A TREATISE ON THE BLOOD, INFLAMMATION, AND GUN-SHOT WOUNDS, BY THE LATE JOHN HUNTER. TO WHICH IS PREFIXED A SHORT ACCOUNT OF THE AUTHOR'S LIFE, BY HIS BROTHER-IN-LAW, EVERARD HOME. IN TWO VOLUMES, FROM THE LONDON QUARTO. VOL. II. PHILADELPHIA: PUBLISHED BY THOMAS BRADFORD, PRINTER, BOOK-SELLER & STATIONER, No. 8, South Front-Street, 1796. TABLE OF CONTENTS. PART II. CHAPTER III. THE ADHESIVE INFLAMMATION, page 3 SECT. I. Action of the vessels in inflammation, 4 II. Of the colour, swelling, and pain of in- flamed parts, 9 III. The heat of parts in inflammation, 16 IV. Of the production of cold in inflam- mation, 25 V. Of the time the adhesive inflammation commences after its cause, and in what cases and parts it is imperfect in its consequences, 28 VI. Of the uniting medium in inflammation, 32 VII. The state of the blood and of the pulse in inflammation, 38 VIII. The effects of inflammation on the con- stitution according to the structure of the parts, situation of similar structure. and whether vital or not vital, 48 IX. General reflections on the resolution of inflammation, 51 X. Of the methods of resolution by consti- tutional means, 59 XI. The use of medicine internally, and of local applications in inflammation, 71 XII. General observations on repulsion, sym- pathy, derivation, revulsion, and translation, 77 Table of contents. XIII. Of the different forms in which medicines are applied, and the subsiding of in- flammation, 85 XIV. Of the use of the adhesive inflammation, 89 CHAPTER IV. OF THE SUPPURATIVE INFLAMMATION, 95 SECT. I. The symptoms of the suppurative inflam- mation, 101 II. Of the treatment necessary in inflammation when suppuration must take place, 104 III. The treatment of the inflammation when suppuration has taken place, 111 IV. Collections of matter without inflam- mation, 114 V. Of the effects such formations of matter have on the constitution, 117 VI. The effects of the suppurative inflamma- tion on the constitution, 119 CHAPTER V. OF PUS, 137 SECT. I. Of the general opinion of the formation of pus, 139 II. Of the properties of pus, 150 III. Of the use of pus, 158 CHAPTER VI. THE ULCERATIVE INFLAMMATION, 161 SECT. I. Of the remote cause of the absorption of the animal itself, 167 II. Of the disposition of living parts to absorb and to be absorbed, 168 III. Of interstitial absorption, 173 IV. Of the progressive absorption, 175 V. Of absorption attended with suppuration, which I have called ulceration 178 VI. Of the relaxing process, 182 Table of contents. VII. Of the intention of absorption of the body in disease, 186 VIII. The modes of promoting absorption, 187 IX. Illustrations of ulceration, 188 CHAPTER VII. GRANULATIONS, 195 SECT. I. Of Granulations independent of suppu- ration, 197 II. The nature and properties of granulations, 199 III. Longevity of granulations, 203 IV. Of the contraction of granulation, 205 CHAPTER VIII. OF SKINNING, 2O9 SECT. I. The nature of the new cutis, 212 II. Of the new cuticle, 214 III. Of the rete mucosum, 215 CHAPTER IX. EFFECTS OF INFLAMMATION, AND ITS CONSEQUENCES ON THE CONSTITUTION, 217 SECT. I. Of the hectic, 218 II. Treatment of the hectic, 225 III. Of dissolution, 226 PART III. CHAPTER I. THE TREATMENT OF ABCESSES, 231 SECT. I. The progress of abscesses to the skin, 233 II. Of the time when abscesses should be opened, 238 III. Of the methods of opening abscesses, and treating them afterwards, 241 Table of contents. PART IV. CHAPTER I. OF GUN-SHOT WOUNDS, 245 SECT. I. The difference between gun-shot wounds and common wounds, 246 II. Of the different effects arising from the difference in the velocity of the ball, 249 III. Of the different kinds of gun-Shot wounds, 252 CHAPTER II. OF THE TREATMENT OF GUN-SHOT WOUNDS, 253 SECT. I. Of the propriety of dilating gun-shot wounds, 256 II. Of the strange course of some balls, 262 III. Penetrating wounds of the abdomen, 266 IV. Of penetrating wounds in the chest, 275 V. Of concussions and fractures of the scull, 280 VI. Of wounds compounded with fractured bones, or containing extraneous bodies, 281 VII. Of the time proper for removing in- curable parts, 283 VIII. Of the treatment of the constitution, 287 Explanation of the plates, 291 [3] CHAPTER III. THE ADHESIVE INFLAMMATION. I SHALL begin by treating of the nature and effects of what I have called the adhesive inflammation, as well as giving a proper idea of it. I shall also open the way to a clear understanding of the many phænomena which attend the suppurative inflammation; but as inflamma- tion does not produce one effect only, but several, and as most of them take place about the same time, it is diffi- cult to determine in the mind, which to describe first. Inflammation in most cases appears to begin at a point; for at the very first commencement, all the local symp- toms are within a very small compass, and they after- wards spread according to the violence of the cause; the disposition in the parts for inflammation, and the nature of the surrounding parts themselves; which susceptibility in the surrounding parts may be either constitutional or local. This is so much the case, that inflammation shall come on at once in a fixed point, giving great pain, and which shall be soon followed by tumefaction. This is also the case with those inflammations which a- rise from accident, for all accidents are confined to fixed and determined limits, but the inflammation which fol- lows is not; it spreads over a large extent, yet the in- flammation is always the greater, the nearer it is to the first fixed point; and gradually becomes less and less in the surrounding parts, till at last it is insensibly lost in them. This spreading of the inflammation is owing to conti- nued sympathy, the surrounding parts sympathizing with the point of irritation; and in proportion to the health of the surrounding parts and constitution, this sympathy A2 4 The adhesive inflammation. is less; for we find in many states of parts, and many constitutions, that there is a disposition to this sympathy, and in such, the inflammation spreads in proportion. I. ACTION OF THE VESSELS IN INFLAM- MATION. THE act of inflammation would appear to be an in- creased action of the vessels *, but whatever action it is, it takes place, most probably in the smaller vessels, for it may be confined almost to a point where nothing but the smallest vessels exist. The larger vessels may be consider- ed as only the conveyors of the materials, for the smaller to act upon and dispose of according to the different in- tentions; however, inflammation in a part, is not only an action of the smaller vessels in the part itself, but in the larger vessels leading to it. This is proved by a whitlow taking place on the end of a finger; for although the in- flammation itself shall be confined to the end of a finger, and the inflammatory sensation or throbbing be situated in this part, yet we can feel by our hands, when we grasp the finger, a strong pulsation in the two arteries leading to the inflamed part, while no such pulsation can be felt in the other fingers; and if the inflammation is very con- siderable, the artery, as high as the wrist, will be sensibly affected, which proves that the arterial system is at that time dilating itself, and allowing a much larger quantity of blood to pass than is usual. This is probably by conti- nued sympathy. Where the inflammation affects the constitution, the vessels of the system rather contract, and keep as it were stationary, which stationary contraction is more or less ac- cording to the state of the constitution; in strong healthy * It may be here remarked, that the action of vessels is commonly supposed to be contraction, either by their elastic or muscular coats; but I have shown that their elastic power also dilated them; and I have reason to believe the muscular power has a similar effect. The adhesive inflammation. 5 constitutions whose powers are equal to the necessary ac- tions, or in parts that affect the constitution less, this con- traction is less and less stationary. The very first act of the vessels when the stimulus which excites inflammation is applied, is, I believe, exactly si- milar to a blush. It is, I believe, simply an increase or distension beyond their natural size. This effect we see takes place upon many occasions, gentle friction on the skin produces it; gently stimulating medicines have the same effect, a warm glow is the consequence, similar to that of the cheek in a blush: and if either of these be in- creased or continued, real inflammation will be the con- sequence, as well as excoriation, suppuration and ulcera- tion. This effect we often see, even where considerable mischief has been done; and I believe it is what always terminates the boundaries of the true inflammation. A musket-ball shall pass a considerable way under the skin, perhaps half way round the body, which shall be discover- ed and traced by a red band in the skin, not in the least hard, only a little tender to the touch; and it shall subside without extending farther. This appearance I shall term a blush; for although this may be reckoned the first act of inflammation, yet I would not call it inflammation, hav- ing produced a lasting effect; I should rather say, that inflammation sets out from this point, and that afterwards a new action begins, which is probably first a separation of the coagulating lymph, and the throwing it out of the vessels. The parts inflamed appear to become more vascular; but how far they are really so, I am not certain, for this appearance does (at least in part) arise from the dilation of the vessels, which allows the red part of the blood to go in- to vessels where only serum and coagulating lymph could pass when they were in a natural state, and still the new- ly extravasated substances become vascular; the effect is most probably owing wholly to the above cause. This incipient enlargement of the vessels upon the first excitement of inflammation is satisfactorily seen in the fol- lowing manner. Make an incision through the skin on the inside of the upper part of a dog's thigh, three inches long; by pulling the cut edges asunder, and observing the exposed surface, we shall see the blush or ash-coloured cellular membrane covering the different parts underneath, 6 The adhesive inflammation. with a few arteries passing through it to the neighbour- ing parts; but in a little time we shall see these vessels in- creasing in size, and also smaller vessels going off from them that were not before observable, as if newly formed or forming; the number and size shall increase till the whole surface shall become extremely vascular, and at last the red blood shall be thrown out in small dots on the ex- posed surface, probably, through the cut ends of the ar- teries that only carried the lymph before. This surface will become in time more opaque, and less ductile. Parts inflamed, when compared with similar parts not inflamed, shew a considerable difference in the size of the vessels, and probably from this cause bring an increased number to view. I froze the ear of a rabbit and thawed it again; this excited a considerable inflammation, and increased heat, and a considerable thickening of the part. This rabbit was killed when the ear was in the height of inflam- mation, and the head being injected, the two ears were removed and dried. The uninflamed ear dried clear and transparent, the vessels were distinctly seen ramifying through the substance; but the inflamed ear dried thicker and more opaque, and its arteries were considerably larger. In inflammation of the eye, which is commonly of the tunica conjunctiva, the progress of inflammation may, in part, be accurately observed, although not so progressively as in a wound. The contrast between the red vessel and the white of the eye, under this coat is very conspicuous, and although we do not see the vessels enlarging in this coat, yet we see the progress they have made, the white appears as if it was becoming more vascular, and these ves- sels larger, till at last the whole tunica conjunctiva shall appear as one mass of blood, looking more like extravasated blood then a congeries of vessels, although I believe it is commonly the last. From these circumstances it must appear, that a much larger quantity of blood passes through parts when infla- med than when in a natural state, which is according to the common rules of the animal œconomy; for, when- ever a part has more to do than simply to support itself, the blood is there collected in larger quantity; this we find to take place universally in those parts whose powers are called up to action by some necessary operation to be performed, whether natural or diseased. The adhesive inflammation. 7 As the vessels become larger, and the part becomes of the colour of the blood, it is to be supposed there is more blood in the part; and as the true inflammatory co- lour is scarlet, or that colour which the blood has when in the arteries, one would from hence conclude, either that the arteries were principally dilated, or at least, if the veins are equally distended, that the blood undergoes no change in such inflammation in its passage from the arteries into the veins, which I think is most probably the case; and this may arise from the quickness of its pass- age through those vessels. When inflammation takes place in parts that have a degree of transparency, that transparency is lessened. This is, proba- bly, best seen in membranes, such as those membranes which line cavities, or cover bodies in those cavities, such as the pia- mater, where, in a natural state, we may observe the blood- vessels to be very distinct. But when we see the blood-ves- sels fuller than common, yet distinct in such membranes, we are not to call that inflammation, although it may be the first step, as we find to be the case in the first action of the vessels in consequence of such irritation as will end in inflammation. As it may not, however, be the first step, there must be other attending circumstances to de- termine it to be the very first action of the vessels in in- flammation, for as that appearance may either belong to a briskness in the circulation in the part at the time, or the very first step in inflammation, their causes are to be dis- criminated by some other symptom; they are both a kind of blush, or an exertion of the action of the vessels; but when it is an effect of an inflammatory cause, it is then only that the inflammation has not yet produced any change in the natural structure of the parts, but which it will soon do.‡ What the action is, or in what it differs from the common action of the vessels, is not easily ascertained, since we are more able to judge of the effects than the imme- ‡ When this appearance is seen any where after death, it should not be called inflammation, even although we knew it was the first action of inflammation; for as we are then only looking out for the causes of death, or the symptoms prior to death, we are only to look out for such as can be a cause, and not lay hold of those that cannot possibly be a cause, which those first actions cannot be. 8 The adhesive inflammation. diate cause. However, it is probably an action of the vessels, which we can better observe than any diseased action in the body, for we can observe the state in which the arteries are, with their general effects; we feel, also, a different temperature respecting heat, yet the immediate cause may not be ascertainable. The vessels, both arteries and veins, in the inflamed part are enlarged, and the part becomes visibly more vascular, from which we should suspect, that instead of an increased contraction, there was rather what would appear an in- creased relaxation of their muscular powers, being, as we might suppose, left to the elasticity entirely. This would be reducing them to a state of paralysis simply; but the power of muscular contraction would seem to give way in inflammation, for they certainly dilate more in inflamma- tion than the extent of the elastic power would allow; and it must also be supposed, that the elastic power of the artery must be dilated in the same proportion. The contents of the circulation being thrown out upon such occasions, would, from considering it in those lights, rather confirm us in that opinion; and when we consider the whole of this as a necessary operation of nature; we must suppose it something more than simply a common relaxation; we must suppose it an action in the parts to produce an increase of size to answer particular purposes; and this I should call the action of dilatation, as we see the uterus increase in size in the time of uterine-gestation, as well as the os tincæ in the time of labour, the consequence of the preceding actions, and necessary for the completion of those which are to follow. The force of the circulation would seem to have some share in this effect, but only as a secondary cause; for I could conceive a part to inflame, or be in a state of inflamma- tion, although no blood were to pass. As a proof of this, we may observe, that by lessening either the action of the heart, or the column of blood, inflammation is lessened; and I may also observe, that we have an increased pain in the inflamed part in the diastole of the artery, and a part inflamed by being gently pressed is made easier. Thus a person with an inflammation in the fingers will find relief by gently pressing it in the other hand. These are strong proofs that it is not a contractile action of the vascular coat of the vessel; for in such a sensible state of vessels if they contracted by their muscular power, the pain would be in their systole; for we find in all muscles which are in The adhesive inflammation. 9 a state of great sensibility, from whatever cause, that they cannot act without giving great pain. Thus an inflamed bladder becomes extremely painful when expelling its con- tents, an inflamed intestine in the same manner; I should say, therefore, that in inflammations the muscular coats of the arteries do not contract. Whatever purpose this increase of the size of the ves- sels man answer, we must suppose it allows a greater quan- tity of blood to pass through the inflamed part than in the natural state, which supposition is supported by many other observations. The part inflamed, I have already observed, becomes to appearance more vascular than when in the natu- ral state, and it is probable that it is really so, both from new vessels being set up in the inflamed part, as well as the new and adventitious uniting substance becoming vascular. Besides, the vessels of the parts are enlarged, so that the red blood passes further than common, which increases those appearances. But the brain appears to be an excep- tion to these general rules; for in all diseases of the brain, where the effects were such as are commonly the conse- quence of inflammation, such as suppuration from acci- dents, I never could find the above appearances; the brain may, perhaps, go directly, into suppuration, as sometimes the peritoneum does; but its slowness of going into sup- puration after the accident, would make us suppose, a pri- ori, that there was sufficient time for adhesions to form. II. OF THE COLOUR, SWELLING, AND PAIN OF INFLAMED PARTS. THE colour of an inflamed part is visibly changed from the natural, whatever it was, to red. This red is of vari- ous hues, according to the nature of the inflammation; if healthy, it is a pale red; if less healthy, the colour will be darker, more of a purple, and so on till it shall be a blueish purple, which I took notice of in the short sketch of the peculiar inflammations; but the parts inflamed will in every constitution be more of the healthy red when the Vol. II, B 10 The adhesive inflammation. parts inflamed are near to the source of the circulation, than when far from it. This increase of red appears to a- rise from two causes; the first is a dilatation of the vessels, whereby a greater quantity of blood is allowed to pass into those vessels which only admitted serum or lymph before. ‖ The second is owing probably to new vessels being set up in the extravasated uniting coagulating lymph. This colour is gradually lost in the surrounding part if the inflammation is of the healthy kind, but in many others it has a determined edge, as in the true erysipelatous, and in some specific diseases, as in the small-pox, where its quick termination is a sign of health. From the account I have given of the immediate effects of inflammation of the cellular membrane, in which I in- clude the larger cavities, the volume of the part inflamed must be increased. This, when a common consequence of inflammation, is not circumscribed, but rather diffused, as the inflammation, however, begins in a circumscribed part, which is at least the case with that arising from violence; the inflammation I just now observed is always the great- est nearest to that point, and is gradually lost in the sur- rounding parts, the swelling of course is the greatest at, or nearest to this point, and it is also lost in the surrounding sound parts. This takes place, more or less, according to the constitution, or the situation of the inflammation; for if the constitution be strong and healthy, the surrounding parts will sympathize less with the point of irritation, so that inflammation and its consequences, viz. extravasation will be less diffused. There will be less of the serum, and of course a purer coagulating lymph, so that the swelled parts will be firmer; but in some specific disease or dissimilar part, as a gland, it has a more determined edge, the surrounding parts not so readily taking on specific diseased action as in other cases. In this both the colour and swelling correspond very much since they both depend on the same principle. The increase of volume is owing to the extravasation of the coagulating lymph, and some serum; in proportion to the inflammation, the degree of which depends on the ‖ The tunica conjunctiva of the eye when inflamed, is a strickling instance of this; but the visible progress of inflamma- tion I have already described in the experiment on the dog. The adhesive inflammation. 11 causes abovementioned, this effect is more or less, and therefore is greatest at the point of inflammation, becom- ing less and less as it extends into the surrounding parts, till it is insensibly lost in them. The extravasation of the serum along with the coagulat- ing lymph is, probably, not a separation of itself, as in a dropsy, but a part of it being separated from the lymph in the coagulation of that fluid, is squeezed into the sur- rounding cellular membrane, where there is but little ex- travasation, and where the cells are not united by it. Thus the circumference of such swelling is a little œdematous; but the whole of the serum, if there be a depending part, will move thither, and distend it considerably, as in the foot in consequence of an inflammation in the leg. But in most cases there is a continued extravasation of serum, long after the extravasation of the coagulating lymph is at at an end; so that depending parts will continue œdema- tous, while the inflammation is resolving, or while suppu- ration, or even healing is going on. The whole swelling looks like a part of the body only a little changed, without any appearance of containing ex- traneous matter; and indeed it is simply formed by an extravasation of fluids without their having undergone any visible or material change, except coagulation. As few uncommon operations can go on in an animal body without affecting the sensations, and as the first principle of sensation arises from some uncommon action, or alter- ation being made in the natural position or arrangement of the parts, we should naturally suppose that the sensation would be in some degree according to those effects, and the sensibility of the parts. One can easily form an idea of an alteration in the structure of parts giving sensation which may even be carried to pain, but that the simple ac- tion of parts should produce sensations and even violent pain is but little known, or at least has been, I believe, but little attended to; all these effects, I think, may just- ly be included under the term spasm ‖; at least we are led by analogy to suppose that they belong to that class. ‖ How far a nerve from a part, or how far the materia vitæ of a part, can act so as to convey sensation I do not know; but we all know that an involuntary action of a voluntary muscle, or the spontaneous action of an involuntary muscle will produce it. 12 The adhesive inflammation. By spasm I should understand a contraction of a muscle, without the leading and natural causes. Thus the contraction of a muscle of the leg, called the cramp, gives considerable pain, often violent, as also the tetanus, and when in a less degree, as in the twinkling of the eye-lid, it gives only sensation, whereas if the muscles were to act by the will, no sensation would be produced. We find that those sensations are more or less acute, according to the quickness or slowness of the progress of these causes, from whence we are naturally led to assign two causes which must always attend one another; for when both do not take place at the same time, the mind then remains insensible to the alteration. This is its being pro- duced in a given time, for the alteration in the position of the parts may be produced so slowly, as not to keep pace with sensation, which is the case with many indolent tu- mors, ascites, etc. on the other hand this alteration in the natural position of parts may be so quick as to exceed sen- sation, and therefore there is a certain medium, which produces the greatest pain. The actions I have been describing being pretty quick in their effects we cannot fail to see why the pain from the in- flammation must be considerable; however the pain is not the same in all the different stages. In the adhesive state of the inflammation it is generally but very inconsiderable, especi- ally if it is to go no further, and is perhaps more of a heavy than an acute pain; when it happens on the skin it often begins with an itching; but as the inflammation is passing from the adhesive to the suppurative, the parts then under- go a greater change than before, and the pain grows more and more acute, till it become very considerable. The nerves also acquire at that time a degree of sensibility, which renders them much more susceptible of impression than when they are in their natural state; thus an inflamed part is not only painful in itself, but it communicates im- pressions to the mind independent of pain, which do not arise from a natural sound part. This pain increases every time the arteries are dilated, whence it would appear that the arteries do not contract by their muscular power, in their systole, for if they did, we might expect a considerable pain in that action which would be at the full of the pulse. Whether this pain arises from the distention of the artery by the force of the heart, or whether it arises from the action of distention from the force of the artery itself, is not easily determined. We know that diseased muscles The adhesive inflammation 13 give much pain in their contraction, perhaps more than they do when stretched *. That the degree of inflammation which becomes the cause of adhesions gives but little pain, is proved from dis- sections of dead bodies; for we seldom or never find a body in dissection which has not adhesions in some of the larger cavities; and yet it may reasonably be supposed, that many of these persons never had any acute symptoms, or violent pain in those parts; indeed, we find many strong adhesions upon the opening of dead bodies, in parts which the friends of these persons never heard mentioned, during life, as the subject of a single complaint. That adhesions can be produced from very slight in- flammation, is proved in ruptures in consequence of wear- ing a truss; for we find the slight pressure of a truss ex- citing such action as to thicken parts, by which means the two sides of the sack are united, though there be hardly any sensation in the part; we also see, in cases where this inflammation arises from violence, it gives little or no pain. A man shall be shot through the cavity of the abdomen, and if none of the contained parts are materially hurt, the adhesive inflammation shall take place in all the internal parts contiguous to the wound made by the ball, and yet no great degree of pain shall be felt. This assertion is still proved by the little pain suffered after many bruises, where there is evident inflammation; and in simple fractures, the pain from the inflammation is very trifling, whatever it may be from the laceration of the parts. But this will be ac- cording to the degree of inflammation, what stage it is in, and what parts are inflamed, as will be fully explained here- after. We find it a common principle in the animal machine, that every part increases in some degree according to the action required. Thus we find muscles increase in size when much exercised; vessels become larger in proportion to the necessity of supply, as for instance, in the gravid uterus; the external carotids in the stag, also, when his * This is very evident in the bladder of urine when infla- med, for in the contraction of that viscus to expel the urine, there is more pain than in the dilatation; indeed, the distention is gradual, and when the urine is wholly evacuated, the irrita- tion produced by the contraction still continues, which produces a continuance of the straining. 14 The adhesive inflammation. horns are growing, are much larger than at any other time; and I have observed, that in inflammation, the vessels be- come larger, more blood passes, and there appear to be more actions taking place; but the nerves do not seem to undergo any change. The nerves of the gravid uterus are the same as when it is in the natural state; neither do the branches of the fifth and seventh pair of nerves in the stag become larger; and in inflammation of the nerves, their blood-vessels are enlarged, and have coagulating lymph thrown into their intestines, but the nerve itself is not increased so as to bring the part to the state of a natural part, fitted for acute sensation, which shews that the motions of the nerves have nothing to do with the œconomy of the part, they are only the messengers of intelligence and order. It appears that only the actions of the materia vitæ in the inflamed parts is increased, and this increase of action in the inflamed part is continued along the nerve which is not inflamed, to the mind, so that the impression on the sensorum is, probably, equal to the action of the inflamed materia vitæ. The quantity of natural sensibility is, I believe, propor- tioned to the quantity of nerves, under any given circum- stance; but I apprehend, the diseased sensibility does not take place at all in this proportion, but in proportion to the diseased action of the materia vitæ. Thus a tendon has very little sensation when injured in a natural state; but let that tendon become inflamed, or otherwise diseased, and the sensation shall be very acute. It may not be improper to observe, that many parts of the body in a natural state, give peculiar sensations when impressed; and when those parts are injured, they give, likewise, pain peculiar to themselves; it is this latter effect, which I am to consider. I may also observe, that the same mode of impression shall give a peculiar sensation to one part, while it shall give pain to another. Thus, what will produce sickness in the stomach, will produce pain in the colon. When the sensation of pain is in a vital part, it is somewhat different from most of those pains that are common. Thus, when the pain arises from an injury done to the head, the sensation is a heavy stupefying pain, rende- ring the person affected unfit to pay attention to other sensations, and is often attended with sickness, from the stomach sympathizing with it. The adhesive inflammation. 15 When the pain is in the heart or lungs, it is more acute and is very much confined to the part diseased. When in the stomach and intestines, especially the upper part of them it is a heavy oppressive sickly pain, but more or less, attended with sickness, according to its pressure or proximity to the stomach; for when situated in the colon, it is more acute, and less attended with sickness. We cannot give a better illustration of this, than by tak- ing notice of the effects of a purge. If we take such a purge as will produce both sickness and griping, we can easily trace the progress of the medicine in the canal; when in the stomach it makes us sick, but we soon find the sickness be- coming more faint, by which we can judge that it has pro- ceeded to the duodenum, and then a kind of uneasiness, approaching to pain, succeeds; when this is the case, we may be certain that the medicine is passing along the je- junum; it then begins to give a sickish griping pain, which I conceive belongs to the ilium; and when in the colon it is a sharp pain, soon after which a motion takes place. The liver, testicles, and uterus, are subject nearly to the same kind of pain as the stomach. A tendon, ligament, and bone, give something of the same kind of pain, though not so oppressive; namely, a dull and heavy pain, often attended with some little sick- ness, the stomach generally sympathizing in such cases. But the skin, muscles, and the cellular membrane, in common, give an acute pain, which rather rouses than op- presses, if not too great. All of this will be further men- tioned when we treat of each part. One cause of this variety of sensations, according as the parts inflamed, are vital or not vital, seems to consist in the different systems of materia vitæ with which those parts are supplied, having, probably, nerves peculiarly con- structed for this purpose; for all the parts which are suppli- ed with branches from the par vagum and intercostals, effect the patient with lowness of spirits from the very first attack of the inflammation: the actions of those parts are involun- tary, and therefore are more immediately connected with the living principle, and consequently that principle is affected whenever any thing affects these nerves. The other system of the materia vitæ, when affected by this inflammation, rather rouses at first the constitution, which shows signs of strength, unless the parts have rather weak powers of recovery, such as tendon, bone, etc. or 16 The adhesive inflammation. are far from the heart, in which cases the signs of weak- ness, sooner or later, appear: hence it would seem that this difference in the constitution, arising from the difference in parts and their situation, arises from the constitution having a disease which it cannot so easily manage, as it can in those parts which are not vital, and in parts that are near to the heart, which circumstances alone become a cause of irrita- tion in the constitution. III. THE HEAT OF PARTS IN INFLAMMATION. When I was treating of the blood, I observed that the heat of the animal was commonly considered as connected with that fluid; but as I had not made up my mind about the cause of the heat of animals, not being satisfied with the opinions hitherto given, I did not endeavour to offer any account of that property; but I shall now consider this power when the animal is under disease, where it would appear often to be diminished, and often increased, and of course the animal often becomes colder and hotter than its natural temperature. There is an endeavour to bring the heat a living body to the temperature of the surrounding medium, but in the more perfect animals this is prevented by the powers in the animal to support its own temperature, more especially in and near the vital parts; therefore, in making experi- ments, to ascertain any variation, it is not necessary to as- certain at the same time the temperature of the atmosphere. Heat, I imagine, is a sign of strength and power of con- stitution, although it may often arise from an increased action either of weak constitutions or of weakened parts. Heat is a positive action, while cold is the reverse, there- fore producing weakness, and often arising from a dimi- nished action of strong parts. It has not yet been considered whether an animal has the power of producing heat equally in every part of the body; although from what is generally advanced on this subject, we are led to suppose that every part has this power; or whether it is carried from some one source of heat by the blood to every part; this may probably not be easily The adhesive inflammation. 17 determined; but I am apt to suspect there is a principal source of heat, although it may not be in the blood itself, the blood being only affected by having its source near the source of heat. That this principle resides in the stomach is probable, or at least I am certain that affections of the stomach will produce either heat or cold. There are affections of the stomach which produce the sensation of heat in it, and the air that arises in eructations, feels hot to the mouth of the person; but whether these sensations arise from actual heat, or from sensation only, I have not been able to determine. Stimulating substances applied to the stomach will pro- duce a glow. Affections of the mind produce the same effect, which last circumstance might seem to contradict the idea of its arising from the stomach; but I suspect that the stomach sympathizes with those actions of the brain which form the mind, and then produces heat, which will be better illustrated in treating of cold. I suspect that the cold bath produces heat in the same way from the sym- pathizing intercourse between the skin and the stomach. That diseases augment or lessen this power in the animal is evident; for in many diseases the animal becomes much hotter, and in many others much colder than is usual to it. This fact was first discovered by simple sensation alone, both to the patients themselves, and the practitioner, before the absolute measurement of the degrees of heat by instru- ments was known; but it was impossible that such know- ledge of it could be accurate, for we find by experiment, that the measurement of degrees of heat by sensation is very vague. This happens because the variations in the degrees of heat in ourselves (which in such experiments is the instru- ment) is not of one standard, but must vary pretty much before we are made sensible of the difference, and therefore there can be only a relative knowledge respecting our own heat at the time. But now our measurement is more determined, and can be brought even nearer to the truth than is absolutely necessary to be known in disease. The increase and decrease of the heat of an animal body may be divided into constitutional and local. The con- stitutional arises from a constitutional affection, and may arise primarily in the constitution itself; or it probably may arise secondarily, as from a local disease with which the VOL. II. C 18 The adhesive inflammation. constitution sympathizes; but of this I am not yet certain, for from several experiments made to ascertam this point, it seemed to appear that local inflammation had little power of increasing the heat of the body beyond the natural stan- dard, although the body was under the influence of the inflammation by sympathy, called the symptomatic fever; but if the heat of the body is below the natural heat, or that heat where actions, whether natural or diseased, are called forth, then the heat of the body it roused to its natural standard *. As it is the principle of increase of local heat in inflam- mation I am now to consider, it should be first ascertained how far such a principle exists in a part, and what that principle may be; the constitutional principle being in some measure not to the present purpose, although it may throw some light on the difference between the powers of the constitutional, and those of the local principle. It is said, that disease, as fever, has been known to raise the heat of the body to twelve degrees above the natural heat; and if so, then there is in such cases either an increased power or an increased exertion of that power; and to know whe- ther this arises only from a constitutional affection at large, or whether it can take place in parts when the constitu- tion is affected by those parts, is worthy of inquiry. The principal instance of supposed increased local heat is in inflammation; and we find that external parts infla- med do actually become hotter; but let us see how far the increase goes. From all the observations and experiments I have made, I do not find that a local inflammation can in- crease the local heat above the natural heat of the animal; and when in parts whose natural heat is inferior to that which is at the source of the circulation, it does not rise so high: those animals too, which appear to have no power either of increase or decrease in health, naturally appear to be equally deficient in disease; as will be seen in the expe- riments. I suspect that the blood has an ultimate standard heat in itself, when in health, and that nothing can increase that heat but some universal or constitutional affection; and probably the sympathetic fever is such as has no power in this way, and that the whole power of local inflammation * Vide Animal Economy, page 87. vol. I. 19 The adhesive inflammation. is only to increase it a little in the part, but that it cannot bring it above the standard heat at the source, nor even up to it in parts that naturally or commonly do not come up to it, as just abovementioned. As inflammation is the principal instance capable of pro- ducing local increased heat, I have taken the opportunity of examining inflammations, both when spontaneous and in consequence of operations. I have also made several experiments for that purpose, which are similar to opera- tions, and cannot say that I ever saw, from all these experi- ments and observations, a case where the heat was really so much increased, as it appeared to be to the sensations. EXPERIMENTS ON INTERNAL SURFACES. EXPERIMENT I. A man had the operation for the radical cure of the hy- drocle, performed at St. George's Hospital. When I opened the tunica vaginalis, I immediately introduced the ball of the thermometer into it, and close by the side of the testicle. The mercury rose exactly to ninety-two degrees. The cavity was filled with lint, dipped in salve, that it might be taken out at will; the next day, when inflammation was come on, the dressings were taken out and the ball of the thermo- meter introduced as before, when it arose to ninety-eight degrees and three-fourths exactly. Here was an increase of heat of six degrees and three- fourths; but even this was not equal to that of the blood, probably, at the source of the circulation in the same man. This experiment I have repeated more than once, and with nearly the same event. As the human subject cannot always furnish us with opportunities of ascertaining the fact, and it is often im- possible to make experiments when proper cases occur, I was led to make such experiments on animals, as appeared to me proper for determining the fact; but in none of them could I ever increase the inflammatory heat so as to make it equal to the natural heat of the blood at its source. EXPERIMENT II. I made an incision into the thorax of a dog, the wound was made about the centre of the right side, and the ther- mometer pushed down, so as to come in contact, or nearly C2 20 The adhesive inflammation. so, with the diaphragm. The degree of heat was one hundred and one; a large doffile of lint was put into the wound to prevent its healing by the first intention, and cove- red over by a sticking plaster. The dog was affected with a shivering. The day following the lint was extracted and the thermometer again introduced, the degree of heat ap- peared exactly the same, viz. one hundred and one. This dog recovered. EXPERIMENT III. An oblique incision was made about two inches deep into the gluteal muscles of an ass, and into this wound was intro- duced a tin canula about an inch and half long, so that half an inch of the bottom of the wound projected beyond the canula; into this canula was introduced a wooden plug, which projected half an inch beyond the canula, so as to fill up the bottom of the wound, and which kept that part of the wound from uniting. The whole was fastened into the wound by threads attached to the skin. Immediately upon making the wound the hall of the thermometer was introduced into it to the bottom, and the mercury rose to one hundred degrees exactly, as it did also at the same time in the vagina. On the next morning the wooden plug was taken out, and the ball of the thermometer (being previously warmed to ninety-nine degrees) was introduced down to the bottom of the wound, which projected beyond the canula, and the mercury rose to one hundred degrees. The wooden plug was returned and secured as before, in the evening the same experiment was repeated, and the mercury rose to one hundred degrees. Friday morning it rose only to ninety- nine degrees. Friday evening it rose to near one hundred and one degrees and half. Saturday morning, ninety-nine degrees, and in the evening one hundred degrees. A similar experiment to this was made on a dog, and the heat was one hundred and one degrees. The day following the heat was the same, as also on the third day, when sup- puration was taking place. EXPERIMENT IV. Although in the experiment upon the dog, by making an opening into the thorax so as to excite an inflammation there, and to affect his constitution, the heat of the part was not The adhesive inflammation. 21 increased; yet in order to be more clear with regard to the result of such an experiment, a wound was made into the abdomen of an ass, and a solution of common salt and water thrown in (about a handful to a pint of water), to excite an universal inflammation in the cavity of the abdomen. This produced great pain and uneasiness, so as to make the animal lie down and roll, becoming as restless as horses when griped. The next morning, Friday, the thermometer was intro- duced into the vagina, and the mercury stood at ninety-nine degrees and a half, nearly the same heat as before the expe- riment; in the evening one hundred and one degrees and a half. Saturday morning, one hundred degrees and a half; evening, a hundred degrees and a half. The vagina therefore, was not rendered hotter by an inflammation which produced what we may call the sympathetic fever. The animal was now killed, and on examining the abdo- men, the side where the wound was made appeared much inflamed, as well as the intestine opposite to this part. All of them adhered together, and the intestine surrounding this part of the adhesions had their peritoneal coat become extre- mely vascular, and matter was formed in the abdomen. But that the heat of a part can be increased above the common standard of a healthy person is certain, when it is such a part as is naturally of the standard heat; as for in- stance, the abdomen. For in lord Hertford's servant, who was tapped eight times, and seven of them in thirteen weeks, the seventh time I held the ball of a thermometer in the stream, as it flowed from the canula of the trochar, and it raised the mercury to one hundred and one degrees, exactly, through the whole time. Twelve days after I tapped him the eighth time, the water was pretty clear; when I held the thermometer in the stream, it rose to one hundred and four degrees. Now as the heat of the abdomen was one hundred and four, we must, I think, suppose that the general heat of the man would also be one hundred and four degrees. EXPERIMENTS ON SECRETING SURFACES. EXPERIMENT I. I took the degree of heat of a dog's rectum, by introdu- cing the thermometer about three inches; and when it was ascertained, four grains of corrosive sublimate were dissol- ved in two ounces of water, and the solution thrown up the rectum. The day following the thermometer was again introduced, and then I found the heat somewhat increased, 22 The adhesive inflammation. but not quite a degree. As far as one might judge from external appearances, the rectum was very much inflamed, as there was a considerable external swelling, forming a thick elevated ring round the anus. EXPERIMENT II. I introduced into the rectum of an ass, the thermometer, and the mercury rose to ninety-eight degrees and a half ex- actly: this was repeated several times with the same result. I then threw up the rectum an injection of flour of mus- tard and ginger, mixed in about a pint of water. About twelve hours after, I introduced the thermometer, and it rose to ninety-nine degrees and an half. The injection was repeated several times, but the heat did not increase. EXPERIMENT III. To irritate the rectum still more, I threw up a solu- tion of corrosive sublimate; and about twelve hours af- ter, I introduced the thermometer, and found no increase of heat. Twenty hours after, I introduced the thermo- meter; but the heat was the same. Sixty hours after the injection, the thermometer being introduced, the mer- cury rose to one hundred degrees, exactly. This injec- tion had irritated it so much, as to give a very severe ten- esmus; and even blood passed. EXPERIMENT IV. The natural heat of the vagina of a young ass was one hundred degrees. A solution of corrosive sublimate, as much as would dissolve in a tea-cup full of water, viz. a- bout ten grains, was injected into the vagina. In about two hours after, the mercury fell to ninety-nine degrees. Thursday morning ninety-nine degrees, evening one hun- dred. Friday morning ninety-nine, evening near to one hundred and one. Saturday morning ninety-nine, even- ing one hundred degrees. This experiment was repeated several times upon the same ass, with the same result. In these experiments it can hardly be said, that the heat was increased. That the inflammation had been raised to a very considerable degree was plain, for it produced a dis- charge of matter which was often bloody, and upon kill- The adhesive inflammation. 23 ing the ass for another experiment, the following appear- ances were found in the uterus. The horns of the uterus were filled with serum, and the inflammation had run so high by the stimulating injec- tions which were used for the experiments on the vagina, that the coagulating lymph had been thrown out so as al- most to obliterate the vagina, uterus, etc. by those adhe- sions which are the ultimate effects of inflammation on se- creting canals, while suppuration is the ultimate effect of inflammation on internal surfaces: there were no signs of inflammation on the external surface of the uterus which is covered by the peritoneum. It may just be remarked, that in most of those experi- ments the heat in the morning was a degree less than in the evening; and I may also remark, that this is common- ly the case in the natural heat of the animal. I wished to know whether such animals as have little or no power of varying their natural heat, had a power of increasing their heat in consequence of injuries; for which purpose I opened into circumscribed cavities in frogs, toads, and snails, and at different periods, after the open- ing was made, the thermometer was introduced. As the heat of those animals is principally from the atmosphere, the external heat is to be connected with the experiments. NOVEMBER 27, 1788. A healthy toad and frog, after having the heat in the stomach ascertained, had openings made through the skin of the belly, large enough to admit a thermometer, and the orifice was kept open by a piece of sponge. Atmosphere...36° Stomach of both...40° Under skin of the belly...40° Atm. Frog. Toad. Stom. Under the skin. Half an hour after the opening . 35° . 40° . 40° . 40° Hour and a half...35° . 39° . 39° Two hours and a half...39° . 39° The abdomen was now opened, and a piece of sponge kept in the orifice. 24 The adhesive inflammation. Atm. Frog. Toad. Stom. Abdomen. The heat...36° 40° 40° 40° Hour and a half after opening...36° 39° 39° 39° Four hours and a half...38° 39° 39° Part of the left oviduct protruded of the natural colour and appearance. Atm. Frog. Toad. Stom. Twenty-one hours and a half 38° 38° 38° 38° Nine hours after...35° 35° 35° 35° The protruded oviduct was more vascular and of a uni- formly red appearance; it was returned into the belly and retained there. Atm. Frog. Toad. Stom. Twenty-four hours...32° 32° 32° 32° Forty-six hours...34° 34° 34° 34° The toad died, and the frog was become very weak and languid: part of the oviduct protruded and had the small vessels loaded with blood. It lived one hundred and eighteen hours, that is, seven- ty-two longer than the toad, during which period its heat corresponded with the atmosphere. Upon examining the abdomen after death, there were no adhesions nor any appearances from inflammation, ex- cept on the protruded oviduct. Some healthy shell-snails had openings made into the the lungs, and their heat ascertained at the following times. Atm. Snail. The heat at the time...34° 38° One hour and a half...32° 32° Six hours and a half...32° 35° Ten hours...31° 36° Twenty-four hours...30° 30° To ascertain the standard heat of a snail. Atm. Snail. A fresh lively snail had its heat in the lungs 30° . . 36° Another...28° . . 35° Another...30° . . 37° The adhesive inflammation. 25 EXPERIMENTS to ascertain the heat of worms, leeches and snails, when compared with the atmosphere, and the changes produced in their heat by inflammation. EXPERIMENT I. Heat of the air in the room...56° - water in the room...57° - some earth-worms...58° 1/2 EXPERIMENT II. Water as a standard...56° 1/4 Leeches in the same quantity...47° EXPERIMENT III. Water as a standard...56° Fresh egg...55° Leeches alone...60° Worms alone...57° Air...54° Worms...58° Leeches...57° Slugs two hours after being wounded...58° Air...55° Worms...55° Leeches...55° Slugs twenty-four hours after being wounded 55° They were all very weak and dying. IV. OF THE PRODUCTION OF COLD IN IN- FLAMMATION. THE production of cold is certainly an operation which the more perfect animals are endowed with; and this pow- er would appear to be both constitutional and local, similar to the power of producing heat. As the word inflamma- VOL. II. D 26 The adhesive inflammation. tion implies heat, and has been used to express that action of the vessels where heat is commonly an effect, it may seem strange that we should treat of cold in the action of inflammation; but probably we have no action in the bo- dy that is not attended with an occasional production of cold; how far this takes place in parts I do not know; but that it takes place constitutionally, from almost every af- fection, is evident, whether it be inflammatory fever, or lo- cal inflammation. As an animal has no standard of cold, but at the source, which is also the standard of heat, it is perhaps impossible to ascertain with certainty the degree of cold produced either by disease, or from the surrounding cold; but perhaps by comparing the part suspected of be- ing colder than is natural from disease, with a similar part under the same external influence of heat and cold, as for instance, one limb with the other, or one hand with the other, a pretty fair inference may be made; and we often find that diseased parts shall become extremely cold, while from other circumstances than disease they should not be so. I suspect that coldness in disease arises either from weak- ness, or a feel or consciousness of weakness in the whole constitution or a part, joined with a peculiar mode of ac- tion at the time. Thus we have many constitutional diseases beginning with absolute coldness, which seems afterwards to termi- nate in a sensative coldness only, as the cold fit of an ague; for I apprehend that the sickness which generally proceeds such complaints, produces universal cold, and once having produced the action of the body arising from abso- lute cold, the action goes on for some time, although the cause no longer exists, which continues the sensation; and although the absolute coldness is gone, yet the action of the parts, which is a continuation of, and therefore si- milar to the action of the absolute cold, is capable of de- stroying, itself by producing the hot fit, if there be power or disposition. That weakness, or a feel of weakness, produces cold is evident; and that universal or constitutional cold arises from the stomach is also evident; for whenever we are made sick an universal coldness takes place; and this is best proved by producing sickness on animals that we can kill, or that die while they are under these affections of the stomach. The experiments I made to ascertain this were The adhesive inflammation. 27 not conducted with great accuracy, as I trusted in them entirely to my own sensations or feelings. EXPERIMENT. I threw three grains of tartar emetic in- to the veins of a healthy bitch, the quantity of water near an ounce. In about twenty minutes she had a stool and voided some single tape-worms. Some of the stools were extremely thin, and made up principally of bile. Some time after she had two more stools, which were thin and bilious. She continued pretty easy for about three hours, but became a little convulsed, which increased, and at last she became senseless, with little twitchings; hardly breath- ing, except with the diaphragm, and having a low, slow pulse. She was very cold to our feel, when applying our hands on the skin of the body. In about ten or twelve hours after the injection, she died. EXPERIMENT. I repeated the above experiment on a- nother bitch, adding a full grain more to the medicine. She vomited in less than a minute after it was thrown in, and strained excessively hard, throwing up a great deal of froth, which was only the mucus of the stomach mixed up with the air in the act of reaching. In less than three mi- nutes she had a stool, which was pretty loose and partly of the natural appearance. She continued reaching and pur- ging for above an hour, and was extremely uneasy, at last she got into a dark corner and lay there, frothing at the mouth, was taken with convulsive twitchings like the former, and died in about five hours after the injection. I opened her body immediately after death, and found the interlines, liver, and heart, not so warm as we usually find them. I have known people who had affections of the stomach and bowels, say, that they had plainly the feeling of cold in their bellies. I knew a gentleman who told me, that often when he threw the wind off his stomach, it felt cold to his mouth and even to his hands, which was by much the best guide respecting sensation. A lady near seventy years of age, has a violent cough, which often makes her puke, and what comes off her sto- mach feels like ice to the mouth. Affections of the mind also produce constitutional cold- ness, but they are such affections as the stomach sympathi- zes with, producing sickness, shuddering, etc. A disagreeable idea or sight will sometimes give a quick 28 The adhesive inflammation. sensation of sickness, and the skin shall sympathize with the stomach, it shall appear to begin, as it were, in the mouth or throat, as if something there had a tendency to come up; the muscles of the neck shall become convulsed, and the head shall be violently shaken; from thence a disa- greeable feeling shall spread over the whole body, passing directly down the back to the feet; commonly expressed by saying "ones flesh creeps"; and hence the words, shud- der and horror, express mental as well as bodily affections. Another action shall be joined with the cold, viz. the ac- tion of sweating, so that a cold sweat shall take place over the whole body. This cold shall be partial, for under many diseases a partial cold sweat will sometimes come on, while other parts remain tolerably temperate. V. OF THE TIME THE ADHESIVE INFLAM- MATION COMMENCES AFTER ITS CAUSE; AND IN WHAT CASES AND PARTS IT IS IMPERFECT IN ITS CONSEQUENCES. It will be often impossible to determine the distance of time between the impression which becomes the cause of inflammation, and the action itself, which will depend upon two circumstances, viz. the nature of the exciting cause, and the susceptibility for such action in the parts. In the exposure of internal surfaces, inflammation is per- haps sooner brought on than in most others; for the incitement is immediate, and there is no remission in the cause itself. In specific diseases its time is perhaps more regular, each having a determined interval between the application of the exciting cause and the appearance of the disease, al- though even in some of these there is a vast difference in the time after contamination, but in those arising sponta- neously it must be uncertain; yet in some cases it can be pretty well ascertained, supposing sensation the first effect of the inflammatory impression; and in such instance we often find it very rapid. They shall be attacked with a violent pain in the part, so much so as hardly to be able to The adhesive inflammation. 29 bear it, which shall be immediately succeeded with a vio- lent inflammation. A lady was walking in her garden, and at once was at- tacked with a violent pain in the middle of the fore part of the thigh, which made her immediately lame; soon after, the skin appeared discoloured, which spread nearly over one-half of the thigh; this part became thick and swell- ed, which appeared to go as deep as the bone; it after- wards suppurated, all in a few days; this appeared to be a well-marked case. The commencement of inflammation after accidents is more easily ascertained, for we must date it from the ac- cident, and we find it is not immediate; for after a wound has been received, inflammation does not begin for twelve, eighteen, or twenty-four hours. It sometimes happens, however, that the adhesive state cannot set bounds to itself, and therefore cannot set bounds to the suppurative. This may be owing to two causes; the one is, the violence of the inflammation, and quickness of the attack of the suppurative spreading be- fore parts have had a sufficient union, and even perhaps joined with a species of suppuration from the very first, so that union is prevented. Secondly, the inflam- mation may, I suspect, be of the erysipelatous kind, especially when there is a tendency, from the beginning, to mortification. This mixing of the suppurative with the adhesive, or the hurrying on of the suppurative, or this mixture of the erysipelatous with the others, I have frequently seen in the abdomen of women who have been attacked with the peritoneal inflammation after child-birth, and which from these circumstances became the cause of their death. In such cases we find matter mixed with coagulating lymph, as if formed with it; for without having been formed with it, it could not have mixed with it after co- agulation; we find also coagulating lymph mixed with the matter, as it were, separated from the inflamed surface by the formation of the matter; and in those cases where there is a tendency to mortification from the beginning, as in strangulated ruptures, we often find the adhesive and suppurative inflammation going hand in hand. All of these causes and effects account for the violence of the symp- toms, the quickness of the progress of the disease, and its 0 The adhesive inflammation. fatal consequences beyond such inflammations as have on- ly the true adhesive progress, or where it takes place per- fectly prior to suppuration. It seems to appear from observation, that some surfaces of the body do not so readily unite by the coagulating lymph as others, and therefore, on such surfaces there is commonly a much larger quantity of this matter thrown out than probably would have been if union had readily taken place; for we may suppose, that where once union has taken place, extravasation is at an end. Thus, we see in (what we may suppose) inflammation of the heart, that the coagulating lymph is thrown out on the exterior sur- face in vast quantities, while at the same time the heart shall not adhere to the pericardium. This is not only seen in the human, but in other animals. In an ox, the heart was furred all over, and in some places, the coagulating lymph was near an inch in thickness. The external sur- face of such hearts have an uncommon appearance; the outer surface of the coagulating lymph is extremely ir- regular, appearing very much like the external surface of a sponge, while the base, or attachment to the heart is very solid and firm. However, in many instances we find the pericardium adhering to the heart, and gene- rally in pretty close contact, which would make us sup- pose that the extent of motion of those two parts on one another is not great. These adhesions affect the pulse much, which is a good reason why nature avoids them as much as possible. On the other hand, it seems de- ducible from observation, that neither the pia nor dura mater are apt to throw out much coagulating lymph, for here it would produce compression; and, therefore, we seldom find adhesions between them; in consequence of such accidents as produce suppuration between these two membranes, we seldom or ever find the surrounding parts adhering so as to confine the matter to the suppura- ting surface. Inflammation of the skin, or such as approaches to the skin produces in general a separation of the cuticle, often of the hair, or the nails. These effects arise sooner or la- ter, according to the nature and degree of the inflamma- tion, but more particularly according to its nature; they take place the least and latest in the true adhesive inflam- mation, which is always attended with the greatest strength. The adhesive inflammation. 