buboes, when opened, difficult to cure, - 26 
C
CANCEROUS ulcer, symptoms and diagnosis of, 181
Cancer, causes of, - 182
- treatment of, - 198
Carbuncles, observations on, - 63
- causes of, - ibid.
Cataplasms, emollient, recommended in the simple vitiated
ulcer, - 136
- warm, their utility in callous ulcers, 157
- their effects in the cure of ulcers, 125
Caustic, lunar, the best escharotic in the fungous ulcer, 145
- when useful in venereal ulcers, - 243
Caustic recommended in venereal ulcers, - 233
Caustics when necessary in callous ulcers, - 157
Cautery, actual, observations on the use of, - 172
Cerate, Goulard's saturnine, recommended in the simple pu-
rulent ulcers - 120
Ceruss, an application for ulcers - 127
Chalybeate and sulphureous waters, their effects in scrophu-
lous ulcers, -254
Charpee, the constant use of in the cure of ulcers to be
avoided, - 123
Cicatrising applications, what, - 99
Cicuta, observations on, - 195
Citrinum, unguentum recommended in cutaneous affections, 224
Cleanliness, particularly necessary in cutaneous ulcers, 216
Compression, its utility in the cure of ulcers in general, 126
- particularly useful in the cure of scrophulous ul-
cers, - 255
Cupping, dry, sometimes proves useful, - 52
- and scarifying, its effects in white swelling, 275
Cutaneous affections, general remarks on, - 208
D
DETERGENTS, their utility in ulcers, - 99
Diathesis 

INDEX. 289
Diathesis phlogistica, - 23
Diet, nourishing, its use in scorbutic ulcers, - 249
— when useful in venereal ulcers, 242
- attention to in the cure of the simple vitiated ulcer, 137
Digestives, their utility in ulcers, -  99
E
EMOLLIENTS, their use in white swellings, - 281
- improper for resolving inflammation, 27
Erysipelas, description of, - 26
Escharotics, their use in cancerous disorders, - 206
- necessary in the cure of the fungous ulcer, 145
- sometimes used in sinuous ulcers, - 151
- sometimes necessary in the cure of ulcers, 128
F
FETOR, method of correcting it in cancerous disorders, 203
Flores martiales, their effects in cancers, - 207
Fomentations, emollient, recommended in the simple vitiated
ulcer, - 136
Friction, its utility in white swellings, - 279
G
GANGRENE, white, -  62
- dry, symptoms of, - 61
- causes of, - 63
- termination of always uncertain, - 24
- prognosis in, - 66
- method of treating, - 68
- blood letting sometimes useful in, ibid. 
- large evacuations hurtful in, - 69
Goulard, his extract of lead, - 32
- his vegeto mineral-water - 33
Granulations, their formation in sores, - 114
Gums, warm, observations on the use of, - 172
H
HEAT, a principal agent in the formation of pus, 44
- best means of applying, - 46
- its influence on the discharge of ulcers, - 95
- a due degree of, necessary in the cure of ulcers, 124
 Herpes, the different species of, 209
I
INFLAMMATION, every part of the body liable to, 17
- predisposing causes of, - 20
- exciting causes of, ibid.
T Inflammation, 