31 In such cases, the separation does not happen till the in- flammation has subsided; and as a proof of this, in the gout, it is least and latest of all; for this is always a healthy inflammation, otherwise it would not take place; but in weak habits, at the early part of the disease, there are of- ten vesications, which are filled with serum, sometimes with coagulating lymph, etc. both of these are sometimes tinged with red blood; when the inflammation is of a weak kind, tending to mortification, the cuticle commonly se- parates early during the time of inflammation, almost be- ginning with it, and of course the vesications will be fill- ed with serum, and often with the red globules; we may observe in wounds of the skin which are not allowed to heal by the first intention, that a separation of the cuticle will take place at the edges of the wound, and this will ex- tend according to the nature of the inflammation, which is according to the nature of the constitution; this will be attended with other concomitant appearances, such as flab- by edges and thin matter: I conceive, in the weak habit it depends on an action of the inflammation itself; but in the strong, it depends on a state in which the parts are left to separate the cuticle. This separation arises, I apprehend, from a degree of weakness approaching to a kind of death in the connection between the cuticle and cutis, from life being in this part naturally very weak. In the beginning of mortification it is produced; in the œdematous and erysipelatous inflam- mations it is greatest, and in putrefaction of dead bodies it is the first operation. I suspect too, that a blistering plaster, hot water, etc. only kills the uniting parts, by which means an irritation is produced in the cutis, and the extravasation is according to that irritation. The connection of the cuticle is more or less destroyed in every inflammation of the skin; for we seldom see an inflammation attack the skin but the cuticle comes off soon- er or later; we generally observe it peeling off in flakes, after inflammation has subsided, and it begins nearest the point of inflammation *. * It may be observed, that when an inflammation attacks the finger ends, or toes, so as to produce suppuration either in the substance of these parts, although not larger than a pimple, or only on the surface of the cutis, an extensive separation of the cuticle takes place, not entirely from the inflammation, 32 The adhesive inflammation. VI. OF THE UNITING MEDIUM IN INFLAM- MATIONS. EVERY new substance that is formed is either for a sa- lutary purpose, or it is diseased. The first consists either of granulations, or of adhesions, whether with the first, or se- cond intention; and all these may be considered as a re- vival of the rational principles and powers of growth, whereas diseased substances are, as it were, monsters. In the adhesive inflammation, the vessels being enlarged, as above described, similar to what they are in the young subject, begin to separate from the mass some portion of the coagulating lymph, with some serum, and also red globules, and throw it out on the internal surface; probably through the exhaling vessels, or perhaps, open new ones, and cover the sides of those cells, which easily unite with the opposite, with which they are in contact, forming the first progress of adhesions. That this is really the case, and that this effect has taken place in consequence of inflammation, is evident from the following observations. In all large cavities, where we can make our observations with certainty, when in the state of inflammation, we find diffused over the sides, or through the cavity, a substance exactly similar to the coagulating lymph when separated from the serum, and red blood, after common bleeding. That the blood, when thrown out of the circulation from an inflammatory state of the vessels, as well as the blood itself, unites parts together, is probably best seen in the inflammation of the larger cavities above- mentioned. The following I shall give as an example, which I have often observed on the peritoneum of those who have died in consequence of inflammation of this membrane. The intestines are more or less united to one another, and, but assisted by it: this is owing, principally, to the cuticle in such places not giving way, being there strong, so that a seem- ing abscess almost occupies the whole finger, etc. this should be opened early to prevent this separation as much as possible or to prevent the separation from extending too far. The adhesive inflammation. 33 according to the stage of the inflammation, this union is stronger or weaker; in some it is so strong as to admit of some force to pull them asunder; * the smooth peritoneal coat is, as it were, lost, having become cellular, like cellular membrane. When the vessels of this part are injected we shall find, that in those parts where a separation has been made by laceration, previous to the injecting, the injection will appear on that surface like small spots or drops, which shews that the vessels had at least passed to the very surface of the intestines. In parts where the union was preserved, I have observed the three following facts. On separating the united parts, I have observed, in some places, the vessels come to the surface of the intestines, and then terminate all at once. In other places, I could observe the vessels passing from the in- testine into the extravasated substance, and there ramifying, so that the vessel was plainly continued from the old into the new. In a vast number of instances, I have observed, that in the substance of the extravasation, there were a great number of spots of red blood in it, so that it looked mottled. The same appearance was very observable on the surface of se- paration, between the old substance and the new, a good deal like petechial spots. How this red blood got here is the thing to be considered, especially as a good deal was within the substance of the coagulum. Was it extravasated along with the coagulating lymph? In this case, I should have rather supposed it would have been more diffused, and if not diffused, more attached to the intestines, and not in the centre of the coagulum; if it had been extravasation, one would have expected extravasation of injection, but we had none in any of these places; I have therefore sus- pected, that parts have the power of making vessels and red blood independent of circulation. This appears to be evi- dently the case with the chick in the egg. * Adhesions in consequence of inflammations become very soon strong, and are very soon elongated; probably as soon as they become organized they adapt themselves to their situation or the necessity. Thus the dog who had his belly opened to wound some lacteals, when killed no the ninth day, had his intestines connected by adhesion in several places, and those very firm and long. Vol. II. E 34 The adhesive inflammation. I have observed, when I was treating of the blood, that it was capable of becoming vascular, when deposited either by accident, or for particular purposes; and I had reason to believe, that a coagulum, or a coagulating lymph had a power of becoming vascular in itself, when it could be sup- plied with blood, and mentioned the coagulum in a larger artery as an instance. Likewise when I was treating of union by the first intention, I explained the intercourse established by the uniting medium becoming vascular, and those vessels uniting across by a process, called inosculation. The same reasoning is applicable to the union by means of the adhesive inflammation; for it is the blood in all cases that is to become vascular; but this takes place sooner or later, according to the apparent necessity. In some it be- comes vascular, immediately; in others very late; and in- deed, in some hardly ever, according to the degree of uti- lity to arise from that change. Where it becomes vascular soonest, there the vessels are found also in greatest numbers, the two effects depending on the same principle. Extravasation, whether of blood, or only of lymph, be- comes vascular, almost immediately, when thrown out into the cavity of the human uterus into the state of pregnancy. Here is an operation necessary to go on, which is more than the simple support of the extravasation itself; but when the extravasation is thrown out by accident, or for the purpose of producing adhesions, the immediate intent is answered without the vessels, and vascularity only becomes necessary afterwards; therefore vascularity in such cases is the second consideration, not an immediate one. But in the case of impregnation it must be immediate, for the simple extrava- sation would not answer the intention. This shews that this extravasation is very different from that of the menses. The new vessels which are formed in the newly extrava- sating and uniting substance, become of use both during the state of adhesion and suppuration. In the first, they serve to give powers of action to this new substance, which assists in preventing suppuration. In the second, where this cannot be done, they assist in form- ing a vascular basis for the granulations. When we cut into inflamed parts after death, we find them firm and solid, resembling the section of a lemon, or some œdematous tumor, where we know extravasation has taken place. The adhesive inflammation. 35 This appearance arises from the cells in the cellular membrane, and other interstices of parts, being loaded with extravasated coagulating lymph; from this circumstance they are cemented together and become empervious to air, not similar in these respects to common cellular membrane, or natural parts. In many places where this extravasation has been in considerable quantities, it is formed in time in- to cellular membrane. I have observed, that this mode of the separation of co- agulating lymph is not peculiar to inflammation; it is se- parated in many diseases. It is thrown out to form tumours, etc. where inflamma- tion does not seem to be a leading cause; and we often find the adhesive stages, as it were, degenerate into, or ter- minate in the formation of a cyst, to contain the body that was the cause of the inflammation. Thus, a sack is form- ed for bullets, pieces of glass, etc. It is unnecessary to instance every possible situation where adhesions could be produced; they can take place where- ver there two internal surfaces in contact, or that can be brought into contact. I cannot give a better instance of its utility in the animal œconomy than in the following ex- periment: I wished to know in wounds which penetrated into the chest, (many of which I have seen in the army) where suppuration had come on the whole cavity of the chest, as well as on the surface of the lungs, and where the lungs collapsed, how parts were reinstated, or in what form they healed; whether the lungs, etc. lost their suppurating disposition, and dilated, so as to fill the chest again. To as- certain this as far as one well could, I made the following experiment on a dog. October 1777, I made an opening between the ribs in- to the chest of a dog, and touched the edges of the wound all round with caustic to prevent it from healing by the first intention, and then allowed the dog to do as he pleased. The air at first passed in and out of his chest by the wound. He eat, etc. for some days, but his appetite gradually began to fall off. He breathed with difficulty, which increased; he lay principally on that side which we find people do who have the lungs diseased in one side only or principally; and he died the eleventh day after the opening. On opening the body, I found the collapsed lungs passing directly across the chest and attached to the inside of the wound all round 36 The adhesive inflammation. so that they excluded the cavity of the chest from all exter- nal communication. This circumstance of the lungs fall- ing across the chest was owing to his having lain principally on that side, which I conceived to have been only acciden- tal. The cavity of the chest all round was filled with air. That part of the external surface of the lungs which did not adhere, that is to say, the upper surface of the dia- phragm, and that part of the pleura which covered the ribs were entirely free from inflammation, or suppuration; this cavity, from these adhesions, being rendered a perfect ca- vity, shews that air, simply has no power to excite inflam- mation when the cavity is otherwise perfect; which the ad- hesions had effected; this shews also that adhesions of two surfaces round the exposed part, exclude every part from the necessity of inflammation, as was explained when treat- ing of inflammation. From the connection between the living powers of the solids and the fluids, we can hardly suppose that such an uncommon action could take place in the vascular system, without producing its effects, upon the fluids; and, there- fore, from reasoning we might suppose, that the coagulat- ing lymph undergoes some changes in its passage through the inflamed vessels, which obliges it to coagulate more imme- diately, or much sooner than it otherwise would†. For in those cases of inflamed arms, after bleeding, and inflammations in consequence of other causes, we find that the cavities of the veins are in many places furred over, and in others united by means of the coagulating lymph. Now if this coagulating lymph is similar in its productions to that which we have been describing, it must have been thrown out from the vasa vasorum, these vessels having se- parated it and poured it into the cavity of the veins, and it must there have coagulated immediately; in this separation therefore, from the blood, it must have undergone some change, arising from the actions of the vessels; for if this † This is contrary to the disposition of inflammatory blood when taken out of the vessels and allowed to go through its spon- taneous changes; from which it would appear that the gene- ral affection of the blood (which I would call sympathy of the coagulating lymph with the universal irritation) is different from its affection or disposition when employed for the purposes of union The adhesive inflammation. 37 lymph was no more than the coagulating lymph with its common properties, or the properties common to that which is circulating in the same vein which receives it, it would in such cases only continue to throw in more coagulating lymph, in addition to what was circulating, and therefore, probably, it would be carried along with the blood to the heart, as a part of the common mass. From this we should infer that this coagulating matter is not simply the coagulat- ing lymph, such as it is when circulating, but somewhat dif- ferent, from having undergone a change in its passage through the inflamed vessels, partaking of the disposition of those solids which are inflamed, through which it passed. This process cannot, therefore, be supposed to be merely extravasation; for I conceive that an œdema would be a con- sequence of simple extravasation. But this may be taken up in another point of view, and upon the same principle. The inflamed vessels may give a disposition to the blood, as it is moving slowly along, to coagulate on its surface; and this is probably the more just idea of the two; as we find that the vessels, both veins and arteries, can give this dispo- sition, and to a very great extent: we find in the beginning of mortification, the blood coagulating in the vessels, so as to fill them up entirely, and this proceeding the mortifica- tion, seems to be for the purpose of securing the vessel be- fore it is to give way; we, therefore, cannot doubt of a co- agulating principle being given to the blood from the vessels; and as a further proof of this, we may observe that the ex- travasated coagulating lymph, which produces either adhe- sions or forms tumors, (which is often the case) is always of the nature of the diseased solids that produced it. If the case is venereal, the new substance is of the same nature; if cancerous, it is cancerous; for I find that it has, when absorbed, the power of contaminating, similar to matter or pus produced by the sores or ulcers of such diseases; the absorbent glands being often affected by the absorption of the coagulating matter of a schirrous beast. Whatever change the coagulating lymph has undergone in this operation of inflammation, it seems so far the same, as to retain still the nature of the coagulating lymph, and to possess the living principle; this is most probably in a greater degree, and therefore, the coagulating lymph is still better fitted to be formed into a part of the solids of the bo- 33 The adhesive inflammation. dy, as will be taken notice of when we come to treat of the state of the blood in the inflammation. But it is not absolutely necessary that the coagulating lymph should first undergo a change in the extravasated ves- sels, before it can become a living solid, or unite living so- lids; for we find that common blood extravasated from a ruptured vessel is, perhaps, equally efficacious in this respect, therefore the red globules do not retard union, but they may promote it. VII. THE STATE OF THE BLOOD, AND OF THE PULSE, IN INFLAMMATION. FROM what has been said of the living power of the blood I think we must allow that it will be commonly affected much in the same manner with the constitution, and that disease will have nearly the same effect upon it, as it has on the body; because, the same living principle runs through the whole. We find this to be nearly the case; for till a disease has affected the constitution, the blood continues the same as before; but as the constitution becomes affect- ed, the blood also becomes affected, and undergoes the same changes, which, probably, may be ascribed to conti- guous sympathy between the vessels and the blood; and we shall find that the changes in the blood is often as much ex- pressive of disease as any other part of the body. It is ex- pressive of strong action, as well as of weak action; but as it does not give sensation, it cannot convey to the mind all the varieties of disease that may take place in it; yet I could conceive, if the blood was to be primarily affected, that an impression would be made upon the mind, from its affecting the vessels in which it moved. However, it is not always the case that the state of the blood and the other symptoms are expressive exactly of the same thing; the blood often expressing less, and often more; when the action of the so- lids is of the inflammatory kind, or which, perhaps, is the same thing, when there is too great an action of the solids, the blood more readily admits of a separation of its visible The adhesive inflammation 39 parts, and the coagulating lymph coagulates more slowly, but becomes firmer when coagulated; this last circumstance however, might be supposed not to be so clear, for its firm- ness may be owing to its want of the red particles, which certainly gives the blood a brittleness in proportion to their quantity; but although this may have some effect, yet it is very little; for we find blood of loose texture in some in- flammations, when deprived of its red part; when blood has this disposition it is called sizy blood. These changes in the nature of the blood depend so much upon the above- mentioned causes of inflammation, that it is impossible to say whether they do not constitute the first universal effect produced from the local inflammation, and whether the constitutional is an effect of this change in the blood. I knew a man who was stabbed in the loins, and according to the consequent symptoms, was most probably wounded or hurt in some viscus within the abdomen. At first he had no symptoms, but simple pain in the part, I therefore only bled him, by way of precaution, and the blood was perfect- ly natural; in less than a quarter of an hour after, constitu- tional symptoms came on, such as rigor, sickness, etc. and on opening the same orifice; and taking away more blood, this second quantity had a very thick and strong buff upon it, having all the appearance of inflammatory blood; while this constitutional disposition lasted, which was some time; his blood continued the same, which was proved by the subse- quent bleedings. The subsiding, however, of the red glo- bules in the blood when in an inflamed state, although pret- ty frequent, is not always an attendant, or in other words (and perhaps upon some other principle) the blood is not al- ways attended with this appearance, when the visible symp- toms are the same. A young woman was attacked with a violent cough, oppression in breathing, quick, full, and hard pulse. She was bled, which gave her ease; the blood was sizy; the symptoms again returned, and she was bled a se- cond time; which also relieved her, and the blood was more sizy than before, so far all the symptoms agreed; the symptoms again recurred and were more violent than be- fore; she was bled a third time, and a third time relieved; but this blood was not in the least sizy, although it came from the vein very freely. Here then, the blood, under the same disease, lost this disposition, although the symp- toms remained the same. As inflamed blood leaves a por- 40 The adhesive inflammation. tion of the coagulating lymph free from the red globules at the top, and as that can be accounted for upon the principle of the coagulating lymph, in such cases not coagulating so fast as when the blood has not this appearance, and as the coagulation hinders any comparative experiment respecting the weight of the red globules of each, I tried to see if they sunk in serum faster in the one kind of blood than in the o- ther; I took the serum of inflammatory blood, with some of the red part, and also some serum of blood free from in- flammation, with nearly the same quantity of the red part; they were put into phials of the same size; I shook them at the same time, then allowed them to stand quiet, and observed that the red globules subsided much faster in the inflammatory blood than in the other. To ascertain whether this arose from the red globules being heavier, or the serum lighter, I poured off the serum from each, as free from red blood as possible, then put the red part of the one into the serum of the other, and shook them to mix them well; and, upon letting them stand quiet, the red globules appeared to fall equally fast. From these experiments it appears, that the red part of inflammatory blood was hea- vier than that which is not so, and the serum was lighter, and the difference pretty nearly equal; for if we could sup- pose that the red globules were one-tenth heavier, and the serum one-tenth lighter, then the difference in the subsiding of the red globules of inflammatory blood in its own serum, to that which is not inflammatory, would be as one to five; and, if they were to be changed, then they would be equal. To see whether the blood from an inflamed part was diff- erent from that drawn from a part not inflamed, the fol- lowing experiments were made: A large leech was applied to an inflamed surface, and when it had sucked itself full, another leech was suffered to fill itself from the breast where no inflammation existed; they were both cut in two, and the blood received in two tea-cups, kept moderately warm in a dish of warm water; both of them coagulated without the serum separating; but the inflamed blood was evidently of a lighter colour than the blood from the uninflamed part; but neither had the ap- pearance of a buffy coat. Whether the disposition for inflammation, and the change produced in the blood, arise from a real increase of The adhesive inflammation. 41 animal life, or whether it is only an increase of a disposition to act with the full powers which the machine is already in possession of, is not easily determined; but it appears to be certain, that it is either the one or the other: there are some circumstances, however, that would incline us to su- spect it to be the latter, because there is often inflammation when the powers of the machine are but weak, where it ap- pears to be only an exertion of very weak powers, arising from some irritation produced; in such cases the blood will shew signs of weakness although sizy. This appears to be equally the case in local inflammation, and inflammatory fevers, or in the symptomatic fever*. That it is an increase of the one or the other, and that the sensible effect produced arises from the action taking place, both in the solids and fluids, is proved by the method of treatment, which will be further illustrated in speaking of the mode of cure: on the other hand, where there is great debility in the solids, where the powers of preservation (the first animal powers) are weak, therefore the action weak, and where of course the body must have a tendency to dis- solution, there we find the very reverse of the former ap- pearance in the blood. Instead of separating distinctly, and coagulating firmly, we have the whole mass of blood keeping mixed, and hardly any coagulation, only becoming of a thicker consistence. * On the other hand it would appear reasonable to suppose, that there was really an increase of animal life, for women who are breeding, and are in perfect health, always have sizy blood; and this is most remarkably the case with all animals in similar situations; now it would appear necessary for an animal, when- ever put into a situation where greater powers are wanted, to have these powers increased. In a breeding woman there is a process going on, though natural yet uncommon, and which re- quires a greater exertion, or a greater quantity of powers than usual, and therefore we have them produced. This process of breeding although in many of its symtoms it is similar to fever, is yet very different; for actual fever kept up for nine months would destroy the person, while on the other hand, many are relieved by such a process. If these observations are just, this blood should not be called inflammatory blood, but blood whose powers of life are increa- sed. F 42 The adhesive inflammation. This effect, or appearance often takes place in those who die instantaneously. I suspect that in such cases the blood dies first, and also instantaneously. In the commencement of most diseases, and even through the whole course of many, the situation of the blood appears to be an object with nature. In some the blood forsakes the skin and extremities, and we may suppose the smaller vessels in general; for when we can observe internal parts, so we find it, such as the mouth in general, eyes, etc. a general paleness takes place, which is best seen in the lips, and even a shrink- ing of the external visible parts takes place, especially the eyes, so that the person looks ill, and often looks as if dying. The pulse is at this time small, which shows that the whole arterial system is in action. This appears to arise from debility, or the want of powers in the constitution to be acted on by such a disposition at the time, so that the whole powers or materials of life are called into the vital parts or citadel, and the outworks are left to themselves. Such is the case with fainting; the cold fit of an ague; the cold fit or beginning of a fever; rigors or beginnings of exacerbations; it is also the case with the hectic. In the commencement of diseases it does not appear to arise from real debility of constitution, but the novelty of the action, and of course a debility in that action, and in that only; but in the hectic, where a real debility has taken place, those appearances are owing to that cause; however, even in the hectic, this debility is assisted by the unnatural- ness of the action. In the first, where there are real powers, it would appear as if nature was struggling with the new disposition, and it either becomes destroyed entirely or in part, and the blood is then determined to the skin; and we may suppose into the smaller vessels in general; then the pulse becomes full; the whole action now appears to be there, and it becomes hot; when that action in the skin ceases, a perspiration takes place, and nature seems in many cases to be at rest; in some disorders this cessation is perfect for a time, as in agues; sometimes wholly, as in slight colds; but often imperfectly, as in continued fevers, where the sensation appears only to arise from weariness, which prevents the continuance of the action, not from an alteration of the disposition. The adhesive inflammation. 43 In other diseases the blood is thrown very early upon the exterior parts. The face shall look bloated, the eyes full, the skin red, dry and hard to the touch. These symptoms, I suspect, belong more to fevers of the putrid kind, and have less connexion with surgery than the former. The pulse is often as strong a sign of the state of the con- stitution as any other action that takes place in it, though it is not so always; but as the pulse has but one circum- stance attending it, that we can really measure, all the others being referable to the sensation or feeling of the person who is to judge of it, the true state of the pulse is not easily ascertained. The knowledge of the soft, the hard, and the thrill, are such as can only be acquired with accuracy by the habit of feeling pulses in these different states, and by many is not to be attained; for simple sen- sation in the minds of any two men are seldom alike. Thus, we find, it happens with respect to music; for what would be disagreeable and not in harmony to one ear, which is nice and accustomed to the harmony of sounds, will not be so to another. The late Dr. Hunter was a striking instance of this; for though he was extremely accurate in most things, he could never feel that nice distinction in the pulse that ma- ny others did, and was ready to suspect more nicety of discrimination that can really be found. Frequency of pul- sation in a given time is measurable by instruments; smart- ness or quickness in the stroke, with a pause, is measure able by the touch; but the nicer peculiarities in the pulse are only sensations in the mind. I think I have been certain of the pulse having a disagreeable jar in it when o- thers did not perceive it, when they were only sensible of its frequency and strength; and it is perhaps this jar that is the specific distinction between constitutional disease or irritation and health; frequency of pulsation may often a- rise from stimulus, but the stroke will then be soft; yet softness is not to be depended on as a mark of health, it is often a sign of dissolution; but there must be other attend- ing symptoms. In the consideration of the peculiarities of the pulse, it is always necessary to observe, that there are two powers acting to produce them, the heart and the arteries; that 44 The adhesive inflammation. one part of the pulse belongs to the heart alone, another to the arteries alone, and the third is a compound of both; but the actions of the heart and arteries do not always cor- respond; the heart may be in a state of irritation, and act quickly in its systole, while the arteries may be acting slow- ly; for the heart is to be considered as a local part, while the vessels must be considered as universal, or even consti- tutional. The stroke, (which is the pulse) with the num- ber of them that are made in a given time, whence the pulse is commonly called quick or slow, their regularity and ir- regularity as to time, and the quickness of the stroke itself, belongs to the heart. The quickness of the heart's action often takes place, although the pulsations are not frequent, which gives a kind of rest or halt to the artery or pulse, es- pecially if the pulse be not frequent. The hardness, the vibratory thrill, the slowness of the systole, with the full- ness and smallness of the pulse belong to the arteries. As the pulse arises from the actions of the solids or machine, its state will be of course according to the nature of the ma- chine at the time, and therefore is capable of being in one of these stares, natural and diseased. In most diseases of the constitution, whether originating from it, or arising in consequence of diseases of parts, where the constitution becomes affected by sympathy, the pulse is altered from a natural to a diseased state, the de- gree of which will be regulated by those affections. This alteration is commonly so constant, and so regularly of the nature of the disease, that it is one of the first modes of intelligence we have recourse to, in our inquiries into its nature; but alone it is not always a certain guide; for where there are peculiarities of constitution, we find the pulse corresponding to those peculiarities, and, perhaps, in direct contradiction to the accustomed state of the local af- fection. The same parts too, under disease, give very ir- regular, or uncertain signs in the actions of the heart and vessels, such as diseases, or injuries done to the brain. The varieties which the pulse admits of are several. It is increased in its number of strokes, or it is diminished. It is regular or irregular, as to time, in its strokes; it is quick in its stroke, or diastole, and slow in its systole. It is hard in its diastole, and it vibrates in its diastole. In most cases, probably where the constitution is in a state of irritation, the pulse will be quick and frequent in The adhesive inflammation. 45 its number of strokes in a given time, and the artery will become hard from a constant, or spasmodic contraction of its muscular coats, so as to give the feel of hardness to the touch; besides which, the diastole of the artery is not re- gularly uniform and smooth, but proceeds by a vast num- ber of stops, or interruptions, which are so quick as to give the feel of a vibration, or what we would express, by a thrill. The pulse under such a disposition, or mode of action, may be either full, or small. These two very opposite effects do not seem to arise from a difference in the quantity of blood, which might at first be supposed; I should rather suspect that they arise from a difference in the degrees of strength, which will be more or less, according to the nature of the parts inflamed, and the degree of irritability of the patient at the time. These give, more or less, an anti-diastolic disposition to the ar- teries; and while the arteries have the power of contrac- tion, and are in a state of irritation, this effect will always take place. It is certain at least, that the arteries do not commonly, in such a state of constitution, dilate so freely and so fully as at other times, and as this will vary very quickly, (if the constitutional irritation varies quickly) it is more reasonable to suppose, that it is an immediate effect of the arteries, than an increase, and decrease of the quantity of blood. If this be really the case, then we should naturally sup- pose that the motion of the blood in the arteries would be increased in proportion to their diminished size; except we should also suppose that the diastole, or the systole, or contraction of the heart, is also diminished in the same proportion. The first of these, I think, may probably be the case, as we find that the blood forsakes the surface of the body in such a state of the constitution, as will hereaf- ter be observed, therefore must be collected in the larger veins about the heart. If the heart was to dilate and throw out its whole con- tents at each systole, then the velocity of the blood, in the arteries under such a state of contraction of arteries would be immense, and it might then be pushed into the smaller vessels on the surface of the body, which it certainly is not. 46 The adhesive inflammation. The quick, hard, and vibratory pulse is generally an at- tendant upon inflammations; and whether it be attended with fullness, or the contrary, depends a good deal upon the part that is inflamed, which either increases, or de- creases the irritability, which will be described in treating of the different parts inflamed. In such a state of the constitution, as produces such a pulse, the blood, which appears to be only a passive body, acted upon by the heart, so as to produce the diastole of the artery, and reacted on by the vessels, making the com- plete pulse, this blood, I say, is generally found in a diffe- rent state from that where there are not these symptoms in the pulse; they, as it were, constantly attend each other, or are the reciprocal cause and effects of one another, as was taken notice of when I was speaking of the state of the blood in inflammation. From the account I then gave of the state of the blood in inflammation, and have now given of the pulse, under the same action, it should naturally be expected, that they should explain each other; which, for the first part they certainly do; yet, these appearances of the blood, and the kind of pulse, are every now and then appearing to be in opposition to each other, in their common attending circumstances; but this cannot be known till the person is bled; when the pulse is quick and hard, with a kind of vibration in the action, we generally have sizy blood. This may arise from fever, or such inflammation, etc. as affects the constitution, or vital parts, these being so diseased as to keep up a constitutional irritation, which will always be an attending symptom; but, when we have neither a quick, nor hard pulse, both, perhaps below par, and ra- ther small, no visible fever, nor inflammation, but, proba- bly, some strong, undetermined symptoms, such as pain, which is moveable, being, sometimes in one place, some- times in another, but at the same time seeming to impede no natural function, yet upon bleeding, the blood shall be sizy, and the size shall have strong powers of contraction so as to cup. A gentleman was ill with a pain, chiefly in his right side, but upon the part being rubbed, or application be- ing made to it, the pain seemed to move to some other part; from which circumstance it was supposed to have connexion with the bowels; at other times he was tolerably The adhesive inflammation. 47 well. His pulse was slow, small, and soft, and not at all, to the feel, like a pulse which required bleeding. He de- sired to be bled, and when bled, the blood was extremely sizy; the size being strong, and contracting so much as to draw in the edges, forming the upper surface into a hol- low, or cup. His pulse became fuller, quicker, and harder; he was bled a second time; the blood was the same, and the above symptoms increased so much; that I observed, immediately after the second bleeding, his pulse was quick- er, harder, and fuller, than it was just before the bleeding. That it might be quicker and fuller, I could conceive, be- cause I have often seen such effect from bleeding, where there had been an oppressed and languid pulse; but I can- not say that I ever saw a case where the pulse became hard- er, and acquired the vibration, except when debility, or languor was produced, and where the blood was weak in its powers of coagulation, being flat on the coagulated sur- face. Another want of correspondence, or irregularity, takes place when a constitution sympathizes with a local in- flammation. There are cases where the pulse becomes slow, and often irregular; such are mostly to be found in all people, when the constitution is affected either original- ly or sympathetically, and in such, I suspect that a disposi- tion for dissolution, and perhaps mortification, is much to be feared. A man, aged sixty-eight years, had an occasional in- flammation in one of his legs, which often ulcerated, and which seemed to arise more from a defect in the constitu- tion than to be simply local. In those indispositions, his pulse seldom exceeded forty in the minute, and as he began to get better, his pulse became more and more frequent. The varieties of the pulse arising from the seat of the in- flammation, and the nature of the part inflamed, will be expressed when I treat on inflammations in different situa- tions and parts. 48 The adhesive inflammation. VIII. THE EFFECTS OF INFLAMMATION ON THE CONSTITUTION, ACCORDING TO THE STRUCTURE OF PARTS, SITUATION OF SIMILAR STRUCTURES, AND WHETHER VITAL OR NOT VITAL. THESE circumstances make a very material difference in the effects on the constitution, arising from local inflam- mation; for we shall find that the effects on the constitu- tion are not simply as the quantity of inflammation, but ac- cording to the quantity and parts combined, (supposing constitutions to be equal) which I shall now consider sepa- rately. In common parts, as muscle, cellular membrane, skin, etc. the symptoms will be acute; the pulse strong and full, and the more so, if it be felt near to the heart; but perhaps, not so quick as when the part is far from it; since there will be less irritability. The stomach will sympathize less, and the blood will be pushed further into the smaller vessels. If the inflammation is in tendinous, ligamentous, or bo- ny parts, the symptoms will be less acute, the stomach will sympathize more, the pulse will not be so full, but perhaps quicker, because there will be more irritability, and the blood will not be so much pushed into the smaller vessels, and therefore forsake the skin more. It seems to be a material circumstance, whether the in- flammation is in the lower or upper extremity; that is, far from, or near to the heart; for the symptoms are the more violent, the constitution is more affected, and the power of resolution seems to be less, when the part inflamed is far from the source of the circulation, than when near it, even when parts are similar, both in texture and use. Whatever course the inflammation is to run, or in what ever way it is to terminate, it is done with more ease when near to the heart than when far off. All the parts that may in one sense be called vital, do not produce the same effects upon the constitution; and the difference seems to arise from the difference in their con- The adhesive inflammation. 49 nexions with the stomach. It is to be observed, that vital parts may be divided into two, one of which is in itself im- mediately connected with life, as the stomach; the other, where life only depends upon it, in its action or use; the heart, lungs, and brain are only to be considered in this last light; therefore, they have a considerable sympathizing af- fection with the stomach; the symptoms are rather depress- ing; the pulse is quick, small, and the blood is not pushed into the smaller vessels. If the heart or lungs are inflamed, either immediately, or affected secondarily, as by sympathy, the disease has more violent effects upon the constitution than the same quan- tity of inflammation would have, if it was not in a vital part, or was in one with which the vital parts did not sym- pathize; for if it is such as the vital parts sympathize with readily, then the sympathetic action of the vital parts will affect the constitution, as in an inflammation of the testicle. The pulse, in such cases, is much quicker and smaller than when in a common part, as a muscle, cellular membrane, or skin; but not so much so as in the stomach, and the blood is more sizy. When the inflammation is in the heart only, its actions are extremely agitated and irregular. If in the lungs, singly, the heart in such cases would appear to sym- pathize, and not allow of a full or free diastole. The stomach does not in common sympathize in such ca- ses, which is the reason, perhaps, of the inflammation not depressing; but it is to be observed, that I make a material difference between the inflammation of the lungs, com- monly called a pleurisy, and those diseases that begin slow- ly, and spin out to great lengths, and which are truly scro- phulous, producing the hectic; for in them we have the hectic pulse, and not the inflammatory. If the stomach is inflamed, the patient feels an oppression and dejection through all the stages of the inflammation; simple animal life seems to be hurt and lessened, just as sen- sation is lessened when the brain is injured; the pulse is generally low and quick, the pain is obtuse, strong, and op- pressing, such as a patient can hardly bear. If the intestines are much affected, the same symptoms take place, especially if the inflammation be in the upper part of the canal; but if it is the colon only which is af- VOL. II. G 50 The adhesive inflammation. fected, the patient is more roused; and the pulse is fuller than when the stomach only is inflamed. If it be the uterus, the pulse is extremely quick and low. If it be a testicle that is inflamed, the pain is depressing, the pulse is quick, but not strong. When the inflammation is either in the intestines, tes- ticle, or uterus, the stomach generally sympathizes with them, which will produce, or increase the symptoms pe- culiar to the stomach. In inflammation of the brain, I be- lieve the pulse varies more than in inflammations of any other part; and, perhaps, we are led to judge of inflamma- tion there, more from other symptoms than the pulse. I believe the pulse is sometimes quick, flow, depressed, full, etc. and which may accord with the other symptoms, such as delirium, stupor, etc. It is to be observed, when the attack upon these organs, which are principally connected with life, proves fatal, that the effects of the inflammation upon the constitution run through all the stages with more rapidity than when it hap- pens in other parts; so that at its very beginning, it has the same effect upon the constitution, which is only produc- ed by the second stage of fatal inflammation in other parts. Debility begins very early, because the inflammation itself is interfering immediately with the actions of life; and also in such parts universal sympathy takes place more readily, because the connexion of these parts by sympathy is more immediate; and if the sympathy is similar to the action, then the whole is, in some degree, in the same action. If the inflammation comes on in a part not very essential to life, and with such violence as to affect the actions of life, or to produce universal sympathy, the pulse is fuller and stronger than common; the blood is pushed further in- to the extreme arteries than when the inflammation is in a vital part; the patient, after many occasional rigors, is at first rather roused, because the actions of the part are roused; and the effects in the constitution are such as do not impede any of the operations of the vital parts. It is allowed to proceed to greater lengths, or greater violence in itself, before the constitution becomes equally hurt by it; and the constitutional symptoms pro- duced at last, may be said to arise simply from the violence of the inflammation; but this will take place, more or less, according to circumstances; it will be according to The adhesive inflammation. 51 the nature of the parts, whether active as muscles, or inac- tive as tendons; also according to the situation of the same kind of parts, as well as according to the nature of the con- stitution. If the constitution is strong, and not irritable, the pulse will be as above; but if the constitution is ex- tremely irritable and weak, as in many women who live se- dentary lives, the pulse may be quick, hard, and small, at the commencement of the inflammation, similar to the in- flammation of vital parts. The blood may be sizy, but will be loose and flat on the surface. IX. GENERAL REFLECTIONS ON THE RESO- LUTION OF INFLAMMATION. I NOW come to the most difficult part of the subject, for it is much more easy to describe actions, than to assign mo- tives; and without being able to assign motives, it is impos- sible to know when or how we may or should check actions or remove them. I have endeavoured to shew, that an animal body is susceptible of impression, producing action: that the action, in quantity, is in the compound ratio of the impression, the susceptibility of the part, and the pow- ers of action of the part or whole; and in quality, that it is according to the nature of the impressing power and the parts affected. I have also endeavoured to shew that im- pressions are capable of producing, or increasing natural ac- tions, and are then called stimuli: but that they are likewise capable of producing too much action, as well as depraved, unnatural, or what are commonly called diseased actions. The first of these I have mentioned by the general term, ir- ritations: the depraved, etc. come in more properly in treat- ing of peculiar, or specific actions. Since then an animal body can be made to increase its natural action, or to act improperly by impression, so we can see no reason, when it is acting too violently, why it should not be restrained by impression; or when acting im- properly, in consequence of these impressions, why it should not be made to act properly again by the same mode, name- ly, by impressions. 52 The adhesive inflammation. These modes of action we are first to understand, and then the power of correcting, or counteracting those impressions, in order to diminish, or prevent the action, so as to pro- duce one that is healthy or natural; besides, an injury which produces a new mode of action, and a disease, which is a new mode of action, often happen when the machine is in perfect health, and in such a state as is perfectly in harmony with that health; but which state is not suitable to disease; therefore, it is to be presumed, the more per- fect health the body enjoys, the less it bears a change in its actions. Thus we know, that strong health does not bear considerable injuries, such as accidents, operations, etc. A man in strong health, for instance, will not bear a com- pound fracture in the leg, or an amputation of the same, so well as a man accustomed to such diseases, and reduced by them. We find, commonly, that our artificial mode of reduction, is by far too quick, and is almost as much a vi- olence on the constitution, as the injury; when, therefore, considerable injuries or diseases commence, the constitution is to be brought to that state which accords best with that accident, or disease. The knowledge of that state of the bo- dy, at that time, as well as the operations of the whole an- imal, or of its parts, when arising from a disturbed or de- ranged state, or a diseased disposition, are to be considered as the first step towards a rational cure: but this alone is insufficient; the means of bringing the body to that state are also necessary which will include the knowledge of certain causes and effects, acquired by experience, including the ap- plication of many substances, called medicines, which have the power of counteracting the action of disease: or of sub- stances perfectly inefficient in themselves, but capable, un- der certain circumstances, of producing considerable effects such as water, when hot and cold; or a substance when it varies its form, as from fluidity to vapour. Of these vir- tues we know nothing definitely; all we know is, that some are capable of altering the mode of action, others stimulat- ing, many counter-stimulating: some even irritating, and others quieting, so as to produce either a healthy disposition and action in a diseased part, or to change the disease to that action which accords with the medicine, or to quiet where there is too much action; and our reasoning goes no further than to make a proper application of those substan- ces, with these virtues. The difficulty is to ascertain the The adhesive inflammation. 53 connexion of substance and virtue, and to apply this in re- straining or altering any diseased action; and as that can- not be demonstrated a priori, it reduces the practice of medicine to experiment; and this not built upon well de- termined data, but upon experience, resulting from proba- ble data. This is not equally the case through the whole practice of medicine, for in many diseases we are much more certain of a cure than in others; but still, even in them the certainty does not arise from reasoning upon any more fixed data, than in others, where the certainty of a cure is less; but it arises from a greater experience alone; it is still no more than inferring that in what is now to be tried, there is a probable effect or good to arise in the experiment, from what has been found serviceable in simi- lar cases: diseases, however, of the same specific nature, not only vary in their visible symptoms or actions, but in many of those that are invisible, arising probably from pecu- liarities of constitution, and causes, which will make the effects of application vary, probably, almost in the same proportion; and as those varieties may not be known, so as either to adapt the specific me- dicine to them, or to suit the disease to the medi- cine, it will then be only given upon a general principle, which of course may not correspond to the peculiarities. Even in well-marked specific diseases, where there is a specific remedy, we find that there are often peculiarities, which counteract the simple specific medicine. This we even see in poisons, the most simple specific of all, because its ef- fect arises in all cases from one cause; the peculiarities, therefore, in the disease must arise from a peculiarity in the constitution, and not from the cause of the disease. The inflammation I have been treating of, is the most simple of any, because it is the simple action of the parts unmixed with any specific quality, arising from causes of no specific kind, and attacking constitutions, and parts, not necessarily having any specific tendency; the cure, therefore, or method of terminating the inflammation, which is called resolution, (in cases that will admit of it) must also be very simple, if we knew it; and accordingly, when the cure of such is known, it lays the foundation of the general plan for the treatment of all inflammations of the same kind: but it very rarely happens that a constitution is perfectly free * Vide the varieties of the inflammation, in the introduction, 54 The adhesive inflammation. from a tendency to some disease*; we seldom, therefore, see simple salutary actions of parts tending to relieve them- selves from a violence committed: some constitutions being so irritable, that the inflammation has no disposition to ter- minate, and others so indolent that the inflammation passes into another species, as into scrophula; all of which will require very different treatment. The same varieties take place in specific inflammations; as also in inflammations arising from poisons; for many will have the true inflammatory disposition joined with the specific; in such, therefore, the same plan is to be pursued with the addition only of the specific treat- ment; but this must not be omitted, as the inflammation depends upon the specific disease. It is this critical know- ledge, which becomes the basis of practice; and it is this which requires the greatest sagacity; and I must own, it requires more knowledge than comes to the share of most practitioners. As every inflammation has a cause, that cause should be removed before resolution can take place; for the animal œconomy having a disposition within itself to discontinue diseased action, that of course subsides upon the removal of the cause; and this disposition is so strong in some, as to appear to act alone. That removing the cause is a mode of resolution, is proved in the venereal bubo; for by taking off the venereal action with mercury, the inflammation subsides, if another mode of action does not arise*. Inflammation, where it must suppurate, is most probably a restorative act, and cannot be resolved in those cases where restoration becomes necessary; as for in- stance, in a wound that is kept exposed, the inflammatory act of restoration becomes, or is rendered, necessary, and it takes place; but bring those parts together, or let the blood coagulate and dry upon it, and it becomes unnecessary. I have already observed, when treating of the causes of in- flammation, which might be called the spontaneous, that they probably arose from a state of parts, in which they could not exist, similar to exposed surfaces, and therefore this act of restoration became necessary: if this be true, then probably by altering that state of parts, as we can by bringing the divided parts together, the inflammation would either not rise, or immediately cease; but as we are not in all cases acquainted with the mode of restoring those * Vide Treatise on Venereal Disease. The adhesive inflammation. 55 natural actions, we are obliged to be restricted to those methods that render them easier under this state, and which are often capable of turning the balance in favor of resolution. As inflamed parts are not always visible, it becomes ne- cessary that we would have some rule to inform us, whe- ther the part is inflamed or not; to ascertain which, we must have recourse to all the symptoms formerly mentioned, except the visible ones. We ought also to have a guide re- specting the kind of inflammation, more especially as it is not sufficient, in many cases, to be guided entirely by the appearances, even where it is in sight; it is often, there- fore, very necessary to inquire into the cause of the inflam- mation, the nature of the constitution, the effects that for- mer inflammation has produced, and even into the temper and mind of the patient. The cure of inflammation is resolution; and the attempt towards it, is principally to be made when the inflammation is in the adhesive state; for we find that often it goes no further, but subsides, and this is resolution; probably the sooner after its commencement it is the better. The ob- ject of the attempt is to prevent suppuration taking place, although suppuration may be considered as a resolution, but it is the mode of resolution we commonly wish to avoid. Resolution is in general only to be attempted, with any probability of success, under the following circumstances: when the inflammation is in consequence of the constitu- tion, or a disease of the part: secondly, in cases of acci- dent, where there is neither no exposure, or where it has been removed in time: as, for example, by bringing the parts in contact: thirdly, where the life of the part has not been destroyed. In all such cases we find that resolution can take place; but in those cases arising from accident, and a continuance of exposure joined, or where death of the parts is produced by the accident, it becomes impossi- ble to hinder the suppuration from taking place. I have already observed, that in many bruises, as well as simple fractures, where the cavities are not exposed, and where they are to heal by the first and second intention, the inflammation, in most of these cases, is capable of be- ing resolved; although, in some such cases, the inflamma- tion runs so high as to threaten suppuration. I have also already shewn, that in parts which have been divided and exposed, the inflammation is, by bringing them together, 56 The adhesive inflammation. in a great measure prevented; or if it has taken place pre- vious to the union, that the same operation of union is sufficient to produce resolution; and I have likewise shewn that where parts were not brought together, nature at- tempted to prevent inflammation, by covering the wound with blood, and forming an eschar, which, in many cases, will either prevent, or remove inflammation; all of which shews a power of resolution, even in the cases where the parts have been exposed. As it is commonly supposed that there are a great many local diseases that should not be resolved, the first thing ne- cessary to be considered, is, when the resolution should or should not be attempted. On the contrary, there are cases where inflammation is to be excited, but these arise commonly from disease, which is not to our present pur- pose; yet it sometimes happens in accidents, where in- flammation is necessary, that it is not sufficient for the re- instatement of the injured parts, as in some simple frac- tures, where the first bond of union, the extravasated blood, had not fulfilled its purpose, and had been absorbed, and where the inflammation was too slight to supply its place; so that union of parts was prevented, and another mode became necessary, not at all a consequence of inflamma- tion, viz. granulations without suppuration; all of which retards still more the restoration of the parts. As this de- fect can only be known in bone, and in the soft union of the bone, which is similar to the union in the soft parts, it is reasonable to suppose, it may also take place in the soft parts; more especially those which are tendinous, or ligamentous, where we find recovery very slow, for the soft union in bones differs in nothing from that of the soft parts; it may, therefore, be a much more common defect than is generally imagined. In such cases, if it could be known, it would be proper to encourage, or even excite inflammation. If we cannot, probably, in any case deter- mine where it should be excited, nor even where it should be checked, yet we can say in many cases, where it is unnecessary to check it. Before we attempt to check in- flammation, we should have reason to suppose it is go- ing further than is necessary for the natural cure; and therefore it is laying the foundation of work for the sur- geon. It may be very difficult to say, in many cases, when it should be checked. The most simple reason The adhesive inflammation. 