290 INDEX.
Inflammation, proximate cause of, - 21
- more frequent in young than in old people, ibid.
- more frequent in men than in women, ibid.
- symptoms of, accounted for, - 23
- prognosis in, - 24
- resolution of, not always advisable, 25
- its influence on the discharge of ulcers, 112
Injections, escharotic, an application in sinuous ulcers, 151
Issues, their debilitating effects, - 92
- their effects in the cure of ulcers, - 89
- in what manner they operate, - 90
- often necessary in the simple vitiated ulcer, 139
- their utility in scrophulous ulcers, - 257
- their use in cutaneous affections, - 227
- their efficacy in cutaneous ulcers, - 220
L
LAXATIVES, useful in resolving inflammation, - 35
- cutaneous affections, - 219
- the scorbutic ulcer, - 248
- their effects in gangrene, - 68
- useful in white swellings, - 277
Lead, preparations of, their sedative powers, - 29
- external application of, never prejudicial, 31
- preparations of, not to be employed for promoting
suppuration, - 30
- useful in cutaneous ulcers, 217
Leeches, observations on their use in white swellings, 276
- sometimes useful in carious ulcers, - 180
Ligature, sometimes proper in the fungous ulcer, 147
- directions for using in the fungous ulcer, ibid. 
Lime-water, an useful application in ulcers, - 127
- useful in carious ulcers, -  176
- in cutaneous ulcers, - 217
Lungs, why very liable to inflammation, -  22
Lymph, coagulable, its influence in the formation of pus, 41
M
MEL rosarum, its use in scorbutic ulcers, - 249
Mercurials, their effects in scrophulous ulcers, 254
Mercury, simple triturated, the best form of exhibiting it, 239
- solution of, proper in the callous ulcer, 158
- dissolved in spirit of nitre, a strong and useful cau-
stic, - 146 
Mercury


INDEX. 291
Mercury, its utility in venereal ulcers, - 233
- its use in white swellings, - 277
its effects in scorbutic ulcers, - 150
- corrosive sublimate, its use in cutaneous affections,  217
Mercurius præscipitatus ruber, its use in venereal  ulcers, 237
Mezereon, decoction of, its use in cutaneous affections, 218
Miasmata, putrid, their deleterious influence, - 67
Mortification, definition of, - 19
- characteristic symptoms of, - 61
Myrrh, tincture of, sometimes useful in the cure  of ulcers, 129
N
NITRE, observations on the use of, in the cure of ulcers, 142
O
OIL, warm, its use in white swellings, - 281
Ointments, proper in carious ulcers, - 177
Omentum, the warm application of, useful in white swell-
ings, 282
Opiates, internal use of, beneficial in inflammation, 35
- useful in wounds, - ibid.
- their use in white swellings, - 286
- sometimes proper in the simple vitiated ulcer, 137
- why commonly avoided in inflammation, 36
Opium, as an external application, sometimes inadmissible in
inflammation, - 28
P
PARK, Mr. observations on his method of amputating the
ends of bones, - 179
Perspiration, not necessary for resolving tumors, 34
Phlegmon, definition of, - 18
- terminations of, - ibid.
- resolution of, what, - 19
- resolution of, when to be desisted from, 36
- more apt to terminate in suppuration in some parts
than in others, - 37
- in membranous parts does not easily suppurate, ibid.
Posture, attention to, recommended in the cure of ulcers, 129
Pus, definition of, - 38
- different opinions of its formation, ibid. 
- does not exist in the blood, - 40
- is formed from serum, - ibid.
- Sir John Pringle's experiments upon, - ibid.
Pus, 

292 INDEX.
Pus, Mr. Gaber's experiments upon, - 50
- symptoms of its full maturation, - 49
Precipitate, red, when useful in venereal ulcers, - 242
R
REGIMEN, directions for, in the cure of ulcers, - 131
- in carious ulcers, - 179
Remedies, internal, their use in cutaneous ulcers, - 214
Rest, always necessary in the cure of ulcers, - 129
Rollers, flannel, recommended in the cure of ulcers, 111
S
SACCHARUM saturni, the best preparation of lead, 31
Saccharum saturni, form of using it, - 32
Saturnine applications, their effects in scrophulous ulcers, 155
Saturni, sacch. combined with lac sulphuris, useful in cuta-
neous affectons, -  221
Sal ammoniac, useful in gangrene, - 75
Saw, spring, observations on its use in removing carious
bones, - 177
Sarsaparilla, decoction of, its use in cutaneous ulcers, 218
- useful along with mercury, 239
Scalpel, when necessary in callous ulcers, - 157
Scarrifications, proper in carious ulcers, - 180
- not necessary in mortification, - 74
Schirrus, not an usual consequence of inflammation, 19
Scrophulous tumors, when not to be  meddled with, 26
Scurvy, general remarks on, - 244
Sea-bathing, its use in scrophulous ulcers, - 254
Sedatives, their external application in inflammation, 27
Setons, method of introducing, - 56
- prove frequently hurtful in hydrocele, - 59
- their utility in white swellings, - 284
- recommended in the cure of the sinuous ulcer, 152
Spasm, the proximate cause of inflammation, - 22
Spirits, ardent, an useful application in ulcers, - 128
Stimulents, their effects in gangrene, - 70
- sometimes necessary for promoting suppuration, 47
Stocking, laced, its use in the cure of ulcers, - 110
- its use in callous ulcers, - 158
Styptics, sometimes necessary in ulcers, - 118, 127
Sublimate, corrosive, its use in cutaneous affections, 226
- its use in venereal ulcers, 240
Sulphur,