57 will be to lessen pain, arising in a part not merely when moved or touched, but in the act of inflammation. Se- condly, where it may be uniting parts, the union of which we wish to avoid; but this is an uncertain guide, even if we knew adhesions were taking place, for adhesions often prevent suppuration. Thirdly, to prevent the in- flammation from suppurating; and in this last, although the most obvious, yet there is less certainty how far we may advise the attempt. It is also the most difficult to effect; for in many cases of spontaneous inflammation, if it arises from a state under which the parts cannot exist, nor their functions go on, similar to an exposed breach in the solids, then resolution should not be at- tempted: it may be palliated when going beyond what is necessary for suppuration; but when this practice is carried farther, it rather retards that salutary process. From the foregoing statement of particulars, it must ap- pear, that in many cases it is unnecessary to check inflam- mation; in others it would be wrong, and in many very ne- cessary and probably the best guide is its going further than appears from the cause to be salutary; yet in practice we find applications, and other modes of resolution, immedi- ately had recourse to, which must be considered as oppro- brious to surgery. Inflammations, in consequence of accidents, ought in general to be resolved, if possible. It is perhaps impossible to produce a single instance where a contrary practice would be preferable, except as above related, where its consequence would be to answer some great purpose; and it is also conceivable, that this local disease, produced by accident, might relieve the constitution from some prior disorders, similar to what is understood to be the effects of an issue. Mr. Foote was relieved of head-achs, of long standing, by the loss of a leg, which may be considered as a proof of this; but he afterwards died of a complaint in his head, very similar to an apoplexy. It might be suppo- sed, on the other hand, that the temporary cure was the cause of the apoplexy. Inflammation, in consequence only of a disease in a part, appears to be under the same circumstances, with respect to resolution; but an inflammation arising from a preceed- ing indisposition in the constitution (commonly called cri- VOL. II. H 58 The adhesive inflammation. tical) has always been classed among those which should not be cured locally, and this has got the term of repulsion: it has been insisted on, that the inflammation should rather be encouraged, and suppuration produced, if possible. If the inflammation is really a concentration of the constitu- tional complaint, and that by not allowing it to rest here, the same disposition is really diffused over the whole animal again, and at liberty to fix on some other part, it certainly would be better to encourage its stay; but, in such cases it is always understood that the inflammation is in such parts as will readily admit of a cure when suppuration takes place; for if the disease be otherwise situated, then the cure of the constitution by suppuration will be a mode of cure which will reflect back another disease upon it, under which it will sink: resolution of inflammation, therefore, in the first of these situations should, if possible, be brought about. For instance, many deep-seated inflammations, if allowed to suppurate, would of themselves most cer- tainly kill. This might be illustrated by the gout, when either in the head or stomach, for when in such parts it had better be repelled, and left to find another part less con- nected with life; which, if in the feet, would be called re- pelling of it; but still it does not appear to me necessary that it should suppurate, for suppuration is only a conse- quence of the inflammation, and not an immediate conse- quence of the original or constitutional disease, but a second- ary one*: as suppuration, therefore, is only a thing super- added, and as we shall find that inflammation generally subsides when suppuration comes on, I see no reason why inflammation in the present case, should not as well subside by resolution as by suppuration: however, it may be sup- posed, that although suppuration is not the natural, or im- mediate effect of the disease, yet as it is a continued local * This is contrary to the common received opinion, but it is according to my idea of suppuration, for I have all along con- sidered inflammation as the disease, and suppuration only as a consequence of that disease; and have supposed the disease to be gone when suppuration has taken place; but, according to the common opinion, suppuration was the thing to be wished for; because all diseases arose from humors; but as we have not once mentioned humors, and therefore made it no part of our system, we must also drop it at present. The adhesive inflammation 59 action, and the thing sought for by the constitution, and as inflammation must precede it, the parts must submit to those regular processes; for it must be supposed to be capa- ble of diverting the disease to this part. X. OF THE METHODS OF RESOLUTION BY CONSTITUTIONAL MEANS. THE first thing to be considered is the kind of inflam- mation; when visible, which will in some degree shew the kind of constitution; the next is the nature of the part in- flamed, and the stage of inflammation; for upon these de- pend in some measure the method of relief. In cases of ex- posed internal surfaces, the inflammation cannot be resolv- ed, because the cause still exists till inflammation has resolv- ed itself; but it may be lessened, and this probably takes place by lessening every thing which has a tendency to keep it up; and in all likelihood, little more can be done in spontaneous inflammations; for as yet we know of no me- thod which will entirely quiet or remove the inflammatory disposition or mode of action, as there is no inflammatory specific with which we are acquainted. When I described inflammation, I observed there was either an increase of life, or an increased disposition to use with more violence the life which the machine, or the part was in possession of; and also there was an increased size of vessels, and of course an increased circulation in the part inflamed, and in the constitution in general. If this theory of the mode of ac- tion of the vessels in inflammation is just, then our prac- tice is reducible to two principles; one consisting in remov- ing the cause of that action; the other in counteracting the effect. In the first, as we seldom know the cause, but only see the effect, except in some specific diseases, for which we have a specific remedy, we do not know with a- ny degree of certainty how to act; but as the second, that is, the effect, is more an object of our senses, we can ap- ply with more certainty our reasoning upon it; for rea- soning from analogy will assist us in our attempts. We 60 The adhesive inflammation. find, from common observation, that many circumstances in life, as also many applications to parts, will call forth the contraction of the vessels: we are, from the above the- ory, to apply such means; and whatever will do this, with- out irritation, will so far counteract the effect*. I have already observed, that wherever there has been a violence committed, or some violent action is going on, there is a greater influx of blood to that part. Lessening, therefore, that influx becomes one mode of relief; for as the vessels dilate, they should not be encouraged in that action. Al- though the increased influx is to be considered chiefly as an effect, yet it is to be considered as a secondary cause; and from our ignorance of the immediate cause, it is probably only through such secondary causes that we can produce a- ny effect; and upon these principles, most likely rest, in some measure, the method of resolution; for whatever will lessen the power and disposition, will also lessen the effect; and possibly these will likewise lessen the force of the circu- lation. If the inflammation is attended with considerable action and power, as it were, increasing itself, then the modes of resolution are to be put in practice; the one by producing a contraction of the vessels, the other by soothing or lessen- ing irritability, or the action of dilatation. The first, or contraction of the vessels, is produced in two ways; one by producing weakness; for weakness excites the action of contraction of the vessels; the other, by such applications as induce the vessels to contract. The means of producing absolute weakness are bleeding and purging; but the bleeding also produces irritability for a time, and is often attended by a temporary weakness of another kind, viz. sickness. The inconvenience, however, arising from this practice is, that the sound parts must nearly, in the same propor- tion suffer with the inflamed: for, by bringing the inflamed part upon a par with health, the sound parts must be brought much lower, so as to be too low. The soothing may be * As this is a new theory of the action of the vessels in in- flammation, and the only one that can possibly direct to a me- thod of cure, it is to be hoped that attention will be paid to it; and, if just, that more certain methods of resolution will be dis- covered. The adhesive inflammation. 61 producing by sedatives, relaxants, antistimulents, etc. such as many sudorifics, anodines, etc. The first method will have the greatest, the most perma- nent, and the most lasting effect; because, if it has any ef- fect at all, the diseased action cannot be soon renewed. The second will act as an auxiliary; for so far as irritation is a cause, this will also lessen it; and the two should go hand in hand; for wherever we lessen power, we should, at the same time, lessen the disposition for action, or else we may increase the disposition; but neither bleeding, purging, nor sickness, can possibly lessen the original inflammatory dispo- sition; for none of them will resolve a venereal inflamma- tion, when mercury will: nor will they resolve the erysipe- latous inflammation, although that inflammation has the very action for which we should bleed in the common in- flammation, viz. dilatation of vessels. However, these means may, in some sense, be reckoned direct; for whate- ver will produce the action of contraction in the vessels is counteracting the action of dilatation. Lessening the power of action belonging to any disposition, can only lessen or pro- tract the effects, which, however, will be of singular service, as less mischief will be done, and it will often give the disposition time to wear itself out. Means employed, on this princi- ple, should be such as give the feel of weakness to the constitution; which will effect the part, and will make the vessels contract; but this practice should not be carried so far as to produce the sense of too much weakness, for then the heart acts with great force, and the arteries dilate. Bleeding then, as a general principle, is to be put in prac- tice; but this must be done with judgement; for I conceive the effects of bleeding to be very extensive. Besides the loss of any quantity of blood being universally felt, in propor- tion to the quantity lost, an universal alarm is excited, and a greater contraction of the vessels ensues, than simply in proportion to this quantity, in consequence as it would ap- pear, of a sympathetic affection with the part bleeding. Too much blood, in an inflammation, is a load upon the actions of the circulation. Too little, produces debility and irritability; because, there is a loss of powers, with an increased action to keep up, which is now not supported. It would seem that violent actions of a strong arterial sys- tem, required less blood than even the natural actions; and even less still than a weak or irritable system; from whence 62 The adhesive inflammation. we must see, that bleeding can either relieve inflammatory action, or increase it, and therefore not to be used at ran- dom. As many patients that seem to require bleeding have been already bled, it may not be improper to inquire how they bear, or are affected by bleeding; for, certainly, all constitutions (independent of every other circumstance) do not bear this evacuation equally, and it is probable, that its effects on inflammation may be nearly in the same propor- tion; if so, it becomes a very useful caution; for although the loss of blood may, as a general principle, be set down as a weakener, and probably the greatest, as we can kill by such means, yet the loss of certain quantities in many con- stitutions is necessary for health: this is either when there is a disposition to make too much blood, or a constitution that cannot bear the usual quantity; in such, when known, bleeding with freedom is certainly necessary. If the in- flammation is known to be attended with real powers, bleeding is absolutely necessary, in such quantity as to take off from the force of the circulation, which arises from too much blood; or if that is not sufficient, then as much as will cause a contraction of the vessels; but in cases of too great an action of weak parts, then the proper quantity to be taken, is no more than may assist the dilatation of the ves- sels, which will lessen the violence of motion in the blood, or remove the sensation in the part inflamed of having too much to do; the quantity, therefore, must be regulated according to the symptoms, and other circumstances; for instance, according to the visible indications. We are to remark here, that every part of the body, un- der inflammation, will not bear bleeding alike. I believe that the constitution bears bleeding best, when the inflam- mation is in parts not vital, and those near the source of the circulation: whatever disturbs some of the vital parts, depresses, but not equally in all; and in them it becomes more necessary to be particular, for in accidents of the brain, bleeding freely, even so as to produce sickness and fainting, is necessary. It is probable, that the sickness at- tending such accidents, is designed to lessen the influx to the head, and occasion the vessels of the brain to contract. The indications for bleeding are first, according to the violence of the inflammation, joined with the strength of the constitution, which will in general point out the kind of The adhesive inflammation. 63 inflammation. Secondly, according to the disposition to form much blood: thirdly according to the nature of the part, whether vital or not: fourthly, according to its situa- tion, in point of distance from the heart: fifthly, accord- ing to the effect of the inflammation on the constitution. With regard to this evacuation, it is worthy of particu- lar consideration, whether or not in all cases, where it can be put in practice, bleeding in or near the part will answer better than taking the blood from the general habit; for certainly less may be removed in this way, so as to have equal effect upon the part inflamed, (and probably upon e- very other disease that is relieved by bleeding) and yet af- fect the constitution less; for although, in many cases, the general habit may be relieved by bleeding, yet the part af- fected, where it can act, will in all cases require this evacu- ation most, and local bleedings will keep nearer these pro- portions, whereas taking blood from the general system is just the reverse. That local bleeding has very consider- able effects on the inflamed part, is proved by the gout; for applying leeches to the part inflamed, commonly relieves that part, and often almost immediately*. We find that bleeding by leeches alone will remove a tumour in the breast, having all the appearances of a schirrus, which can- not be considered as inflammatory; its powers, therefore, extend beyond inflammation. We find relief by bleed- ing in the temporal artery, or jugular vein, for complaints in the brain; or cupping and bleeding with leeches, on or near the part; as applying leeches to the temples in inflam- mations of the eye. I have observed that there is something similar to sympa- thetic affection in bleeding. I conceive that all the sym- pathetic powers, the universal, continued, and contiguous, may be brought into action from the local influence of bleeding. Thus, bleeding in the part inflamed, I can con- ceive, does more than simply emptying the vessels mechan- ically, for that would be soon restored from the general cir- culation; but it acts by continued sympathy, viz. the ves- sels of the part being opened, they contract for their own defence, and this is carried further among the vessels of the part; so that bleeding from the part acts in two ways, viz. mechanically, by relieving the vessels of some blood, so * It is not meant here to recommend bleeding in this disease. 64 The adhesive inflammation. as allow them to contract in proportion as the load is taken off; and also to excite them to contraction, in order to prevent the effusion of blood. I suppose, likewise, that contiguous sympathy comes into action; for this would appear from practice and observation to be a principle in bleeding; therefore, in inflammation of contiguous parts, it is proper to bleed from the skin opposite to them, as from the skin of the abdomen, in complaints of the liver, stomach, and bowels; and likewise from the loins in inflammatory affections of the kidneys. In affections of the lungs, bleed- ing opposite to them is of service; but in such cases, it is not clear where the inflammation is; for if in the pleura, then it does not act upon this principle, but by continued sympathy: bleeding on the scalp relieves head-achs; and the relief given to the testicle by bleeding from the scrotum, inflammation of that body, proves the principle. Where the first indication for bleeding takes place, viz. where there is violent inflammation, with strength of con- stitution, bleeding freely, will be of singular service. The same mode of practice is also to be followed under the cir- cumstance of strength, with respect to the second, third, fourth, and fifth; but each will not require the same quan- tity to be taken under equal strength of constitution, as will be taken notice of when treating of them separately. As it seldom happens that bleeding once will be sufficient in a considerable inflammation, the first, or preceeding blood taken, becomes a symptom of the disease. If the coagulat- ing lymph is long in coagulating, so that the globules have time to subside, there will be what is called a thick buff; and if its surface is considerably cupped, then future bleed- ings may be used with less caution; because such appear- ance indicates strong powers of coagulation, which always shews strength in the solids; but if the blood is weak in its powers of coagulation, lies flat in the dish, then we must be cautious in our future bleedings; or if it was strong at first in its powers of coagulation, and after repeated bleed- ings becomes weak, then we must not pursue this further; but in some cases it is proper to pursue it to this point, for we shall sometimes find that the inflammatory symptoms shall not cease after repeated bleedings, if the strength con- tinues; but the moment a degree of looseness is produced in the blood, that moment will the inflammatory action cease. The following case is a strong instance of this. A lady had The adhesive inflammation. 65 a violent cough, tightness in respiration, loss of appetite, strong sizy blood, and the symptoms continued to the sixth bleeding, when the blood was not quite so sizy; but the most remarkable change was, its remaining flat on the surface. Upon this bleeding, all the symptoms disappeared; and here, although the blood became weak in its power of coa- gulation, yet it did not produce irritability in the constitu- tion, the vessels of the inflamed parts having still had pow- er to contract. On the other hand, there may be indica- tions for bleeding sparingly: first, when there is too much action, with weakened powers: secondly, when there is a disposition to form but little blood: thirdly, when the part affected is far from the source of the circulation. From the above three dispositions that require bleeding sparingly, or with caution, I may observe, that it will most probably be proper in all such cases to bleed from, or as near the part affected as possible, in order to have the great- est effect, with the loss of the least quantity of blood; more so than when the constitution is strong; because the con- stitution in such cases should feel the loss of blood as lit- tle as possible; if from the part, leeches will answer best, because commonly little irritation follows the wound of a leech‡: however, this can only be put in practice in inflam- mations not very remote from the surface. But in many cases the blood cannot be taken away from the part itself, but only from some neighbouring part, so as to affect the part in- flamed: thus, we bleed in the temporal artery for inflamma- tion of the eyes; we bleed in the jugular veins for inflamma- tion of the brain; and also in the temporal artery, to lessen the column of blood going to the brain, by the internal caro- ‡ However, this is not always the case; for it sometimes hap- pens that an unkindly inflammation attends the wound, though not extensive. It sometimes, also, happens that the lymphatic glands swell in consequence of their bite; but these so rarely occur, and are of such little consequence when they do that they are not to be regarded. From thence it has been conceived, that there was something poisonous in the bite of a leech; but I think there are no proofs of it: however, from another effect, I conceive there is a power or property applied to the wound, which hinders the irritation of contraction that naturally takes place in a wounded vessel, producing, probably, a paralysis for a time. Vol. II. I 66 The adhesive inflammation. tids. But in many situations it will, probably, be impossi- ble to do this, with any hopes of success, and therefore we may have recourse to the sympathetic affections before de- scribed. Too much action, with small powers may often, if not always, be classed with the irritable constitution, and blee- ding should then be performed with very great caution: one case out of many I shall relate as an instance of great action with debility. A gentleman had one of the most violent in- flammations I ever saw, in one of his eyes attended with vio- lent pain in his head, the blood extremely sizy, all of which denotes great action of parts; yet the buff of the blood was so loose when coagulated, that it could hardly bear its own weight, or make any resistance to the finger when pressed; and although he was bled pretty freely, yet he ne- ver found any relief from it. This blood becoming a symp- tom, both of the constitution and disease, manifestly showed weak powers from its looseness, and too great action from its slowness of coagulation, which was the cause of the buff. The following case is another strong instance of great action in a weak, irritable habit. A lady had a violent in- flammation at the root of the tongue, so as to form a con- siderable suppuration; with a pulse of one hundred and twenty, one hundred and twenty-five, and often one hun- dred and thirty, in a minute: her blood was extremely sizy, yet she received but little benefit from the first bleed- ing, although the blood coagulated pretty firmly, which indicated strength. She was of an irritable constitution, so as to receive less benefit from bleeding than another; and when bled three times, the blood became extremely loose in its texture, which bark removed, as well as the other symptoms. Upon leaving off the bark, the symp- toms all recurred, and when she was bled again for the second attack, which was the fourth time the blood, al- though inflammatory, had recovered a good deal of its proper firmness; but in the second bleeding, for this second attack, it was less so; and in the third it was still less. Suspect- ing that bleeding in the present case would not produce re- solution, I paid particular attention to the pulse at the time of bleeding, and found that in this last bleeding the pulse increased in its frequency even in the time of bleeding; and within a few minutes after the bleeding was over, it had The adhesive inflammation. 67 increased ten strokes in the minute*. These bleedings re- tarded suppuration, but by producing irritability they could not effect resolution. Where there is a disposition to form but little blood, when known, bleeding should be performed with great caution. When the inflammation is far from the source of the cir- culation, the same precautions are necessary. In general it can be taken away from the part in such cases. But these are only so many facts, that require peculiar symptoms to ascertain them. The common indications of bleeding, besides inflamma- tion, are too often very little to be relied upon; and I shall consider them no further than as it concerns inflammation; which will indeed throw light on other cases. The pulse is the great indication in inflammation; but not always to be depended upon. In inflammations that are visible, a knowledge of the kind of inflammation is in some degree ascertained, as has been observed, we therefore go upon surer ground in our indications for bleeding: but all inflammations, are not visi- ble; and it is, therefore, necessary to have some other crite- rion: however, if we could ascertain the pulse, peculiar to such and such appearances, in visible inflammation, and that was universally the same in all such appearances, we might then suppose that we had got a true indicative crite- rion for our guide, and therefore apply it to invisible in- flammation, so as to judge of the inflammation by the state of the pulse; but when we consider, that the same kind of inflammation in every part of the body will not produce the same kind of pulse, but very different kinds, not according to the inflammation, but according to the nature of the parts inflamed, and those other parts also not visible, we lose at once the criterion of pulse as a guide. When we consider, also, that there shall be every other sign, or symptom of inflammation in some viscus, and from the symptoms the viscus shall be well ascertained, yet the pulse shall be soft, * This, of the pulse increasing upon bleeding, is not always to be set down as a sure sign of irritation being an effect; for in a sluggish pulse, arising from too much blood, the increase of stroke, and freedom given to the circulation is salutary; but when a pulse is already quick, an increase must arise from irri- tation. 68 The adhesive inflammation. and of the common frequency; and upon bleeding, in con- sequence of these inflammatory symptoms, the blood shall correspond exactly with all of them, except the pulse, it shall be sizy, firm, and cup, as was the case in a lady, which has been before described, we shall be still farther convinced that the pulse is a very inadequate criterion, if a pulse be hard, pretty full, and quick, bleeding appears to be the immediate remedy, for hardness rather shews strong contractile action of the vessels not in a state of in- flammation, which also implies strong action of the blood; and from such a pulse, a sizy blood will generally be found; but even a quick, hard pulse, and sizy blood, are not al- ways to be depended upon as sure indications of bleeding being the proper method of resolution of inflammations; more must be taken into the account. The kind of blood is of great consequence to be known; for although it should prove sizy, yet if it lies squat in the bason, and it is not firm in texture, and if the symptoms, at the same time, are very violent, bleeding must be per- formed very sparingly, if at all; for I suspect that under such a state of blood, if the symptoms continue, bleeding is not the proper mode of treatment. The cases of this kind, which have been related, are strong proofs of this. As the pulse abstracted from all other considerations, is not an absolute criterion to go by, and as sizy blood, and a strong coagulum are after proofs, let us see if there are any collateral circumstances that can throw some light on this subject, so as to allow us to judge, a priori, whether it be right to bleed or not, where the pulse does not of itself indicate it. Let us remember, that in treating of inflam- mation of different parts, I took notice of the pulse pecu- liar to each part, which I may now be allowed to repeat. First, I observed that an inflammation in parts not vital, or such as the stomach did not sympathize with, if there were great powers, and the constitution not very irritable, the pulse was full, frequent, and hard. Secondly, that on the contrary, in inflammations of the same parts, if the constitution was weak, irritable, etc. then the pulse was small, frequent and hard, although perhaps not so much so as when in vital parts. Thirdly, that when the inflamma- tion is in a vital part, such as the stomach, intestines, or such as the stomach readily sympathizes with, then the pulse is quick, small, and hard, similar to the above. Now, 69 The adhesive inflammation. in the first stated positions we have some guide, for in the first of these, viz. where the pulse is strong, etc. there bleeding is most probably absolutely necessary, and the symptoms, with the state of blood joined, will determine better the future conduct; but in the second, where the pulse is small, very frequent, and hard, bleeding should be performed with great caution; yet in inflammation of the second stated parts, the constitution seems to be more irritable, giving more the signs of weakness, as if less in the power of the constitution to manage. Bleeding, restricted to two or three ounces, can do no harm, by way of trial; and, as in the first case, the symp- toms and blood are to determine the future repetition; but in the third, or vital parts, viz. either the stomach, or such as the stomach sympathizes with, we are yet, I am afraid, left in the dark respecting the pulse. Perhaps, bleeding at first with caution, and judging from the blood and its effects upon the other symptoms is only the criterion we can go by. The kind of constitution will make a material difference, whether robust, or delicate. The mode of life will also make a material difference, whether accustomed to considerable exercise, and can bear it with ease: constitutions so habituated will bear bleeding freely, but those with contrary habits will not. The sex will likewise make a difference, although the mode of life will increase that difference; therefore men will bear bleed- ing better than women: even age makes a material difference, the young being able to lose more blood than the old; for the vessels of the old are not able to adapt themselves so rea- dily to the decreased quantity; it even should not be taken away so quickly; and probably the constitution may, in some degree, have lost the habit of making blood, since it has lost the necessity. The urine will throw some light on the disease; if high coloured, and not much in quantity, it may be presumed, with the other symptoms, that bleeding will be of singular service; but if pale, and a good deal of it, although the other indications are in favour of bleeding, yet it may be ne- cessary to do it with caution. However, bleeding should in all cases be performed with great caution, more particularly at first; and no more taken than appears to be really necessary; it should only be 70 The adhesive inflammation. done to ease the constitution, or the part, and rather lower it where the constitution can bear it: but if the constitution is already below or brought below a certain point, or gives the signs of it from the situation of the disease, then an irritable habit takes place, which is an increased disposition to act without the power to act with. This, of itself, be- comes a cause of the continuance of the original disposition, and therefore will admit neither of resolution, nor suppu- ration, but continue in a state of inflammation; which is a much worse disease, than the former. Upon any other principle than those abovementioned, I cannot see why bleeding should have such effects in in- flammation as it sometimes has. If considered in a me- chanical light, as simply lessening the quantity of blood, it cannot account for it; because the removal of any natural mechanical power, can never remove a cause which nei- ther took its rise from, nor is supported by it: however, in this light it may be of some service; because all the actions relative to the blood's motion will be performed with more ease to the solids, when the quantity is well proportioned. It is probably from that connexion between the solids and fluids, that the constitution, or a part, is in a state of perfect quietude, or health, in which we find that the flu- ids are, and ought to be, in a large quantity; but in a state of inflammation, or increased powers and actions, those proportions do not correspond, at least in the parts inflam- ed; and by producing the equilibrium between the two, suitable to such a state, the body becomes so far as this one circumstance can affect it, in a state of health; and this in many cases will cast the balance in favour of health: it is not, however, sufficient to produce this effect in all in- flammations. How far taking the blood from parts peculiarly situated with respect to the parts inflamed, is more efficacious, I believe is not yet determined; as bleeding in the left side for an inflammation in the right, upon the supposed princi- ple of derivation, which might be classed with remote sym- pathy; but so far as the loss of the blood acts mechanical- ly, viz. so far as it simply empties the vessels, it certainly can have no more effect than if taken in any other way; nor can it affect the living principle, either universally, or locally, more in this mode than in any other; but how far it can affect the sympathizing principle, I do not know. The adhesive inflammation. 71 Bleeding is often performed from no constitutional indi- cation, but only as a preventive, arising from experience; such as in consequence of considerable accidents, as blows on the head, fractured bones, etc. but this is not to the pre- sent purpose. XI. THE USE OF MEDICINES INTERNALLY, AND OF LOCAL APPLICATIONS IN IN- FLAMMATION. EVERY thing given to the body, or applied to the part inflamed, that can abate inflammation, or its effects in the constitution, may be called medicine; such therefore, di- vide themselves into constitutional, and local: the first will be internal, the second external; but whichsoever way they are applied, they that tend to lessen inflammation, have their effects local; for mercury, although given in- ternally, for a venereal ulcer in the throat, yet acts locally on the disease; but those that tend to remove constitutional affections, have their effects constitutional. The internal medicines generally ordered for the resolu- tion of inflammation, are such as tend to have similar ef- fects to that which is produced by bleeding; namely, low- ering the constitution, or the action of the parts; and this has usually been performed principally by purges; and the medicines that were given to remove, or lessen the effects of inflammation on the constitution, have been such as ge- nerally tend to lessen fever, or the effects that the inflamma- tion has upon the constitution. Purges were generally given in cases of inflammation, probably at first from the idea of humors to be discharged and such practice will answer best where bleeding suc- ceeds; because it will lower the body to a move natural standard, and of course the inflamed part, as a part of that constitution; but here the same cautions are necessary that were given upon bleeding, because nothing debilitates so much as purging, when carried beyond a certain point. One purging stool shall even kill, where the constitution is very much reduced, as in many dropsies: therefore, keep- 72 The adhesive inflammation. ing the body simply open, is all that should be done. However, although purging lowers considerably, yet its ef- fect is not so permanent as that of bleeding; it rather low- ers action, without diminishing strength for if a person was to feel the loss of blood equal to a purge, that sensa- tion would be more lasting. Many constitutions rather acquire strength upon being gently purged; particularly such as have been living above par; but such strength as is acquired by putting the body in good order, I should suppose is not inimical to inflam- mation. In irritable habits, where the inflammation becomes more diffused, greater caution is necessary, with regard to purging, as well as bleeding; for I observed on the sub- ject of bleeding, that in such constitutions, no more blood should be taken than would relieve the constitution, as it were mechanically, but not such a quantity as to have a tendency towards lowering or weakening that constitution; for in such cases the action is greater than the strength; and whenever the disposition between these two is of this kind, we cannot expect any thing salutary from this mode of treatment, and therefore should not increase it. In such cases, the very reverse of the former method should often be practised; whatever has a tendency to raise the constitution above irritability, should be given; such as bark, etc. The object of this last practice consists in bringing the strength of the constitution, and part, as near upon a par with the action as possible, by which means a kindly resolution, or suppuration, may take place, according as the parts in- flamed are capable of acting. Medicines, which have the power of producing sickness, lessen the action, and even the general powers of life, for a time, in consequence of every part of the body sympathi- zing with the stomach, and their effects are pretty quick. Sickness lowers the pulse; makes the smaller vessels con- tract, and rather disposes the skin for perspiration, but not of the active or warm kind; but I believe it should proceed no farther than sickness; for the act of vomiting is rather a counteraction to that effect, and produces its effects from another cause, and of course of another kind, which I believe rather rouse: it is probably an action ari- sing from the feel of weakness, and intended to relieve the person from that weakness. It is similar to the hot fit of The adhesive inflammation. 73 an ague; a counteraction to the cold one. There are few so weak, but they will bear vomiting, but cannot bear sick- ness long. If we had medicines, which, when given internally, could be taken into the constitution, and were endowed with a power of making the vessels contract, such I appre- hend, would be proper medicines. Bark has certainly this property, and is of singular service, I believe, in every in- flammation attended with weakness, and therefore, I con- ceive, should be oftener given than is commonly done; but it is supposed to give strength which would not accord with inflammations attended with too much strength and consi- derable irritation. Preparations of lead, given in very small doses, might be given with success, in cases attended with great strength. Applications to the body to cure or resolve inflammations are, with regard to their mode of application, of two kinds; one is applied to the part inflamed, the other to some distant part: the first may be called local or absolute, respecting the part itself; the second, relative; but even the first may be considered as having a relative effect in one of its modes of action, viz. that called repulsion, from which local applications have by some been objected to, and it is principally local applications that can repel, although not literally. The first, or absolute effects of medicine, may be divided into two kinds, viz. one, the simple cure of the part; the second, producing an irritation of another kind in the part; both, however, act locally, and their ultimate effect is lo- cal. Local applications to a part, where that application possesses really the powers of resolution, must be much more efficacious than any of the other modes of resolution; for instance, mercury has much greater powers when appli- ed immediately to the venereal complaint, than when applied to the nearest surface; where, however, we have not medi- cines that can resolve inflammation by application, then of course the other method is the most efficacious, but whe- ther we have external or local applications which have re- ally a tendency to lessen the inflammatory disposition, is not well ascertained. I doubt our being in possession of VOL. II. K 74 The adhesive inflammation. many that can remove the immediate cause. Such would of course remove the action, or if not wholly, would at least lessen it, and allow the inflammation to go off. But most of our powers in this way appear to be of the soothing kind, which, therefore, lessen the action, although the cause may still exist, and hence the effects are also les- sened. This either produces a termination of the inflam- mation, or it is protracted, the cause lessens, and the in- flammation wears itself out. As inflammation has too much action, which action gives the idea of strength, such applications as weaken have been recommended, and cold is one of them. Cold, according to its degrees, produces two very different effects, one is the exciting of action without lessening the powers, the other is absolutely debilitating, while at the same time it excites action, if carried too far; in the first, it becomes like suitable exercise to the vascular system, as bodily exer- cise is to the muscles, increasing strength; but when car- ried or continued beyond this point, it lessens the powers, and becomes a weakner, calling up the action of resist- ance after the powers are lessened; therefore cold should not be indiscriminately used, and should be well propor- tioned to the powers. Cold produces the action of contraction in the vessels, which is an action of weakness. A degree of cold sud- denly applied, which hardly produces more than the sense of cold, excites action after the immediate effect is over, which is the action of dilatation, and which is the effect of the cold-bath when it agrees; and as cold produces weakness in proportion to its degree, its application should not be carried too far, for then it produces a much worse disease, irritability; or over action to the strength of the parts, and then indolence too often commences. Cold might be supposed to act on an inflamed part, similar to its action on a frozen part, restraining action, keeping it within the strength of the part in the one case, so as not to allow death to take place from over action; and in the other, to keep it within bounds*. * As cold can be applied upon two very different principles, it is necessary to mention which is here meant. When cold is ap- plied either within the powers of resistance of the part, to ex- cite heat; or only for so short a time as to give the stimulus of The adhesive inflammation. 75 Lead is also supposed to have considerable effects in this way; but I believe much more is ascribed to it than it de- serves. The property of lead appears to be that of lessening the powers and not the action, therefore should never be used but when the powers are too strong, and acting with too much violence: however, lead certainly has the power of producing the contraction of the vessels, and therefore where there is great strength, lead is certainly a powerful applica- tion. Applications which can weaken should never be applied to an irritable inflammation, especially if the irritability arises from weakness; I am certain I have seen lead in- crease such inflammations, particularly in many inflamma- tions of the eyes and eyelids; and I believe it is a bad ap- plication in all scrofulous cases; in such cases the parts should be strengthened without producing action. Warmth, more especially when joined with moisture, called fomentation, is commonly had recourse to; but I am certain that warmth when as much as the sensative prin- ciple can bear, excites action; but whether it is the action of inflammation, or the action of the contraction of the vessels, I cannot determine; we see that in many cases they cannot bear it, and therefore might be supposed to increase the action of dilatation, and do hurt; but if that pain a- rises from the contraction of the inflamed vessels, then it is doing good, but this I doubt, because I rather conceive the action of contraction would give ease. Acids have certainly a sedative power, as also alcohel, and I believe many of the neutral salts. I believe it is not known that we have the power of add- ing strength to a part by local application; that, in gene- ral, I believe must arise from the constitution; for although cold, then a re-action takes place, and warmth is the conse- quence; but if cold is applied beyond the powers of resistance, then a contraction of the vessels takes place, and that contrac- tion is in some degree permanent; but this must be done with caution, for if continued too long, it will produce debility, and action will be excited which will be irritable. In the pre- sent, the application of cold should only be sufficient to excite the contraction of the vessels, and that not contained too long, for reasons above assigned. 76 The adhesive inflammation. we have the power of giving action, yet this does not im- ply strength. Many local applications are recommended to us, respect- ing many of which I have my doubts. The mode of cure by an irritation different from the dis- ease, appears to increase the disease, but by destroying the first mode of action it produces another disease, viz. one according to the mode of irritation of the application, and which more easily admits of a cure than the first. I be- lieve, however, that this takes place principally in specific diseases, and not so readily in common inflammation; for a common inflammation most probably would be increased by it. I have known specific inflammations much more easily cured by their specific medicine, than the common inflammation of the same constitution, viz. I have seen a gonorrhœa and a chancre cured much more easily in some constitutions, than an inflammation from an accident, and oftener than once or twice in the same person. However, this mode will not do in all specific diseases, for the scorfu- la will not change its nature by it, nor will the irritable, although specific. The venereal gonorrhœa (if parts are very irritable) is an instance of this, for irritating injections increase it; still we have many cutaneous inflammations cured in this way; for a pretty strong solution of corrosive sublimate will remove an inflammation of the skin. The unguentium citrinum mixed with any common ointment, cures many inflammations of the eyelids; yet I believe that artificial irritations are similar to one another; and I do not know if there be any difference between them, although I can conceive one may agree better with some constitutions than others. However, these local or immediate applica- tions can only be such as come in contact with the disease, which always must be some exposed surface, as when the skin of the eyelids, tonsils, etc. are inflamed; but even there some part must be affected by continued sympathy, if they produce a cure, as the inflammation generally goes beyond the surface of immediate contact. That inflammation which admits of repulsion, although by local means, might be considered here but from its ef- fects and connexion with the constitution, it comes in more properly with the several relations, under which I shall consider it. The adhesive inflammation. 77 XII. GENERAL OBSERVATIONS ON REPUL- SION, SYMPATHY, DERIVATION, REVUL- SION, AND TRANSLATION. THESE terms are meant to be expressive of a change in the situation of diseased actions in the body, and they are so named according to the immediate cause; for any one disease may admit of any of these modes equally; that is, a disease which admits of being repelled, may admit of being cured by sympathy, which probably includes derivation, re- pulsion, and translation. That such a principle or princi- ples exist, is, I think evident; but the precise mode of ac- tion is, I believe, not known; that is, it is not known what part of the body more readily accepts of the action of ano- ther; if there are such parts, they might be called corre- spondent parts, whether the action changes its place from repulsion, sympathy, derivation, or translation. In deriva- tion and repulsion, whether one mode of irritation is better than another, to invite or divert the action, and whether parts of a peculiar action do not require a peculiar irritation to divert them; to all this we are likewise totally strangers. It is not to my present purpose to go into the different ef- fects of this principle; although I must own it might be as useful a part of the healing art as any; and even more, for it is probably the least known, as being the lead intelligi- ble, and therefore the more use may be derived from its in- vestigation. The operations denominated by these terms, so far as they exist, appear all to belong to the same principle in the animal œconomy, for they all consist either in a change of the situation of a disease or its action; a change of the si- tuation, as in the gout, a change of the action, as a swelling of the testicles in the stopping of a gonorrhœa. This last is not properly a change of the situation of the disease, but only of the general inflammatory action without the specific action, these principles can only produce a change in the seat of action; not in any of the consequences of disease; they have in some instances a connexion with the natural operations of the body, as it were interfering with them; and when 78 The adhesive inflammation. that is the case, they in general must produce disease of some kind. Thus, the stopping of the menses, a local na- tural action, arising from the constitution, which may be effected by local applications, called repelling, by a de- rangement of the constitution, and by many consequences which depend on a deranged constitution simply, or it may be drawn off by a derangement of the constitution, which is a kind of derivation or revolution. We find that local ap- plications derange also other parts, which have no visible ef- fect upon the part of application as the above, nor any vi- sible connexion with the parts which assume the action. Thus cold, especially if wet be applied to the feet, will bring on complaints in the stomach and bowels, by sympa- thy; and the same mode of application of cold, if local, will produce a local complaint: as cold air blowing on a part will bring on rheumatism. These changes were all supposed formerly to be of more consequence than I apprehend they really are; for they are only the change of situation of disease. They were intro- duced into the œconomy of disease from the idea of humors. Repellants were such applications as drove the humours out of a part, which would fall on some other; sympathy con- sisted in another part taking them up; derivation was a drawing off, or inviting the humors; revulsion was the same, and translation was the moving of humors from one part to another. Thus we have those different terms applied to that connexion of parts, by which one part being affected, some other is affected or relieved; or, as in translation, some other part takes up the disease as it were voluntarily, as is often the case in the gout. All of these produce one of the symptoms of a disease, viz. sensation and inflamma- tion; but I believe seldom or ever real diseased structures. This agrees with what was formerly observed, that local inflammations, depending on the constitution, seldom or e- ver suppurate. I believe that these powers have greater effects in diseas- es, depending on, or producing action and sensation, which are called nervous, than on those producing an alteration in the structure of parts. Thus, we have the cramp in the leg cured by a gentle irritation round the lower part of the thigh, such as a gar- ter, which may be said to arise from derivation, or sympa- thy. The adhesive inflammation. 79 I have known in a nervous girl, a pain in one arm cured by rubbing the other. These cures by derivation, repulsion, translation, etc. do not deserve that name, although the patients are cured of the original disease, as in many cases there is as large a quan- tity somewhere else in the body uncured: for example, in those cases where the cure is from some local inflammation being produced, and perhaps more violent than the first; but in other cases where the cure arises only from an action in a part without a diseased alteration of structure, then the cure, in such cases, is performed without any other dis- ease having been produced; such as sickness or vomiting, curing a disease of the testicles. I have already observed that local applications were prin- cipally supposed to repel, by the first or second mode of ac- tion; yet internal medicines having a specific, or what might be called a local action, although given internally, may repel by stopping the diseased action in the part which it chiefly affects, such as mercury falling on the mouth, might repel a disease from the mouth. Hemlock might do the same, with regard to the head; or turpentine with re- gard to the urethra. In the last, we often find by taking balsams, that by stopping the discharge, a swelling of the testicles comes on, or an irritable bladder. As repulsion in this way is not so evident, it is less noticed. The uncer- tainty in the power of medicines, respecting repulsion, has- led surgeons into more errors than any other principle in the animal œconomy, with regard to diseases. It has pre- vented their acting in many cases, where they might have done it with safety and effect. A stronger instance can- not be given than in that species of the venereal disease, call- ed a gonorrhœa, which they did not venture to cure by lo- cal applications, for fear of driving it into the constitution, and producing a pox; but they did not consider that a gon- orrhæa did not arise from the constitution, but may be said to arise from accident, or at least is entirely local, and there- fore no repulsion could take place. The idea of repelling was first introduced when local diseases were supposed to arise from a deposit or derivation of humors to a part, and is still retained by those who cannot or will not allow them- selves to think better; yet still the term might be applied to diseased action, for the removal of many diseased actions 80 The adhesive inflammation. from a part which fall on some other part, is certainly the repelling of that diseased action; but since it is not subdu- ed, but only driven from the part, as is often the case with the gout, no cure is performed by this means. Both or either of the two local methods of removing dis- ease, just now mentioned, viz. whether by simply curing the disease, or by destroying the diseased action, in consequence of exciting an action of another kind, may produce the ef- fect called repulsion; but the former, I believe, can only take place in inflammations arising from the constitution, and which being prevented from settling in this part, re- turn upon the constitution again, and often fall upon some other part, viz. one next in order of susceptibility for such inflammation, as is often the case in the gout, and in ma- ny other diseases besides inflammation, as in many nervous complaints. St. Vitus' dance is a remarkable instance of it; but in this case it is not to be considered as a cure of the dis- ease, but only as a suspension of its action in this part. I could conceive it possible that the second mode of local cure, which is by producing an irritation of another kind, might not repel; although it cured the first or local complaint, because there is in such modes of cure still a larger quanti- ty of inflammation in the part than was produced by the disease (although of another kind); but as the idea of re- pelling is to have a disease somewhere, although not in the same place, keeping it in the present situation may be as pro- per, if not more so, than in any other it might go to. But if, on the other hand, the constitution requires to have a lo- cal complaint arising from itself, which, as it were, is drawing off, or relieving this constitutional disposition, then curing the one already formed, by producing another in the same part, can be of no service; for if the artificial dis- ease is not of the same nature with the constitutional one, (which it cannot be) if it destroys the other, then it cannot act as a substitute for the other. We may observe that by producing an irritation of another kind in the gout, we may destroy the gouty inflammation in the part, but cannot al- ways clear the constitution of it; there is, therefore, no be- nefit arising from such practice in these cases. The repelling powers which act from applications be- ing made, to the parts immediately affected, or by the change of one disease into another, become the most difficult of any to be ascertained; because it must be very difficult to The adhesive inflammation. 81 say, what will merely repel and what will completely cure, or perfectly change the disease. Repulsion is certainly to be considered as a cure of the part, whatever may be the consequence; and a change in the disease is certainly a cure of the first, although a disease may still exist in the part. That an artificial irritation made on one part does not (always at least) cure or remove a diseased irritation of a specific nature in another part, is, I think, evident in many cases, even although that specific should be an affection of the constitution. This, at least, was evident in a case of the gout, for when the gout was in some of the vital parts, and sinapisms were applied to the feet, they did not relieve those vital parts: although the inflammation in consequence of the sinapisms was considerable; but this inflammation brought on the gout on the feet; and as soon as this hap- pened, the vital parts were relieved; from which it would appear, that a specific irritation required a specific deriva- tor. It maybe supposed that the inflammation, in conse- quence of the sinapisms, brought on, or produced, such a derangement in the feet as made them more susceptible of the gout; or the inflammation became an immediate cause of the action of gout taking place there. It is plain too, that where there is a gouty disposition, or a gouty action, in the constitution, a derangement in a part may bring it on; for in the above person, who had still those internal spasms recurring upon the least exercise or anxiety of mind, but was in all other respects, and at all o- ther times well, by applying sinapisms a second time to his feet, till a considerable cutaneous inflammation came on, the gout attacked the ball of the great toe of the right foot, and the last joint of the great toe of the left, which lasted about two days. This attack of gout, however, did not re- lieve him of the remaining spasms, as the first did; and therefore was to be considered an additional gouty action. This could certainly not have taken place if the constitu- tion had not been gouty. In diseases where we have no specific application capa- ble of acting immediately, the advantages gained by deriva- tion, revulsion, or sympathy, are much greater in many ca- ses than by the effects of any local application at present VOL. II. L 82 The adhesive inflammation. known; and the medicines which are capable of produc- ing this effect are often such as would either have an ef- fect if applied to the diseased part, or would increase it. This arises from the dissimilar actions of the two parts; that is, the diseased actions of the one being similar to, or produc- ing the actions of recovery in the other; nor is it difficult to conceive why it should be so; for since the medicines are not specifics, but only invite or remove the disease by that connexion which the living powers of the one part have with those of another, it is reasonable to suppose that this principle of action between the parts must be much stronger than the effects of many medicines which have only a ten- dency to cure; or perhaps no tendency that way at all. Thus we find, that vomits will often cure inflammations of the testicles, when all soothing applications prove ineffec- tual, and when the same emetic could not have the least effect on the part itself, were it applied to it. Thus, we also find that a caustic behind the ear will re- lieve inflammations of the eyes or eyelids, when every appli- cation to the parts affected has proved ineffectual, and when this caustic, if applied to the parts themselves only as a sti- mulant, would increase the disease. Sympathy, perhaps, (except the continued) includes the mode of action in all of those which I have called relative, viz. repulsion, derivation, revulsion, and translation; at least it is probably the same principle in the whole. What I would call a cure by sympathy, is producing a curative action in a sound part, that the diseased may take on the same mode of action from sympathy, that it would take on, if the cu- rative was applied to it; so that sympathy might even be supposed to repel in cases which would admit of repelling, and fall on some other part, although not the part necessa- rily where the application was made. The difference be- tween derivation, or repulsion, and sympathy, consists in derivation producing a disease in a sound part to cure a di- sease in another part, as was observed; while sympathy is applying the cure to a sound part to cure the diseased; but in many cases it will be very difficult to distinguish the one from the other. Sympathy is very universal, or more general than any others; for there are few local diseases that do not extend beyond the surface of contact, which produces continued The adhesive inflammation. 83 sympathy; and also, there are few parts that have not some connexion with some other part, which gives us remote sympathy. It may be recollected, that when sympathy was treated of, it was divided into continued, contiguous, remote, simi- lar, and dissimilar. The cure by continued sympathy is that application which we have reason to suppose would cure if applied to the part itself; such as applying mercury to the skin over a venereal node. The node is cured by its sympathizing with the mercurial irritation of the skin; and the action of the sym- pathizer here is similar to the action of the part of applica- tion. Remote sympathy is seldom or ever produced by a similarity of action in similar parts; but most probably cures by dissimilar modes of action in the two parts, and therefore might be called dissimilar sympathy, viz. by sti- mulating the part of application in such a way that the sympathizer shall act in the same way as if the real appli- cation of cure was made to it, and yet the mode of action of the part of application shall not be at all similar to the sympathizer. I can even suppose a local disease cured by sympathy and by that medicine which would increase it, if applied immediatly to it. Let us suppose, for exam- ple, any diseased mode of action, and that this mode could be increased by some irritating medicine, if applied to it; but apply this irritator to some other part which this disea- sed part sympathizes with, and that the sympathetic act in the diseased part shall be the same as if its curative medi- cine was applied to it, similar to what would have taken place, if its specific irritator was applied; then, in such a case the medicine would cure by sympathy, although it would increase the disease if applied locally, or have no effect at all. The contiguous sympathy is where it would appear to act from the approximation of dissimilar parts, and there- fore is not continued sympathy; neither can it be called re- mote sympathy, as there appears to be no specific connex- ion, but to arise entirely from contiguity or approximation of parts. Of this kind are blisters on the head, curing head- ach; on the chest, curing pains in the chest; to the pit of the stomach, to cure irritations there; to the belly, to cure complaints of the bowels. 84 The adhesive inflammation. The applications which act by contiguous sympathy are only those which can be applied to the nearest surface to that which is inflamed, and the inflamed part beyond this sur- face becomes affected in some degree, similar to the part of application, such as the applications to the eyelids, when it is in the eye; to the scrotum, when in the testicle; to the abdomen, when some of the bowels are inflamed; to the thorax, in inflammations of the lungs etc. These may be either of the specific, stimulating, or sooth- ing kinds, something which affects the parts in such a manner as that a remote diseased action ceases. It may be specific, as opium applied to the pit of the stomach cur- ing an irritation of that viscus; stimulating, as blisters to cure inflammation in the subjacent viscera, as has been mentioned; soothing, as fomentations to the abdomen to relieve complaints in the bowels. Derivation means a cessation of action in one part, in consequence of an action having taken place in another; and when this is a cessation of a diseased action, then a cure of that action in the original part may be said to be per- formed; this cure was brought into use from the idea of humors; that is, the drawing off of the humors from the seat where they had taken possession; but I believe much more has been ascribed to it than it deserves. How far it really takes place, I have not been able fully to ascertain in all its parts; that is, how far the real disease is invited, and accepts of the invitation; but I have alrea- dy observed, that there is such a principle of disease in the animal œconomy, although we must see from derivation, that the same quantity, or perhaps more irritation is retain- ed in the constitution; yet the artificial irritation produced being either such as more readily admits of a cure than the diseased part, or being in parts which are not so essential to life, an advantage by this means is gained; thus burn- ing the ear is practised as a cure for the tooth-ach, and the part which is burnt more readily admits of a cure, than the tooth. We also find that blisters often cure or remove deep seated pains, such as head-ach, and relieve the blad- der when applied to the perineum. Blisters and caustics behind the ear, cure also inflammations of the eye. The adhesive inflammation. 85 Less may be said on revulsion, since we have explained derivation. To draw off a disease always implies safe ground, and can be applied with safety in any disease: revulsion can best be applied, when the disease attacks essential parts where the application cannot be so near as to imply deriva- tion. Thus we find that vomits will cure an inflammation of the testicles, white swellings, and even venereal buboes; and sinapisms applied to the feet relieve the head. Translation differs from derivation, revulsion, and repul- sion, only as it proceeds from a natural or spontaneous cause, whereas these proceed from an artificial, accidental, or external cause, and the common principle of them all seems to be sympathy; for if not an act of its own, then it must be either repelled, derived, or from sympathy. Very strange instances of translation are given us; it has been supposed, that pus already formed has been translated to another part of the body deposited there in form of an abscess, and then discharged; this is an operation absolute- ly impossible; matter absorbed may be carried off by some of the secretions, such as by the kidneys, which have a pow- er of removing more than they secrete; but the deposition of pus is the same with its formation. Both revulsion and repulsion may be reckoned a species of translation. The gout moving of its own accord from the stomach to the foot, or from one foot to the other, may be reckoned a translation of the gout. XIII. OF THE DIFFERENT FORMS IN WHICH MEDICINES ARE APPLIED, AND THE SUB- SIDING OF INFLAMMATION. FORMENTATIONS, or steams, washes, and poultices, are the common applications to a part in the state of inflamma- tion. The first, and last, are commonly applied to inflam- 86 The adhesive inflammation. mation arising from external violence, and proceeding to suppuration; the second, commonly to internal surfaces, as the mouth, nose, urethra, vagina, rectum, etc. The action of the two first is but of very short duration. Fomentations and steams, are fluid bodies raised into va- por: they may be either simple, or compound; simple, as steam, or vapor of water; compound, as steam of wa- ter impregnated with medicines. This mode of applying heat, and moisture, appears from experience to be more efficacious than when these are ap- plied in the form of a fluid; it often gives ease at the time of the application, while at other times it gives great pain; but if it does give ease, the symptoms generally return between the times of applying it, and with nearly the same violence. How far the application of a medicine for fifteen minutes out of twenty-four hours can do good, I am not certain: we find, however, that the application of a vapor of a specific medicine, though but for a few minutes in the day, will have very considerable effects: fumigations with cin- nabar, may serve as an instance. The fomentations are commonly composed of the decoction of herbs; sometimes the marsh mallows, etc. but oftener of the decoction of herbs possessing essential oil, which I believe are the best, because I suppose that whatever will excite contraction of the vessels, will in some degree counteract the dilating principle: vinegar, as well as spirits, are put into it; how far they stimulate to contraction, I do not know, but ra- ther believe they remove irritation, which must lessen the inflammatory action. Washes are in general fluid applications, and are more commonly applied to inflammations of internal surfaces, than of the common integuments: there are washes to the eye, called collyria; washes to the mouth and throat, call- ed gargles; washes to the urethra, called injections; and to the rectum, called clysters; but I am fearful that we are not yet acquainted with the true specific virtues of these washes, at least there is something very vague in their application. There are, for instance, astringent washes for the inflammation of the eye, such as white and blue vitriol, alum, etc. stimulating warm gargles for inflamma- tions of the throat, such as mustard, red port, claret with vinegar and honey; but to moderate or resolve external inflammations, they do not apply substances with any such The adhesive inflammation 87 properties. How absurd would it appear to surgeons in general, if any one made use of the same application to an inflammation in any other part; yet I do not know if there is any difference between an inflammation of the eye or throat, and one in any other part, if the inflammations are of the same kind: mercury cures a venereal inflammation either of the eye or throat, as easily as a venereal inflamma- tion any where else, because it is an inflammation of the same kind. These applications, like fomentations, are of short du- ration, for there is no possibility of applying these powers constantly, except in the form of a poultice, whose opera- tion is somewhat similar; and, indeed, they are only sub- stitutes for a poultice, where that mode of application can- not be made use of, as I observed with respect to internal surfaces. Poultices are constant applications, and like fomentations may be two kinds, either simply warm and wet, or medi- cated. The greatest effect that a poultice can produce must be immediate, but its power will extend beyond the surface of contact, although only in a secondary degree. To the common inflammation, the simplest poultice is supposed to be the best, and that effect I believe is only by keeping the parts easier under the complaint; but I am of opinion, that such do not affect the inflammation any other way. A common poultice is, perhaps, one of the best ap- plications when we mean to do nothing but to allow nature to perform the cure with as much ease to herself as possi- ble. Poultices may be medicated, so as to be adapted to the kind of inflammation; such as the solution of lead, opi- um, mercury, etc. in short, they may be compounded with any kind of medicine. Whatever the disposition is, which produces inflamma- tion, and whatever the actions are which produce the ef- fects, that disposition under certain circumstances, viz. when it arises either from the constitution or the parts, can be removed, and of course the actions excited by it. The disposition for inflammation shall have taken place, and the vessels which are the active parts, shall have dilated, and al- lowed more blood to enter them, so that the part shall look red, but no hardness or fullness shall be observed, and the 88 The adhesive inflammation. whole shall subside before adhesions have been formed; or if inflammation has gone so far as to produce swelling, which is the adhesive stage of the disease, it by certain me- thods can be frequently so assuaged as to prevent suppura- tion taking place, and then the parts will fall back into their natural state, which is called resolution; some adhe- sions being perhaps the only remaining consequences of the inflammation. The same methods are likewise often used with consider- able success in lessening inflammation arising from violence, so as to prevent suppuration entirely; but in many of these cases they are not sufficient, and in those where it cannot be prevented, yet it may be lessened by the same means. As the first symptom of inflammation is commonly pain, so is the first symptom of resolution a cessation of that pain, as well as one of the symptoms of suppuration, which is a species of resolution. I have known the cessation of pain so quick, as to appear like a charm, although no other visi- ble alteration had taken place, the swelling and colour be- ing the same. Why inflammation of any kind should cease after it has once begun, is very difficult to explain, or even to form an idea of, since yet we have no mode of counteracting the first cause or irritation; it may be supposed to arise from the principle of parts adapting themselves in time to their present situation, which I call custom, and that therefore in order to keep up the inflammation, it would be necessary for the cause to increase, in proportion as the parts get re- conciled to their present circumstances; but allowing this to be the cause, it will not account for their returning back to their natural or original state, when this increase of irri- tation ceases, and only the last or original irritation remains; for upon this principle, they only grow more easy under their present state; or perhaps, which is worse, acquire a habit of it, which may be the cause of many indolent spe- cific diseases. If we suppose the removal of the original cause to be sufficient to stop the progress of inflammation, and when this is stopped, that the parts cannot easily remain in the same inflamed state, but by their own efforts begin to re- store themselves to health; which we can easily conceive to be the case in the specific diseases, especially those arising The adhesive inflammation. 89 from poisons of such kinds as to be capable of a termination as the small pox; or where a cure can be administered for the effects of the poison, as in the lues venera; then we must conclude that the inflamed state is an uneasy state, a force upon the organs which suffer it; like the bending of a spring, which is always endeavouring to restore itself, and the moment that the power is removed, returns back to its natural state again; or it may be like the mind, forgetful of injuries. XIV. OF THE USE OF THE ADHESIVE IN- FLAMMATION. THIS inflammation may be said in all cases to arise from a state of parts in which they cannot remain, and therefore an irritation of imperfection takes place. It may be look- ed upon as the effects of wise counsels, the constitution be- ing so formed as to take spontaneously all the precautions necessary for its defence; for in most cases we shall evident- ly see that it answers wise purposes. Its utility may be said to be both local and constitutional, but certainly most so with regard to the first. Its utility is most evident when it arises from a disease in a part, whe- ther this proceeds from the constitution or otherwise, and when it does, it must be considered as arising from a state in which that part cannot exist, as in exposure, and therefore is the first step towards a cure. It is often of service in those ca- ses which arise from violence, although not so necessarily so, the injured parts not being always under the necessity of having recourse to it, as was shewn in treating of union by the first intention. When the adhesive inflammation arises from the con- stitution, it may depend on some disease of that constitu- tion; and if so, it may be conceived to be of use to it, VOL. II. M 90 The adhesive inflammation. especially if it should be supposed to be the termination of an universal irritation in a local one, by that means reliev- ing the constitution of the former, as in the gout; but when it is only the simple adhesive inflammation that takes place, I am rather apt to think that it is more a part of the disease, than a termination of it, or an act of the con- stitution. The adhesive inflammation serves as a check to the sup- purative, by making parts, which otherwise must infallibly fall into that state, previously unite, in order to prevent its access, as was described in the adhesive inflammation be- ing limited; and where it cannot produce this effect, so as altogether to hinder the suppurative inflammation itself from taking place, it becomes in most cases a check upon the extent of it. This we see evidently to be the case in large cavities, as in the tunica vaginalis after the operation of the hydrocle; for after the water has made its escape, parts of the collapsed sack frequently unite to other parts of the same sack by this inflammation, and thereby preclude the suppurative from extending beyond these adhesions, which so far prevents the intention of the surgeon from having its full effect: and often on the other hand, the adhesive state of the inflammation takes place universally in this bag, in consequence of the palliative cure, which pro- duces the radical, and thereby prevents a relapse. In the hernea it performs a cure by uniting the two sides of the sack together, by means of slight pressure, so that we should understand perfectly its mode of action, where it can prevent a cure, and where it can perform one. In still larger cavities, such as the abdomen, where often only a partial inflammation takes place, as is frequently the case after child-bearing, and in wounds of this cavity, we find this inflammation produced, which either prevents the sup- purative altogether, or if it does not, it unites the parts sur- rounding the suppurative center, and confines the suppura- tion to that point; and as the abscess increases in size, the adhesive inflammation spreads uniting the parts as it spreads, so that the general cavity is excluded. Thus the suppura- tion is confined to the first point, and forms there a kind of circumscribed abscess, as will be more fully explained hereafter. In inflammations of the pleura or surface of the lungs, the same thing happens, for the adhesive inflammation The adhesive inflammation. 91 takes place, and the surfaces are united, which union going before the suppurative confines it to certain limits, so that distinct abscesses are formed in this union of the parts; and the whole cavity of the thorax is not involved in a general suppuration; such cases are called the spurious empyema. The cellular membrane, every where in the body is unit- ed exactly in the same manner, the sides of the cells throw out, or as it were, sweat out the uniting matter, which fills the cavities and unites the whole into one mass. The adhesive inflammation often disposes the parts to form a cyst, or bag; this is generally to cover some extra- neous body that does not irritate so much as to produce suppuration; such as a sack formed to inclose a bullet, pieces of glass, etc. With the same wise views it unites the parts or cellular membrane which lies between an abscess, and the spot where that abscess has a tendency to open, as will be more fully explained hereafter, when I come to treat of ulcera- tion. The lungs are so circumstanced as to partake of the ef- fects of two principles, the one as an internal uniting sur- face, the other as a secreting surface; the last of which constitutes the peculiar structure and use of this viscus; and the first is no more than the reticular or uniting sub- stance of those cells. The internal or the uniting mem- brane of the lungs unites readily by the adhesive inflamma- tion, as in cellular membrane through the body generally; but the air-cells, like the inner surface of the urethra, nose, intestines, etc. pass directly into the suppurative inflamma- tion, and therefore do not admit of the adhesive, by which means the matter formed is obliged to be coughed up, which produces symptoms peculiar to the parts affected; and it is perhaps almost impossible to produce an inflam- mation on either of those two surfaces without affecting the other; which, probably is one reason why the treatment of inflammation in those parts is attended with such bad suc- cess. We cannot give a better illustration of the use of the ad- hesions produced in consequence of this inflammation, than to contrast it with the erysipelatous, of which I have alrea- dy given an account. 92 The adhesive inflammation. When the erysipelatous inflammation takes place, the matter gets very freely into the surrounding and sound cellular membrane, and then diffuses itself almost over the whole body; while, in another kind of constitution, the ad- hesive inflammation would have been produced, to have pre- vented its progress. A man was attacked with a violent inflammation on each side of the anus, which I did not see till some days after it began. It had the appearance of the suppurative inflam- mation joined with the erysipelatous; for it was not so cir- cumscribed as the suppurative, nor did it spread upon the skin like the true erysipelatous, and the skin had a shining œdematous appearance. The inflammation went deeper into the cellular membrane than the true erysipelatous. He was bled. The blood was extremely sizy. He took a purge, and was fomented. He had a difficulty in mak- ing water, most probably from the pressure of the swelling upon the urethra. The day following I observed that the scrotum of that side was very much swelled, which had extended up the right spermatick chord; on examining this swelling, I plainly felt a fluid in it, with air, which sound- ed on being shaken. The case now plainly discovered it- self. I immediately opened the suppuration on each side of the anus, which discharged a dusky coloured pus, very fœtid, with a good deal of air. Upon squeezing the swell- ing in the scrotum, etc. I could easily discharge the matter and air by these openings, therefore made him lie princi- pally upon his back, and squeeze these swellings often, with a view to discharge this matter by the openings; the matter at the part where it was formed, was not contained in a bag or abscess, but formed in the cellular membrane, without previous adhesion. The scrotum now inflamed, and seemed to have a tendency to open; at least it looked livid and spotted. I opened it at this part, and it discharged a good deal of matter and air. A general suppuration came upon the whole cellular mem- brane of those parts, and the matter passed up through the cellular membrane of the belly; and the cellular membrane of the loins was loaded with matter, from its sinking down from the cells of the abdomen. I made openings there, and could squeeze out a great deal of matter and air. A mortification came on just above the right groin, and when The adhesive inflammation. 93 I removed the slough, matter was discharged. I also made openings on the loins, on the side of the abdomen, etc. He lived but a few days in this way, in which time the cellular membrane was hanging out of the wounds like wet dirty tow. The adhesive inflammation takes place in consequence of accidents, when it is impossible it should ever produce the same good effects, such as in wounds which are not al- lowed or cannot heal by the first intention; for instance, a stump after amputation, and many other wounds; but it is one of those fixed, and invariable principles of the animal machine which upon all such irritations, uniformly produces the u- niting process, though like many other principles in the same machine, these effects, are perhaps not so much required, so that although a wound is not allowed to heal, or cannot heal by means of the adhesive inflammation, yet the sur- rounding parts go through the common consequences of being wounded, and the surrounding cells are united, as was described when I treated of union by the first intention. It first throws out the blood, as if the intention was to u- nite the parts again; the newly cut or torn ends of the vessels, however, soon contract and close up, and then the discharge is not blood, but a serum with the coagulating part of the blood, similar to that which is produced by the adhesive state of inflammation, so that they go through the two first processes of union; therefore the use of the adhe- sive inflammation does not appear so evidently in these ca- ses, as in spontaneous inflammation; however, in case of wounds, which are allowed to suppurate, it answers the great purpose of uniting the cells at the cut surface from their being simply in contact with each other, as has been described, which confines the inflammation to that part, without which the irritation arising from this state of im- perfection might have been communicated from cell to cell, and proceed farther than it commonly does. The cut ves- sels, by this means, are also united, which hinders the pro- gress of inflammation from running along their cavities, as we find sometimes to be the case in the veins of a wounded surface, where this inflammation has not taken place. From every thing which has been said, it must appear, that all sur- faces which are suppurating in consequence of this inflamma- tion, have their basis in that state of the adhesive inflammation, which very nearly approaches to suppuration; and this in- flammation is less and less, as it recedes further from the suppurating centre.  [95] CHAPTER IV. OF THE SUPPURATIVE INFLAMMATION. WHEN the adhesive inflammation is not capable of resolution, and has gone as far as possible to prevent the necessity of suppuration, especially in those cases that might have admitted of a resolution, as in spontaneous* inflam- mations in general, where there has neither been an expo- sed laceration of the solids, nor, as beforementioned, loss of substance, but where the natural functions of the part have only been so deranged that it was unable to fall back into a natural and sound state again; or secondly, where it was a consequence of such accidents, as the effects of the adhesive could not in the least prevent, (as in wounds that were prevented from healing by the first or second inten- tion) then under either of these two circumstances suppur- ation takes place. The immediate effect of suppuration, is the produce of the pus, from the inflamed surface, which appears in such cases or under such circumstances to be a leading step to the for- mation of a new substance, called granulations, which gran- ulations are the third method in the first order of parts, of restoring those parts to health; but upon all internal canals, suppuration is certainly not a leading step to granulations, which will be explained hereafter. The same theory of the adhesive inflammation respecting the vessels is, I believe, applicable to the suppurative; for when suppuration is the first, we have the vessels in the same state as in the adhesive when it happens, but their dis- positions and actions must have altered, there being a great difference in their effects. * I have used this word to denote a case where no visible cause of inflammation existed; for strictly there can be no such thing in nature as spontaneous. 96 Of the suppurative inflammation. This is so much the case, that the true inflammatory dis- position and action almost immediately ceases upon the commencement of suppuration; and although the vessels may be nearly in the same state, yet they are in a much more quiescent state than before, and have acquired a new mode of action. I shall endeavour to establish, as an invariable fact, that no suppuration takes place which is not preceded by in- flammation; that is, no pus is formed but in consequence of it; that it is an effect of inflammation only, is proved in abscesses, from a breach in the solids attended with expo- sure, and from extraneous matter of all kinds, whether in- troduced or formed there. In abscess, suppuration is an immediate consequence of inflammation; from the expo- sure of internal cavities no suppuration comes on till in- flammation has formed the disposition and action; and al- though we find collections of extraneous matter, something like pus, in different parts of the body, yet such extraneous matter is not pus: however, towards the last, in such collections, pus is often formed, but then this is in consequence of inflammation having taken place towards the surface, and when such collections are opened they immediately inflame, universally similar to every branch of the solids, and then the suture discharge is pus, all of which I shall now treat. The irritation, which is immediately the cause of suppu- ration, is the same, from whatever cause it may proceed, si- milar to that which produces the adhesive stage; it is a simi- lar process going through the same stages, and is attended with nearly the same circumstances, whether it takes it rise from external violence, the constitution, or a disposition in the part if all other circumstances are equal; however, it is not so general in its causes as the adhesive, for the thick- ening process will take place in many diseases, where true suppuration is not admitted; as in some scrofulous cases, some venereal, and also cancers; suppuration, therefore, depends more on the soundness of parts than the adhesive, and this is so much the case, that we can, in some degree, judge of a sore simply by its discharge. It appears very difficult to give a true and clear idea of the whole chain of causes leading to suppuration. The im- mediate state of parts, which may be called the immediate cause, I conceive to be such as cannot carry on its usual Of the suppurative inflammation. 97 functions of life, and which state of parts I have called the state of imperfection, let the cause of that state be what it will; we have shown that irritation simply is not always sufficient, it often only brings on the adhesive stage, which is in most cases intended to prevent the suppurative, as has been observed. It is a curious fact, to see the same mode of action pro- ducing two such contrary effects, and each tending to a cure; the first producing from necessity the second, and being al- so subservient to it. Violence done to parts is one of the great causes of suppuration; but we have already remarked that violence simply does not always produce this inflam- mation: that it must be a violence followed by a prevention of the parts performing their cure in a more simple way, viz. a restoration of the structure, so as to carry on the an- imal functions of the part, or in other words, a prevention of union by the first or second intention, or attended with this circumstance of the parts being kept a sufficient time in that state into which they were put by the violence; or what is something similar to this, violence attended with death in a part, such as in many bruises, mortifications, sloughs in consequence of caustics, etc. which, when sepa- rated, have exposed internal surfaces.* Various have been the opinions on this subject; and as every violence committed from without, under the circum- stances before mentioned, is exposed more or less to the surrounding air, the applications of this matter to internal surfaces has generally been assigned as a cause of this inflam- mation; but air certainly has not the least effect upon those parts; for a stimulus would arise from a wound were it e- * But here we may just remark, that the first processes towards suppuration in cases of mortification, where a se- paration must take place prior to suppuration, are different from the foregoing; because, the living surface is to separate from it the dead parts, and therefore another action of the liv- ing powers is required, which is what I call ulceration; and by the phænomena on this occasion, it would appear that nature can carry on two processes at one and the same time; for while the separation is carried on by the absorbents, the arteries are form- ing themselves for suppuration; so that at the same time the part is going through these two very different species of inflam- mation. VOL. II. N 98 Of the suppurative inflammation. ven contained in a vacuum. Nor does the air get to the parts that form circumscribed abscesses so as to be a cause of their formation, and yet they as readily suppurate in con- sequence of inflammation as exposed surfaces. Further, in many cases of the emphysema, where the air is diffused over the whole body, we have no such effect, and this air not the purest, excepting there is produced an exposure or imperfection of some internal surface for this air to make its escape by, and then this part in flames. Nay, as a stronger proof, and of the same kind with the former, that it is not the admission of air which makes parts fall in- to inflammation, we find that the cells in the soft parts of birds, and many of the cells and canals of the bones of the same tribe of animals, which communicate with the lungs*, and at all times have more or less air in them, never in- flame; but if these cells are exposed in an unnatural way, by being wounded, etc. then the stimulus of imperfec- tion is given, and the cells inflame, and unite if allowed; but if prevented, they then suppurate, granulate, etc. The same observation is applicable to a wound made in- to the cavity of the abdomen of a fowl; for there the wound inflames and unites to the intestines to make it a perfect cavity again; but if this union is not allowed to take place, then more or less of the abdomen will inflame and suppu- rate. If it was necessary that air should be admitted in order for suppuration to take place, we should not very readily account for suppuration taking place in the nose from a cold, as this part is not more under the influence of air at one time than at another; nor is the urethra in a gonor- hœa affected by the air more at that time than at any other; these parts being at all times under the same circumstances with respect to air, therefore there must be another cause. The sympathetic fever has been supposed a cause, which will be considered when I treat of the formation of pus. In cases of violence I have endeavoured to give a tole- rably distinct idea of the steps leading to suppuration; but we are still at a loss with respect to the immedi- ate cause of those suppurations which appear to arise spontaneously; for in these it is almost impossible to deter- * Vide Observations on certain Parts of the Animal Econo- my, page 89. Of the suppurative inflammation. 99 mine whether the inflammation itself be a real disease, viz, an original morbid affection, or whether it may not be (as is evidently the case from external violence) a salutary pro- cess of nature to restore parts whose functions, and per- haps texture, has been destroyed by some previous, and al- most imperceptible disease or cause. Suppuration being, in cases of violence, a means of restoration, affords a presum- ption that it is a like instrument of nature in spontaneous cases. If it is the first, viz. a real disease, then two causes that are different in themselves can produce one effect, or one mode of action, for the result of both is the same; but if it is the last, then suppuration must be considered as de- pending on exactly the same stimulus being given, as in the abovementioned instance of violence. Suppuration does not arise from the violence of the ac- tion of the parts inflamed, for that circumstance simply ra- ther tends to produce mortification; and we see that in the gout which does not suppurate, there is often more violent inflammation than in many others that do; all internal ca- nals likewise suppurate with very slight inflammation, when not in an irritable habit; but if of a very irritable disposi- tion, the action will almost exceed suppuration, and by its becoming milder, suppuration will come on. But if we suppose the cause of inflammation to be a dis- position in the parts for such actions, without the parts themselves being either diseased, or in such state to be simi- lar to the destruction or alteration of their texture, this in- flammation then may prise from a vast variety of causes, with which we are at present totally unacquainted; nay, which we do not perhaps even suspect; and this last opini- on, upon a slight view, would seem to be the most proba- ble, because we can frequently put back these spontaneous inflammations, which would not be the case if they came on from the destruction of a part, or any thing else, whose stimulus was similar to it; for no such thing can be done with wounds, if they are not soon united by the first inten- tion, they must suppurate; however, this argument is not conclusive, for we can prevent suppuration in those arising from accident, by uniting them by the second intention, which is preventing suppuration, by acting as a kind of re- solution. Although suppuration is often produced without much visible violence of action in the part, yet when it is a con- 100 Of the suppurative inflammation. sequence of a healthy inflammation, we find in general that the inflammation has been violent. It is always more violent than in its preceding inflamma- tion; and in such cases it would appear to be little more than an increased action, out of which is produced an entire new mode of action, and which of course destroys the first. It is from this violence that it produces its effects so quickly; for the inflammation which is capable of produ- cing quickly so great a change in the operations of the parts, as suppuration, must be violent; because it is a violence committed upon the natural actions and structure of the parts. This inflammation will also be more or less, according to the violence of the cause producing it, compared with the state of the constitution and parts affected. The inflammation which precedes suppuration is much more violent in those cases where it appears to arise spon- taneously, than when it arises from any injury done by vio- lence. A suppuration equal in quantity to that from an amputation of the thigh, shall have been preceded by a much greater inflammation than that which is a consequence of the amputation. This inflammation would seem to vary somewhat in its effects according to the exertion of that power during its progress; for in proportion to its rapidity the cause is cer- tainly more simple, and its termination and effects more speedy and salutary; and this idea agrees perfectly with in- flammation in consequence of accidents, for there it runs through its stages more rapidly, and with less inflamma- tion; necessity appears to be the leading cause here. This seems to be the case even in those parts which have a tendency to slow and specific diseases; as for example, in the breasts of women, or the testicles in men. For if these parts inflame quickly, the effects will be more salutary than if they inflamed slowly. In other words, those parts are capable of being affected by the common suppurative inflammation, which in most cases terminates well; per- haps the specific inflammation is slow in its progress and operation, and such slowness marks it to be an inflamma- tion of some specific kind. In whatever light we view this fact, it at least leads us with more certainty to what the effects of an inflammation will be, and thus often to form a just prognostic. Of the suppurative inflammation. 101 Suppuration takes place much more readily in internal canals, than internal cavities. Suppuration takes place more readily upon the surface of canals than in either the cellular or investing membrane. The same cause which would produce a suppuration in the first parts, would only produce the adhesive in the other; for instance, if a bougie is introduced into the urethra, for a few hours, it will produce suppuration; while, if a bou- gie was introduced into either the tunica vaginalis testis, or the abdomen, but for a few hours, it would only give the disposition for adhesions, and even might not go the length of this stage of inflammation in so short a time; but such surfaces often produce a greater variety of matter than a sore, it is not always pus; and this, probably, arises from the cause not being so easily got rid of. An irritation in the bladder from stone, stricture in the urethra, or disease of the bladder itself, gives us a great variety of matter; pus, mucus, slime, are often all found; sometimes only one or two of them. I have some idea that the mucus is easiest of production; but I am certain, that for the formation of slime, the greatest irritation is required. I. THE SYMPTOMS OF THE SUPPURATIVE INFLAMMATION. THIS inflammation has symptoms common to inflamma- tion in general; but it has these in a greater degree than the inflammation leading to it, and has also some symp- toms peculiar to itself; it therefore becomes necessary to be particular in our description of these peculiarities. The sensations arising from a disease generally convey some idea of its nature; the suppurative inflammation gives us as much as possible the idea of simple pain, without hav- ing a relation to any other mode of sensation: we cannot annex an epithet to it, but it will vary in some degree, ac- cording to the nature of the parts going into Suppuration, and what was remarked, when treating of the adhesive state, is in some degree applicable here. 102 Of the suppurative inflammation. This pain is increased at the time of the dilating of the arteries, which gives the sensation called throbbing, in which every one can count his own pulse from paying at- tention merely to the inflamed part; and perhaps this last symptom is one of the best characteristics of this species of inflammation. When the inflammation is moving from the adhesive state to the suppurative, the pain is considera- bly increased, (and which would seem to be the extent of this operation in the part); but when suppuration has ta- ken place, the pain in some degree subsides; however, as ulceration begins, it in some degree keeps up the pain, and this is more or less; according to the quickness of ulcera- tion, but the sensation attending ulceration gives more the idea of soreness. The redness that took place in the adhesive stage is now increased, and is of a pale scarlet. This is the true arteri- al colour, and is to be accounted a constant symptom, as we find it in all internal inflammations, when at any time exposed, as well as in those that are external. Besides, I observed in the introduction to inflammation, and when treating of the adhesive state, that the old vessels were dilated, and new ones were formed; these effects, therefore, are here carried still farther in the surrounding parts, which do not suppurate, and constitute two other causes of this redness being increased, by the vessels becom- ing still more numerous, and the red part of the blood be- ing pushed more forward into many vessels, where only the serum and coagulating lymph went before. The part which was firm, hard, and swelled, while in the first stages, or the adhesive state, now becomes still more swelled by the greater dilatation of the vessels, and greater quantity of the extravasated coagulating lymph thrown out, in order to secure the adhesions. The œdematous swelling surrounding the adhesive gra- dually spreads into the neighbouring parts. In spontaneous suppurations one, two, three, or more parts of the inflammation lose the power of resolution, and assume exactly the same disposition with those of an exposed surface, or a surface in contact with an extraneous body. If it is in the cellular membrane that this disposition takes place, or in the investing membranes of circumscribed ca- vities, their vessels now begin to alter their disposition and mode of action, and continue changing till they gradually Of the suppurative inflammation. 103 form themselves to that state which fits them to form pus; so that the effect or discharge is gradually changing from coagulating lymph to pus; hence we commonly find in ab- scesses, both coagulating lymph and pus, and the earlier they are opened the greater is the proportion of the for- mer. This gave rise to the common idea and expression, "That the matter is not connected;" or, "The abscess is not yet ripe." The real meaning of which is, the ab- scess is not yet arrived at the true suppurative state. From hence it must appear that suppuration takes place upon those surfaces without a breach of solids or dissolution of parts, a circumstance not commonly allowed *; and when got beyond the adhesive state they become similar in their suppuration to the inner surfaces of internal canals. There is a certain period in the inflammation, when the suppurative disposition takes place, which is discovered by new symptoms taking place in the constitution, viz. the shi- vering. Although the sudden effects produced in the constitu- tion would shew that this change of disposition is pretty quick, yet its effects in the parts must be far from immedi- ate, for some time is required for the vessels to be formed by it, so as to produce all the consequences intended by na- ture; and, indeed, we find it is some time before suppu- ration completely takes place; and that it is sooner or la- ter according as the inflamed state is backward in going off; for while the inflammation lasts the part, as it were, hangs between inflammation and suppuration. The effect of inflammation appears to be the producing of the suppurative disposition, or that state of a part which disposes it to form pus; in doing this the inflammation * The knowledge of this fact in some of the larger cavities is not quite new; for I remember, about the year 1749 or 1750, that a young subject came under our inspection, and on opening the thorax it was found on the left side to contain a considerable quantity of pus. Upon examining the pleura and surface of the lungs, they were found to be perfectly entire. This was taken notice of by Dr. Hunter as a new fact, that suppuration could take place without a breach of surface; and he sent to Mr. Samuel Sharp to see it. It was also new to him, and he published it in his Critical Inquiry. Since that pe- riod it has been often observed in the peritoneal inflammation, 104 Of the suppurative inflammation. seems first to be carried to such a height as to destroy that state of the parts on which itself depends, the consequence of which is, that they lose the inflammatory disposition, and come into that which fits them for forming pus. It seems to be a fixed and most useful law in the animal œconomy, that in spontaneous inflammation, when it has either destroyed the natural functions of parts, so much as to prevent their returning by a retrograde motion, as it were, to the state from whence they set out, or where the first cause was a destruction of the natural functions, as an exposure of internal surfaces, that they form a disposition to the second method of cure. That the disposition for suppuration is very different from the actual state of in- flammation, though produced by it, is proved by a variety of observations; for no perfect suppuration takes place till the inflammation is gone off; and as the inflammation ceases, the disposition to suppuration gradually comes on. If too by any peculiarity in the constitution or inflamma- tion by which it is continued, or if by any accident an in- flammation is brought on a healthy sore, the discharge and other appearances become the same as they were when the part from whence they arose was first in an inflamed state, very different from those observed when it was arriv- ed at the state of a kind of suppuration. II. OF THE TREATMENT NECESSARY IN IN- FLAMMATION, WHEN SUPPURATION MUST TAKE PLACE. IN cases of inflammation arising from accident, but so circumstanced, that we know suppuration cannot be pre- vented, the practice will be to moderate the inflammation, if necessary, but not with a view to prevent suppuration; for if the powers are very great, and the violence committed very considerable, the inflammation will probably be very violent; and if it should have equal effects on the consti- tution, which will be in proportion to the quantity of sur- face inflamed, then certain constitutional means of re- lief will be necessary, such as bleeding, purging, regi- Of the suppurative inflammation. 105 men, and perhaps producing sickness; because while that inflammation continues to have effects upon the constitu- tion, the suppuration which takes place will not be so kind- ly, as it would otherwise be; but if the constitution is of the irritable kind, which will be generally known by the inflammation, the same practice as mentioned above is ne- cessary; in short, whatever is to be the consequence, whe- ther resolution or suppuration, the irritability and the too great action of the vessels, whether arising from too great powers, or too great action with small powers, are to be corrected or removed, as they in all cases counteract salu- tary operations. In cases where the constitution has sympathized much with the inflamed part, such medicines as produce a slight perspiration much relieve the patient; such as antimoni- als, Dover's powders, saline draughts, spirits of mendereries, etc. because they endeavour to keep up an universal harmo- ny, by putting the skin in good humour, which quiets eve- ry sympathizing part, and by counteracting the effects of the irritability. Opium often lessens actions, although it seldom alters them, when only given as an opiate, and may be of a temporary service: however, this is not always a consequence of opium, as there are constitutions where it increases irritation, and of course diseased action. Fresh wounds, considered simply as wounds, are all of the same nature, and require one uniform treatment; the intention being to put them into that situation in which they can suppurate with most ease to themselves; and the first dressings commonly remain till suppuration comes on, unless some peculiarity from the situation of parts, or other col- lateral circumstances, should make it necessary to remove the dressings or vary the treatment. The difference between one wound and another, with respect to the nature of the part wounded, will vary very much; some will have small vessels wounded that cannot be conveniently got at in order to tie them up, yet should be stopt from bleeding, which can be done by the mode of dressing, and therefore require dressing suitable to this cir- cumstance alone. Wounds opening into cavities where peculiarities of the contained parts are joined with the injury done to them by Vol. II. O 106 Of the suppurative inflammation. the accident will require a suitable mode of dressing; the influence too that a simple wound in the containing parts may have upon those in the cavity, as a wound into the belly, thorax, joints, skull, etc. will oblige the surgeon to vary the mode of dressing from that of a simple wound. While many wounds will require being kept open for fear of uniting a- gain, in order to answer some future purpose, as the wound made into the tunica vaginalis testis, for the radical cure of the hydrocele; others may require attention being paid to them before suppuration comes on, and therefore should be so dressed as to admit of being soon and easily removed, to examine the parts occasionally as the symptoms arise. This ought to be the case in wounds of the head, attended or not attended with fracture of the skull. But whatever mode of application may be thought necessary to answer the various attending circumstances, yet as they are all wounds which are to come to suppuration, one general me- thod is to be followed respecting them all, as far as those peculiarities will allow. The application which has been made to wounds for some years past in this country, has been in general dry lint; what brought this application into common practice, most probably was, its assisting in stopping the hemorrhage; and as most wounds are attended with bleeding, it became universal; but as it became universal, it lost the first in- tention, and became simply a first dressing. I need hardly remark here, that all wounds that are to suppurate are first attended with inflammation, and there- fore are so far similar to spontaneous inflammations which are to suppurate. If this observation is just, how contradic- tory must this mode of treatment be to common practice, when spontaneous inflammation has already taken place; for let me ask, where is the difference between an inflam- mation with a wound, and one without? And also, what should be the difference in the application to a part that is to inflame, (while that application is made to the part) and one applied to an inflammation which has already taken place? The answer I should make to such a question is; there is no difference. Wounds that are to suppurate, I have already observed, are first to go through the adhesive and suppurative inflam- mation. These inflammations in a wound, are exactly si- milar to those spontaneous inflammations which suppurate Of the suppurative inflammation. 107 and form an abscess, or those inflammations which ulcer- ate on the surface, and form a sore. The applications to these which are now in practice, I have formerly observed, are poultices and fomentations; these, however, appear to be applied without much critical exactness or discrimination, for they are applied before sup- puration has taken place, and where it is not intended it should take place; they are applied to inflammations where it is wished they should suppurate; and applied after sup- puration has taken place. Now, with respect to suppuration itself, abstracted from all other considerations, the indication cannot be the same in all of those states; but if poultices and fomentations are found to be of real service in those two stages of the disease, then there must be something common to both, for which they are of service, abstracted from sim- ple suppuration. I also formerly observed, that poultices were of service when the inflammation had attacked the skin, either of itself, or when an abscess had approached so near that the skin had become inflamed, and that this ser- vice consisted in keeping the skin soft and moist. This ap- pears to me to be the use of a poultice in an inflammation, either before suppuration or after, as inflammation still ex- ists, till it is opened; for inflammation is necessary in an abscess, while it is making its approaches to the skin, which I have called the ulcerative, and then, and only then, it be- gins to subside; it is therefore still proper, in as much as it is of service to inflammation; so far, therefore, their prac- tice is right and consistent, as the first reason exists through the whole; but when applied to inflamed parts, which are meant not to suppurate, their reasoning or principles upon which they applied it must fail them, although the applica- tion is still very proper. If my first proposition is just, viz. that wounds which are allowed to suppurate, are similar to inflammations that are also to suppurate; then let us see how far the two practices agree with this proposition. Lint, I have observed, is appli- ed to a fresh wound, which is to inflame; and the same lint is continued through the whole of the inflammation till suppuration comes on, because it cannot be removed. Lint, considered simply as an application to fresh wounds which are to inflame, is a very bad one, for it more or less adheres to the surface of the wound, by means of the extravasated blood; hence it becomes difficult of removal, and often 108 Of the suppurative inflammation. shall remain in sores for months, being interwoven with the granulations, especially when applied to the surface of cir- cumscribed cavities, such as the tunica vaginalis testis, after the operation for the hydrocele; however, this is not al- ways the greatest inconvenience, the circumstance of its be- ing loaded or soaked with blood, subjects it to become ex- tremely hard when it dries, which it always does before the separation takes place, which separation is only effected by the suppuration. In this way it becomes the worst dress- ing possible for wounds. As poultices are allowed by most to be the best applica- tion to an inflamed part, not attended by, or a consequence of a wound, but considering it simply as an inflammation, I do conceive that the same application is the best for eve- ry inflammation, let it be from whatever cause; for the idea I have of the best dressing to a wound, simply as a wound which is to inflame, is something that keeps soft and moist, and has no continuity of parts, so that it is easily se- parated. The only application of this kind is a poultice, which, from these qualities, is the very best application to a fresh wound. It keeps it soft and moist, and is at all times easily removed, either in part or the whole. The same medical advantage is gained here, as when it is applied to an inflamed part; but although it had not these advantages, yet the circumstance of being easily re- moved is much in its favour, especially when compared to dry lint. But a poultice from other circumstances, cannot at all times and in all places be conveniently applied. To preserve the above properties, it is necessary there should be a mass, much too large for many purposes; but when they can be used with tolerable convenience, they are the best applications. When they cannot be applied with case, I should still object to dry lint, and would there- fore recommend the lint to be covered with some oily substance, so that the blood shall not entangle itself with the lint, but may lie soft, and come easily off. This mode of dressing should be continued for several days, or at least till fair suppuration comes on, and when that has taken place, then dry lint may be with great pro- priety used, except the sore is of some specific kind, which is seldom the case in fresh wounds; for accidental wounds seldom happen to specific diseases; and a wound in con- Of the suppurative inflammation. 109 sequence of an operation should not be specific, because the specific affection (if there is any) should have been re- moved by the operation; and should therefore be a wound in the sound part; as after an amputation of a scrofulous joint, or the extirpation of a cancerous breast. Or if they take on some specific disposition afterwards, then they must be dressed accordingly, as will be explained hereafter. Poultices are commonly made too thin, by which means the least pressure, or their own gravity, removes them from the wound; they should be thick enough to support a cer- tain form when applied. They are generally made of stale bread and milk; this composition, in general, makes a too brittle application, it breaks easily into different portions, from the least motion, and often leaves some part of the wound uncovered, which is frustrating the first intention. The poultice which makes the best application, and con- tinues most nearly the same between each dressing, is that formed of the meal of linseed; it is made at once‡ and when applied it keeps always in one mass. Fomentations are generally applied at this stage of the wound, and they generally give ease at the time of applica- tion, which has (joined with custom) been always a suffi- cient inducement to continue them. As soon as suppura- tion is well established, the part may then be dressed accord- ing to the appearances of the sore itself. The kind of wound to which the above application is best adapted, is a wound made in a sound part, which we in- tend shall heal by granulation. The same application is equally proper, where parts are deprived of life, and con- sequently will slough. It is therefore the very best dress- ing for a gun-shot wound, and probably for most lacerated wounds. For lint applied to a part that is to throw off a a slough, will often be retained till that slough is separated, which will be for eight, ten, or more days. ‡ Take boiling water, q. s. and stir in the linseed till it be- comes of a sufficient thickness, and then add a small quantity of some sweet oil. 110 Of the suppurative inflammation. In the treatment of wounds that are to suppurate, it is in one view of the subject right to allow the parts to take their natural and spontaneous bent. From the natural elas- ticity of the skin, and the contraction of muscles, the parts wounded are generally exposed, and from the consequent in- flammation, they generally become more so. This is common- ly more the case in wounds produced by accident; for as a small wound and much old skin are always desirable, sur- geons very wisely are anxious to wish for both. In many operations, they are desirous of preserving the skin, viz. where they are removing parts, as a limb; dissecting out tu- mors, or opening an abscess; all of which is extremely proper, and they continue to practice upon this principle immediate- ly upon the receiving the wound, and in performing any of the abovementioned operations; for the skin, after amputation, is drawn down, and bound down, and the wounds are press- ed together by bandages. In one point of view, this is be- ginning too early; it is beginning it when nature has the very opposite principle in view. Inflammation, the parts must submit to; and as inflammation by its effects will ge- nerally have a tendency to make them recede more, in this light it is proper not to check the effects of inflammation, therefore let them take their own way till inflammation subsides, and granulations are formed, which granulations, I have already observed, by their power of contraction, will do what we wanted to have done; and if, from some of the first circumstances not being properly attended to, the contraction of the granulations is not sufficient, then is the time to assist, and not before. However, if we take up this in another point of view, we shall see a considerable utility arising from bringing the skin as much as possible over the wound, and keeping it there; for in the time of inflamma- tion the parts will adhere or unite in this situation, by which means the sore will be less than it otherwise would; and I conceive that this practice, when begun, should be for some time continued, for fear the adhesions may not be sufficient to stand their ground till the granulations can assist. It often happens in many wounds, both from accident and operations, that part of the wound may with great pro- priety be healed by the first intention; such as in many ac- cidents on the head, when a part of the scalp has been torn off, on the face, etc. as also after many operations, espe- cially where the skin is loose, as in the scrotum; or where Of the suppurative inflammation. 111 the skin has been attended to in the time of the operation, as in some methods of amputation, extirpation of breasts, etc. a part of the saved skin, etc. may be made to unite to the parts underneath by the first intention, and therefore only part of the wound allowed to suppurate; in all such cases, a proper contracting or sustaining bandage may be applied with great advantage; even stitches may be used with great propriety, as was recommended in the healing wounds by the first intention. III. THE TREATMENT OF THE INFLAMMATION WHEN SUPPURATION HAS TAKEN PLACE IN spontaneous inflammations, whether from a consti- tutional or local affection, when suppuration has taken place, it is most probable that another mode of practice must be followed than that which was pursued to prevent it; but even now, if a stop could be put to the further for- mation of matter, after it has begun, it would in many cases be very proper, and still prevent a great deal of mis- chief. Suppuration does certainly sometimes stop, after having begun, which shows that there is a principle in the animal œconomy of diseases from which the machine is capable of producing this effect*. * I have formerly observed, that the inflammation goes off of- ten without producing suppuration; and I have also mentioned instances of suppuration going off without the parts having pro- duced granulations, and then the parts fall back into the adhe- sive state, and the matter being absorbed, they are left in near- ly the same state as before the inflammation came on, as a pre- sumptive proof of this, in many of the large cavities, which have been allowed to inflame and suppurate, (by having been opened) we find them often doing well without ever forming granula- tions, and that suppuration generally goes off; and I do not believe ever fall back into the adhesive state, so as to unite the parts, but the parts resume their original and natural state or disposition, and no adhesions are formed; this appears sometimes to happen in cases of the empyema after the operation has been performed; I have seen cases where wounds had been made in- to the cavity of the thorax, where there was every reason to suppose the whole cavity was in a state of suppuration, and yet those patients got well; I can hardly suppose that in these cases the parts had granulated and united in the cure, as the cellular 112 Of the suppurative inflammation. I have seen buboes cured by vomits, after suppuration had been considerably advanced; and it is a very common termination of scrofulous abscesses; but in scrofulous abs- cesses we very seldom find inflammation; this process ap- pears to be a leading circumstance in ulceration, which is the very reverse of union; even in superficial sores, which are the most likely to continue suppuration, if excited, we find by allowing them to scab, when they will admit of it, that the act which admits of scabbing is the very re- verse of suppuration, and it ceases; however, it is a pro- cess which the animal œconomy does not readily accept of, and our powers in producing this effect are but very small; if these powers could be increased by any means, it would be a salutary discovery; because suppuration itself, in ma- ny cases, proves fatal; for instance, suppuration of the brain and its membranes; of the thorax and its contents; as well as of the abdomen and its contents; in short, suppuration of any of the vital parts often kills of itself, simply from the matter being produced; but this practice will by most be forbid in many cases of suppuration; for it is supposed this very suppuration is a deposit of matter or humors already formed in the constitution; but it is to be hoped that time and experience will get rid of such prejudices. When suppuration cannot be stopped or resolved, then in most cases it is to be hurried on, which generally is the first step taken by surgeons. membrane does; because I have seen many similar cases, where the patients have died, and no granulations have been found; and I have seen cases of the hydrocele attempted to be cur- ed radically by the caustic; when the slough came out, suppura- tion came on; but the orifice healing too soon, suppuration has ceased, and the cure was thought to be completed; but a re- turn of the disease has led to another attempt and by laying open the whole sack, it has been found that the tunica vaginalis was perfectly entire. In such the fluids were a mothery serum. I have seen abscesses go back in the same manner: but I believe that this process is more common to scrofulous suppurations than any other; and I believe to the erysipelatous. I have seen joints heal after having suppurated and been opened, without having produced granulations leaving a kind of joint, even when the cartilages have exfoliated from the ends of the bones, which was known by the grating of the two ends of the bones on one ano- ther. Of the suppurative inflammation. 