INDEX. 293
Sulphur, its efficacy in cutaneous eruptions, - 223
Sulphuris, lac, useful in cutaneous affections, - 224
Suppuration, symptoms of, - 19
- definition of, - 38
- means of promoting, - 42
Swellings of a critical nature not to be repelled, - 26
- white, diagnosis of, - 273
- symptoms and causes of, - 261
- different species of, - 262
- symptoms of the rheumatic species of, 264
- symptoms of the scrophulous species of, 268
- treatment of, - 275
T
THERIAC, an application in gangrene, - 75
Throat, why liable to inflammation, - 22
Trepan, its use in carious ulcers, - 175
U
ULCER, definition of, - 79
Ulcers, varieties of, - 80
- arrangement of, - 81
- causes of, - 83
- prognosis in, - 84
- may always be healed with safety, - 87
- long-continued, dangerous to the constitution, 97
- of fleshy parts, heal more easily than others, 85
- in the cure of, the effects of compression, 110
- division of, into different classes, - 100
- simple, different species of, - ibid.
- compound, different species of, - ibid.
- remarks on the growth of new parts in, 103
- general corollaries relating to the management of, 257
Ulcer, simple purulent, observations on, - 101
- symptoms of, ibid.
- causes of, - 102
- prognosis in, - 103
- remarks on the cure of, 1l8
- warm gums, balsams, &c. hurtful in,  119
- simple vitiated, observations on, 133
- symptoms of,- 134
- causes of, - 135
- prognosis in, - ibid.
Ulcer, 

294 INDEX.
Ulcer, simple vitiated, cure of, - 136
- sungous, observations on, 142
- symptoms of, - ibid.
- causes of, - 143
- cure of, - 144
- sinuous, observations on, - 149
- symptoms and causes of, - 150
- cure of, 151
- the usual method of opening, ibid.
- callous, observations on, - 155
- symptoms and causes of, - ibid.
- cure of, 157
- carious, observations on, 160
- symptoms and diagnosis of, - ibid.
- causes and prognosis in, - 166
- cure of, - 169
- cancerous, observations on, - 181
- causes of, - 182
- treatment of, - 195
- cutaneous, observations on, - 208
- often connected with other diseases, 221
- cure of, - 213
venereal, observations on, - 228
- varieties of,  - 229
- appearances of, - 231
- cure of, - 236
- scorbutic, observations on, - 244
- symptoms and causes of, - 245
- the cure of, 248
- applications proper in, - 251
- scrophulous, observations on, - 252
- symptoms and causes of, - ibid.
- cure of, - 253
Unguents, blunt, the action of lead, - 33
Unguentum, Ægyptiacum, its use in scorbutic ulcers, 249
- cereum, recommended in the cure of ulcers, 120
- saturninum, its use in the cutaneous ulcer, 221
Vegetables, their use in the scorbutic ulcer, 248
W
WALNUT tree, the leaves of, useful in carious ulcers, 175
Warm water, falls of useful in white swellings, 278
Water, 

INDEX. 295
Water, cold, effects in white swellings, - 279
Wine, its effects in gangrene, - 70
Woods, decoction of, its use in cutaneous affections, 218
- useful along with mercury, 239
Z
ZINC, its use in cutaneous ulcers, - 221
FINIS.