113 How far suppuration can be increased by medicine or ap- plication I do not know; but attempts are generally made; and thence we have suppurating cataplasms, plasters, etc. recommended to us, which are composed of the warmer gums, seeds, etc. but I doubt very much if they have considerable effect in this way; for if the same applications were made to a sore, they would hardly increase the dis- charge of that sore, probably rather decrease it; however, in many cases, where the parts are indolent, and hardly ad- mit of true inflammation, in consequence of which a per- fect suppuration cannot take place by stimulating the skin, a more salutary inflammation may be produced, and of course a quicker suppuration: but in the true suppuration, where inflammation preceded it, I believe it is hardly necessary to do any thing with respect to suppuration itself; however; from experience, I believe these applications have been found to bring the matter faster to the skin, even in the most rapid suppurations, which was supposed to be an in- creased formation of matter; but it can only be in those cases where the inner surface of the abscess is within the in- fluence of the skin. This effect arises from another cause or mode of action being produced, than that of quickening suppuration, which is the hastening on of ulceration. I have mentioned that ulceration was an effect of, or at least attended by inflammation; and, therefore, whatever in- creases that inflammation, will also increase the ulcerations which will bring the matter sooner to the skin, without an increased formation of matter. Poultices of bread and milk are commonly used to infla- med parts when suppuration is known to have taken place; this application can have no effect upon suppuration, ex- cepting by lessening inflammation, or rather making the skin easy under it; for we observed, that true suppuration did not begin till inflammation was abated; but the in- flammation must have reached the skin before poultices can have much effect, for it can only affect that part. It may be thought necessary that the ease of the patient should be considered, and we find that fomentations and poultices often produce that effect; we find too, that by keeping the cuticle moist and warm, the sensitive opera- tions of the nerves of the parts are soothed, or lulled to rest; while, on the contrary, if the inflamed skin is allow- VOL. II. P 114 Of the suppurative inflammation. ed to dry, the inflammation is increased, and as probably suppuration is not checked by such treatment, it ought to be put into practice; as warmth excites action, it is proba- ble, the warmer the fomentation, so much the better; and in many cases the action is increased so that they can hard- ly bear it. IV. COLLECTIONS OF MATTER WITHOUT INFLAMMATION. I HAVE hitherto been describing true suppuration, which I have said, "I believe is a consequence only of inflam- mation," a process generally allowed. Also in treating on the cause of suppuration, viz. inflammation, I hinted, that there were often swellings, or thickening of parts without the visible or common symptoms of inflammation, viz. without pain, change of colour, etc. and I also hinted, in treating of suppuration, that there were collections of mat- ter somewhat similar to suppuration, which did not arise in consequence of the common inflammation; these I shall now consider: I conceive all such collections of matter to be of a scrofulous nature; they are most common in the young subject, and seldom found in the full-grown or old. It is commonly called matter, or pus, and therefore I choose to contrast true suppuration with it. Although I have termed this suppuration, yet it has none of its true characters, any more than the swellings, which are the forerunners of it, have the true characters of inflammation; and as I did not call them inflammatory, strictly speaking, I should not call this suppuration; but I have no other term expressive of it. Many indolent tumors, slow swellings in joints, swell- ings of the lymphatic glands, tubercles in the lungs, and swellings in many parts of the body, are diseased thicken- ings, without visible inflammation; and the contents of some kinds of encysted tumor; the matter of many scrofu- lous suppurations, as in the lymphatic glands; the suppu- ration of many joints, viz. those scrofulous suppurations in the joints of the foot and hand; in the knee, called white Of the suppurative inflammation. 115 swellings; the joint of the thigh, commonly called hip cases; the loins called lumbar abscesses; the discharge of the abovementioned tubercles in the lungs, as well as in many other parts of the body, are all matter formed with- out any previous visible inflammation, and are therefore, in this one respect, all very similar to one another. They come on insensibly; the first symptom being commonly the swel- lings, in consequence of the thickening, which is not the case with inflammation, for there the sensation is the first symptom. These formations of matter, although they do approach the skin, yet do not do it in the same manner as collections of pus. They do not produce readily either the elongat- ing or the ulcerative process, and as the matter was not preceded by the adhesive inflammation, these collections are more easily moved from their original seat into some o- ther part, by any slight pressure, such as the weight of their own matter, which I have called abscesses in a part, in op- position to abscesses of a part: when the matter does ap- proach the skin, it is commonly by merely a distention of the part, coming by a broad surface, not attended with a- ny marks of pointing. Their surrounding parts or boundaries are soft, not be- ing attended with thickening; more especially those in a part. Such collections of matter are always larger than they would have been, if they had been either a consequence of inflammation, or attended by it; this is owing to their indo- lence, allowing of great distention beyond the extent of the first disease, even moving into other parts, whereas an ab- scess, in consequence of inflammation, is confined to the extent of inflammation that takes on suppuration, and its rapid progress towards the skin prevents distention, and of course extension of the disease. All those formations of matter, not preceded by inflam- mation, nor a consequence of it, are, I believe, similar to each other, having in this respect one common principle, very different from inflammation. The cancer although it produces a secretion, yet does not produce pus till ex- posed; it is, therefore, one of those diseases, like the scrofula, which does not suppurate till inflammation comes on, and even seldom then; for true suppuration arises from inflammation, terminating in a disposition to heal, 116 Of the suppurative inflammation. which is not the case with cancer. In the scrofulous sup- puration there is often a like reluctance to heal. The kind of matter is another distinguishing mark, be- tween that produced in consequence of inflammation, and what is formed without it; the last being generally com- posed of a curdly substance, mixed with a flaky matter, the curdly substance is, we may suppose, the coagulating lymph deprived of its serum *, and the other, or flaky, is probably the same, only in smaller parts; it looks like the precipitate of animal matter, from an acid or alkali. So far these productions of matter in their remote and immediate cause, are not in the least similar to that arising from common inflammation, nor is the effect, viz. the mat- ter similar; and to show still further, that suppuration is always preceded by inflammation, the very surfaces which formed the above matter, immediately produced true mat- ter, when the inflammation comes on, which it always does whenever opened; which I shall now consider. Since they are not similar in their causes or modes of production, let us next examine how far they are similar in their first steps towards a cure. All parts which form matter of any kind, viz. whether in consequence of inflammation or otherwise, must go through similar processes to produce the ultimate effect or cure: the first step in either, is the evacuation of this mat- ter, for till this is effected, nature cannot pursue the pro- per means towards a cure; and if opened, the second step is granulation, and the third cicatrization. To accomplish the evacuation of the matter, there are two modes, one is the absorption of the matter, which is very common in the scrofula, or those productions matter, not preceded by inflammation. This produces no alteration in the part, ex- cept that it gradually creeps into a sound state, the parts u- niting again that had been separated by the accumulation of the matter; it produces, also, no alteration in the con- stitution. Absorption, however, seldom takes place in sup- puration, which is the consequence of inflammation. The other mode of discharging this matter is either by opening * I may observe here, that the coagulating lymph of long standing, is not similar to the recent. This is similar to blood in general, for we find that the blood in aneurisms, which was first coagulated, is very different from that which has only co- agulated lately. Of the suppurative inflammation. 117 the abscess, in order to allow it to pass out, or by allowing ulceration to take place from the inside to produce its e- scape; and this process, in the present case, having peculiar- ities different from those arising from inflammation, it is necessary they should be understood. Ulceration, in con- sequence of suppuration arising from inflammation, is very rapid, especially if the suppuration is so likewise; but ul- ceration, in consequence of matter being formed, which is not the effect of inflammation, is extremely slow; it will re- main months, even years, before the parts have completely given way; they commonly come to the skin by a broad surface, and not pointing like a circumscribed abscess in consequence of inflammation; so far are these two different. V. OF THE EFFECTS SUCH FORMATIONS OF MATTER HAVE ON THE CONSTITUTION. WHATEVER maybe the extent of such collections of mat- ter, they seldom or ever affect the constitution, unless they are seated in a vital part, or so connected with it as to dis- turb its functions. This is an effect of indolence in any disease. A young person shall have a lumbar abscess, for instance, for years, without a single constitutional symptom. It shall appear to be making its way through a number of parts, such as the loins behind, the buttocks, the lower part of the abdomen before, and through the upper part of the thigh; and in each part shall shew large collections of matter. All these shall even attend the same person, yet not any bad symptoms, no shiverings shall accompany this suppuration.* In some there is not even the least degree of lameness, but this is of- ten the first stage of the disease in the lumbar abscess. * I have heard surgeons ask such patients, if they had rigors, even alluding to the time of increase; this was applying the idea of the symptom of one disease to another, and also the first stage of a disease to the second. 118 Of the suppurative inflammation. Let us next consider and compare the consequences at- tending these two collections of matter when opened. When an abscess, in consequence of inflammation is o- pened, it immediately proceeds towards a cure, and per- haps it may have gone some steps towards a cure before o- pening, the inflammation still lessens, the suppuration be- comes more perfect, granulations begin to form, and all of these steps naturally take place, because inflammation had been the cause; but when a collection of matter, not pre- ceded by inflammation, is opened, a very different process is first to take place, viz. inflammation is now excited over the whole cavity of the abscess, which afterwards produces a perfect matter, similar to that produced in consequence of inflammation, when it is the original disease; and which now produces its constitutional affection, if it is such as to have connexion with the constitution; but this will depend on the size of the abscess, the situation, and the nature of the parts, etc. however, it sometimes happens that they inflame before they are opened; but this is in consequence of the matter distending the cavity, and thereby acting as an ex- traneous body. I have seen white swellings in the knee in- flame before they were opened, then ulceration takes place, and the pus brought soon to the skin, even after it had been confined for months, without producing the least tendency to ulceration, because there had been none to inflammation; but the confinement of the matter becomes a cause of the inflammation, and then ulceration takes place. The inflammation and new suppuration taking place in consequence of opening into these abscesses is exactly simi- lar to those arising in consequence of wounds or openings made into natural cavities; it was still, therefore, necessary, that they should go through all the common steps towards restoration; but, unfortunately, such inflammations have begun at the wrong end; they have also set down upon a specific disease, which they can seldom alter to their own nature. The inflammation is in such cases extended over a much larger surface than the original; which is not the case in abscess, in consequence of inflammation, for there the inflammation was the cause and confined to the point. In some cases, as in lumbar abscess, the extent of sur- face to inflame is immense, in comparison to the extent of the original disease, and of course, when such abscesses in- Of the suppurative inflammation. 119 flame, the symptoms in the constitution are in the same proportion. How different is this from the opening of the abscess in consequence of inflammation! There we have no inflamma- tion following, except, what arises in consequence of the wound made in the solids in the operation of opening; but when it is allowed to open of itself, there is no consequent inflammation, but suppuration goes on. But it would ap- pear that when those collections of matter are allowed to open of themselves, that the succeeding inflammation does not so readily take place, as when opened by art. I have seen large lumbar abscesses open of themselves on the low- er part of the loins, which have discharged a large quanti- ty of matter; then closed up, then broke out anew, and so on for months, without giving any other disturbance; but when opened, so as to give a free discharge to the matter, inflammation has immediately succeeded, fever has come on, and from the situation of the parts inflamed, as well as their extent, death in a very few days after has been the conse- quence; it, therefore, often becomes a question whether we should inlarge the first opening or not. We may observe in general, that in cases of this kind, where they are to terminate ill, that is, where they cannot be cured, and are such as to affect the constitution, the consequent inflamma- tion upon opening them, which produces the sympathetic fever, has that fever commonly terminating in the hectic, or continued into the hectic before any recess takes place, so that the one is continued into the other, without any intermission; however, this is not always the case, and those variations will depend on the state of the sore, the state of the constitution, etc. VI. THE EFFECTS OF THE SUPPURATIVE IN- FLAMMATION ON THE CONSTITUTION. IT is to be observed, that every local complaint of any consequence, or which has considerable and quick action within itself, although not of considerable magnitude, affects more or less the constitution, and gives rise to what has been called the symptomatic fever. These symptoms are 120 Of the suppurative inflammation. the sympathies of the constitution with a local disease or in- jury, and will vary according to a vast variety of circumstances. They will vary according to the nature of the constitution- which admits of great differences, and which will include different ages; they will vary according to the na- ture of the part in a state of disease, which also ad- mits of great differences; they will vary according to the quantity of mischief done, as well as the man- ner of its being done: that is, whether so as to call forth immediate inflammation as a wound; or, not so immediate, as from having only killed a part; they will vary according to the situation of similar parts in the body; and they will vary according to the stage of the disease. This last varia- tion may be divided into two kinds, the one which begins slowly and increases progressively, as in the venereal dis- ease, and the sympathetic affections of course come on gra- dually; the other, where it begins at once with violence and diminishes. The first of this last division we have no- thing to do with at present; it is, therefore, the kind of constitution, the kind of parts, the diseases which com- mence with so much violence as to affect the constitution at once with the constitutional effects arising from the lo- cal disease being incurable, that form our present subject. I shall observe here, that every disease, whether local or constitutional, that has the power of termination in itself, commonly has its regular progress and stared times of ac- tion; in some, however, there are no changes in the modes of action, the disease coming on and dying away; but in others there are; and in those where changes take place, there are stated periods for those changes, so as to render them re- gular. As regularity in the modes of action in disease is conducive to the termination of that disease, it is a thing very much desired; for these changes are a cessation of the action, either temporary or permanent. As the consti- tution sympathises with a local irritation, and as that sym- pathy is according to the constitution, to the violence of the irritation, and to the nature of the parts irritated; and the symptoms of that sympathy must be similar to constitu- tional complaints that are commonly taking place; and if the local complaints should not be known, then they will be taken for constitutional complaints wholly, and treated as such; but often from their continuance, some local affec- tion is suspected; local complaints, however, are common- Of the suppurative inflammation. 121 ly preceded or attended with some local symptom either directly or indirectly, or with some collateral symptom or symptoms, so as to direct us to the cause. Local complaints attended with inflammations, the objects of surgery, are often attended with, or rather consequent upon violence of some kind; such as the loss of a part, either fluid or solid, which the constitution feels, and which loss, or violence, adds to the constitutional affection. This will be according to the quantity of injury or loss of living matter, whether blood, or some solid, the time in the operation, the state of the parts operated upon, and the nature of the part remov- ed. I have seen a man die almost immediately upon the loss of a testicle. I have seen convulsions immediately at- tend the operation for the hydrocele, so that I have almost despaired of recovery. I have seen a most violent sympa- thetic fever, delirium, and death, follow, in consequence of dividing parts in the leg, and searching after a bleeding ar- tery. The loss of a limb above the knee is more than ma- ny can bear; the cutting for the stone, where it breaks, and may be an hour in extracting, is also more than many can bear; the parts being in such diseased state, as not to be re- lieved, have continued the symptoms of the disease; and the loss of a testicle, although of so small a size, when com- pared with many other parts which we can lose with impu- nity, yet from its vital connexion is more serious. We cannot bear to lose much brain. The loss of too much blood is often an attendant on, or a consequence of operations; but sometimes takes place without much violence. This produces very considerable constitutional effects; bringing on weakness, and many complaints, depending as it were, upon debility, which are what are commonly called nervous. I have seen a locked jaw come on in consequence of the loss of a considerable quantity of blood, the cause of the loss being but trifling, and giving no symptoms whatever. The nature of the cause of inflammation, produces, I be- lieve, but little variation in the constitution; for of what- ever kind it is, the symptoms in the constitution will be in all cases nearly the same, proportioned only to the violence and rapidity of its progress; and as this inflammation is pretty violent, more especially if it produces healthy sup- puration, it generally producer more violent effects upon VOL. II. Q 122 Of the suppurative inflammation. the constitution than any other; this however, will be in some degree according to the susceptibility of the constitu- tion for inflammation; and if any difference takes place in the inflammation in one constitution from that of another, it will arise from the nature of the constitution, the nature of parts, and their situation, and not from the nature of the cause. The sympathy of the constitution with a local disease, is what I have called universal sympathy, and is perhaps, the most simple act of a constitution; it is the sympathy, with a simple violence, as a cold, etc. but still it will vary in different constitutions, because all constitutions will not act alike under the influence of a local disease, although it will vary according to the stages of inflammation, according to the natural disposition of the parts inflamed, and the situa- tion of those parts in the body; yet it may be the most sim- ple act of that constitution at the time; for although it would appear at the time to be an increase of the disease by its becoming universal, yet as it is a natural consequence it is a much better sign of health, than if no fever had oc- curred in consequence of considerable injuries; for if there was no inflammation, there would probably be little or no fever. Nature requires to feel the injury, for where, after a considerable operation, there is rather a weak quiet pulse, often with a nervous oppression, with a seeming difficulty of breathing and a loathing of food, the patient is in a dan- gerous way. Fever shews powers of resistance, the other symptoms shew weakness finking under the injury. This is like the effects of the cold-bath; yet we see it calling forth, or rousing up to action, some peculiarity in the con- stitution, or a part, which may be continued after the sympathetic action is lost, and which may again reflect back upon the part its reluctance to heal. This may be exemplified by affection or injury, scrofula, even cancer, etc*. * I believe that local specific irritations do not produce much variety in the constitution; for I am persuaded that specific local irritations are not capable of altering that constitution, similar to the plague and other coutageous diseases. I believe that mor- bid poisons do not act by any peculiar mode of action in the part, so as to affect the constitution in any peculiar way, but such as are capable of continuing so long as to weaken that con- stitution, as for instance, the lues, when of long standing; Of the suppurative inflammation. 123 Rigors are commonly the first symptom of a constituti- onal affection; but a rigor is productive of other effects, or symptoms, as it were naturally rising out of the rigor; and these are according to the nature of the constitution: in a strong constitution, a hot period succeeds, as if the consti- tution was roused to action to resist debility, which ter- minates the rigor; and this hot fit terminates in perspira- tion, which is the complete action of the disease, re- storing tranquility, which is the cure, and is the best ter- mination that can happen where a rigor takes place; for it shews that the constitution has the power of terminating the effects of the cause. I believe, however, that in most cases it shews a degree of weakness, especially if easily ex- cited, or a peculiarity of constitution. But as the cause is still continuing in cases of rigor arising from local irrita- tion, these rigors may recur; and if they recur, it shews a constitution ready to be affected; however, if they do recur at stated periods, it still shews the constitution to be able to resist the effects of the disease. Further, if the constitution is weak, a rigor comes on, and no hot fit suc- ceeds, but it runs directly into the sweat; it will proba- bly be cold and clammy. If it is a constitution of another kind, the hot fit will continue, having only a kind of abate- ment, but no sweat or perfect intermission will take place, and therefore the whole action has not taken place. Rigors from local irritation, attended with the full action, and at regular stated times, have all the characters of an intermittent fever; but it may be observed that, in common, rigors preceding suppuration are not followed by so much heat and sweating, as an intermittent is. In spontaneous inflammations, it is not so easy to ascer- tain, whether the constitution or the part is first affected, and if it always could, it would be the best guide to know whether the inflammation was local entirely, or an effect of a constitutional affection; nothing but the priority of but this will be similar to every other lasting disease; for at first it certainly does not affect the constitution so as to alter the dis- position of a wound made upon any part. I am not so certain respecting natural poisons. The tecuna, poisoned arrow, etc. would seem to produce a peculiar constitutional affection, from a local cause; for we can hardly suppose absorption to have ta- ken place in so short a time. 124 Of the suppurative inflammation. the symptoms can in some degree fix this; but the consti- tutional symptoms are often of slight, at least at first, as not to be taken notice so. However, we know that indisposi- tions of the constitution are productive of local complaints, which are often attended with inflammation, but which is often according to the nature of the parts*, the constitution being first diseased; and we know that in many fevers there is suppuration in some part of the body, and often in particular parts, such as the parotid glands, probably accor- ding to the nature of the fever; such inflammations will, according to their violence, add to the constitutional affec- tion. Constitutional affection arising from inflammations will be almost coeval with the inflammations, or at least will very soon follow; however, that will be according to the circumstance before related; for inflammation is an act of the part, attended with a degree of violence, and the con- stitution will feel it sooner or later, according to circum- stances: we see in cases of inflammation of the testicles from a gonorrhœa, (which must be considered as entirely local) that the constitution is soon affected by it. But constitu- tional symptoms arise from external violence alone, and more especially when attended with loss of substance; and they will be sooner or later, according to the degree of the violence, and the importance of the part lost agreeably to what has been said; but simple violence, even with the loss of a part, I have already observed, is not of such con- sequence as we should at first imagine: for in consequence of the loss of a limb, if the parts are allowed to heal by the first intention, the constitution is but little affected; it is, therefore, violence with loss of substance, and which is to produce inflammation and suppuration, that gives rise to the constitutional symptoms; and when these commence, or, more probably, when the part sets about these opera- tions, the constitution becomes affected. It is more the new disposition in these parts, than the quantity of inflam- matory action in them, by which the constitution is affect- * Local inflammations arising from derangement of the con- stitution, I think are most commonly of the scrofulous kind, more especially when in parts of a particular nature, such as lymphatic glands, ligamentous or tendinous parts, which, when in particular situations, are often supposed to be venereal. Vi- de Treatise on Venereal Disease. Of the suppurative inflammation. 125 ed; for we shall see, that upon the simple commencement of the suppurative disposition, before it has taken place, rigors, etc. come on. The constitutional effects arising upon the commence- ment of inflammation independent of situation, of vital parts, nerves, etc. are greater or less according to the na- ture of the disease. When the adhesive stage commences, it has but very little effect upon the whole system; there is sometimes however, a rigor, although not always; this is more in common spontaneous inflammations than in those arising from an injury done to apart, but such are seldom or ever alarming. When the suppurative disposition takes place, new effects upon the constitution arise, which are very considerable and varying in themselves. The cold fits, or rigors, are more frequently felt at the commencement of the suppurative than at the beginning of the adhesive in- flammation, more especially too if it is what we commonly call spontaneous inflammations, which advance to suppura- tion; for in those inflammations occasioned by an accident, or an operation, which must suppurate, they appear to set out at the very first with a kind of suppurative disposition. Those arising in consequence of spontaneous inflammation, or from an injury, are not lasting, are often succeded by hot fits, and if they terminate in perspiration then the pa- tient is relieved; and are more or less so according to the greatness of the present inflammation and the suppuration that is likely to follow, joined to the nature of the parts and their situation: if in vital parts they will be most violent, and next to these, in parts far from the heart. This cold fit is, indeed, a constant symptom in most local diseases, which affect the constitution; and in this case, plainly shews that the constitution is so affected, or sympathizes with the part. It is thus also, that fevers usually commence, and upon the absorption of any poisonous matter the same symptoms appear. I have seen them arise from a simple prick in the end of the finger, made with a clean sewing needle*, exactly similar to those arising from the absorption of poison. Disagreeable applications to the stomach produce them, and also disagreeable affections of the mind: but ri- gors are not confined to the commencement of disease, for * Hence it would seem as if simple irritation in a part, was capable of affecting the whole nervous system. 126 Of the suppurative inflammation. they occur in its progress, and sometimes at its termination, as will be mentioned. It is probable that the stomach is the cause of those ri- gors, by its taking part in the diseased action of the con- stitution; for as the stomach is the seat of simple animal life, and thereby the organ of universal sympathy of the ma- teria vitæ, or the living principle, it is of course more or less affected upon all these occasions; so that an affection of any part of the body and of the mind, can produce ve- ry nearly the same effect, as that which arises from disa- greeable applications to the stomach itself; which accounts for that viscus taking part in all constitutional affections. I am inclined to believe, that sympathy of the stomach which occasions sickness, arises from causes producing weakness or debility. It takes place from injuries or disorders of the brain, which occasions universal debility; it arises from loss of blood, and also from epileptic fits. How far the sick- ness is to be considered as an effect which is to produce ac- tion, viz. vomiting and which action is to reflect strength back upon the constitution, I do not know; but it is cer- tain, that people who are sick, and going to faint, are prevented by the action of vomiting; the act of vo- miting, therefore, appears often to be a cause of the prevention of the fits coming on, by rousing up the ac- tions of life. The rigors I should be apt to suspect arise from weakness at the time. A sudden alteration, a sudden call, or a sudden and universal irritation upon the constitu- tion, will, I imagine, produce immediate weakness; for e- very new action in a constitution, must produce or tend to produce a weakness in that function; the effects of which will vary according to the necessity, and state of the constitution. In some cases where the constitution is strong, and as it were equal of itself to the task, it will call up the animal powers to ac- tion, and produce the hot fit of a fever; but in weak constitu- tions, or in such as threaten dissolution, as in many diseases, especially towards the close, it loses by every rigor, and is seldom capable of producing a hot fit, but only occasions a cold clammy sweat; hence, cold sweats, when a person is in extremities, is a common symptom. That rigors are an effect of every sudden change in the constitution, and are not peculiar to the commencement of disease, is evi- dent from the following cases; which also prove, that even the change to health shall produce the same effect, so that Of the suppurative inflammation. 127 not only in its commencement, and in its different stages, a disease shall produce rigors, but in its termination or crisis. A boy about eleven months old was taken ill with a com- plaint, which could not be well understood from the symp- toms, and which came on insensibly. His pulse was quick and full, for which he was bled three times, and the blood was rather sizy; the tongue was white; he was not very hot, but uneasy and restless, with loss of appetite. His stools were upon the whole pretty natural; he was observed to be every other day rather worse, although there never was a perfect intermission, but only a kind of remission. After having been ill for about a fortnight in this way, he was taken with a cold shivering fit, succeeded by a hot fit, and then a sweat. My opinion was, that the disease was now formed, and that he would have more at the intermit- ting times; but he had no more after. In short, the dis- ease formed itself into that which has but one fit, and in this formation he had those symptoms. I have seen the same symptoms in many diseases, especially those occasioned by an operation, which in general alarm, but which should not if they go through their stages. A patient of mine at St. George's Hospital was cut for the stone; he had no un- common symptoms for several weeks, when he was taken with a cold fit, which was succeeded by a hot one, and then by a profuse sweat. The young gentlemen of the hospital were rather alarmed, conceiving them to be the signs of dis- solution; but I told them that this was of no consequence, as the disease had completed its full action. That it was either a regular ague, or arose from the irritation of the wound; and if the first, he would have more of them at stated periods, which the bark would probably cure; but if the second, it might not return; for, since the constitution was in possession of the complete action, that when the parts got better he would be well. He had no more; and went on doing as well as if no such fit had ever taken place. This is not the only instance of this nature. Here it is to be considered, that those affections of the constitution, are effects of the local action of the solids, either when produced by spontaneous causes, or by accident; but there are sometimes constitutional symptoms, or univer- sal sympathies, which arise immediately out of the act of the violence itself, and which are often dangerous. Loss 128 Of the suppurative inflammation. of blood maybe reckoned one cause, which will bring on all kinds of constitutional complaints, in consequence of weakness being produced, either immediate, as fainting, or secondary, as in dropsies, as well as nervous affections; the locked jaw, for instance; or violence alone without the loss of blood, may often produce immediate fatal effects. I have seen a man thrown into such convulsions from the operation of the hydrocele being performed upon him, that I began to despair of his recovery. I have known a man die immediately of castration. These symptoms are somewhat similar to the second, or nervous, but are still very different; for in the present, the persons are as it were lost to themselves, being rendered senseless, therefore, it is probably more an affection of the brain than the nerves. Another symptom attending inflammation when it has affected the constitution, is frequent exacerbations, or peri- ods in which the inflammation appears to be increased. They have great affinity to the rigors we have been men- tioning. Exacerbations are common to all constitutional diseases, and would often appear to belong to many local complaints. They are commonly regular if the constitution is strong, having their stated times, and in proportion as they are so the disease is less dangerous. They are a repetition of the first attack, but seldom so strong, except where there is a perfect cessation in the disease between the fits. This is an attribute belonging to life; and shews that life cannot go on the same continually in any state, but must have its hours of rest, and hours of action. In this, as in almost every other symptom of disease, the effect has been considered as a cause; for exacerbations have always been considered as owing to the disease having its time of subsiding, or lessening, and its time of increase. This idea might pass as just in fevers where causes are not known; but where the causes continue the same, as in local diseases, we, à piori, should not expect it; yet we find in such cases, periods of increase, and decrease of the symp- toms, in the constitution, and therefore we must search af- ter some principle belonging to animal life, as a cause of this. We shall find that an animal is so constituted as to be incapable of existing for any continuance of time in any Of the suppurative inflammation. 129 one state whatever; the actions of the sensitive principle, when in perfect health, have their regular exacerbations, viz. watching, and sleep; it is disease that interrupts this regularity of the actions of health; therefore we find that the actions of disease cannot always go on in the same way; nature rests insensible of the disease, while the disease exists at all times alike: since this is the case, where we see evi- dently a continuance of the remote cause, and that the constitution is only capable of being affected by this cause at stated times; according to the species of irritation giv- en, and the constitution at the time; may we not reason- ably suppose this to be the case, where the cause is invisi- ble, as in fevers. Whether these exacerbations are an effect of an occasi- onal increase of the inflammation, or whether the inflam- mation is increased by the paroxysm of the fever, is not easy to determine; but they attend each other. An ague is a disease which exists in the constitution, be- tween the fits, as much as at the time of the fit; but the constitution becomes insensible of it, and the action can only last a stated time. The process of ulceration seldom appears to affect the whole system; it is hardly known to exist, but in the ap- pearance of the parts, viz. when the part which contains the matter gets softer to the touch, or when an ulcer be- comes larger. But that rigors take place upon the com- mencement of ulceration, I think is evident; although it cannot well be known in all cases; for ulceration will be so close upon suppuration in most cases, that it will be difficult to distinguish which was the cause of the rigor; but where suppuration has taken place, and the abscess is open- ed, so that the first act of suppuration is finished, yet if it is not opened so as to allow of a ready outlet to the matter; for instance, if not opened at a depending part, the pres- sure of the matter against the most depending part of the abscess will produce ulceration there, and rigors will take place. Those rigors, however, will not commence for some time after the first opening, because the first opening will for some time remove the disposition for ulceration all over the surface of the abscess; but when it finds that this opening is not sufficient to take off the pressure, then it sets VOL. II. R 130 Of the suppurative inflammation. about forming another opening, and when it does so, the rigors will recur, and with as much severity as before. This is supposed by some to be new matter forming from fresh inflammation, and by others to be the absorption of matter already formed. Although ulceration does not af- fect the constitution equal to the mischief it is doing, yet its operations are often much affected by indispositions of the constitution; in some indispositions its progress is in- creased, in others it is even brought on, as in many old sores, especially of the lower extremities; and in some in- dispositions its progress is lessened or stopped. The constitutional symptoms arising from a local com- plaint may be divided into three as to time, the immediate, indefinite, and remote. Of the first, or immediate, there appears to be but one; of the second, there is probably a great variety, at least, appearing in very different forms and at very different periods, in respect of the original cause. Of the remote there is probably only one. The immediate I shall reckon that which is called, the sympto- matic fever; and what I shall reckon the second are, ner- vous affections, as spasms, both temporary and permanent, and delirium. Whether the symptomatic fever, the spasms, or the delirium, come first, is not certain, for often all con- cur or occur at the same time; but as the sympathetic fe- ver is most constant, and is more an universal principle, it is to be reckoned the first. And the third, which I have called, remote, is what is understood by the hectic; to which may be added the symptoms of dissolution, which is the last stage of all, and may be a consequence of either the above, or any other disease. The first of the constitutional affections is commonly called, the symptomatic fever; but which I choose to call the sympathetic inflammatory fever. This is immediate, or nearly so, and is the sympathy of the constitution, with the first stages of a local disease, which excites an alarm in the constitution, thereby rousing up its powers to pro- duce succeeding actions. This would appear to show very much the nature of the constitution at the time; for not being of any specific nature, both inflammation and fever are led of course into the nature, both the constitution by the natural tendency of the constitution itself, and there- fore partake of it, and only become more or less of a speci- Of the suppurative inflammation. 131 fied, in proportion as the constitution has more or less of a specific susceptibility or disposition. I have already observed, that affections of the constitu- tion often commence with rigor. However, the com- mencement of the sympathetic fever is not always attended with that effect; and I believe it is the best constitution where it is not; and in that case, it changes into a regular fever of the inflammatory kind. If the constitution has powers, heat comes on, attended with dry skin, frequent and commonly a full pulse, having at the same time a de- gree of hardness in the stroke; watchfulness, high co- loured urine, loss of appetite for solids, and thirst; all these will vary according to various visible circumstances, as well as according to many invisible ones, some one symptom being more in one constitution, and less in a- nother. It is in many instances difficult to determine what is cause, and what is effect. It has been commonly supposed that this fever was necessary for the operation of suppura- tion, and therefore the fever did not arise from the sympa- thy of the constitution with a local injury, but as a necessa- ry effect to become a cause of suppuration. If this was the case, we could have no suppuration which had not been preceded by fever; and the fever must have been e- qual in all cases in the same constitution, let the quantity of injury be what it will. For if a pimple, or the suppura- tion of a scratch depended upon fever, they would re- quire as much fever for their production of inflamma- tion and suppuration as the largest abscess, or largest wound; for a point that inflames and suppurates is un- der the same predicament with respect to the whole that a thousand are; and a large abscess is to be considered as only made up of a thousand points. One venereal sore requires as much mercury to cure it as a thousand. One plant requires as much wet weather and sunshine as a mil- lion. A principle that affects universally can only affect a part in proportion to the quantity of the universal affection there is in the part, each part has just its portion of general influence. Now, according to this proposition, which is undeniable, a scratch requires the same quantity of fever that an ampu- tation of the thigh does. Let us see how this accords with common experience; we find that inflammations and sup- 132 Of the suppurative inflammation. purations of sores shall take place without any fever; that the fever, in consequence of an injury, is not in all cases in the least proportioned to the quantity of injury, inflamma- tion, and suppuration, which it always should, if the last was an effect of it; and we know if an increase of fever comes on, superadded to the sympathetic, that suppura- tion is retarded or stopped altogether, instead of being quickened. From the same mode of reasoning it should be exactly the same whether the fever produce suppuration in a vital part or not a vital part. It is much more easy to conceive that an injury done to vital part shall be the cause of universal sympathy, than that a vital part should require more fever to make it inflame and suppurate than a part does which is not vital. This theory would at once overset our obser- vation that the constitution is affected or sympathizes more readily with some parts than with others. In many cases of spontaneous inflammations and suppurations it was natu- ral to suppose that the fever was the cause of the suppura- tion; but if persons who thought so had observed accurate- ly, they would have divided spontaneous suppuration into two kinds; one, whose remote and immediate cause was local, and therefore in such the fever followed the local ac- tion, as in injuries; the other, where the remote cause was fever, which produced the injury; and the injury, whatever it was, produced the inflammation and suppura- tion; so that here fever preceded, and was necessary for the remote cause, but not as the immediate; and indeed, as a proof of this, suppuration hardly takes place till the fever is gone. The small-pox is of this last kind; as probably many other contagious diseases. Those symptoms continue more or less, according to the degree of injury, the nature and situation of parts, and the constitution; but as they arise from a local cause, which subsides, they of course subside also; however, as the constitution has often an inflammatory tendency, or a tendency to some other disease, besides the action arising from the violence singly, the parts often run into it, and this is reflected upon the constitution, which passes into that action to which it has a tendency, by which fever is kept up, and thereby inflammation. The subsiding of these symptoms is the cure; and where they are simply the effects of the violence, the fever cures Of the suppurative inflammation. 133 itself; therefore, the only thing necessary is to lessen its violence; but if the injury is of any specific kind, that specific quality must be corrected, if possible, and then the cure will take place. As the motion of the blood in the whole system is in- creased, and as we have reason to suppose it is locally in- creased, then what will diminish the motion of the blood, will relieve in this respect; there are two methods of doing this; the first, by taking off its force; and this will be ef- fected by bleeding. This, if it does not lessen its motion, or take off from the sympathy of the constitution, with the local disease, yet it lessens the momentum in the whole and in the part, which is taking off the effect of the excess of motion in the blood. The other is diminishing the action of the parts by affect- ing the constitution, which may be done by purging; in this light, bleeding may also be in some degree considered. It becomes in such cases very necessary to relieve the con- stitution by lessening the action of that constitution; for although what has been advised, was to lessen the inflam- mation itself, and thereby lessen its effects on the constitu- tion, yet as that seldom is done sufficiently to remove any affection of the constitution, we must therefore pay atten- tion to that constitution; the two remedies will in some degree go hand in hand, one assisting the other; for in- stance, in a strong healthy constitution where the sympto- matic fever runs high, bleeding and purging will have their double effects, but still the constitution may require its peculiar medicines, which will in a secondary way re- lieve the inflammation. The secondary constitutional symptoms are not so deter- mined as to time; I have called them nervous, although not strictly so in every case, because more variety of affec- tions are produced than from any cause I know; yet these affections seem all to have more connexion with the nervous than the vascular system, and are severally excited by the particular tendency or susceptibility of different constitu- tions. Many of them, I believe, are more common to the young than the old, which come under the doctrine of universal nervous sympathy, with a local complaint; of this kind are universal convulsions from teething or worms; local convulsions, as St. Vitus's dance, and probably ma- 134 Of the suppurative inflammation. ny others not so well marked, as those which worms and teething often produce. I have seen hickup come on early in consequence of an operation; but in this stage of the ner- vous affection, little was to be apprehended, although it certainly shewed a peculiarility of constitution, and such as should be attended to; but when hickup occurs towards the last stages, it shews strong signs of dissolution. Many full-grown persons are also subject to very severe af- fections of the nervous kind, especially those people who are called nervous; and more particularly still those who have bad affections, in consequence of complaints of the stomach. In such constitutions there is observed great dejection, sinking, cold sweats, hardly any pulse, loss of appetite, no sleep, etc. seeming to threaten dissolution; those symptoms are worse by fits. Delirium appears to arise from nervous affection of the brain, or sensorium, producing a sympathy of the action of the brain, with the materia vitæ of the parts; not sensation as a head-ach, but action, producing ideas without the exciting impression, and therefore delu- sive. This symptom is common to them all; it is fre- quently a consequence of their being violent, or carried to considerable length in their several kinds: often arising in consequence of compound fractures, amputation of the lower extremities, injuries done to joints, brain, etc. but not so often attending the hectic, although it is often a symptom of dissolution. We have agues also from many diseases of parts, more especially of the liver, as also of the spleen, and from induration of the misenteric glands. The following cases are remarkable instances of well marked constitutional diseases from local irritation, where the constitution took on a particular action, to which it had a strong tendency. A gentleman had a very bad fistula in perinæo from a stricture, and when the water did not come freely, an inflammation in the part and scrotum was pro- duced, and then he had an ague, which was relieved for a time by the bark. Two children had an ague from worms, which was not in the least relieved by the bark, but by de- stroying the worms they were cured. As these diseases which I have brought into this class are of such various kinds, each must be taken up apart, and treated accordingly; but they are such as yield very little to medicine, for in some the constitutional disease is formed, and does not require the presence of the local disease to keep Of the suppurative inflammation. 135 it up, as in the tetanus; and in others, the local disease being still in force, it is not to be expected, that the consti- tutional affection is to be entirely relieved, although in some degree it may. In those which form a regular constitu- tional disease, such as an ague, although the local diseases may still exist in full force, yet some relief may be expect- ed; the bark is to be administered, although not with a view to cure, as the immediate cause still exists; but bark will in some lessen that susceptibility in the constitution, and may cure at least for a time, as I have seen in agues arising from the fistula in perinæo. But the susceptibility in the two children, cited above, was so strong for such a disease, that the bark was not sufficient; and therefore, when the local cause is not known, and when the common remedies for such effects do not cure them, some local disease should be suspected. We see often such symptoms arising from dis- eases of the liver, and the bark curing this symptom, yet the liver shall go on with its disease, and probably faster, as I believe bark is not a proper medicine for diseases of this viscus; such complaints of the liver have been too often at- tributed to the curing of the ague improperly by bark. St. Vitus's dance, and many other involuntary actions, have a- risen from the same cause; such constitutions required on- ly an immediate cause to produce the effects. It it possi- ble, however, that no other mode of local irritation would have produced the same effect, every constitution having a part that is capable of affecting it most. We find also local effects in consequence of local injuries, as the locked jaw, etc. which are remote sympathies with the part affected, which may become pretty universal, and which cannot be called immediate effects as to time, as they are often form- ing after the sympathetic fever has taken place, especially the locked jaw, which appears in many cases to be formed in the time of the preceding disease, and not appearing till it had subsided. There are certain intermediate steps be- tween the inflammatory and the hectic state; but neither cure nor dissolution take place in this period. The following case illustrates the effects of inflammation on the constitution. A lady, of what is called a nervous constitution, arising in some degree from an irritable stomach, often troubled with flatulencies, and what are called nervous head-aches, with 136 Of the suppurative inflammation. pale urine at those times, uncomfortable feelings and often sinkings, had a tumor removed from the bread, and like- wise from near the arm-pit; nothing appeared uncommon for a few days, when very considerable disorders came on. She was attacked with a shivering or cold fit, attended with the feel of dying, and followed with cold sweat. It being supposed that she was dying, brandy was thrown in, which soon brought on a warmth, and she was relieved; the fits came on frequently for several days, which were always relieved by brandy; and she took in one of the most vio- lent of them about half a pint of brandy. While under these affections she took the bark as a strengthener; the musk, occasionally, as a sedative in pret- ty large quantities; camphorated julap frequently, as an antispasmodic; and towards the last she took the valerian in large quantities: but whatever effect these might have in lessening the disease on the whole, they were certainly not equal to it without the brandy. Brandy removed those dying fits, and I thought they became less violent after tak- ing the valerian. A question naturally occurs; would the brandy alone, if it had been continued as a medicine, have cured her, with- out the aid of the other medicines? The other medicines, I think, certainly could not have done it; nor do I believe that the brandy could have been continued in such quan- tity as to have prevented their returns, if so, then the two modes were happily united, the one gradually to prevent, the other to remove immediately the fits when they came on. This case from the general tenor of the constitution, was running with great facility into the hectic. [137] CHAPTER V. OF PUS. HITHERTO I have been treating of the operations of parts, preparatory to the formation of pus; I am now come to the formation of that fluid, its nature and supposed uses. The immediate effect of the mode of action above de- scribed, is the formation of a fluid, commonly termed pus; this is very different from what was discharged in the time of the adhesive stage of the inflammation, when either form- ed in the cellular membrane or circumscribed cavities; it is also very different from the natural secretion of internal canals, though it is probably formed in both by the same vessels, but under very different modes of action. The cellular membrane, or circumscribed cavities, have their vessels but little changed from the adhesive state at the commencement of the suppurative disposition; so that they still retain much of the form they had acquired by the first state, the discharge being at the beginning little more than coagulating lymph mixed with some serum. This is scarcely different from the adhesive stage of the inflamma- tion; but as the inflammatory disposition subsides, the new disposition is every instant of time altering those vessels to their suppurative state; the discharge is also varying and changing from a species of extravasation to a new formed matter peculiar to suppuration; this matter is a remove fur- ther from the nature of the blood, and becomes more and more of the nature of the pus; it becomes whiter and VOL. II. S 138 Of pus. whiter, losing more and more of the yellow and green, which it is apt to give the linen that is stained with it in its first stages, and in consistence more and more viscid, or creamy. By the formation of this new substance, the coagulating lymph, which was extravasated in the adhesive state of the inflammation, and adhered to the sides of the cells, either in cut surfaces as in wounds, in abscesses, or circumscribed ca- vities, is pushed off from these surfaces, and if it is the inner surface of a cavity, it is pushed into it, so that the cavity contains both coagulating lymph and pus; or if it is a cut surface, the coagulating lymph is separated from it by the suppuration taking place, and is thrown off; but as such surfaces are generally dressed immediately after the operation, while the wound is bleeding, this blood unites the dressings to the sore, which is assisted afterwards by the coagulating lymph thrown out in the adhesive stage, the whole, viz. dressings, blood, and coagulating lymph are generally thrown off together, when suppuration com- mences on these surfaces. This is the process which takes place in the first formation of an abscess, and the first pro- cess towards suppuration in a fresh wound. Upon the internal surfaces of the canals, the parts do not go through all those steps; they would appear to run into suppuration almost instantaneously; however, inflam- mations even here is a kind of forerunner of suppuration. This discharge, from internal canals, has never been rec- koned true matter, it has been called mucus, etc. but it has all the characters of true pus, which I am yet acquaint- ed with. Pus is not to be found in the blood, similar to that which was produced in the first stage; but is formed from some change, decomposition, or separation of the blood, which it undergoes in its passage out of the vessels, and for effect- ing which the vessels of the parts have been formed, which produces a subsiding of the inflammation from which it took its disposition; hence it must appear, that the formation of pus consists of something more than a straining of juices from the blood. Many substances indeed which are to be considered as extraneous bodies in the blood, being only mixed with, and not making an essential part of that fluid, and perhaps even necessary to it, may pass off with the pus, as with every ether secretion, yet the pus is not be consi- Of pus. 139 dered on that account as simply parts of the blood unchang- ed; but we must look upon it as a new combination of the blood itself, and must be convinced that in order to carry on the decompositions and combinations necessary for producing this effect, either a new or peculiar structure of vessels must be formed, or a new disposition, and of course a new mode of action of the old must take place. This new structure, or disposition of vessels, I shall call glandular, and the effect or pus, a secretion. I. OF THE GENERAL OPINION OF THE FOR- MATION OF PUS. THE dissolution of the living solids of an animal body into pus, and that the pus already formed has the power of continuing the dissolution, is an old opinion, and is still the opinion of many; for their language is, "Pus corrodes, "it is acrid, etc." If this idea of theirs was just, no sore which discharges matter could be exempted from a conti- nual dissolution; and I think it must appear inconsistent, that the matter which was probably intended for salutary purposes, should be a means of destroying the very parts which produced it, and which it is meant to heal. Proba- bly they took their idea from finding, that an abscess was a hollow cavity in the solids, and supposing the whole of the original substance of this cavity was now the matter which was found in it. This was a very natural way of account- ing for the formation of pus, by one entirely ignorant of the moving juices, the powers of the arteries, and the ope- ration of an abscess after it was opened; for the know- ledge of these three, abstracted from the knowledge of the abscess before opening, should have naturally led them to account for the formation of pus from the blood by the powers of the arteries alone; for upon their principle these abscesses should continue to increase after opening, as fast as before. Upon this principle being established in their minds; viz. that solids were dissolved down into pus, they built a practice which was to bring all indurated parts to suppuration if possible, and not to open the suppuration 140 Of pus. in such parts early; this was done with a view to give such solids time to melt down into pus, which was the expres- sion; but according to their own theory, they seemed to for- get that abscesses formed matter after opening, and there- fore the parts stood the same chance of dissolution into pus as before. Also, from being possessed of this idea, that solids went into the composition of pus, they never saw pus flowing from any internal canal, as in a gonorrhœa, etc. but they concluded that there was an ulcer; we would for- give such opinions, before the knowledge that such sur- faces could and generally did form pus without a breach of the solids; but that such an opinion should exist after- wards is not mere ignorance, but stupidity; and the very circumstance of internal circumscribed cavities, as the ab- domen, thorax, etc. forming pus, where they might often have seen pints of matter, and yet no breach in the solids to have produced it, which is a proof beyond controversy, should have taught them better; such ideas discover defect of knowledge and incapacity for observation. The moderns have been still more ridiculous, for know- ing that it was denied, that solids were ever dissolved into pus, and also knowing that there was not a single proof of it, they have been busy in producing what to them seem- ed proof. They have been putting dead animal matter in- to abscesses, and finding that it was either wholly or in part dissolved, they therefore attributed the loss to its be- ing formed into pus; but this was putting living and dead animal matter upon the same footing, which is a contradic- tion in itself; for if the result of this experiment was re- ally according to their idea of it, the idea of living parts being dissolved into pus must fall to the ground, because living animal matter and dead animal matter can never stand upon the same ground. Common observation in their profession should have taught them, that even extraneous animal matter would lie in abscesses for a considerable time before it was even dissol- ved. They might have observed in abscesses arising ei- ther from violence, or from a species of erysipelatous in- flammation, that there were often sloughs of the cellular membrane, and that those sloughs would come away like wet tow, and therefore were not dissolved into pus. They might also have observed in abscesses on tendinous parts, as about the ancle, etc. that often a tendon became Of pus. 141 dead and sloughed away, and that these sores do not heal till such parts have sloughed, and this is often not accom- plished for months, and yet all this time those sloughs are not formed into pus. They might have also known, or observed, that pieces of dead bone shall lie soaking in mat- ter for many months, and yet not dissolve into pus; and al- though bones in such situations shall lose considerably of their substance (which might by the ignorant be supposed to have been dissolved into pus) yet that waste can be ac- counted for and proved on the principle of absorption; for they always lose on that surface where the continu- ity is broke off, and which is only a continuation of the se- parating process.* To see how far the idea was just, that dead animal matter was dissolved by pus, I put it to the trial of experiment, because I could put a piece of dead a- nimal matter of a given weight into an abscess, and which could at stated times be weighed; to make it still more sa- tisfactory, a similar piece was put into water, kept to near- ly the same heat: they both lost in weight, but that in the abscess most, and there was also a difference in the manner, for that in the water became soonest putrid; but these ex- periments having been made as far back as the year 1757, I shall not rely on their accuracy, but state them as made by my brother-in-law, Mr. Home, and, as given in his Dissertation on the Properties of Pus, page 32, under the idea that pus had a corroding quality. "As pus has been supposed to have a corroding quality," I may add even upon the living solids, "I made the fol- lowing experiments to ascertain the truth, or falacy of such an assertion, and found it to be void of foundation, and to have arisen from the inaccuracy of observers having preven- ted them from seeing the distinctions between pus in a pure state, and when mixed with other substances. "EXPERIMENT. "I made a comparative trial upon matter contained in an abscess, and on pus and animal jelly out of the body. The matter and jelly were in equal quantities and contai- * It may be supposed that bones are not capable of being dis- solved into pus; but we know that bone has animal substance in it, and we also know that this animal substance is capable of being dissolved into chyle. 142 Of pus. ned in glass-vessels, kept nearly in the temperature of the human body. To make the comparative trials as fair as possible, a portion of muscle, weighing exactly one drachm, wasimmersed in the matter of a compound fracture in the arm of a living man, and a similar portion into some of the same matter out of the body; also a third portion into fluid calf's foot jelly, in which the animal substance was pure, having neither wine nor vegetables mixed with it. These three portions of muscle were taken out once every twenty- four hours, washed in water, weighed and returned again. The results were as follows: "In twenty-four hours.—The portion of muscle in the abscess weighed sixty grains, was pulpy and soft, but quite free from putrefaction: that portion immersed in the pus, weighed forty-six grains, was pulpy, soft, and had a sligh- tly putrid smell: the portion in the jelly weighed thirty- eight grains, was smaller and firmer in its texture. "Forty-eight hours.—The portion of muscle in the abs- cess weighed thirty-eight grains, and had undergone no change: that in the matter weighed thirty-six grains, was softer and more putrid: that in the jelly thirty-six grains and smaller. "Seventy-two hours.—The portion of muscle in the abs- cess weighed twenty-seven grains, was drier and firmer: that in the matter eighteen grains, and was rendered fibrous and thready: that in the jelly unaltered. "Ninety-six hours.—The portion of muscle in the abscess weighed twenty-five grains: that in the matter was dissol- ved: that in the jelly weighed thirty-six grains*. "One hundred and twenty hours.—The portion of mus- cle in the abscess weighed twenty-two grains, not at all pu- trid: that in the jelly thirty-four grains, not at all putrid. "One hundred and forty-four hours.—The portion of muscle in the abscess weighed twenty-two grains, and was * One reason probably for the piece of meat so soon becom- ing putrid and dissolving in the pus, was its being kept in the same pus the whole time; therefore its dissolution was owing more to putrefaction than a dissolving quality in the pus; where- as the piece in the abscess had its matter continually changing, which is the common result in a sore, and if it had a corroding quality independent of the putrefaction, it ought to have been dissolved first; but we may observe that, the piece of muscle in the abscess, and the piece in the jelly were nearly upon a par. Of pus. 143 free from putrefaction: that in the jelly thirty-four grains." The supposed facts of the solids dissolving being established in the mind as so many data to reason from, they had now no difficulty to account for the formation of pus from both the solids and the fluids; fermentation started up in the mind immediately as a cause; but there must be a cause for fermentation; and according to this idea, there are facts which go against it: first, let us consider internal canals, where only mucus is naturally formed, taking on the for- mation of pus without the loss of substance, or any previ- ous ferment, and leaving it off. Now if a fermentation of the solids and fluids was the immediate cause, I should beg leave to ask what solids were destroyed in order to enter into the composition of the pus discharged; for the whole penis could not afford matter enough to form the pus, which is discharged in a common gonorrhœa; I should also beg leave to be informed, how that fermentation of the fluids ever ceased, for there is the same surface, secreting its mucus, whenever the formation of pus ceases. Besides, if dissolved solids enter necessarily into the com- position of pus, by the power of some ferment, it may be asked by what power the first particle of this fluid in an ab- scess or sore is formed, before there is any particle existing which is capable of dissolving the solids? An abscess shall form, and suppuration ceasing, it shall become stationary, perhaps for months, and at last be ab- sorbed, and the whole shall heal; what becomes of the ferment the whole time it is stationary? It has been supposed that blood when extravasated be- comes of itself pus; but we find blood, when extravasated, either from violence or a rupture of a vessel, as in an aneu- rism, never of itself becomes pus; nor was pus ever for- med in such cavities till inflammation had taken place in them, and that in such cavities there was to be found both the blood and the matter; if the blood had coagulated, (as it seldom does in those cases of violence) it would be found still coagulated, and if it had not coagulated the pus would be bloody. True pus has certain properties, which when taken singly may belong to other secretions, but when all joined, form the peculiar character of pus, viz. globules swimming in a fluid, which is coagulable by a solution of sal ammoniac, 144 Of pus. which no other animal secretion that I know is; and at the same time a consequence of inflammation; these circum- stances taken together may be said to constitute pus. As inflammation does not produce at first true pus, I made the following experiments to ascertain its progress or formation. To do this it was only necessary to keep up an irritation on some living part a sufficient time to oblige it to set about the natural consequent actions, and the smooth coat of an internal cavity appeared to me to be well calcula- ted for such an experiment, where nothing could inter- fere with the actions of the parts, or their result, and it would also shew its progress on internal surfaces, which shows its progress in wounds and abscesses. II. EXPERIMENTS TO ASCERTAIN THE PRO- GRESS OF SUPPURATION. EXPERIMENT I. THE tunica vaginalis of a young ram was opened and the testicle exposed. The surface of the testicle was wiped clean, and a piece of tale was laid upon it. The surface almost immediately became more vascular; five minutes af- ter, the tale was removed and examined in a microscope, but no globules could be observed, only a moisture which appeared to be serum. Ten minutes after, there were ir- regular masses formed on the tale, some transparent, with determined edges, but no globules: fifteen minutes after, nearly the same. At twenty minutes, there was an appearance of globules. At twenty-five minutes, there were globules in clusters; but I could not say exactly what those globules were. At thirty-five minutes, the globules more distinct, more diffused, and numerous. At fifty-five minutes, the globules still more perfect and distinct. At seventy, the globules more irregular, and of course less distinct. At eighty-five, the globules more distinct and nume- rous. Of pus. 145 At one hundred, more irregular and less distinct, form- ing little masses. At two hours, the masses more transparent, and the glo- bules fewer. At two hours and an half, the masses transparent, and no distinct globules. At four hours, some transparent masses appearing to contain globules At seven hours, distinct globules and numerous. At eight hours, the globules more dictinct and some- what larger. At nine hours, less appearance of globules. At twenty-one hours, the testicle was covered with lint, and the skin brought over and kept together with a ligature, and allowed to remain for twelve hours, which, from the first, was thirty-three hours; when it was opened, it was wiped dry, and apiece of talc applied for five minutes; the quantity of fluid very small, but containing globules small and numerous. N.B. In this time when the testicle was covered, there were strong adhesions took place between the testicles and tu- nica vaginalis, which shows that probably the inflammation moved back to the adhesive stage whenever two similar sur- faces were opposed. Forty hours, the above repeated and the globules a lit- tle more distinct. Forty-four hours, the appearance of globules very di- stinct, and it looked like common matter diluted. EXPERIMENT II. An opening was made through the linea alba below the navel, several inches long, into the cavity of the belly of a dog, care being taken that no blood should pass into that ca- vity; a piece of talc was applied to the peritoneum so as to be covered with the fluid which lubricates that surface; to do which, it was found necessary to draw it over some considerable surface: this fluid was examined in the field of the microscope, and appeared to contain small semitrans- parent globules, few in number, swimming in a fluid. The lubricating fluid in the cavity of the abdomen, ap- pears from repeated experiments on healthy dogs, to be so VOL. II. T 146 Of pus. small in quantity as only to give a polish to the different sur- faces, but not sufficient to have a drop collected. After five minutes, the surfaces had more moisture upon them, which being examined as before, the globular ap- pearance was more distinct. In fifteen minutes, the surfaces were more vascular; a portion of intestine was wiped dry, and a piece of talc ap- plied to it; the fluid collected on it had a great number of globules, which were smaller than those at first observed. In an hour, this portion of intestine had its blood-vessels considerably increased in number; the whole surface ap- pearing of an uniformly red colour: this was wiped dry and a piece of talc laid upon it; the fluid collected did not appear to be made up of globules, but of very small parts which had some transparency, but not exactly regular in their figure, which became still more evident on drying, when they lost the transparency altogether; these were most probably coagulating lymph. This was repeated upon the surface of the spleen, which had its surface excessively red, from the increased number of small vessels carrying red blood, and the result was exact- ly similar. From these experiments, the fluid which lubricates the peritoneum seems to undergo changes, in consequence of exposure, and at last, when inflammation takes place, to have coagulating lymph substituted for it. Although the lubricating fluid of the peritoneum is so small in quantity in a natural state, yet before that cavity has been exposed for half an hour, the quantity is much in- creased, and has a mottled appearance of oil and water; but from the appearance in the microscope, it is only an in- crease of the original fluid with some coagulating lymph, although mistaken by some anatomists for an oily lubricat- ing liquor. EXPERIMENT III. At half past seven o'clock in the morning, an incision was made with a lancet into the upper fleshy part of a young ram's thigh, into which was introduced a silver canula, a- bout a quarter of an inch in diameter, and three quarters long, with a great number of small holes in the sides, and open at the bottom; it was fastened by means of ligatures to the skin, and a small cork adapted to it. Of pus. 147 The blood was sponged out several, times, and the cork kept in during the intervals. At half past nine the cork was withdrawn, and the canula was found to contain a flu- id; a piece of talc was dipped in it, and the appearance was evidently globular, exactly like the red globules without the colour. At eleven; the quantity of fluid much increased, and the same appearance. At one, the quantity half filling the pipe, of a reddish brown colour; the globules more numerous, without co- lour when diluted with water. At three, the quantity considerable, the globules smaller, freer from colour. At half past five, the same. EXPERIMENT IV. In the same manner the canula was introduced into the fleshy part of an ass's thigh, at nine in the morning; and at one o'clock, as also at two, there was a fluid tinged with red globules. At four, there were no diffused globules, but there ap- peared to be small flakes in a transparent fluid; however they proved to be clusters of globules. At seven, next morning, which was twenty-two hours, there was found in the canula, common pus. From the experiments on internal surfaces, it would ap- pear that pus was formed coeval with its secretion; but from Mr. Home's experiments, page 51, it would rather ap- pear that the globules were not formed till some time after secretion, and this sooner or later, according to circumstan- ces, which we probably do not know. So far these experiments explain the progress of suppu- ration on internal surfaces, and I shall now give its progress on the cutis, when deprived of its cuticle, from Mr. Home's Dissertation on that subject before mentioned. "I applied a blistering plaster of the size of a half-crown piece to the pit of the stomach of a healthy young man. In eight hours a blister arose, which was opened, and the con- tents removed; they were fluid, transparent, and coagulated by heat; had no appearance of globules, when examined by the microscope; and in every respect resembled the serum of blood. The cuticle was not removed, but allowed to collapse, and the fluid, which was formed upon the surface of the cutis, was examined from time to time by a microscope, to de- 148 Of pus. termine as accurately as possible the changes which took place. "The better to do this, as the quantity in the intervals stated below must be exceedingly small, a piece of talc, very thin and transparent, was applied to the whole surface, and covered with an adhesive plaster; and the surface of the talc applied to the skin was removed and examined by the microscope, applying a fresh piece of talc after every examination, to prevent any mistake which might have a- risen from the surface not being quite clean. "The fluid was examined by the microscope, to ascer- tain its appearance; but as the aqueous part in which the globules of pus swim, is found by experiment to coagulate, by adding to it a saturated solution of sal ammoniac, which is not the case with the serum of the blood nor the transpa- rent part of the milk, I considered this as a property peculiar to pus; and consequently that it would be a very good test by which to ascertain the presence of true pus. "In eight hours.—From the time the blister was applied, the fluid discharged was perfectly transparent, and did not coagulate with the solution of sal ammoniac. "Nine hours.—The discharge was less transparent; but free from the appearance of globules. "Ten hours.—The discharge contained globules which were very small, and few in number. "Eleven hours.—The globules were numerous, but still the fluid did not coagulate with the solution of sal am- moniac. "Twelve hours.—The appearance much the same as be- fore. "Fourteen hours.—The globules a little larger, and the fluid appeared to be thickened by a solution of sal am- moniac. "Sixteen hours.—The globules seemed to form themselves into masses; but were transparent. "Twenty hours.—The globules were double the size of those first observed at ten hours, and gave the appear- ance of true pus, in a diluted state: the fluid was coagu- lated by a solution of sal ammoniac; the globules at the same time remaining perfectly distinct, so that I should consider this as true pus. "Twenty-two hours.—No change appeared to have taken place. Of pus. 149 "Thirty-two hours.—The fluid was considerably thicker in consistence, the number of globules being very much increased: but in no other respect that I could observe, did it differ from that formed twenty hours after the ap- plication of the blister." To ascertain the progress of suppuration on canals, or se- creting surfaces, I have often examined the matter on a bougie, that had been introduced into the urethra, and found it to be formed earlier than either of the times be- forementioned; Mr. Home's experiment makes it five hours; but we often find a gonorrhœa coming on at once, not having in the least been preceded by a leading discharge. Since that period experiments have been made on pus, from different kinds of sores, with an intention to ascer- tain the nature of the sore by the result of such analysis. That sores give very different kinds of pus is evident to the naked eye, and that the different parts of which the blood is composed will come away in different proportions, we can make no doubt; and we find that whatever is in solution in the blood, comes away more in one kind of pus than another, which are all so many deviations from true pus; we may also observe, that such kinds of pus change, after being secreted, much sooner than true pus, which will be observed by and by. From all this I should be apt to conceive, that such experiments will throw little light on the specific nature of the disease, which is the thing want- ed. From such experiments we may find out that pus, from a venereal bubo in its height of malady, or that from a cancer, is bad matter, but cannot ascertain the difference between those two matters and all others, nor the specific difference between the two. The small-pox, although as malignant a disease as any, and one which produces a pus as replete with poisonous particles as any, yet gives a true pus, when not of the confluent kind, which disposition is not small-pox. The reason why it is good pus, is, because its inflammation is of the true suppurative kind; and the reason why it is of the true suppurative kind, is, because the parts have the power of curing themselves, just as much as in any accident which happens to such a constitution; but this is not the case with either the venereal disease or the cancer; from the moment these set out, their dispositions tend to become worse and worse; but the venereal bubo, if mercury is given so as to affect it, soon gives us another 150 Of pus. kind of pus, although this has the poison equally in it; therefore it is not the circumstance of containing a poison which makes it what is called a bad pus, but it's being form- ed from a sore that has no disposition to heal: as we cannot give healing action to a cancer, so we never can have a good pus. The observation respecting the small-pox is ap- plicable to the venereal gonorrhœa; for this complaint hav- ing the power of curing itself, its pus is good in proportion to that power; but as the periods of cure are not so de- termined as in the small-pox, neither is its time in produc- ing good pus so determined; but like the small-pox, as well as the venereal disease when it is healing, we have good pus, although it contains the poison. From the above experiments it must appear unnecessary to give the chemical analyses of what is commonly called pus, for whatever comes from a sore has that name, although very different in many cases from what I should call true pus; and we shall find in those sores that have some specific quality which hinders them from healing, that the discharge is not pus. Probably the chemical properties may be nearly the same in them all. II. OF THE PROPERTIES OF PUS. PUS, in the most perfect state, has at the first view certain peculiar qualities. These are principally colour and con- sistence; but it appears that the colour takes its rise from the largest portion of the whole mass being composed of very small round bodies, very much like those small round globules, which swimming in a fluid make cream: I should suppose those round globules to be white in themselves, as cream would appear to be; although it is not necessary that the substance of matter which reflects a white, should be itself white; for a vast number of transparent bodies being brought together will produce a white, such as broken glass, broken ice, water covering globules of air, making froth, etc. Of pus. 151 These globules swim in a fluid, which we should at first suppose to be the serum of the blood, for it coagulates with heat like serum, and most probably is mixed with a small quantity of coagulating lymph; for pus in part coagulates, after having been discharged from the secreting vessels, as mucus is observed to do. But although it is thus far simi- lar to serum, yet it has properties that serum has not. Ob- serving there was a similarity between pus and milk, I tried if the fluid part of pus could be coagulated with the juice of the stomach of other animals, but found it could not. I then tried it with several mixtures, principally with the neu- tral salts, and found that a solution of sal ammoniac coagu- lated this fluid; not finding that a solution of this salt co- agulated any other of our natural juices, I concluded that globules swimming in a fluid that was coagulable by this salt was to be considered as pus, and would be always form- ed in sores that had no peculiar backwardness to heal. The proportion that these white globules in the pus bear to the other parts depends on the health of the parts which formed it; for when they are in a large proportion, the matter is thicker and whiter, and is called good mat- ter; the meaning of which is, that the solids which pro- duced it are in good health; for these appearances in the matter are no more than the result of certain salutary pro- cesses going on in the solids, the effect of which processes is, to produce the disposition on which both suppuration and granulation depend; all this is a good deal similar to the formation of milk; for in the commencement of the secretion of this fluid, it is at first principally serum, and as the animal advances towards delivery, the globules are forming and become more in quantity, and the animal that has them in largest quantity has the richest milk; like- wise when they are naturally leaving off secreting milk, it again takes an exact retrograde motion; and we may also observe, that if any local affection attacks this gland, such as inflammation, the milk is falling back to the state I have been now describing; or if any constitutional affection takes place, such as fever, etc. then this gland suffers in the same manner. Pus is specifically heavier than water; it is probably near- ly of the same weight with blood or any other animal sub- stance rendered fluid. 152 Of pus. Pus, besides the abovementioned properties, has a sweet- ish and maukish taste, probably from having sugar in it, which is very different from most other secretions, and the same taste takes place, whether it is pus from a sore, viz. an ulcer, or an irritated inflamed surface. Thus, if any have an ulcer in their nose, mouth, throat, lungs, or parts ad- jacent, so that the matter shall come into the mouth un- altered by putrefaction, they will be able to taste it from its having this property; whereas the mucus and saliva of those parts is tasteless. The same thing happens when an irritation to inflammation takes place on the surface of those parts without ulceration. If the internal surface of the nose is inflamed, so that when we blow it on a white handkerchief, we see the sub- stance discharged of a yellow colour; we also find that when we draw up the same substance into the mouth, that it has a sweetish maukish taste. If it is the surface of the mouth or throat that discharge this matter, the same taste is observable; and if it is brought up from the trachea and lungs, in consequence of the common effects of a cold on those parts, the same taste is also to be observed; so that pus, from whatever surface, whether an irritated natural surface, or the surface of a common sore, has this proper- ty. Pus has a smell in some degree peculiar to itself; but this differs; some diseases, such for instance, as the venereal gonorrhœa, it is pretended may be known by the smell. To ascertain the properties of pus, or to distinguish it from mucus, it has, with mucus, been put to the test of chemistry. Solution in menstrua, and precipitation were thought to be a test of their distinction. This principle in its very first appearance is unphiloso- phical, and was at the very first treated by me as absurd. I conceived that all animal substance whatever, when in so- lution, either in acids or alkalies, would then be in the same state, and therefore that the precipitation would be the same in all. Calcarious earth, when dissolved in an acid, (for instance, the muriatic) is in that acid in the same state, whether it has been dissolved from chalk, lime-stone, mar- ble, or calcareous spar; and the precipitations from all are the same. However, whatever my opinion might be, yet bold as- sertions, the result of described experiments, made me a- Of pus. 153 void falling into the same error, of describing what I ne- ver had seen; I made, therefore, some experiments on this subject; and in consequence of having previously formed the abovementioned opinion, I was more general in my ex- periments. I made them on organic animal matter, as well as on inorganic, and the result was the same in all. As organic animal matter, I took muscle, tendon, car- tilage, gland, viz. liver and brain. As inorganic animal matter, I took pus, and the white of an egg, and dissolved each in the vitriolic acid, and then precipitated the solution with vegitable alkali. Each precipitation I examined with such magnifiers as plainly shewed the forms of the precipitate; all of which appeared to be fleaky substances. The precipitate by the volatile alkali, appeared exactly the same. To carry those experiments a little further, I dissolved the same substance in the vegetable caustic alkali, and pre- cipitated the solution with the muriatic acid, and examin- ed each precipitate with the microscope, and the appear- ance was the same, viz. a fleaky substance, without any regular form. To see how far the nature of sores, might be ascertain- ed from the nature of their discharge, matter from a cance- rous sore has been analysed, and the result has been, that such matter differs from true pus; but this explains noth- ing more than what the naked eye can perceive, that it is not pus; but it will not shew the specific difference be- tween the matter from a cancer and matter from a venere- al bubo, where mercury has not been given, nor will it tell that one is cancer and the other is venereal. We might as well analyse the urine at different times, in order to ascer- tain the nature of kidnies at those times. The quality of pus is always according to the nature of the parts which produce it; and whatever specific quali- ties the parts may have besides, the pus has also this speci- fic quality; hence we have venereal matter from venereal sores, small-pox matter from small-pox sores, cancerous matter from cancerous sores, etc. It is not in the least af- fected by the constitution, except the parts which produce it are also affected by the constitution. VOL. II. U 154 Of pus. Pus is so far of the same specific nature with the part which produces it, that it does not become an irritator to that part; it is perfectly in harmony with it, the part is not in the least sensible of it; therefore the pus of a suppu- rating surface is not an irritator to the same surface, but may be an irritator to any other not of the same kind; hence no suppurating surface of any specific kind can be kept up by its own matter, for if this had not been the case, no sore of any specific quality, or producing matter of an irri- tating quality, could ever have been healed. This is simi- lar to every other secretion of stimulating fluids, as the bile, tears, etc. for those do not stimulate their own glands or ducts, but are capable of stimulating any other part of the body. The venereal gonorrhœa, small-pox, etc. healing or recovering of themselves, are striking instances of this; howevever, we find matter under certain circumstances stimulating its own sore, and also secretion stimulating their own canals, as the secretions of the intestines stimula- ting themselves; but how far this may not arise from one part of the intestines being so diseased, as to secrete a sti- mulating fluid, and coming to a sound part, stimulates that only I will not determine. This I am certain happens to the rectum and anus; for it very often happens in purg- ing, that the watery stools shall irritate those parts so much as to make them feel as if they were scalded. This idea seems reasonable on another principle; for when we con- sider matter in the gross, we shall find that it is often mixed with extraneous substances which make no part of it, be- ing probably strained from the blood; and also, probably, undergoing a change afterwards from its not being pure pus; nor do these always arise entirely from the nature of the sore; for they are produced by sores of very different spe- cific qualities, it being the species of matter itself which arises from the nature of the sore; however, the kind of sore will often produce more or less of this extraneous mat- ter, and this additional substance may act as stimulus on every kind of sore. What I have considered thus far, is the natural process of a sound constitution and sound parts; since a sore that is going through all the natural stages to a cure, is not to be called a disease. A proof of this is, that whenever a real disease attacks either the suppurating surface, or the constitution, these Of pus. 155 processes of nature are destroyed, and the very reverse takes place; the production of true pus ceases, and the fluid becomes changed in some measure in proportion to these morbid alterations; in general it becomes thinner and more transparent, as if the part was returning back to the ad- hesive state, it partakes more of the nature of the blood, as is the case in most other secretions under similar circum- stances. This, in common language, is not called pus, but sanies. Pus, arising from such state of sores, has more of the se- rum, and frequently of the coagulating lymph in it, and less of the combination that renders it coagulable with a solution of sal ammoniac. It has a greater propor- tion also of the extraneous parts of the blood that are solu- ble in water, such as salts; and becomes sooner putrid. The two last species of matter not being of the same spe- cific nature with the sore, they have the power of stimu- lating even their own sore. On this last account too, pus becomes more irritating to the adjoining parts, with which it comes in contact, produ- cing excoriation of the skin, and the ulcerative inflamma- tion; as the tears, when they run out, excoriate the skin of the cheek from the quantity of salts which they contain. From this effect the matter has been called corrosive, a quality which it has not; the only quality which it poss- esses being that of irritating the parts with which it comes in contact, in such a manner that they are removed out of the way by the absorbents, as will be described when treat- ing on ulceration. In these instances of the change in the pus, we may say that the change is effected by the decomposition and new combination not being carried on so perfectly; this may probably depend on the secreting vessels having lost their due structure and action, and this appears to be so much the case, that they not only fail in this operation, but the other offices of those vessels, viz. the production of granu- lations is also checked; for the vessels forming themselves into a certain structure which fits them for secreting pus, it is so ordered, that the same structure also fits them for producing granulations, and thus those two processes are concomitant effects of the same cause, which cause is a pe- culiar organization superadded to the vessels of the part. 156 Of pus. What organization this may be is not in the least known, nor must we wonder at this, for it is exactly the same with every other organ of secretion, about all which we are e- qually ignorant; indeed, some of the differences between one gland and another are made out, and also something of their general structure; but not in such a way as can lead us to the actions and operations of the several parts upon which the nature of the different secretions depend, so as to enable us to conclude à priori, that this or that gland must secrete this or that peculiar juice. Pus, from several circumstances often attending it, would appear in general to have a greater tendency to pu- trefaction than the natural juices have; but I very much suspect that this is not really the case with pure pus; for when it is first discharged from an abscess, it is in general perfectly sweet. There are, however, some exceptions to this, but these depend on circumstances entirely foreign to the nature of pus itself. Thus, if the abscess had any communication with the air while the matter was confined in it, (as is frequently the case with those in the neighbour- hood of the lungs) or if it has been so near the colon or rec- tum, as to have been infected by the fœces, under such circumstances we cannot wonder that it becomes putrid: matter formed early in the state of suppuration, either in ab- scesses, or more especially in consequence of any external violence committed on the solids, has always in it a por- tion of blood; or if some parts of the solids mortify and slough, these will mix with the matter; the same thing happens when the inflammation has something of the erysi- pelatous disposition, so as to have produced a mortification in the seat of the abscess; in all such circumstances we find the pus has a greater tendency to putrify than the pure or true pus, which comes to be discharged afterwards in sound abscesses or healing sores; and accordingly the matter from recent sores becomes very putrid between every dressing; whereas, when the same sores are further advanced, it is perfectly sweet at the same periods; but although the im- perfect or heterogeneous matter that is formed at first is li- able to putrefy when exposed, yet if it is perfectly confined in an abscess, it will remain a considerable time without pu- trefaction; the suppuration, however, in consequence of the erysipelatous inflammation, which is often attended with suppuration produced by internal mortification, is, as Of pus. 157 we have observed, an exception to this rule; for although confined from external air, yet the matter becomes soon pu- trid, and this most probably arises from the solids them- selves first becoming putrid. A similar observation may be made with respect to sores which have been in the habit of discharging good pus; for if by any accident an extravasation of blood is produced in these parts, or a disposition is brought on to throw out blood, which mixes with the pus, the discharge changes from its former sweetness, and becomes much more putrid and of- fensive. It appears that pure matter, although easily ren- dered susceptible of change by extraneous additions, is in its own nature pretty uniform and immutable. It appears so unchangeable, that we find it retained in an abscess for weeks, without having undergone any change; but these qualities being only to perfect pus; for if a sore from a sound state changes its disposition and becomes inflamed, the matter now produced from it, though there be no ex- travasated blood or dead solids, becomes much sooner putrid than that which was discharged before this alteration of disposition, and shall become much more irritating, as has already been observed. From the abovementioned considerations, we can explain why the discharge in many specific diseases, although not in all, is so much more offensive than in common sores; for in these cases it is commonly not true pus, and is general- ly mixed with blood. In the same manner, likewise, where there are diseased bones, or other extraneous bodies which excite irritation, sometimes even to so great a degree as to cause the vessels to bleed, and often wounding the vessels of the part, the matter is always found to be very offensive, one mark (al- though not commonly accounted for) of a diseased bone. Our silver probes are rendered almost black, when in- troduced into the discharge of an unhealthy sore; prepa- ration of lead are the same, when applied to such matter. It even dissolves animal substance; if, for instance, a fresh wound has its lips brought together and held there with sticking plaster spread upon leather, we shall find if the wound suppurates, that the parts of the straps of leather going over the wound will be between the first and second dressing quite dissolved, dividing the straps into their two ends; and the plaster, which commonly has lead in it, 158 Of pus. shall become black, where it has come in contact with this matter. This change in the colour of metals is also pro- duced by eggs, when not perfectly fresh, although not be- come putrid; and probably this property is assisted by the boiling or roasting. Dr. Crawford, in his experiments on the matter of cancers and animal hepatic air, attributes the dissolution of the metals to that air†. III. OF THE USE OF PUS. THE final intention of this secretion of matter is, I be- lieve, not yet understood, although almost every one thinks himself able to assign one; and various are the uses at- tributed to it. It is by some supposed to carry off humors from the constitution. It is sometimes supposed a constitu- tional disease changed into a local one, and so discharged or thrown out of the body, either in form of, or with the pus, as in those cases to be called critical abscesses; but even those who see this final intention are very ready to over- turn it, by supposing that this matter is capable of being taken back again into the constitution by absorption, and producing much worse evils than those it was meant to re- lieve. I believe that the supposed cases of absorption are more numerous than those where it is supposed to relieve; if so, then by their own account nothing is gained. Or it is presumed to carry off local complaints from other parts of the body by way of derivation, or revulsion; for this reason sores, as issues, are made in sound parts, to allow other sores to be dried up; or even with a view to oblige parts to dissolve themselves into pus, as indurated swellings; but we have endeavoured to show that the solids make no part of pus. A secretion of pus is also looked upon as a general pre- vention of many, or of all the causes of disease; issues, therefore, are made to keep off both universal disease as well as local. But I am apt to believe that we are not yet † Philos. Transact. vol. 80th, year 1790, part 2nd page 385. Of pus. 159 well, or perhaps at all acquainted with its use, for it is com- mon to all sores; takes place in the most perfect degree in those sores which may be said to be the most healthy, and especially in those where the constitution is most healthy. We find also that very large discharges, when proceed- ing from a part which is not essential to life, produces ve- ry little change in the constitution, and as little upon being healed up, whatever some people may suppose to the con- trary. One might naturally imagine, that it was of service to the sore which formed it, to keep it moist, etc. for all internal surfaces have their peculiar moisture; but as a sore is to heal, and if allowed to dry, so soon as to form a scab, then a sore is disposed to form no more pus, and heal faster; it is the mode of dress- ing external sores that keeps up this secretion, which in this respect maintains the sore in the state of an internal one; but this will not account for the formation of an abscess, which is the formation of pus we can best account for, since it produces the exposure of internal surfaces; in ma- ny cases it is of singular service, to procure the second mode of cure, and open a communication between the dis- ease and the external surface of the body. It also forms a passage for the exit of extraneous bodies; but all these are only secondary uses.  [161] CHAPTER VI. THE ULCERATIVE INFLAMMATION. IN considering the origin and course of the blood, it would have been most natural to have considered ab- sorption, or the absorbing vessels; for in one point of view, they may be considered as the animal consisting of so many mouths, every thing else depending upon them, or belonging to them; for in tracing these dependences we find that there exists ultimately little else but absorbents. The stomach and the organs connected with it in such animals as have a stomach, are to be considered as subser- vient to this system; and many an animal is to be consi- dered as consisting of a number of stomachs; a piece of co- ral, for instance, appears to be no more than a thousand stomachs, all taking in food for digestion, and absorption for increase, and support of the whole; for each stomach does not increase, as the piece of coral increases, but they multiply in number, and of course the whole piece of coral increases; for although each appears to be a distinct animal, yet it is not so; but as this is too general a view of this system for our present purpose, I shall leave it, and confine myself principally to the uses of the absorbents in the diseases of which I am going to treat; and as one of their uses in diseases, and indeed the principal one, has not been described, nor in- deed in the least conjectured, that it may be clearly under- stood or distinguished from the other known uses, I shall relate first the more common uses which have been for- merly assigned to this system. First, the absorbents take up extraneous matter, in which is included nourishment. VOL. II. X 162 The ulcerative inflammation. Secondly, superfluous and extravasated matter, whe- ther natural or diseased. Thirdly, the fat. Fourthly, they produce a waste of parts, in consequence of which muscles become smaller, bones become lighter, etc. Although these two last effects were perhaps not express- ly said to be carried on by absorption, either by veins, or any other system of vessels, yet we must suppose they were understood: so far the absorbents have in general been considered as active parts in the animal œconomy; but from a further knowledge of these vessels, we shall find that they are of much more consequence in the body than has been imagined, and that they are often taking down what the arteries had formerly built up; removing whole or- gans, becoming modellers of the form of the body while growing; also removing many diseased and dead parts, which were beyond the power of cure; of all which I shall now take particular notice. As these vessels are productive of a vast variety of effects in the animal œconomy, which are very dissimilar in the intention and effect, they may be reviewed in a variety of lights, and admit of a variety of divisions. I shall consider them in two views: first, as they absorb matter, which is not any part of the machine; secondly, as they absorb the machine itself. The first of these is the well-known use, the absorption of matter, which is no part of the machine. This is of two kinds, one exterior matter, in which may be ranked e- very thing applied to the skin, as also the chyle; and the other interior, such as many of the secreted juices, the fat, and the earth of bones, etc*. These are principally with a view to its nourishment, and also answer many oth- er purposes; so that the action of absorbing foreign matter is extremely extensive; for besides its salutary effects, it is often the cause of a thousand diseases, especially from poi- sons, none of which are to my present purpose. In the second of these views, we are to consider them as removing parts of the body itself, in which they may be * It may be necessary to remark here, that I do not consider either the fat, of the earth of bones, as a part of the animal; they are not animal matter; they have no action within them- selves. They have not the principle of life. The ulcerative inflammation. 163 viewed in two lights. The first is, where only a wasting is produced in the whole machine, or part, such as in the wasting of the whole body, from an atrophy; or in a part, as in the wasting of the muscles of the leg, etc, from some injury done to some nerve, tendinous part, or joint; all of which I call interstitial absorption, because it is removing parts of the body out of the interstices of that part which remains, leaving the part still as a perfect whole*. But this mode is often carried further than simply wasting of the part; it is often continued till not a vestage is left, such as the total decay of a testicle, so that the interstitial absorp- tion might be understood in two senses. The second is, where they are removing whole parts of the body. This may be divided into the natural, and the diseased†. In the natural they are to be considered as the modellers of the original construction of the body; and if we were to consider them fully in this view, we should find that no alteration can take place in the original formation of many of the parts, either in the natural growth, or that formation arising from disease, in which the absorbents are not in action, and take not a considerable part: this absorption I shall call modelling absorption. If I were to consider their powers in this light, it would lead me into a vast variety of effects, as extensive as any principle in the animal œconomy, for a bone cannot be formed without it, nor probably many other parts. A part which was of use in one stage of life, but which becomes entirely useless in another, is thus re- moved. This is evident in many animals; the thymus gland is removed; the ductus arteriosus, and the membrana pupillaris is removed. This process is, perhaps, more re- markable in the changes of the insect, than in any other known animal. Absorption in consequence of disease, is the power of removing complete parts of the body, and is in its operation somewhat similar to the first of this division, or modelling process, but very different in the intention, and therefore in its ultimate effects. * This mode of absorption has always been allowed, or sup- posed, whether performed by the lymphatic veins, or lymphat- ics. † These uses I claim as my own discovery. I have taught them publicly ever since the year 1772. 164 The ulcerative inflammation. This process of removing whole parts in consequence of disease, in some cases produces effects which are not simi- lar to one another; one of these is a sore or ulcer, and I therefore call it ulcerative. In other cases no ulcer is pro- duced, although whole parts are removed, and for this I have not been able to find a term; but both may be de- nominated progressive absorption. This process of the removal of a whole solid, part of the bo- dy, or that power which the animal œconomy has taking part of itself into the circulation by means of the absorbing vessels, whenever it is necessary, is a fact that has not in the least been attended to, nor was it even supposed, and having now been noticed, I mean to give a general idea of it. I may just be allowed once more to observe, that the oil, or fat, of animals, and the earth of bones, have always been considered as subject to absorption; and some other parts of the body being liable to wasting, have been supposed to suffer this by absorption; but that any solid part should to- tally be absorbed, is a new doctrine. This use of the absorbents I have long been able to de- monstrate; and the first hints I received of it, were in the waste of the sockets of the teeth, as also in the fangs of the shedding teeth. It may be difficult at first to conceive how a part of the body can be removed by itself; but it is just as difficult to conceive how a body can form itself, which we see daily taking place; they are both equally facts, and the know- ledge of their mode of action, would answer perhaps ve- ry little purpose; but this I may assert, that whenever any solid part of our bodies undergoes a diminution, or is bro- ken in upon, in consequence of any disease, it is the absorb- ing system which does it. When it becomes necessary that some whole living part should be removed, it is evident that nature, in order to effect this, must not only confer a new activity on the absorbents, but must throw the part to be absorbed into such a state as to yield to this operation. This is the only animal power capable of producing such effects, and like all other operations of the machine arises from a stimulus, or an irritation; all other methods of de- struction being either mechanical or chemical. The first by cutting instruments, as knives, saws, etc. the second by caustics, metallic salts, etc. The ulcerative inflammation. 165 The process of ulceration is of the same general nature in all cases; but some of the causes and effects are very dif- ferent from one another. The knowledge of the use of this system is but of late date; and the knowledge of its different modes of action is still later. Physiologists have laboured to account for its modes of action; and the principle of capillary tubes was at first the most general idea, because it was a familiar one. But this is too confined a principle of an animal machine, nor will it account for every kind of absorption. Capillary tubes can only attract fluids; but as these inquirers found that solids were often absorbed, such as schirrous tumors, coagulated blood, the earth of bones, etc. they were driven to the necessity of supposing a solvent; this may or may not be true; it is one of those hypotheses that can never be proved or disprov- ed, and may for ever rest upon opinion. But my concep- tion of this matter is, that nature leaves as little as possible to chance, and that the whole operation of absorption is per- formed by an action in the mouths of the absorbents: but even under the idea of capillary tubes, physiologists were still obliged to have recourse to the action of those vessels to carry it along after it was absorbed; and might therefore as well have carried this action to the mouths of these ves- sels. As we know nothing of the mode of action of the mouths of these vessels, it is impossible we can form any opinion that can be relied upon; but as they are capable of absorbing substances in two different states, that of solidi- ty and fluidity, it is reasonable to suppose that they have different modes of action; for although any construc- tion of parts that is capable of absorbing a solid, may also be such as is capable of absorbing a fluid; yet I can suppose a construction only capable of absorbing a fluid, and not at all fitted for absorbing a solid, though this is not likely; and to see the propriety of this remark more forcibly, let us only consider the mouths of different ani- mals, and I will venture to say, that the mouths of all the different animals have not a greater variety of substances to work upon, than the absorbents have, and we may observe that with all the variety of mouths in different ani- mals, this variety is only for the purpose of adapting them to absorb solids, which admit of great variety in form, texture, etc. every one being capable of absorbing fluid mat- ter, which admits of no variety. 166 The ulcerative inflammation. This process of the removal of parts of the body, either by interstitial or progressive absorption, answers very ma- terial purposes in the machine, without which many local diseases could not be removed, and which, if allowed to re- main, would destroy the person. It may be called in such cases, the natural surgeon. It is by the progressive absorption, that matter or pus, and extraneous bodies of all kinds; whether in consequence of or producing inflammation and suppuration are brought to the external surface; it is by means of this that bones ex- foliate; it is this operation which separate sloughs; it is the absorbents which are removing whole bones, while the arteries are supplying new ones; and although in these last cases of bones it arises from disease, yet it is somewhat simi- lar to the modelling process of this system in the natural formation of bone; it is this operation that removes useless parts, as the alveolar processes, when the teeth drop out, or when they are removed by art; as also the fangs of the shedding teeth, which allows them to drop off; and it is by these means ulcers are formed. It becomes a substitute in many cases for mortification, which is another mode of the loss of substance; and in such cases it seems to owe its taking place of mortification to a degree of strength or vigor, superior to that where morti- fication takes place; for although it arises often from weak- ness, yet it is an action, while mortification is the loss of all action. In many cases it finishes what mortification had begun, by separating the mortified part. These two modes of absorption, the interstitial and the progressive, are often wisely united, or perform their pur- poses often in the same part which is to be removed; and this may be called the mixed, which I believe takes place in most cases, as in that of extraneous bodies of all kinds com- ing to the skin; also in abscesses, when in soft parts. It is the second kind of interstitial absorption, the progressive and the mixed, that becomes mostly the object of surgery, al- though the first of the interstitial sometimes takes place, so as to be worthy of attention. This operation of the absorption of whole parts, like many other processes in the animal œconomy, arising from disease, would often appear to be doing mischief, by de- stroying parts which are of service, and where no visible good appears to arise from it; for it is this process which The ulcerative inflammation. 167 forms a sore called an ulcer; such as in those cases where the solids are destroyed upon the external surface, as in old sores in the leg, breaking out anew, or increasing; but in all cases it must still be referred to some necessary purpose; for we may depend upon it, that those parts have not the power of maintaining their ground, and it becomes a substi- tute for mortification; and indeed in many ulcers, we shall see both ulceration and mortification going on, ulceration removing those parts that have power to resist death. I OF THE REMOTE CAUSE OF THE ABSORP- TION OF THE ANIMAL ITSELF. THE remote cause of the removal of parts of the animal appears to be of various kinds, and whatever will produce the following effects, will be a cause. The most simple intention, or object of nature, seems to be the removal of a useless part, as the thymus gland, membrana pupilaris, ductus arteriosus, the alveoli when the teeth drop, or the crystalline humor after coughing, and pro- bably the wasting of the body from fever either acute or hectic. These parts are removed by the absorbents, either as useless parts or in consequence of strength being unne- cessary while under disease, or such as not to accord with dis- ease. * Another cause is a weakness, or the want of power in the part to support itself under certain irritations, which may be considered as the basis of every cause of removal of whole parts; as the absorption of calluses, cicatrices, the gums in salivation; also that arising from pressure, or irri- * It might be asked as a question, whether the waste of the constitution in disease arises from the body becoming useless when under such diseases, as may be observed of muscles when their joint, tendon, etc. is diseased; or whether it accords bet- ter with the diseased state, and may even tend to a natural cure? 168 The ulcerative inflammation. tating applications, under which may be included the at- tachment of dead parts to a living one; all of which may be accounted for upon the same principle of parts or organs not being able to support themselves under the present evil. From the above account of the final cause of the absorp- tion of whole parts from disease, it would appear that they are capable of being absorbed from five causes. First, from parts being pressed; secondly, from parts being considera- bly irritated by irritating substances; thirdly, from parts being weakened; fourthly, from parts being rendered use- less; fifthly, from parts becoming dead. The two first, for instance, parts being pressed, and parts being irri- tated, appear to me to produce the same irritation; the third, or weakness, an irritation of its own kind; and the fourth, or parts being rendered useless, and the fifth, or parts becoming dead, may be somewhat similar. It is probable that every cause above enumerated is ca- pable of producing every mode; or rather effect of absorp- tion whether interstitial or progressive; but pressure attended with suppuration always produces the progressive, whether applied externally or, internally, as in the case of abscesses. II. OF THE DISPOSITION OF LIVING PARTS TO ABSORB AND TO BE ABSORBED. THE dispositions of the two parts of the living body, which absorb and are absorbed, must be of two kinds res- pecting the parts; one passive and the other active. The first of these is an irritated state of the part to be absorbed, which renders it unfit to remain under such circumstances; the action excited by this irritation being incompatible with the natural actions and the existence of the parts whatever these are, therefore become ready for removal, or yield to it with ease. The second is the absorbents being stimulated to action by such a state of parts, so that both conspire to the same end. The ulcerative inflammation. 169 When the part to be absorbed is a dead part, as nourish- ment or extraneous matter of all kinds, then the whole dis- position is in the absorbents. When those immediate causes arise in consequence of pressure, it would appear that absorption takes place more readily under certain circumstances than others, although the remote causes of them appear to be the same, therefore something more than simple pressure; for we find that pressure from within produces ulceration or absorption much more readily than from without; for if it was pres- sure only, absorption then would be according to the quantity of pressure; but we find very different effects from the same quantity of pressure under the abovementioned circum- stances; for when from without, pressure rather stimu- lates than irritates; it shall give signs of strength, and pro- duce an increase of thickening; but when from within, the same quantity of pressure will produce waste; for the first effect of the pressure from without is the disposition to thicken, which is rather an operation of strength; but if it exceeds the stimulus of thickening, then the pressure be- comes an irritator, and the power appears to give way to it, and absorption of the parts pressed takes place, so that nature very readily takes on those steps which are to get rid of an extraneous body, but appears not only not ready to let extraneous bodies enter the body, but endea- vours to exclude them, by increasing the thickness of the parts. Many parts of our solids are more susceptible of being absorbed, especially by ulceration, than others, even un- der the same or similar circumstances, while the same part shall vary its susceptibility according to circumstances. The cellular and adipose membranes are very particular- ly susceptible of being absorbed, which is proved by mus- cles, tendons, ligaments, nerves and blood vessels being found frequently deprived of their connecting membrane and fat; especially in abscesses, so that ulceration often takes a roundabout course to get to the skin, following the track of the cellular membrane; and the skin itself, when the pressure is from within, is much less susceptible of ul- ceration than the cellular and adipose membrane, which re- tards the progress of abscesses, when they are so far advanc- ed, and also becomes the cause of the skin's hanging over VOL. II. Y 170 The ulcerative inflammation. spreading ulcers, which are spreading from the same cause more especially too, if the part ulcerating is an original part. Ulceration never takes place on investing mem- branes of circumscribed cavities, excepting suppuration has taken place; and, indeed, ulceration in such parts would be a sure forerunner of suppuration. New formed parts, or such as cannot be said to constitute part of the original animal, as healed sores, calluses of bones, especially those in consequence of compound frac- tures admit more readily of absorption, especially the pro- gressive, than those parts which were originally formed; this arises probably from the principle of weakness, and it is from this too, that all adventitious new matter, as tu- mors, are more readily absorbed than even that which is a substitute for the old. Thus we have tumors more readily absorbed than a callus of a bone, union of a tendon, etc. because they have still less powers than those which are sub- stitutes for parts originally formed. Ulceration in consequence of death in an external part, takes place soonest on the external edge between the dead and the living. This is visible in the sloughing of parts; for we may observe that sloughs from caustics, bruises, mor- tifications, etc. always begin at the external edge. An internal pressure produced by an extraneous body, acts equally on every side of the surrounding parts, and therefore every part being pressed alike, ought, from this cause alone, to produce absorption of the surrounding parts equally on all sides; supposing the parts themselves simi- lar in structure, or which is the same, equally susceptible of being absorbed; but we find that one side only of the surrounding living parts is susceptible of this irritation, therefore one side only is absorbed; and this is always the side which is next to the external surface of the body. We therefore, have always extraneous bodies of every kind, determined to the skin, and on that side to which the extra- neous body is nearest, without having any effect, or pro- ducing the least destruction of any of the other surrounding parts. From this cause we find abscesses, etc. whose seat is in, or near the centre of a part, readily determined to the surface on the one side, and not on the other; and whenever the lead is once taken, if immediately goes on. But as some parts, from their structure, are more suscep- tible of this irritation than others, we find that those parts The ulcerative inflammation. 171 composed of such structure, are often absorbed, although they are not in the shortest road to the skin; this structure is the cellular membrane, as will be taken notice of here- after. We find the same principle in the progress of tumors; for although every part surrounding a tumor is equally pressed, yet the interstitial absorption only takes place on that side next the external surface, by which means the tu- mor is, as it were, led to the skin; from hence we find that absorption of whole parts more readily takes place, to allow an extraneous substance to pass out of the body, than it will to allow one to pass in. Thus we see, that the slight pressure produced by matter on the inside of an abscess has a great effect, and the mat- ter is brought much faster to the skin (although very deep) than it would by the same quantity of pressure applied from without; and, indeed, so slight a pressure from without would rather tend to have an opposite effect, namely, that of thickening. The reason of this is evident; one is, a readiness in the parts to be freed from a disease already existing; the other is, a backwardness in the parts to admit a disease. This principle, therefore, in the animal œconomy produces one of the most curious phœnomena in the whole process of ul- ceration, viz. the susceptibility which the parts lying be- tween an extraneous body and the skin have to ulcerate, while all the other sides of the abscess are not irritated to ulceration; and the necessity there is that it should be so, must be very striking; for if ulceration went on equally on all sides of an abscess, it must increase to a most enormous size, and too great a quantity of our solids must necessarily be destroyed. Bones, we have observed, are also subject to similar cir- cumstances of ulceration; for whenever an abscess forms in the centre of a bone, or an internal exfoliation has taken place, the extraneous body acts upon the internal surface of the cavity, and produces ulceration. If the matter or dead piece of bone is nearer one side than the other, ulceration takes place on that side only; and here too the provision of nature in abscesses comes in, for the adhesive inflammation extends itself on the outside in proportion as ulceration extends itself on the inside of the cavity, and as ulceration approaches, to the surface of the 172 The ulcerative inflammation. bone, the adhesive disposition is given to the periosteum, then to the cellular membrane, etc. And what is very cu- rious, this adhesive inflammation assumes the ossifying dis- position, which I have called the ossific inflammation, and appears as a spreading ossification, in the same manner as in the callus of a simple fracture. The consequence of these two processes taking place to- gether in bones is very singular, for the ulcerative process destroying the inside of a bone while the ossifying makes addition to its outside, the bone often increases to a prodi- gious size, as in cases of spinæ ventosæ; but in the end the ulceration on the inside gets the better, and the matter makes its escape. Nature has not only made what might be called an in- stinctive provision in the parts to remove themselves, so as to bring extraneous bodies to the skin for their exit, and thereby, from this principle, has guarded the deeper seat- ed parts; but has also guarded all passages or outlets, where, from reasoning, we might suppose no great mischief could arise from bringing extraneous bodies thither; and in ma- ny cases a seeming advantage would be gained; such pas- sages appearing to be more convenient for the exit of such matter, and likely to produce less visible mischief in pro- curing them. Thus a tumor in the cheek, close on the internal mem- brane of the mouth, and some way from the skin, shall in its growth push externally, especially if there is matter in it, and in time come in contact with the skin and adhere to it, while it shall have made no closer connexion with the skin of the mouth; if it should suppurate, and more especially if it be of a scrofulous kind, which is flow in its progress, it will break externally; we even see abscesses in the gums opening externally, where the matter has been o- bliged to go a considerable way to get to the skin. The same guard is set over the cavity of the nose; if an abscess forms in the antrum, frontal sinus or faccus lacri- malis, all of which are nearer to the cavity of the nose than the external surface of the body, ulceration does not follow this shortest way, which would be directly into the nose, but leads the matter to the neared external surface. I have seen an abscess in the frontal sinus, first attended with great pain in the part, then with inflammations on the whole forehead, at last matter has been felt under the The ulcerative inflammation. 173 skin; and on being opened it has led into one or both si- nuses, and almost the whole bone has exfoliated. For such an abscess, the nearest passage would have been directly in- to the nose. Abscess in the lacrimal sac, forming, what is called the fistula lacrimalis, arises also from the same cause; a curious circumstance takes place here; but whether pe- culiar to this part or not, I do not yet know. Besides the disposition for ulceration externally at the inner corner of the eye, there is a defence set up upon the inside, so that the membrane of the nose thickens very considerably; how far a thickening takes place on the inside of the nose, opposite to the antrum, in abscesses of that cavity, or how far it is an universal principle in other passages, I have not been able to learn, but am inclined to believe it is not universal. From this principle we can see why openings made into these passages to make the matter come that way are more unsuccessful, than reasoning (without the know- ledge of this principle) would lead us to believe; the open- ing, therefore should not be made on the inside (even where we can do it) excepting the matter is very near, or else the opening should be made very large; and probably, in such cases, it may be necessary to take out a piece, so as to prevent the uniting process, which is here very strong. Illustrations will be given in other passages, when treat- ing of ulceration in general tending to the external surface. III. OF INTERSTITIAL ABSORPTION. INTERSTITIAL absorption, I observed, was of two kinds, with respect to effect, or rather had two stages. The first was, where it took place only in a part, as in the wasting of a limb in consequence of its being rendered use- less, whether from disease in a joint, a broken tendon, or the dividing of a nerve whereby its influence is cut off; or where it takes place in the whole body, in consequence of some disease, as in acute fever, hectic fever, diabetes, a- trophy, or the like. The second is the absorption of a whole part, where not a vistige is left. This would seem to be of two kinds; one, where it is only a consequence of 174 The ulcerative inflammation. another disease, and is a necessary and useful effect of that disease, as in assisting in bringing parts to the surface; but the other appears to arise from a disease in the part it- self; as the total decay of the alveoli; without any disease in the teeth or gums, which in the end suffer; as also a total wasting of a testicle, the absorption of a callus, etc. It is the first of these two kinds which is most to my present purpose, and deserves our particular attention. It takes place in a thousand instances; we find it gradually taking place in the part of the body which happens to the between insysted tumors, and the external surface, when they are making their way to the skin. This absorption is commonly slow in its progress, so much so, as even to make the ultimate effect, although con- siderable, not sensible till a certain length of time has elaps- ed. This mode of removing parts, appears to arise from pres- ure, as in the former; but here some principles are rever- sed. The contents of an incysted tumor do not give the stimulus of removal to that side of the syst nearest to the external surface, as happens in an abscess, so as to produce a removal of the surface pressed by its contents, which would be the progressive ulceration, as in our first division; but the tumor gives the stimulus to the sound parts, be- tween it and the skin, and an absorption of those parts takes place, similar to that which I suppose takes place in the removal of calluses of bones, from weakness. We find when- ever an incysted tumor is formed in the cellular membrane, it in time makes its approaches towards the skin, by the cel- lular membrane and other parts between it and the skin being absorbed, so that the whole substance between the cyst and skin becomes thinner and thinner, till the cyst and the external skin meet or come in contact, and then in- flammation begins to take place; for as the parts are now soon to be exposed, inflammation takes place to produce a quicker absorption, which borders often upon ulceration. The mode of action in this last case may be, in one respect, very similar to the foregoing solid tumor, for besides the interstitial absorption, the cyst may be looked upon as a tu- mor acting upon, or stimulating the parts between it and the skin; therefore the tumor causes absorption of the con- tiguous cellular membrane, upon which it presses. This pro- cess of interstitial absorption of parts is very evident, even in common abscess; where a progressive absorption is going on, it is assisted by this. The ulcerative inflammation. 175 I have already observed, that the interstitial absorption is not attended with, nor produces suppuration. IV. OF THE PROGRESSIVE ABSORPTION. THE first or principle mode of this action, is the removing of those surfaces that are immediately contiguous to the ir- ritating causes which is an absorption of necessity. These causes, I have observed, are of three kinds; one, pressure; another, irritating substances; and the third, considerable inflammation on a weak part, especially those new-formed parts that become a substitute for the old. Absorption, from pressure, is the removal of the part pressed, which may arise from a number of causes. There are tumors, which by pressing upon neighbouring parts, produce it; the pres- sure of the blood in aneurisms produces it, etc. also that surface of an abscess which is in contact with the pus, or any other extraneous body; or the ulceration of that part of the surface of the body, which is in contact with a body pressing, as the buttocks or hips of those who lie long upon their backs. The heels of many people, who also lie long in the same position, as is the case with those who are un- der the cure of a fracture of the leg; in which case it seems to be a substitute for mortification, and is rather a proof of the strength of the patient; for if very weak con- stitutionally, the same parts certainly mortify; as also the con- stant pressure of chains on the legs of prisoners; harness on the breasts of horses. The second of this cause of absorption is the action of irritating substances, such as the tears passing constantly over the cheeks; as also many irritating medicines, produc- ing too much action, and probably at the same time weaken- ing the parts. The third is, the formation of an ulcer, or sore, on a surface, in consequence of some disease, which has been the cause of inflammation. Bones are subject to the same effect from pressure as the soft parts; as in con- sequence of aneurisms; as also from the pressure from tu- mors: likewise in cases of the spina ventosa, where in some 176 The ulcerative inflammation. there is nothing to be found in the cavity of the swelling but blood coagulated; in others, a grumous or curdly subs- tance. This blood, or substance, increasing, continues the pressure, and the inside of the bone is in time absorbed. I have already observed, that the progressive absorption is divisible into two kinds; one without suppuration the o- ther with. I shall now observe, that the absorption which does not produce suppuration, may take place, either from pressure made by sound parts, upon diseased parts, or by diseased upon sound parts; as the effect that the pres- sure of the coagulated blood has in aneurisms, the moving blood in the same, which is a sound part, contained in dis- eased arteries not capable of supporting the pressure of the moving blood; as also many tumors, which are diseased parts, pressing upon natural sound parts, and these diseas- ed parts are simply endowed with life, which I apprehend makes some difference in the effects respecting the formation of pus; also uncommon pressure made by such substances as are not endowed with any irritating quality, sufficient to produce the suppurative inflammation, as a piece of glass, a lead bullet etc. all of which I shall now more fully explain. Of this first division, viz. from pressure without suppu- ration, we have several instances; in aneurisms; especially when they are in the aorta, and principally at the curve; and when arrived at a considerable size, so as to press a- gainst the surrounding parts, particularly against the back- bone, as also against the sternum; all of which will be ac- cording to the situation of the aneurism; we find in such cases, that from the dilatation of the artery (which arises from the force of the heart) the artery is pressed against those bones, and that the substance of the artery in the part pressed is taken into the constitution. This absorption be- gins at the external surface of the artery, where it comes in contact with the bone, and continues there till the whole artery is absorbed; then the bone itself comes in contact with the circulating blood, and not being naturally intend- ed to be washed by moving blood, the bone or bones are al- so absorbed from this pressure, and motion of the blood a- gainst them. The adhesive or strengthening disposition takes place in the surrounding parts, and is of great service here, as it unites the circumference of the unabsorbed part of the artery to the surrounding parts; as also the cellular The ulcerative inflammation. 177 membrane beyond the surface of absorption, (when in soft parts) similar to the preceding adhesive inflammation go- ing before ulceration in an abscess; but it is here much stronger, for strength is wanted as well as adhesion while it is dilating; so that a cavity of some strength for the mov- ing blood is always kept entire, and no extravasation can take place, nor can the parts readily give way. Another instance of this absorption occurs in those cases where living tumors make their way to the skin without the formation of an abscess. I once saw a remarkable instance of this in a Highland soldier, in the Dutch service, who had a solid tumor formed, either in the substance of the brain, or, what is more probable, upon it, viz. in the pia mater, for it seemed to be covered by that membrane: the tumor was oblong, above an inch thick, and two or more inches long; it was sunk near its whole length into the brain, seemingly by the simple effects of pressure; but the outer end of it, by pressing against the dura mater, had pro- duced the absorbing disposition in that membrane, so that this membrane was entirely gone at that part. The same irritation from pressure had been given to the scull, which also was absorbed at this part; after which, the same disposition was continued on to the scalp. As these respective parts gave way, the tumor was push- ed further and further out, so that its outer end came to be in this new passage the absorbents were making for it in the scalp, by which it probably would have been discharged in time, if the man had lived; but it was so connected with the vital parts, that the man died before the parts could re- lieve themselves; while all these exterior parts were in a state of absorption, the internal parts which pressed upon the inner end of the tumor, and which pressure was sufficient to push it out, did not in the least ulcerate, nor did the tu- mor itself, which was pressed upon all sides, in the least give way in its substance. No matter was to be observed here from either the dura mater, the unconnected edge of the bones of the scull, nor from that part of the scalp which had given way; and, perhaps, the reason was, the tumor being a living part, and not an extraneous one. The general effect was, however, similar to the progress of an abscess, in so much that it was on that side nearest to the ex- VOL. II. Z 178 The ulcerative inflammation. ternal surface of the body that the irritation for absorption took place. The first species of the absorption of whole parts is sel- dom or never attended with pain. Its progress is so very slow, as to keep pace with our sensations, and in many ca- ses it is not even attended with inflammation. I believe that this absorption seldom or ever affects the constitution, although, in some cases it takes its rise from affections of the constitution, as in the cases of the absorp- tion of callus. V. OF ABSORPTION ATTENDED WITH SUP- PURATION, WHICH I HAVE CALLED UL- CERATION. I SHALL now give an account of that part of the actions of the absorbing system, which I call ulceration, and which is the second of our first division, respecting the formation of pus, viz. that which is connected with the formation of that fluid, being either a consequence of it, or producing it, and is that which in all cases constitutes an ulcer. It is this which principally constitutes the progressive absorp- tion. * This differs from the foregoing in some circumstances of its operations. It either takes place in consequence of sup- puration already begun, and then the pus acts as an extra- neous body, capable of producing pressure; or absorption attacks external surfaces from particular irritations or weak- ness, in which case suppuration, forming an ulcer, must * I have given it the term ulceration, because ulcer is a word in use to express a sore, and it is by this process that many ul- cers are formed. The operations produced in ulceration, have not hitherto been in the least understood, therefore a ve- ry erroneous cause of these operations has been always suppos- ed. It has always been supposed that those solids which were visibly gone, were dissolved into pus: from whence arose the idea of matter being composed of solids and fluids, which we have endeavoured to refute. The ulcerative inflammation. 179 follow, let the cause of that breach or loss of substance be what it may. In order to produce ulceration from pressure, I may again take notice, that it requires a much greater pressure from without than from within; and when it is from within, the ulceration is quicker, when near to the skin, than when deep or far from it; the nearer to the skin, the inflamma- tion more readily takes place; and I have also observed, that inflammation, although it takes place in deep seated parts, yet it seldom or never extends deeper, but approach- es towards the external surface; and as inflammation seems to proceed and is essential to this process, we see the rea- son why it should take place sooner if near to the skin, and go on faster the nearer it comes to it. The process of ulceration which brings matter to the ex- ternal surface is not wholly the absorption of the inner sur- face of the abscess, for there is an interior or interstitial ab- sorption of the parts lying between the inner surface of abscess and the skin, similar to the approach of incysted tu- mors, as has been described. And besides this assistance, I have already observed, there is a relaxing and elongat- ing process carried on between the abscess and the skin; and at those parts only where the matter appears to point. This process of ulceration, or absorption, with suppura- tion, is almost constantly attended by inflammation; but it cannot be called an original inflammation, but a conse- quent, which gave rise to the term ulcerative inflammation. It is always preceded by the adhesive inflammation, and perhaps it is simply this inflammation which attends it; we find the adhesions produced answering very wise purposes; for although the adhesive inflammation has preceded the suppurative, and of course all the parts surrounding the abscess are united, yet, if this union of the parts has not extended to the skin, where the abscess or matter is to be discharged, in such a case, wherever the ul- ceration has proceeded beyond the adhesions there the mat- ter will come into un adhering parts; the consequence of which will be, that the fluid, or matter, will diffuse itself in- to the cellular membrane of the part, and from thence over the whole body, as in the erysipelatous suppuration; but to prevent this effect, the adhesive inflammation takes the lead of ulceration. There are many other causes of ulcer- ation, which take place on surfaces, where we do not see 180 The ulcerative inflammation. the same necessity for it; when the matter formed can be, and is discharged without it; such parts are many old sores; the inside of the stomach and intestines, and indeed all the surfaces abovementioned, which do not admit readi- ly of the adhesive inflammation; under some circum- stances admit of the ulcerative. This effect would appear to arise from the violence of the inflammation, the parts be- ing so weakened, either by it, or some former disease, that they can hardly support themselves; for we find in saliva- tions, where the whole force of the mercury has been de- termined to the mouth, they have become weakened by long and violent action; the gums and inside of the mouth will ulcerate; also, from the same weakening disposition, the gums will ulcerate in bad scurvies; therefore weakness join- ed with inflammation, or violence of action, appears to be the immediate cause in such cases. The effect then of irritation, as above described, is to pro- duce first the adhesive inflammation in such parts as will readi- ly admit of it, and if that has not the intended effect, the sup- purative takes place, and then the ulceration comes on to lead the matter already formed to the skin, if it is confined. The natural consequence of suppuration in such parts, is the growth of new flesh, called granulations, which are to repair the loss the parts sustained by the injury done; but in all outlets, where the adhesive would be hurtful, the ir- ritation first only produces the suppurative inflammation; but if carried further, the adhesive will take place, as has been described; and, as in such parts the matter formed has an outlet, ulceration is also avoided; and, as in such cases, no parts are destroyed, granulations are also excluded. There appears to be a curious circumstance attending ul- ceration, which is the readiness with which it seems to ab- sorb every other substance applied to it, as well as the bo- dy itself; at least this appears to be the case with the small- pox after inoculation; as also the venereal chancre; whe- ther arising from the absorbents at the time being in the act of absorbing, or whether they promiscuously absorb what is applied, along with the part themselves. In such case it might be a question also, whether the parts of the body which they do absorb have the same disposition with the pus of that part, as in the cancer, therefore, contaminate the constitution, as in the small-pox and venereal dis- ease, as readily as if it was the pus. The ulcerative inflammation. 181 From what has been observed, it must appear that any irritation which is so great as to destroy Suddenly the natu- ral operations of any one part, and the effect of which is so long continued as to oblige the parts to act for their own relief, produces in some parts, first the adhesive inflamma- tion; and if the cause be increased, or continue still longer, the suppurative state takes place, and all the other conse- quences, as ulceration; or, if in the other parts, as secret- ing surfaces, then the suppurative takes place immediately; and if too violent, the adhesive will succeed; or if parts are very much weakened, the ulcerative will immediately succeed the adhesive, and then suppuration will be the con- sequence. This species of ulceration in general gives considerable pain, which pain is commonly distinguished by the name of soreness; this is the sensation arising from cutting with an instrument, which operation is very similar to ulcera- tion; but this pain does not attend all ulcerations, for there are some of a specific kind, which give little or no pain, such as the scrofula; but even in this disease, when the ulceration proceeds pretty fast, it gives often considera- ble pain; therefore the pain may be in some degree pro- portioned to the quickness of its operation. The greatest pain which in general attends this operation arises from those ulcerations which are formed for the pur- pose of bringing the matter of an abscess to the skin: as al- so where ulceration begins upon a surface, or is increasing a sore. Whether the increase of pain arises from the ul- cerative inflammation, singly, or from the adhesive and ul- cerative going on together in the same point, is not easily determined; but in some cases these three are pretty rapid in their progress, and it is more than probable that the pain arises from all these causes. In those cases where ulceration is employed in separat- ing a dead part, such as sloughing, exfoliation, etc. it is seldom attended with pain; perhaps it may not be easy to assign a cause for this. The effects that ulceration has upon the constitution I have mentioned, with the effects that other local complaints have upon it. It is easy to distinguish between a sore that is ulcerating, and one which is standing still, or granulating. 182 The ulcerative inflammation. The ulcerating sore is made up of little cavities or hol- lows, and the edge of the skin is scalloped or notched; is thin, turned a little out, and overhangs, more or less, the sore. The sore is always foul, being probably composed of parts not completely absorbed; and discharges a thin mat- ter. But when the ulceration stops, the edge of the skin be- comes regular, smooth, a little round or turned in, and of a purple colour, covered with a semi-transparent white. VI. OF THE RELAXING PROCESS. BESIDES these two modes of removing whole parts, act- ing singly or together, there is an operation totally distinct from either, and this is a relaxing and elongating process, carried on between the abscess and the skin, and at those parts only where the matter appears to point. It is possi- ble that this relaxing, elongating, or weakening process may arise in some degree from the absorption of the interior parts; but there is certainly something more, for the skin that co- vers an abscess is always looser than a part that gives way from mere mechanical distention, excepting the increase of the abscess is very rapid. That parts relax, or elongate, without mechanical force, but from particular stimuli, is evident in the female parts of generation, just before the birth of the fœtus; they be- come relaxed prior to any pressure. The old women in the country can tell when a hen is going to lay, from the parts becoming loose about the anus. That this relaxing process takes place between an abscess and the skin is evident in all cases, but was more demonstra- tively so in the following case than commonly can be obser- ved where an increase of surface takes place without the visible loss of substance, for here both could be exactly as- certained; and, indeed, no abscess could swell outwards, excepting by distention, without it. The ulcerative inflammation. 183 In the following case this process was particularly evi- dent. A lad about thirteen years of age, was attacked with violent inflammation in his belly, without any apparent cause. The usual means were used, but without effect. His belly began to swell in a few days after the attack, and his skin became cold and clammy, especially his feet and hands. Once, when he made water, it was transparent like spring water, with a little cloud of mucus. In several places of the belly, there appeared a pointing, as if from matter; one of those, which was just below the sternum, became pretty large, and discoloured with a red tint. Although there was not any undulation or perfect fluctuation (there not being fluid enough for such a feel) yet it was plain there was a fluid, and most probably from the pointings, it was matter in conse- quence of inflammation, and that it was producing ulceration on the inside of the abdomen for its exit; therefore it was thought advisable, as early as possible, to open the belly at one of those parts. I made a small opening into the pointing part, just below the sternum, hardly an inch long: when I was performing the operation, I saw plainly the head of the rectus muscle, which I cut through in the direction of its fibres. There was immediately discharged by this wound about two or three quarts of a thin bloody matter. The swelling of the abdomen subsided of course; his pulse began to rise and become more full and soft; and his extremities became warmer; he was ordered bark, etc. but he lived only about sixty hours after the operation. On opening his abdomen after death we found little or no matter lying loose; all had made its escape through the wound. The whole intestines, stomach, and liver, were united by a very thick covering of the coagulating lymph, which also passed into all the interstices between them, by which means they were all united into one mass, the liver also adhered to the diaphragm, but none of the viscera ad- hered to the inside of the belly on its fore part, for there the matter had given the stimulus for ulceration, which prevents all adhesions. The process of ulceration had gone on so far as to have destroyed the whole of the peritoneum on the fore part of the abdomen, and the transversales, and recti muscle, were cleanly dissected on their inside. 184 The ulcerative inflammation. The tendons of the lateral muscles that pass behind the heads of the recti, were in rags, partly gone, and partly in the form of a slough. From this view of the case, we must see how nature had guarded all the most essential parts. In the time of the ad- hesive stage, she had covered all the intestines with a coat of coagulating lymph, so as to guard them; and this, probably, upon two principles, one, from their being canals; and therefore loath to admit of penetration in that way; the other, from their being more internal than the pirates of the abdomen; one side is therefore thickened for their defence, while the other is thinned for the relief of the part. Here the cavity of the abdomen had assumed all the pro- perties of an abscess, but it was so connected with the vi- tal parts, which also suffered much in the inflammation, that the patient could not support the necessary processes towards what would be called a radical cure in many other parts; and indeed, considering the mischief done to the abdomen and its viscera, it is astonishing he lived so long. The most curious circumstance that happened, was the appearance of pointing in several places; for why one part of the abdomen should have pointed more than another is not easily accounted for, since every part of the anterior portion was nearly equally thin, each part was equally in- volved in the abscess, and the ulceration had not yet be- gun with any of the muscles. To account for this, let us suppose that one, two, or three parts (by some accident) were more susceptible of the ulcerative stimulus than the others, and that the parts were ready to give way; but al- though these parts which were pointing, were the places where ulceration would have gone on brisker, yet it had not proceeded further here than in any other part; it had only gone through the peritoneum, and the tendons of the broad muscles; and the recti muscles were sound and per- fect at the place where I made the opening, which was the most protuberant of any; therefore this pointing did not appear to arise from weakness or thinness of this part; and, even supposing that the pointing was an effect of weak- ness, it would imply a great deal of pressure on the inside, (which at least was not the case here) and simple pressure, although a hundred times greater, which we often see take The ulcerative inflammation. 185 place in dropsies, would not produce a pointing, if not at- tended with some specific power. If pressure then was not sufficient to produce this effect in the present case, and if the parts which pointed were as mechanically firm as at any other, to what other cause can we attribute the distention of this part, but to the weaken- ing, elongating, and relaxing process, which I have already described. This observation of the relaxing process going on in the substance of the parts where it points, is verified in a thou- sand instances: suppose a large abscess in the thigh, only covered by the skin and adipose membrane, which shall go on for months without producing ulceration, and of course not point any where, but shall be a smooth, even, and uni- form surface, let it receive the stimulus of ulceration in any one part, that part will immediately begin to point, al- though it may be thicker there than at some other parts of the same abscess. The pressure necessary to allow extraneous matter to make its escape, need not be great; for in many abscesses which have been opened, or have opened of themselves, but not at the most depending part, so that the matter is allowed to stagnate at the lower part of the cavity, mak- ing a very slight pressure, we find that this alone is sufficient to produce ulceration in that part, and of course a fresh o- pening is produced, more especially if near the skin; this we see often takes place in abscesses of milk breasts, when the opening is not at a depending part, and appears to be common in the fistula in ano; for it frequently happens that the ulceration goes on at first towards the gut; but be- fore this has taken place, ulceration has gone on some way by the side of it, to bring the matter externally, which weight of matter is alone sufficient to continue the same process. VOL. II. Aa 186 The ulcerative inflammation. VII. OF THE INTENTION OF ABSORPTION OF THE BODY IN DISEASE. THIS, like every thing else in nature, involves in it two consequences, the one beneficial, the other hurtful; both of which this has in a considerable degree: however, if we understood thoroughly all the remote causes we should probably see its utility in every case, and these effects, how- ever bad in appearance, yet are necessary, of course in the end salutary. The use arising from what may be called the natural absorption of parts, such as the forming or mo- delling process, as also the absorption of parts become unfit for the new mode of life, as the absorption of the thymus gland, etc. is involved in its necessity, and belongs to the natural history of the animal; but that arising from disease is directly to the present purpose. In the history I have just given, its use must, I apprehend, be evident; for we plainly see, in each mode of absorption, it often produces very salutary effects; and we may say, that although it often arises from disease, yet its operations and effects are often not at all a disease; and, probably, in those cases where we cannot assign a cause, as in wasting of parts, atro- phy, etc. yet it is most probable that its use is considerable. It is likely, that under such a disease, or state of body, or parts, it would be hurtful to have them full and strong; where it produces a total waste of a part, its utility is pro- bably not so evident; but in the progressive absorption, where it is leading bodies externally, or in consequence of suppuration, where it is bringing matter externally, its use is plain; or even in the formation of an ulcer, or the spreading of an ulcer, its use may be considerable. I have formerly called it the natural surgeon; and where it can do its business it is in most cases preferable to art: this is so evident in many cases, that it has been a constant practice to attempt to promote it, in bringing abscesses to the sur- face, and in the exfoliation of bone, etc. although not ac- counted for upon the principle of absorption, yet the effect was visible, and its use allowed. The ulcerative inflammation. 187 VIII. THE MODES OF PROMOTING ABSORP- TION. THE history that was given of the causes of absorption, in some degree explains the modes of promoting it; but as there were some natural causes which we cannot imitate, it is principally those that can be rendered useful that we are to take notice of in this place. To promote absorption of the body itself, is no difficult operation; it is only to lessen the supply, and increase the waste, which last is often done by medicine; or to take such things as will render the supply less efficacious, as vine- gar or soap; but probably these act principally on the fat: to promote absorption of diseased parts, or parts increas- ed, or parts newly formed, is not so easy a talk, although the latter may be the most easy of the whole; for I have as- serted, that newly formed parts are weaker in their living powers than the original formed parts; this, in some de- gree, gives us a hint; for if we have a mode of producing a waste of the original body, under this general waste, new formed parts must suffer in a degree proportional to their weakness; and therefore will suffer a diminution in the same proportion; but this is too often not sufficient, or at least what would be sufficient for the disease would be too great for the constitution to bear: however, we find in particu- lar cases, that this practice has some effect; probably the best debilitating medicine is mercury, and it probably may act in more ways than one. It may promote absorp- tion from a peculiar stimulus, producing necessity, or a state under which the parts cannot exist. Electricity, and most other stimulants, probably act in the same manner; for we find that violent inflammation is often a cause. Death in a part is sure to promote absorption, in order to produce a separation of the dead parts: and we even find that a part being diseased gives a tendency to separation, and only re- quires a considerable inflammation to promote it, such as warts coming away in consequence of inflammation. A diseased part has such power of giving the proper stimulus to the adjacent sound part, that if injured, or rendered dead in part by the application of a caustic, for instance, the sound part underneath will begin to relax, and shew 188 The ulcerative inflammation. more distinctly the limits or boundaries of the disease; so that a separation of the diseased parts begins to take place, although the caustic has not reached nearly so far, and may give us an intimation of the extent of the disease, which we could not get before. It is in some measure upon this principle that arsenic removes tumors which extends be- yond the immediate effect of the medicine. Pressure is one of the causes of absorption in general, particularly the progressive, which, in the resolution of parts, is not the mode wanted; but it also assists in produc- ing the interstitial; and if it could be made to produce the second of the interstitial, viz. absorption of the whole, as in the total decay of the thymus gland, then it would be suf- ficient in those cases where it could be applied: but the pres- sure must be applied with great care; for too much will either thicken or ulcerate, which last may be a mode of absorption we do not want: however, these effects will happen according to circumstances; for I have an idea, that entirely new formed parts, as tumors, will not be made to thicken by pressure, therefore may be pressed with all the force the natural surrounding parts will allow. On the other hand there are many cases where we would wish to prevent absorption; but when this is the case, we should be certain that the part which was to have been absorbed is such as can be rendered useful afterwards; of which I have my doubts in many cases. IX. ILLUSTRATIONS OF ULCERATION. NOW that I have been endeavouring to give ideas of these effects of inflammation, viz. adhesion, suppuration, and ulceration, let me next mention some cases which fre- quently occur, as illustrations, which will give a perfect i- dea of these three inflammations: and, for the clearer un- derstanding them, I shall illustrate them upon the inflam- mation, suppuration, and ulceration of the large circum- The ulcerative inflammation. 189 scribed cavities. For instance, an inflammation attacks the external coat of an intestine; the first stage of this inflam- mation produces adhesions between it and the peritoneum lining the abdominal muscles: if the inflammation does not stop at this stage, an abscess is formed in the middle of these adhesions, and the matter acts as an extraneous body; the abscess increasing in size from the accumulation of mat- ter, a mechanical pressure is kept up, which irritates, and the side next to the skin is only susceptible of the irrita- tion; this irritation not destroying the disposition to form matter, suppuration is still continued, and the ulcerative inflammation takes place. If suppuration began in more parts of the adhesions than one, they are commonly united into one abscess; an ab- sorption of the parts between the abscess and the skin takes place, and the matter is led on to the external surface of the body, where it is at last discharged. If the disposition for ulceration was equal on every side of the abscess, it must open into the intestine, which is sel- dom the case, although it sometimes does; for the same precautions are not taken here as in many other situations; for in some others, as in the nose, in the case of an abscess of the lacrimal sack, the passage is thickened towards the nose. In the case above-described, however, the abdomi- nal muscles, fat, and skin are removed, rather than the coats of the intestine. Cases of this kind have come under my own observation. In this case, if adhesions had not preceded ulceration, the matter must have been diffused over the whole cavity of the belly; if the adhesive inflammation had not likewise gone before the ulceration in the abdominal muscles, etc. the matter would have found a free passage from the ab- scess into the cellular membrane of the abdomen, as soon as the ulceration had got through the first adhesions, as is of- ten the case in erysipelatous suppurations. Abscesses between the lungs and the pleura, in the liver, gall-bladder, etc. rise to the surface from the same cause; also in lumbar abscesses, where one would at first imagine the readiest place of opening would be the cavity of the abdomen, or gut; the parts nearest to the skin are remov- ed, and the matter passes out that way; however, in ab- scesses so very deep, it does not always happen that one 190 The ulcerative inflammation. side only is susceptible of the irritation, and we shall find that the matter is taking different courses. Abscesses in the substance of the lungs sometimes differ from the above described; for they sometimes open into the air-cells: it is, because the adhesive inflammation finds it difficult to unite the air-cells, and branches of the tra- chea, (as was described in treating of that inflammation) and also in the substance of the lungs, it may be difficult to say where it can take a lead externally, from which, probably, the air-cells become similar to an external surface, and then ulceration takes place on that side of the abscess which is nearest to the cells; therefore we find that the matter gets very readily into the air-cells, and from thence into the trachea. That the air-cells do not take on the adhesive state is e- vident in most abscesses in this part; for we find in most of those cases that the air cells are exposed, as also the branch- es of the trachea, and the parts of the lungs which com- pose this abscess have not the firmness and solidity which the adhesive inflammation generally produces in those parts where it takes place. Thus too we find it going on in large abscesses, even after they have been opened, but are so situated or circumstan- ced as to have some part of the abscess on that side imme- diately under the skin pressed by some other part of the bo- dy which lies underneath. For instance, when a large ab- scess forms on the outer, and upper part of the thigh, op- posite the great trochanter, which is a very common com- plaint, and an opening is made into it, or it bursts below, or on the side of that bone, but not directly opposite to the trochanter itself, in such cases it frequently happens, that the pressure of the trochanter on the inside of the abscess, viz. the cellular and adipose membrane, and the skin cover- ing the trochanter, that this pressure produces ulceration of these parts; which process is continued on through the skin, and makes a second opening directly upon the tro- chanter. It is curious to remark, how these processes of nature fulfil their appointed purposes, and go on no further; for any young flesh, or granulations, which may have formed upon the trochanter, which very often happens before this ulceration is completed, yet these do not ulcerate, although The ulcerative inflammation. 191 the pressure was as great, or greater upon them than it was upon the parts which gave way. This is upon the principle, that pressure from without has not the same effect as from within. The fistula lau- rimelis is another strong proof of ulceration only taking place towards the external surface, and securing the deep- er seated parts; as also the ulceration in consequence of matter in the frontal sinuses. An effect of the same kind we have observed in milk- breasts. In these cases the suppuration commonly begins in many distinct portions of the inflamed parts, so that it is not one large circumscribed abscess, but many separate si- nuses are formed, all of which generally communicate: now it usually happens, that only one of these points exter- nally; which being either opened or allowed to break, the whole of the matter is to be discharged this way; but it frequently happens, that the matter does not find a ready outlet by this opening, and then one or more of these dif- ferent sinuses make distinct openings for themselves; which shews how very easily the slight pressure of such a trifling confinement of matter can produce the ulcerative inflam- mation. Ulceration is therefore no more than an opera- tion of nature to remove parts out of the way of all such pressure as the parts cannot support; and accordingly it be- gins where the greatest pressure is felt, joined with the na- ture of the parts and its vicinity to the kin. It is curious to observe that the ulcerative process has no power over the cuticle, so that when the matter has got to that part it stops, and cannot make its way through, till the cuticle bursts by distention; but in general the cuticle is so thin as to give but very little trouble *: however, * This is the reason why many abscesses in the palms of the hands, soles of the feet, fore part of the fingers, and about the nails, commonly called whitlows, etc. more especially in work- ing people give so much pain in the time of inflammation, and are so long in breaking, even after the matter has got through the cutis to the cuticle; the thickness of the cuticle, as also the rigidity of the nail, acting in those cases like a tight bandage, which does not allow them to swell or give way to the extravasation; for in the cuticle there is not the relaxing power, which adds considerably to the pain arising from the inflammation; but when the abscess has reached to this thick cuticle it has no power of irritation, and therefore acts only 192 The ulcerative inflammation. in many places it is so thick as to be the cause of very trou- blesome consequences. Thus far I have considered ulceration as arising from vi- sible irritations, joined with a susceptibility of the parts for such particular irritation; but, besides those above-de- scribed, we often have instances of ulceration taking place from a disposition in a part, and where perhaps no reason can be assigned, but weakness in the part. I observed be- fore, that some parts of the body were more susceptible of ulceration than others. I then spoke of original parts; but I now remark that, newly formed parts are much more susceptible of ulceration than the original; such as cicatrices, granulations, calluses, etc. for we find this disposition often taking place in old cicatrices from very slight by distention; and this is in most cases so considerable, as to produce a separation of the cuticle from the cutis, for a consi- derable way round the abscess; for I observed, when on inflammation, that it commonly produced a separation of the cuticle; all of which circumstances taken together make these complaints much more painful than a similar sized abscess in any other soft part. The application of poultices, in these cases, is of more benefit than in any other, because here they can act mechanically, viz. the moisture being imbibed by the cuticle, as in a sponge, and thereby softening the cuticle, by which means it becomes larger in its dimensions, and less dura- ble in its texture. These cases should be opened as soon as pos- sible, to avoid the pain arising from distention, and the separa- tion of the cuticle; when it is conceived it means to point at any one part, paring off the thick cuticle, near the cutis, is allow- ing the matter to make its escape more readily, when it has got through the cutis. There is a circumstance which almost al- ways attends the opening such an abscess, viz. the soft parts un- derneath push out through the opening in the cuticle, like a fun- gus, which, when irritated from any accident, give a greater idea of soreness perhaps than any other morbid part of the ma- chine ever does: this is owing to the surrounding belts of cuti- cle not having given way to the increase of the parts underneath, by which means they are squeezed out of this small opening, like paint out of a bladder. It is a common practice to eat this down by escharotics, as if it was a diseased fungus; but this additional pain is very unnecessary, as the destroying a part which has only escaped from pressure, cannot in the least affect that which is within; and by simply poulticing till the inflammation, and of course the tumefaction subsides, these pro- truded parts are gradually drawn into their original situations. The ulcerative inflammation. 193 causes; such as irregularity in the way of life, or violent exercise, which is seen every day in our hospitals, where the parts seem incapable of supporting themselves. Re- markable instances of this are recorded in Anson's Voyages, where the habit was so much debilitated, as to allow all the old sores to ulcerate, or break out anew: the calluses were absorbed and taken into the circulation; and we also find, that, all these parts perform the operation of slough- ing when dead, much sooner than original parts. Now it is evident, in these cases mentioned in Anson's Voyages, that the whole frame of body was weakened by the hardships suffered in this expedition; and that the young, or new formed substances would suffer in a greater degree, arising from their being less firm and fixed than that which had been an original formation, and subsisted from the first; and, as no repaired parts are endowed with the powers of action or resistance, equal to an original pare, it is no wonder that this new flesh, sharing in the general debility, became incapable of supporting its texture: per- haps a very sense of this debility proved an irritation, or the cause of that irritation which produced the absorption of parts; however, that may be, it is a general fact that, parts which are not originally formed, commonly give way soon- er in depravations of the habit: in like circumstances, also, old sores that are healing, will breakout, spread, and un- do, in twenty-four hours, as much of the parts as has been healing in so many weeks. All these observations tend to prove, that new formed parts are not able to resist the power of many diseases, and to support themselves under so many shocks, as parts origi- nally formed; which will be still further illustrated, in treating of the power of absorption. I observed that, although a part is losing ground or ulce- rating, yet it continues suppurating; for while a matter- forming surface is ulcerating, (whether an original formed part of the body, such as in most abscesses, or a new form- ed substance, such as granulations) we find that it still se- cretes pus. In such cases the adhesive inflammation proceeds very rapidly, and would seem to prepare the parts as it goes for immediate suppuration the moment they are exposed. VOL. II. Bb  [195] CHAPTER VII. GRANULATIONS. WE come now to trace the operations of nature in bringing parts whose disposition, action, and structure, had been preternaturally altered, either by accident, or diseased dispositions, as nearly as possible to their original state. In doing this we are to consider the constitution, and the parts as free from disease; because all actions which ten to the restoration of parts are salutary; the animal powers being entirely employed in repairing the loss, and the injury, sus- tained both from the cause, and arising from the course of the immediate effects, viz. inflammation, suppuration, and ulceration: now such operations cannot certainly be looked upon as morbid. Nature having carried these operations for reparation so far, as the formation of pus, in such cases, endeavours immediately to set about the next order of actions, which is the formation of new matter, upon such suppurating sur- faces as naturally admit of it, viz where there has been a breach of solids, so that we find, following, and going hand in hand with suppuration, the formation of new solids, which constitute the common surfaces of a sore. This process is called granulating, or incarnation; and the substance form- ed, is called granulation. Granulation have I believe, been generally supposed to be a consequence of, or always an attendant on sup- puration: but the formation of granulations is not confined to a breach of solids where the parts have been allowed to suppurate, as either from accident, or a breach of the solids in consequence of and abscess; but it takes place under other circumstances; for instance, when the first and se- 196 Granulations. cond bond of union has failed, as in simple fractures which will be noticed hereafter. Suppuration, I observed, arose in consequence of an injury having been done to the solids, so as to prevent them, for some time, from carrying on their natural functions; and I also observed that, it was immaterial whether this injury had exposed their surfaces, as in cases of accidents and wounds; or whether the surfaces were not exposed, as in cases of abscesses in general; for in either of them sup- puration would equally take place; I likewise observed that, it was not necessary that there should be a breach in the continuity of parts for suppuration to take place in many cases, because all secreting surfaces were capable of sup- puration; but this last seems not to be so commonly the case, with granulations. I believe that no internal canal will granulate, in consequence of suppuration, except there has been a breach of surface, and then it is not the na- tural surface which granulates, but the cellular membrane, etc. as in other parts. Wounds that are kept exposed do not granulate till in- flammation is over, and suppuration has fully taken place; for as the suppurative inflammation constantly follows when wounds come to be under such circumstances, it would seem to be in such cases a leading and necessary pro- cess for disposing the vessels to granulation. Setting out then with the supposition, that this inflamma- tion is in general necessary, under the above circumstances, for disposing the vessels to form granulations we shall at once see how it may operate in the same manner whether it arises spontaneously from a wound, the laceration of parts, mortification, bruise, caustic, or in short any other power which destroys or exposes the innumerable internal cells, or surfaces, so as to prevent their carrying on their natural functions. Few surfaces, in consequence of abscesses, granulate till they are exposed; so that few or no abscesses granulate till they are opened, either of themselves or by art; and there- fore in an abscess, even of very long standing, we seldom or ever find granulations. In abscesses, after they have been opened, there is generally one surface that is more disposed to granulate than the others, which is the surface next to the centre of the body, in which the suppuration Granulations. 197 took place. The surface next to the skin hardly ever has the disposition to granulate: indeed, before opening, its action was that of ulceration, the very reverse of the other: but even, after opening, that side under the skin hardly granulates, or at least not readily. I may farther observe that exposure, is so necessary to granulation, even on such surfaces as arise from a broken continuity of parts, that if the abscess is very deep seated, they will not granulate kind- ly, without being freely exposed, which alone often be- comes a cause why deep seated abscesses do not heal so read- ily, and often become fistulous. Upon the same principle of granulations forming more readily upon that surface which is next to the centre, or op- posite to the surface of the body, is to be considered their tendency to the skin. Granulations always tend to the skin, which is exactly similar to vegetation; for plants always grow from the centre of the earth towards the surface; and this principle was taken notice of when we were treating of abscesses coming towards the skin. I. OF GRANULATIONS, INDEPENDENT OF SUPPURATION. THE formation of granulations, I have observed, is not wholly confined to a breach made in the solids, either by external violence and exposure, or in consequence of a breach in the solids, which had been produced by suppura- tion and ulceration, and afterwards exposed; for parts are capable of forming granulations, or what I suppose to be the same thing, new animal matter, where a breach has been made internally, and where it ought to have healed by the first intention; but the parts being baulked in that o- peration, often do not reach so far as suppuration, so as to produce the most common cause of granulation. The first instance of the kind that gave me this idea, was in a man who died in St. George's Hospital. 198 Granulations. January 1777. A man about fifty years of age, fell and broke his thigh-bone, nearly across, and about six inches a- bove the lower end. He was taken into St. George's Hospital; the thigh was bound up, and put into splints, etc. The union between the two bones did not seem to take place in the usual time. He was taken ill with a complaint in his chest, which he had been subject to before, and di- ed between three and four weeks after the accident. On examining the parts after death, there were found little or no effects of inflammation in the soft parts surround- ing the broken bones, except close to the bones where the adhesive inflammation had taken place only in a small degree. The bones were found to ride considerably, viz. near three inches. The cavity made in the soft parts, in consequence of the laceration made by the riding of the bones, had its parietes thickened, and pretty solid, by means of the adhesive in- flammation, although not so much as would have been the case, if the parts had been better disposed for inflamma- tion: and some parts had become bony. There hardly was found within this cavity any extravasated blood, or coagu- lating lymph except a few pretty loose fibres like strings, which were visibly the remains of the extravasated blood. From these appearances this cavity had evidently lost its first bond of union, viz. the extravasated blood, which took place from the ruptured vessels, and probably the se- cond had never taken place, viz. the coagulating lymph, in consequence of the adhesive inflammation: however, there was an attempt towards an union, for the surround- ing soft parts, we have observed, had taken on the adhe- sive, and ossific inflammation; so that in time there might have been formed in the surrounding soft parts a bony case, which would have united the two bones; but the parts being deprived of the two common modes of union, they were led to a third. From the ends of the bones, and some parts of their sur- face, as well as from the inner surface of the soft parts, there was formed new flesh, similar to granulations. The hollow ends of the bones were filled with this matter, which was rising beyond the common surface of the bone; and in some places adhesion had taken place between it and the surrounding parts, with which it had come in con- Granulations. 199 tact. The same appearance, which this new flesh had in this case, I have several times seen in joints, both on the ends of the bones, and on the inside of the capsular liga- ment, but never before understood how it was formed: hence we find that granulations can, and do arise in parts that are not exposed. This is what I have long suspected to be the case in the union of the fractured patella, and this fact confirms me more in that opinion. Here then we are shewn that, the cause of granulation, or the forming of new flesh for union (independent of ex- travasation, or the adhesive inflammation) is more exten- sive in its effects than we were formerly acquainted with; and that granulations, or new flesh, arise in all cases from the first and second bond of union being lost in the part, (which indeed seldom happens, except from exposure) it therefore makes no difference, whether the first and second bond of union escape through an opening made in the skin, as in a compound fracture, or it loses its living powers, as in the present case, and as I suppose to be the case in a fracture of the patella, which obliges the absorbents to take it up as an extraneous body. II. THE NATURE AND PROPERTIES OF GRA- NULATIONS. GRANULATIONS, and this new formed substance, are an accretion of animal matter upon the wounded or exposed surface: they are formed by an exudation of the coagulat- ing lymph from the vessels, into which new substance both the old vessels very probably extend, and also entirely new ones form, so that the granulations come to be very vascu- lar, and indeed they are more so than almost any other a- nimal substance. That this is the case, is seen in sores eve- ry day. I have often been able to trace the growth and vascularity of this new substance. I have seen upon a sore a white substance, exactly similar in every visible respect 200 Granulations. to coagulating lymph. I have not attempted to wipe it off, and the next day of dressing I have found this very substance vascular; for by wiping or touching it with a probe, it has bled freely. I have observed the same appearance on the surface of a bone that has been laid bare. I once scra- ped off some of the external surface of a bone of the foot, to see if the surface would granulate. I remarked the fol- lowing day that, the surface of the bone was covered with a whitish substance, having a tinge of blue; when I passed my probe into it, I did not feel the bone bare, but only its resistance. I conceived this substance to be coagulating lymph, thrown out from inflammation, and that it would be forced off when suppuration came on; but on the suc- ceeding day I found it vascular, and appearing like healthy granulations. The vessels of granulations pass from the original parts, whatever these are, to the basis of the granulations; from thence towards their external surface, in pretty regular parallel lines, and would almost appear to terminate there. The surface of this new substance, or granulations, con- tinues to have the same disposition for the secretion of pus, as the parts from which they were produced; it is therefore reasonable to suppose that, the nature of the vessels does not alter by forming the granulations; but that they were com- pletely changed for the purpose before the granulations be- gan to form, and that these granulations are a consequence of a change then produced upon them. Their surfaces are very convex, the reverse of ulceration, having a great many points, or small eminences, so as to appear rough: and the smaller these points are, the more healthily we find the granulation. The colour of healthily we find the granulations, is a deep florid red, which would make us suspect that the colour was principally owing to the arterial blood*; but it only shews a brisk circulation in them, the blood not having time to become dark. When naturally of a livid red, they are commonly un- healthy and shews a languid circulation, which appearance * I once began to suspect that the air might have some influence upon the blood, when circulating in the vessels, but from its losing that florid colour in sores of the legs by standing erect, I gave up that idea. Granulations. 201 often comes on in granulations of the limbs from the posi- tion of the body, as is evident from the following case. A stout, healthy, young man, had his leg considerably torn, and it formed a broad sore; when healing it was some days of a florid red, and on others of a purple hue: wonder- ing what this could be owing to, he told me, when he stood for a few minutes it always changed from the scarlet to the modena. I made him stand up, and found it soon changed: this plainly shews that, these new formed vessels were not able to support the increased column of blood, and to act upon it, which proves that a stagnation of blood was produced, sufficient to allow of the change in the co- lour, and most probably both in the arteries and veins. These sores never heal so fast as the others; whether it is occasioned by the position of the body, or the nature of the sore itself, but most frequently so in cases of the last-men- tioned kind. As the position of the body is capable of pro- ducing such an effect, it shews us the reason why sore legs are so backward in healing, when the person is allowed to stand or walk. Granulations when healthy, and on an exposed or flat surface, rise nearly even with the surface of the surrounding skin, and often a little higher; and in this state they are always of a florid red; but when they exceed this, and take on a growing disposition, they are then unhealthy, become soft, and spongy, and without any disposition to skin. Granulations are always of the same disposition with the parts upon which they are formed, and take on the same mode of action. If it is a diseased part, they are diseased; and if the disease is of any specific kind, they are also of the same kind; and of course produce matter of the same kind, which I observed when on pus. Granulations have the disposition to unite with one an- other when sound, or healthy; the great intention of which is, to produce the union of parts, somewhat similar to that by the first intention, or the adhesive inflammation, although possibly not by the same means. The granulations having a disposition to unite with each other upon coming into contact, without the appearance of any intermediate animal substance, perhaps is in the following manner. When two sound granulations approach to- gether, the mouths of the secreting vessels of the one com- VOL. II. Cc 202 Granulations. ing to oppose the mouths of similar vessels of the other, they are stimulated into action, which is mutual; so that a kind of sympathetic attraction takes place, and as they are solids, the attraction of cohesion is established between them; this has been termed inosculation. The vessels thus joined, are altered from secreting to circulating; or it may be in this way, viz. the circulatory vessels come to open upon the surface, and there unite with one another, and the two become one substance; or it may be asked, do they throw out coagulating lymph, when they come into contact, and have a disposition to heal? and does this be- come vascular, in which the vessels may inosculate, similar to union by the first, or second intention? I have seen two granulations on the head, viz. one from the dura mater, (after trepanning) and the other from the scalp, unite over the bare bone which was between them, so strongly in twenty-four hours, that they required some force to separate them, and when separated they bled. The inner surface of the cutis in an abscess, or sore, does not only, not readily granulate, as has been mentioned, but it does not readily unite with the granulations underneath. The final intention of both seems to be, that the mouth of a sore which is seldom so much in a diseased state, should have a natural principle which attends disease, to put it upon a footing with the disease which is underneath; therefore, when abscesses are allowed to become as thin as possible be- fore they are opened, this proportion between the sound skin and the disease is better preserved, and the parts, are not so apt to turn fistulous. When the parts are unfound, and of course the granula- tions formed upon them unfound, we have not this disposi- tion for union, but a smooth surface is formed somewhat similar to many natural internal surfaces of the body, and such as have no tendency to granulate; which continues to secrete a matter expressive of the sore which it lubricates, and in some measure prevents the union of the granulations. I imagine, for instance, that the internal surface of a fistu- lous ulcer is in some degree similar to the inner surface of the urethra, when it is forming the discharge commonly called a gleet. Such sores have therefore no disposition in their granulations to unite, and nothing can produce an u- nion between them, but altering the disposition of these granulations by exciting a considerable inflammation, and Granulations. 203 probably ulceration, so as to form new granulations, and by these means give them a chance of falling into a sound state. Granulations are not endowed with the same powers as parts originally formed. In this respect they are similar to all new formed-parts; and it is from this cause that changes for the worse are so easily effected. They more readily fall into ulceration, and mortification, than originally for- med parts; and from their readiness to ulcerate, they sepa- rate sloughs more quickly. The granulations not only shew the state of the part in which they are formed, or the state in which they are themselves, but they shew how far the constitution is affect- ed by many diseases. The chief of those habits which af- fect the granulations in consequence of the constitution, are, I believe, the indolent and irritable habits, but principally fevers; and these must be such as produce universal irrita- tion in the constitution. The unfound appearances of the granulations shew to what a stand the animal powers are put on such occasions, which does not appear so visibly in the originally formed parts; it is therefore evident, that the powers of the gra- nulations are much weaker than those of the original parts. III. LONGEVITY OF GRANULATIONS. GRANULATIONS are not only weaker in performing the natural or common functions of the parts to which they belong, but they would appear often to be formed with on- ly stated periods of life, and those much shorter than the life of the part on which they are formed. This is most remarkable in the extremities; but where they are capable of going through all their operations, as cicatrization, their life then seems to be not so limited: they are probably then acquiring new life, or longevity every day; but while in a state of granulation, we find them often dying without a- ny visible cause: thus, a person shall have a sore upon the leg, which shall granulate readily, the granulations shall appear healthy, the skin shall be forming round the edges, and all shaw be promising well, when all at once the granula- 204 Granulations. tions shall become livid, lose their life, and immediately slough off; or, in some cases, ulceration shall in part take place, and both together shall destroy the granulations; and probably where ulceration wholly takes place, it may be owing to the same cause. New granulations shall immediately arise as before, and go through the same pro- cess; this shall happen three or four times in the same per- son, and probably for ever, if some alteration in the nature of the parts be not produced. This circumstance of the difference in longevity of granulations in different people, is somewhat similar to the difference in longevity of diffe- rent animals. In cases of short lived granulations, I have tried various modes of treatment, both local and constitutional, to ren- der the life of these granulations longer; but without suc- cess. It would appear from what has been said of suppuration and granulations, that it is absolutely necessary they should take place in wounds which are not allowed to unite by the first intention, before union and cicatrization can take place. Although this in general is the case, yet in small wounds, such as considerable scratches, or where there is a piece of skin rubbed off, we find that by the blood being suffered to coagulate upon the sore, and form a scab, which is allowed to remain, the sore will only be attended by the adhesive inflammation, and will skin over without ever sup- purating; where a small caustic has been applied, we find also, by allowing the slough to dry or scab, that when this is completed the scab will drop off, and the parts shall be skinned; but if the blood has not been allowed to coagu- late and dry, or the slough has been kept moist, the sore will suppurate and granulate. We even see in small sores, which are perfectly healthy, and suppurating, that if the matter be allowed to dry upon them, the suppuration will stop, and the skin form under the scab; the small-pox is a striking proof of this, which was fully treated off in a former part of the work. A blister whose cuticle is not removed, similar to a scab. It does not allow of suppuration. If a separation takes place between the cutis and cuticle, and the cuticle be not removed, nothing will be collected through the whole course, and a new cuticle will be formed; but if the cuti- cle be removed, a greater degree of inflammation will come on, and suppuration will certainly take place. Granulations. 205 IV. OF THE CONTRACTION OF GRANULA- TIONS. IMMEDIATELY upon the formation of the granulations, cicatrization would appear to be in view. The parts which had receded, in consequence of a breach being made into them, by their natural elasticity, and probably by muscu- lar contraction, now begin to be brought together by this new substance; and it being endowed with such properties, they soon begin to contract, which is a sign that cicatriza- tion is to follow. The contraction takes place in every point, but principally from edge to edge, which brings the circumference of the sore towards the centre; so that the sore becomes smaller and smaller, although there is little or no new skin formed. The contracting tendency is in some degree proportioned to the general healing disposition of the sore, and the loose- ness of the parts on which they are formed; for when it has not a tendency to skin, the granulations do not so rea- dily contract, and therefore contracting and skinning are probably effects of one cause. The granulations too being formed upon a pretty fixed surface, which is a consequence of inflammation, are in some degree retarded in their con- traction from this cause; but probably this does not act so much upon a mechanical principle as we at first might imagine; for such a state of parts in some degree lessens the disposition for this process, but this state is every day altering, and in proportion as the tumefaction subsides. Granulations are also retarded in their contraction, from a mechanical cause, when they are formed on parts naturally fixed, such as a bone; for instance, on the skull, the bone, etc. of the shin, for there the granulations cannot greatly contract*. In cases where there has been a loss of substance, mak- ing a hollow sore, and the contraction has begun, and ad- vanced pretty far, before the granulations have had time to rise as high as the skin, in such cases the edges of the skin are generally drawn down, and tucked in by it, in the hol- low direction of the surface of the sore. * This observation should direct us in operations on those parts, to save as much skin as possible. 206 Granulations. If it is a cavity, or abscess, which is granulating, with only a small opening, as in many that have not been freely opened, the whole circumference contracts, like the blad- der of urine, till little or no cavity is left; and if any ca- vity is remaining; when they cannot contract any further, they unite with the opposite granulations, in the manner above described. This contraction in the granulations continues till the whose is healed, or skinned over; but their greatest pow- er is at the beginning, at least their greatest effect is at the beginning; one cause of which is that, the resistance to their contraction in the surrounding parts is then least. The contractile power can be assisted by art, which is a further proof that there is a resistance to be overcome. The art generally made use of is that of bandages, which tend to push, draw, or keep the skin near to the sore which is healing; but this assistance need not be given, or is at least not so necessary, till the granulations are formed, and the contractile power has taken place: however, it may not be amiss to practice it from the very beginning, as by bringing the parts near to their natural position the adhesive inflammation will fix them there; they will there- fore not recede so much afterwards, and there will be less necessity for the contractile powers of the granulations. Besides the contractile powers of the granulations, there is also a similar power in the surrounding edge of the cica- trizing skin, which assists the contraction of the granula- tions, and is generally more considerable than that of the granulations themselves, drawing the mouth of the wound together like a purse; this is frequently so great, as to oc- casion the skin to grasp the granulations which rise above the surface, and is very visible in sugar-loaf stumps, where the projection of the sore is to be considered as above the level of the skin. This contractile power of the skin is confined principal- ly to the very edge where it is cicatrizing; and, I believe, is in those very granulations which have already cicatrized; for the natural, or original skin surrounding this edge does not contract, or at least not nearly so much, as appears by its being thrown into folds, and plaits, while the new skin is smooth and shining. This circumstance of the original surrounding skin not having the power of contrac- tion, makes round wounds longer in healing than long ones; Granulations. 207 for it is much easier for the granulations, and the edge of the skin, to bring the sides of an oblong cavity together, than the sides of a circle; the circumference of a circle not being capable of being brought to a point. Whether this contraction of the granulations is owing to an approximation of all the parts, by their muscular con- traction, like that of a worm, while they lose in substance as they contract; or if they lose without any muscular contraction by the particles being absorbed, so as to form interstices, (which I have called interstitial absorption) and the sides afterwards fall together, is not exactly determined, and perhaps both take place. The uses arising from the contraction of the granulations are various. It facilitates the healing of a sore, as there are two operations going on at the same time, viz. contrac- tion and skinning. It avoids the formation of much new skin, an effect, very evident in all sores which are healed, especially in found parts. In amputation of a thick thigh (which is naturally seven, eight, or more inches diameter before the operation) the surface of the sore is of the same diameter; for the re- ceding of the skin here does not increase its surface, as it does in a cut on a plane; yet in this case, he cicatrix shall be no broader than a crown piece. This can be effected by the contractile power of the granulations, for it is bringing the skin within its natural bounds. The advantage arising from this is very evident, for it is with the skin, as it is with all other parts of the body, viz, that those parts which were originally formed are much fitter for the purposes of life, than those that are newly formed, and not nearly so liable to ulceration. After the whole is skinned, we find that the substance which is the remains of the granulations on which the new skin is formed, still continues to contract, till hardly any thing more is left than what the new skin stands upon. This is a very small part of the comparison with the first formed granulations, and it in time loses most of its ap- parent vessels, becomes white, and ligamentous. For we may observe that, all new-healed sores are redder than the common skin, but in time they become much whiter. As the granulations contract, the surrounding old skin is stretched to cover the parts which had been deprived of 208 Granulations. skin, and this is at first little more than bringing the skin to its old position, which had receded when the breach was first made; but afterwards it becomes considerably more, so as to stretch, or oblige the old skin to elongate; from which we might ask the following question: Does the surrounding skin in the healing of a sore length- en by growth, or does it lengthen by stretching only? I think that the former is most probable; and if this is the case, I should call this process interstitial growth, similar to the growth of the ears of the people in the Eastern islands, particularly as it is an opposite effect to interstitial absorp- tion. Granulations appear to have other powers of action be- sides simply their œconomy tending to a cure. They have power of action in the whole, so as to produce other operations, and even to affect other matter. I conceive that a deep wound, such as a gun-shot wound, advanced to sup- puration, and granulation, and also a fistula, becomes in some degree similar to an excretory duct, having the pow- ers of a peristaltic motion from the bottom towards the o- pening externally. Thus we find that whatever extrane- ous body is situated at the bottom of the sore, is by degrees conducted to the skin, although the bottom of the sore, or fistula, is of same depth. This effect in such sores does not arise from the granulations forming at the bottom, and gradually raising the extraneous body as they form, (which is commonly the case with exfoliations and sloughs) but we find extraneous bodies come to the skin when the bottom of the wound is not granulating. [209] CHAPTER VIII. OF SKINNING. WHEN a sore begins to heal, we find that the sur- rounding old skin, close to the granulations (which had been in a state of inflammation, having probably a red shining surface, as if excoriated, and rather ragged) now becomes smooth, and rounded with a whitish cast as if covered with something white, and the nearer to the cicatrizing edge, the more white it is. This is, I believe, a beginning cuticle, which appearance is probably as early a symptom of healing, and as much to be depended upon as any; so that the dispo- sition in the granulations for healing is manifested in the surrounding skin; and while the sore retains its red edge all round for perhaps a quarter, or half of an inch in breadth, we may be certain it is not a healing fore, and is what may be called, an irritable sore. Skin is a very different substance, with respect to texture, from the granulations upon which it is formed; but whether it is an addition of new matter, viz. a new-formed sub- stance upon the granulations being produced by them, or a change in the surface of the granulations themselves, is not easily determined. In either case, however, a change must take place in the disposition of the vessels, either to al- ter the structure of the granulations, or to form new parts upon them. One would at first be inclined to the former of these opin- ions, we have a clearer idea of the formation of a new sub- stance, than such an alteration in the old. We find the new skin most commonly taking its rise from the surround- ing old skin, as if elongated from it; but this is not always the case. In very large sores, but principally old ulcers, where the edges of the surrounding skin have but little VOL. II Dd 210 Of Skinning. tendency to contract, or the cellular membrane underneath to yield, as well as the old skin having but little disposition to skinning in itself, a cicatrizing disposition cannot be com- municated from it to the nearest granulations by continued sympathy. In such cases new skin forms in different parts of the ulcer, standing on the surface of the granulations, like little islands. This, I believe, never takes place in parts the first time of their being sore, nor in sores which have a strong propensity to skin. Skinning is somewhat like chrystallization, it requires a surface to shoot from, and the edge of the skin all round would appear to be this surface. Whatever change the granulations undergo to form skin they may in general be said to be guided to it by the sur- rounding skin, which gives this disposition to the surface of the adjoining granulations; as adjacent bones give an ossi- fying disposition to the granulations that are formed upon them. This may arise from sympathy; and if it does, I should call it continued sympathy. But when the old skin is unfound, and not able to communicate this disposition, then the granulations sometimes of themselves acquire it, and new skin begins to form where that disposition is strongest in them, so that the granulations may be ready to form new skin, if the surrounding skin be not in a condition to give the disposition. It would appear, however, that the circumference of the sore generally has the strongest disposition to skin, even although the surrounding skin does not assist; for in many old sores no new skin shall shoot from the surrounding skin or be continued, as it were from the old; and yet a circle of new skin shall form, mak- ing a circle within the old, and as it were, detached from it. Skinning is a process in which nature is always a great œconomist, without a single exception: this, however, may probably arise from granulations being always of the na- ture of the parts on which they are formed, and from seldom being formed on parts that are the least of the nature of the skin, they have therefore no strong disposition to form skin. What would seem to make this observation more probable, is, that if the cutis is only in part destroyed, as by a hurt, or caustic, which has not gone quite through the cutis to the cellular membrane underneath, a new cutis will form immediately on the granulations, and in many cases it will form as fast as the slough will separate; the reason is, be- Of skinning. 211 cause the cutis has a stronger tendency to form cutis than any other part, and in many cases it may be said to form it from almost every point. We never find that the new-formed skin is so large as the sore was, on which it is formed; this, I have already obser- ved, is brought about by the contraction of the granulations, which in some measure is in proportion to the quantity of surrounding old skin, attended with the least resistance. If the sore is in a part where the surrounding skin is loose, as in the scrotum, then the contractile power of the granulations being not at all prevented, but allowed full scope, a very little new skin is formed; whereas, if the sore is on any other part, where the skin is not loose, such as the scalp, shin-bone, etc. in that case the new skin is nearly as large at the sore. This we find to be the case also in parts which are so swelled as to render the skin tight, such as the scrotum, when under the distention of a hydrocele, and which some- times happens where a caustic has proved ineffectual; we then find the new skin as extensive as in any other parts e- qually distended. The same thing takes place in white swellings of the joint of the knee; for if a sore is made upon such a part, as is frequently done by the application of caustics, we find that the new skin is nearly of the same size as the original sore. The general principle is also very ob- servable after amputations of the limbs; for if much old skin has been Saved, we find the cicatrix small, while on the other hand, if such care has not been taken, the cicatrix is pro- portionably large. The new skin is at first commonly on the same level with the old, and if there has not been much loss of sub- stance, or the disease is not very deep seated, it continue its position; but this does not appear to be the case with scalds and burns, for they frequently heal with a cicatrix, higher than the skin, although the granulations have been kept even with the skin. It would appear in these cases that a tumefaction of the parts, which were the granula- tions, takes place after cicatrization. Sometimes granulations cicatrize while higher than the common surrounding skin, but then they are such as have been long in that position, as is the case in some issues: I have seen the granulations surrounding a pea rise considera- bly above the skin, near half-a-crown in breadth, and skin 212 Of skinning. over, all but the hole in which the pea lay, the whole look- ing like a tumor. I. THE NATURE OF THE NEW CUTIS. THE new-formed cutis is neither so yielding nor so elas- tic as the original is, and is also less moveable upon the part to which it is attached, or upon which it is formed. This last circumstance is owing to its basis being granula- tions, which are in some degree fixed upon parts united by the adhesive inflammation; and more particularly so, when the granulations arise from a fixed part, such as a bone; the new skin formed upon them being also fixed in pro- portion. It is, however, constantly becoming more and more flex- ible in itself, and likewise more loosely attached, owing to the mechanical motion to which the parts are subject after- wards. The more flexible and loose the parts become, it is so much the better, as flexibility, or the yielding of the parts, preserves it from the effects of many accidents. Parts which have been thickened in consequence of inflam- mation, such as the surrounding parts of new skin have al- ways a less internal power of action in them, than parts which have never been inflamed. This arises from the ad- ventitious substance thrown out in the time of inflammation, being a clog upon the operations of the original; and the new matter not being endowed with the same powers, the part affected, taken as a whole, is by these means considera- bly weakened. Motion given to the part so affected, must be mechani- cal; but that motion becomes a stimulant to the parts mov- ed, that they cannot exist under such motion without a- dapting the structure of the parts to it, and this sets the ab- sorbents to work, or they receive the stimulus of necessity, and absorb all the adventitious or rather superfluous sub- stance; by which means the parts are as much as possible reduced to their original texture. Of skinning. 213 Medicines have not the powers we could wish in many such cases; mercury, however, appears to have the power of producing a similar stimulus to motion, and should be made use of where a mechanical stimulus cannot be appli- ed; and, I believe, when joined with camphire, its powers of producing absorption are increased; when both medicine and mechanical means can be used, so much the mere be- nefit will ensue. When every thing else fails, electricity might be tried. It has been the cause of absorption of tumors. It has re- duced the swellings of many joints in consequence of sprains, and thereby allowed of the freedom of motion. The new-formed cutis is at first very thin and extremely tender, but afterwards becomes firmer and thicker: it is a smooth continued skin, not formed with those insensible indentations which are observed in the natural or original skin, and by which the original admits of any distention the cellular membrane will allow off, as is experienced in many dropsies, white swellings in the joints, etc. This is proved by steeping a piece of dead skin, with a cicatrix in it, in water to make the cuticle separate from the cutis; there we find that the new-formed cuticle becomes but lit- tle larger by such a process, which plainly shews, that the new formed cutis upon which this cuticle was formed, has a pretty smooth continued surface, and not that soft, une- qual surface which distinguishes the original cutis. This new cutis, and indeed all the substance which had been formerly granulations, is not nearly so strong, nor en- dowed with such lasting and proper actions, as the ori- ginally formed parts. The living principle itself is al- so not nearly so active; for when an old sore once breaks out, it continues to yield till almost the whole of the new-formed matter has been absorbed or mortifi- ed; as has been already explained. The young cutis is extremely full of vessels, which af- terwards, in a great measure, either become lymphatic or impervious, or taken into the constitution, so that the skin and granulations underneath are at last free from visible vessels and become white. The surrounding original cutis, being drawn towards a cen- tre by the contraction of granulations, to avoid as much as possible the formation of new skin is thrown into loose folds, while the new looks like a piece of skin upon the 214 Of skinning. stretch, and the whole appears as if a piece of skin had been sewed into a hole by much too large for it; and therefore it had been necessary to throw the surround- ing old skin into folds, or gather the surrounding skin, in order to bring it in contact with the new. The new cu- tis of a sore, I believe, never acquires a muscular structure; nor does it grow larger than the sore which it covers, so as to be thrown into wrinkles similar to the old; and there- fore has always that stretched, shining appearance. II. OF THE NEW CUTICLE. IT does not appear to be so difficult a process for the cu- tis to form cuticle, as it is for the granulations to form cutis; for we find in general, that wherever there is a new cutis formed, it is covered with a cuticle: and in cases of blisters, or any other cause which may have deprived the cutis of its cuticle, we find that the cuticle is soon restored. We are to observe, however, that in such cases it is a sound, original cutis, forming its own cuticle, and having the whole power of forming the cuticle, the surrounding cuti- cle itself having no power of action of this kind: every point of cutis is forming cuticle, so that it is forming equal- ly every where at once; whereas I observed that, the for- mation of the cutis was principally progressive from the surrounding cutis. It is at first very thin, and partakes more of a pulpy than a horny substance; as it gets stronger, it becomes smooth and shining, and is much more transparent than original cu- ticle, which shews more the colour of the rete mucosum. This account relates to the cuticle of sound parts which had gone through all the operations of health, but where there is a retardation in the healing we find that the cuticle is, in some cases, backward in forming, and in others it shall be formed very thick, so as to make it necessary to be removed, it appearing to be a clog upon the cutis, retard- ing the progress of its formation. Of skinning. 215 III. OF THE RETE MUCOSUM. THE rete mucosum is later in forming than the cuticle, and in some cases never forms at all: this is best known in blacks, who have been either wounded or blistered, for the cicatrix in the black is a considerable time before it be- comes dark; and in one black who came under my observa- tion, a sore which had been upon his leg when young, re- mained white when he was old. After blisters too, the part blistered remains white for some time after the cuticle is completely formed: however, in many cicatrices of blacks, we find them even darker than any other part of the skin.  [217] CHAPTER IX. EFFECTS OF INFLAMMATION, AND ITS CONSEQUENCES ON THE CON- STITUTION. THE constitutional affections arising from inflammation, are immediate, and remote. The immediate affections have been already considered, viz. the sympathetic fever, and also the nervous. I shall now treat of the remote, viz. the hectic, and dissolution, which arise from the state of the local affection at the time; the inflammation not being able to go through all the salu- tary steps that have been described. We have diseases, however, sometimes accompanying those salutary process- es, although we should naturally conclude, from the fore- going account, that the suppurative inflammation and sup- puration itself should produce no change in the constitu- tion, but what was attendant upon the inflammation, and might be supposed, perhaps, somewhat necessary to it; and that when inflammation had subsided, and a kind of sup- puration come on, the constitution should be left in a sound state, because it would now appear that all the future processes were settled, and a constitution that was capable of doing this, was also capable of going through all the suc- ceeding operations, as they are only actions of restoration; but we find sometimes the contrary, and the condition in which the constitution is either left, or which it afterwards takes on, proves often much more hurtful than the inflam- mation itself. VOL. II. Ee 218 Effects of inflammation, It appears in many cases that, the inflammation, the at- tendant fever, the going off of these, and the commence- ment and continuance of the suppuration, produce in many persons a change in the constitution, giving a disposition to symptoms, which are called nervous. The locked jaw is often the effect of this leading cause, as well as the hyste- rics, spasms upon the muscles of respiration, and great restlessness, which often prove fatal to the patient; there are, likewise, signs of great and universal debility, or signs of dissolution in the patient, all of which appear to be in- creased by a continuance of the suppuration. Each of these diseases are well marked, and it would appear that the lock- ed jaw, histerics, spasms, and great restlessness, are of the nervous kind, and do not appear to arise from such a con- stitution, as is not equal to overcome the cause; for the cause which produced them being removed, the effects are going on towards health now; as well as before; and if the patient dies of any of those diseases, it is not from the cause, nor from the immediate effect, viz. the local disease, but from the effect which the preceding operations, joined with the healing, have on some constitutions. They all seem to derive their origin from the same root, viz. from all the foregoing processes, which we have been describing; but they are altogether too extensive for our present sub- ject. I. OF THE HECTIC. I HAVE now described the injuries of which inflamma- tion is a consequence; the progress of that action in diffe- rent parts; its effects on the constitution; together with the mode of treatment of both, and have carried it through its various steps to a perfect restoration. I have also al- ready mentioned, that the act of absorption affects some constitutions; but I shall now take notice, that nature is not always equal to those salutary processes, and hence the constitution sometimes becomes particularly affected, pro- ducing symptoms different from those formerly described, and which have been called the hectic. And its consequences on the constitution. 219 This disease is one of our remote constitutional sympa- thetic affections, and appears to arise from a very different origin, from the other sympathizing effects before men- tioned. When it is a consequence of a local disease, it has commonly been preceded by the first process of the for- mer, viz. inflammation and suppuration, but has not been able to accomplish granulation and cicatrization: so as to complete the cure. It may be said to be a constitution now become affected with a local disease or irritation, which the constitution is conscious of, and of which it cannot relieve itself, and cannot cure; for while the inflammation lasts, which is only preparatory, and an immediate effect of most injuries, and in parts which can only affect the con- stitution, so as to call up its powers, there can be no hec- tic. We should distinguish well between a hectic arising from a local complaint entirely, where the constitution is good, but only disturbed by too great an irritation; and a hectic arising principally from the badness of the constitution, which does not dispose the parts for a healing state; for in the first it is only necessary to remove the part (if remo- vable) and then all will do well; but in the other we gain nothing by a removal, except the wound made by the ope- ration is much less, and much more easily put into a local method of cure; so that this bad constitution falls less un- der this, (the operation taken into the account) than un- der the former state; but all this depends on nice discrimi- nation. The hectic comes on at very different periods after the inflammation, and commencement of suppuration, owing to a variety of circumstances. First, some constitutions much more easily fall into this state than others, having less powers of resistance. The quantity of incurable dis- ease must be such as can affect the constitution, and in whatever situation, or in whatever parts, it will be always as to the quantity of disease in those situations or parts in the constitution, which will make the time to vary very considerably. In many diseases it would appear, from the manner of coming on, that they retard the commencement of the hectic, such as lumbar abscesses. But when such abscesses are put into that state, in which the constitution is to make its efforts towards a cure, but is not equal to the talk, then the hectic commences. 220 Effects of inflammation, It takes its rise from a variety of causes, but which I shall divide into two species, with regard to diseased parts viz. the parts vital, and the parts not vital. The only diffe- rence between these two, is, probably, merely in time, with respect to its coming on, and its progress when come on: but what is very similar to the disease of a vital part, is quantity of incurable disease. The causes of hectic, arising from diseases of the vital parts, may be many, of which a great proportion would not produce the hectic if they were in any other part of the body; such, for instance, as the formation of tumors, either in, or so as to press upon some vital part, or a part whose functions are immediately connected with life. Schirri in the stomach, mesenteric glands, which tumors any where else would not produce the hectic; ma- ny complaints too of vital parts, as diseased lungs, liver, etc. all of these produce the hectic, and much sooner than if the parts were not vital. In many cases where those causes of the hectic come on quickly, it frequently follows so quick upon the sympathetic fever, that the one seems to run into the other: this I have often seen in the lumbar abscess. They also produce symptoms according to the nature of the part injured, as coughs, when in the lungs; sickness and vomiting, when in the stomach; and probably bring on many other complaints, as dropsies, jaundice, etc. but which are not peculiar to the hectic. When the hectic arises from a disease in a part not vital it sooner or later commences, according as it is in the pow- er of the parts to heal, or continue the disease. If far from the source of the circulation, with the same quantity of dis- ease, it will come on sooner. When in parts not vital, it is generally in those parts where so great a quantity of dis- ease can take place, (without the power of being diminish- ed in size, as is the case with the diseases in most joints*) as to affect the constitution, and also in such parts as have naturally but little powers to heal; we must at the same time include parts that are well-disposed to take on such specific diseases as are not readily cured in any situation; such parts are principally the larger joints, both of the * The cavity of a joint is such, as not readily to become smaller under disease as in the soft parts, which was described in the contraction of sores. And its consequences on the constitution. 221 trunk and extremities; but in the small joints of the toes, and fingers, although the same local effects take place, as in the larger, yet the constitution is not made sensible of it; we therefore find a scrofulous joint of a toe or finger going on for years, without affecting the constitution. The ankle, wrist, elbow, and even the shoulder, may be affected much longer than either the knee, hip-joint, or loins, before the constitution sympathizes with their want of powers to heal. Although the hectic commonly arises from some incura- ble local disease of a vital part, or of a common part when of some magnitude, yet it is possible for it to be an origi- nal disease in the constitution: the constitution may fall in- to the same mode of action, without any local cause what- ever, at least that we know of. Hectic may be said to be a slow mode of dissolution; the general symptoms are those of a low, or slow fever, attend- ed with weakness, but more with the action of weakness than real weakness; for, upon the removal of the hectic cause, the action of strength is immediately produced, as well as every natural function, however much it was de- creased before. The particular symptoms are debility; a small, quick, and sharp pulse; the blood for saking the skin; loss of ap- petite; often rejection of all aliments by the stomach; wasting; a great readiness to be thrown into sweats; sweat- ing spontaneously when in bed; frequently a constitutional purging; the water clear. This disease has been, and is still in general laid to the charge of the absorption of pus into the constitution from a sore; but I have long imagined that an absorption of pus has been too much blamed as the cause of many of the bad symptoms which frequently attack people who have sores. First, this symptom almost constantly attends suppura- tion when in particular parts, such as the vital parts, as well as many inflammations before actual suppuration has taken place, as in many of the larger joints, called white swellings; while the same kind and quantity of inflamma- tion and suppuration in any of the fleshy parts, and espe- cially such of them as are near the source of the circu- lation, have in general no such effect; in those cases, therefore, it is only an effect upon the constitution pro- 222 Effects of inflammation, duced by a local complaint, having a peculiar property, which I shall now consider. I observed, that with all diseases of vital parts, the con- stitution sympathized more readily than with diseases of any other parts; and also, that all diseases of vital parts are more difficult of cure in general than those which are not vital. I have observed, likewise that all the diseases of bones, ligaments, and tendons, affected the constitution more readily than those of muscles, skin, cellular mem- brane, etc. and we find that the same general principles are followed in the universal remote sympathy, produced by local diseases of those parts. When the disease is in vital parts, and is such as not to kill by its first constitutional effects, the constitution then becomes teazed with a complaint which is disturbing the necessary actions of health, the parts being vital; there is, besides, the universal sympathy, with a disease which gives the irritation of being incurable. In the large joints it continues to harass the constitution with a disease, where the parts have no power, or what is more probable, have no disposition to produce a salutary inflammation and suppuration; the constitution, therefore, is also irritated with an incurable disease. This is the theory of the cause of the hectic, which will be further illustrated: but now let us consider how far the idea of the absorption of matter may be a cause. If the absorption of matter always produced such symp- toms, I do not see how any patient, who has a large sore, could possibly escape this disease; because we have as yet no reason to suppose, that any one sore has more power of absorption than another. If in those cases where there is an hectic constitution, the absorption is really greater than when the habit is healthy, it will be difficult to determine whether this increase of ab- sorption is a cause, or an effect. If it be a cause, it must arise from a particular disposition in the sore to absorb more at one time than common, even while it was in a healthy state; for the sore must be healthy and then absorb, which hurts the constitution; moreover, as the sore is a part of that constitution, it must of course be affected in turn; and what reason we have to suppose that a healthy sore of a healthy constitution should begin to absorb more at one time than another, I must own I can- And its consequences on the constitution. 223 not discover. If this increase of absorption does not de- pend upon the nature of the sore, it must then take its rise from the constitution; and if so, there is then a peculiarity in the constitution, so that the whole of the symptoms cannot arise entirely from the absorption of matter as a cause, but must depend on a peculiar constitution, and absorption combined. If absorption of matter produced such violent effects as are commonly ascribed to it, (which indeed are never of the inflammatory kind, but of the hectic) why does not the venereal matter do the same? We often know that absorp- tion is going on by the progress of buboes; and I have known a large bubo, which was just ready to break, absorb- ed from a few days sickness at sea, while the person conti- nued at sea for twenty-four days after; yet, in such cases, no symptoms appear till the matter begins to have its speci- fic effects, and these very symptoms, are not similar to those which are called hectic. From reasoning, we ought to expect that the venereal matter would act with greater violence than the common matter from a healthy sore. Although matter too is frequently formed on the inside of the veins, in cases of inflammation of their cavities*, and this matter cannot fail of getting into the circulation, yet in these cases we have not the hectic disposition but only the inflammatory, and sometimes death. We likewise find ve- ry large collections of matter, which have been produced, without visible inflammation, such as many of the scrofulous kind, and which are wholly absorbed, even in a very short time, yet no bad symptoms follow†. We may, therefore, from hence I conclude, that the ab- sorption of pus from a sore into the circulation, cannot be a cause of so much mischief as is generally supposed; and if it was owing to matter in the constitution, I do not see how these symptoms could ever cease, till suppuration ceas- ed, which does not readily happen in such constitutions, their sores being tedious in healing. We find, however, that such patients often get well of the hectic before suppura- * Vide Transactions of a Society for the improvement of medical and chirurgical Knowledge. † It may, however, be objected to this, that this is not true matter, or pus; but it may be necessary to shew that the one affects the constitution upon absorption more than the other. 224 Effects of inflammation, tion ceases, even when no medicine was given; and in the case of veins, there is great reason to believe, that after all the bad symptoms are removed, suppuration is still going on, as we find it so in a sore; pus may, therefore, still pass into the constitution from the veins, and yet the hectic may not be produced, which would certainly be the case if those bad symptoms were occasioned by the matter getting into the circulation. But I very much doubt the fact of absorption going on more in one sore than another; and if ever it does I think it is of no consequence; I am much more inclined to be- lieve, that this hectic disposition arises from the effect which irritation of a vital organ, and some other parts, such as joints, (being either incurable in themselves, or being so to the constitution for a time) have on the constitution. We may remark, that in large abscesses which have not been preceded by inflammation, the hectic disposition sel- dom or never comes on till after they are opened, (although they may have been forming matter for months); but in such cases, the disposition often comes on soon after open- ing, and in others very late. Till the stimulus for restor- ing parts is given, no such effect can take place; and if the parts are well-disposed to heal no hectic disposition comes on, neither is the constitution at all affected. In diseased joints also, which are attended with inflammation if the parts were capable of taking on a salutary inflamma- tion, we should have only the first sympathetic fever; but as they seldom are capable of doing this, the constitution becomes teazed with a complaint, not taking on the imme- diate and salutary steps towards a cure. In the venereal dis- ease too, where we know that the venereal matter has got into the constitution, and that the matter is producing its specific effects, yet no hectic comes on, till the constitu- tion is harassed with an incurable disease, and this not till long after all the parts are healed, with regard to recent dis- ease, and no matter is formed for further absorption. That absorption does not take place in sores, we have reason to believe, and upon this fact a mode of dressing sores has been advised. The following is a remarkable instance of it in a bubo: a young man had a chancre and three buboes, one of which appeared when the other two were almost cured. This was very large, and at the bottom of the belly. When it had suppurated, and was pretty near breaking, it dimi- And its consequences on the constitution. 225 nished very quickly, and in two or three days was entirely gone. While this was going on, he observed his urine wheyish and thick, while making it, which went entire- ly off when the bubo had subsided. Before the bubo began to subside, he was rather mending in his health, which continued to mend, nor did the diminution of the bubo alter the state of his health. The hectic, from what has been said, appears in some measure to depend on the parts being stimulated to produce an effect which is beyond their powers: that this stimulus is sooner or later in taking place in different cases, and that the constitution becomes affected by it. The hectic dis- position arises from diseased lungs, lumbar abscesses, white swellings, scrofulous joints, etc. II. THE TREATMENT OF THE HECTIC. WE have as yet, I am afraid, no cure for any of the consequences above related; I believe that depends in the cure of the cause, viz. the local complaint, or in its removal; the effects, I fear, are not to be cured. Strengtheners, and what are called antiseptics, are recom- mended. Strengtheners are proposed on account of the debility which has taken place. Antiseptics have been employed from an idea that pus, when absorbed, gives the blood a tendency to putrefaction. To prevent both of these effects from taking place, the same medicines are however recommended. These are bark and wine. Bark will, in most cases, only assist in supporting a con- stitution. I should suppose it impossible to cure a disease of the constitution till the cause be removed; however, it may be supposed that these medicines may make the constitu- tion less susceptible of the disease, and may also contribute to lessen the cause, by disposing the local complaints to heal: VOL. II. Ff 226 Effects of inflammation. but where the hectic arises from specific disease; as for instance, if a hectic disposition comes on from a vene- real disposition, bark will enable the constitution to sup- port it better than it otherwise could have done; but can never remove it. Wine, I am fearful, rather does harm if it increases the actions of the machine without giving strength, a thing carefully to be avoided; however, I have not yet made up my mind about wine. When the hectic arises from local diseases, in such parts as the constitution can bear a removal of, then the diseas- ed part should be removed, viz. when it arises from some incurable disease in an extremity, and although all the symptoms above-described should have already taken place, we shall find that upon a removal of the limb the symptoms will abate almost immediately. I have known a hectic pulse at one hundred and twenty sink to ninety in a few hours, upon the removal of the hectic cause. I have known persons sleep found the first night without an opi- ate, who had not slept tolerably for weeks before. I have known cold sweats stop immediately, as well as those call- ed colliquative. I have known a purging immediately stop, upon the removal of the hectic cause, and the urine drop its sediment. It is possible too, that the pain in the opera- tion, and the sympathetic affection of the constitution may assist in these salutary effects. It is an action diametrically opposite to the hectic, and may be said to bring back the constitution to a natural state. III. OF DISSOLUTION. DISSOLUTION is the last stage of all, and is common to, or an immediate consequence of all diseases, whether local or constitutional. A man shall not recover of a fe- ver, whether original or sympathetic, but shall move into the last stage, or dissolution. It shall take place in the se- cond stage of a disease, where the state of constitution And its consequences on the constitution. 227 and parts appears to be formed out of the first; as for in- stance, a man shall lose his leg; especially if above the knee; or have a very bad compound fracture in the leg; the first constitutional symptoms shall have been violent, but all shall appear to have been got the better of, and there shall be hopes of recovery, when suddenly he shall be attacked with a shivering fit, which shall not perform all its actions, viz. shall not produce the hot fit and sweat, but shall con- tinue a kind of irregular hot fit, attended with loss of appetite, quick, low pulse, eyes sunk, and the person shall die in a few days. Or he shall go into the common diseased symptoms of the second stage, viz. the nervous, with many of its effects, as the tetanus, and dissolution shall also be a consequence. Or if the local disease does not or cannot heal, and is such as to affect the constitution, it then brings on the hectic, and sooner or later dissolution takes place; for the hectic is an action of disease, and of a particular kind; but dissolution is giving way to disease of every kind, there- fore has no determined form arising from the nature of the preceding disease. It has been supposed, that this disease arises also from the absorption of matter. It appears to be in many cases an effect arising from violent and long continued inflam- mations and suppurations, although not incurable in them- selves; (therefore, in those respects, not similar to the hec- tic) and which in many instances are known to produce the greatest changes in the constitution. Such often arise from very bad compound fractures, from amputations of the extremities, especially the lower, and more particularly the thigh, in which cases the sympathetic fever has run high, which would appear to be necessary, or preparatory; but in the hectic, it is not necessary that the constitution should have suffered at all in the first stages of the disease; disso- lution seems to be more connected with what is past, than with the present alone, which is the reverse of the hectic. We never find this disease take place in consequence of small wounds, or such wounds as have affected the constitution but little in its first stages; but which may affect the con- stitution much in its second, such as small wounds produc- ing the lock jaw. It would appear to take place in our hospitals more generally than in private houses, and more readily in large cities than in the country. We shall find that the hectic and this are by no means the same disease, differing exceedingly in their causes, and in many of their 228 Effects of inflammation, effects; for in the cases of compound fractures and ampu- tations, we find the constitution often capable of going through the inflammatory and sympathetic fever, produc- ing suppuration and granulation, as well as continuing the production of these for some time, yet sinking under them at last, and often immediately, without a seeming cause. This effect will more readily take place, if the person was in full health before the accident or operation, than if he had been somewhat accustomed to the other, or true hectic; for the symptoms of dissolution seldom or never take place, if the violence committed has been to get rid of a hectic cause. It sometimes takes place early, in consequence of local in- jury, and would seem to be a continuation of the sympa- thetic fever; as if the constitution was not able to relieve itself of the general affection, or that the parts could not go into the true suppurative disposition. We see this fre- quently after removing a limb, especially in the lower ex- tremity, and after cutting for the stone in very fat men, a- bove the middle age, and who have lived well. The first symptoms are generally those of the stomach, which produce shivering: vomiting immediately follows, if not an immediate attendant; there is great oppression and anxiety, the persons conceiving they must die. There is a small quick pulse; perhaps bleeding from the whole sur- face of the sore, often mortification with every sign of dis- solution in the countenance; as it arises with the symptoms of death, its termination is pretty quick. Here is a very fatal disease taking place; in some almost immediately, when all appeared to be within the power of the machine, and therefore cannot immediately arise from the sore itself; for it is very common after such operations as usually do well; but the hectic always takes place in consequence of those sores which seldom or never get well in any case; yet the sore certainly assists in bringing on dissolution, because we never see the disease take place when the sore is heal- ed, nor in those where the constitution seems not to be equal to the task, as is the cause of the hectic. The hectic is much slower in its progress, and seems to be a simple and an immediate effect, arising from a conti- nued cause which is local; by removing the cause, there- fore, the effect ceases, and the havoc made upon the consti- tution is soon restored; persons, therefore, do much better in consequence of the hectic having in some degree taken place, prior to the removal of the cause. But dissolution And its consequences on the constitution. 229 is a change of the constitution in consequence of causes which now do not wholly exist, and in many cases it does not take place till the constitution appears to be capable easi- ly of performing all its functions, and a removal of the parts does not relieve, as in the hectic; for dissolution does not depend for its continuance upon the presence of the dis- ease. Death or dissolution, appears not to be going on equally fast in every vital part; for we shall have many people very near their termination, yet some vital actions shall be good, and tolerably strong; and if it is a visible action, and life depends much upon this action, the patients shall not ap- pear to be so near their end as they really are: thus I have seen dying people whose pulse was full and strong as usual, on the day previous to their death, but it has sunk almost at once, and then become extremely quick, with a thrill: on such occasions it shall rise again, making a strong effort, and after a short time, a moisture shall probably come on the skin, which shall in this state of pulse be warm; but u- pon the sinking of the pulse, shall become cold and clammy: breathing shall become very imperfect, almost like short catchings, and the person shall soon die. It would appear in many cases, that disease has produc- ed such weakness as at last, to destroy itself: we shall even see the symptoms, or consequences of disease, get well before death. A gentlewoman, who was above seventy-five, was anasarcous all over: the abdomen was very full and large; she made but very little water; her breathing was so diffi- cult as to make her purple in the face, so that most pro- bably there was water in the chest; her pulse was extremely irregular; fluttering, trembling, intermitting and small. Her legs were punctured with a lancet, and discharged very freely for more than three weeks, which emptied the cellular membrane of the body, as well as in some degree the abdomen; the breathing became free and easy, so that we supposed the water in the chest was absorbed; the pulse became regular, soft, and fuller, and the appetite in some degree mended; in which state she seemed free from dis- ease, having only some of the consequences still remaining. The quantity of urine increased to the natural quantity; but notwithstanding actual disease seemed to be gone, yet she became weaker and weaker, in which state she existed for near a month, and died. Some days prior to death, a 230 Effects of Inflammation, &c. purple and then a livid appearance came upon the legs, with some spots of extravasated blood above where the punc- tures had been made, on which blisters arose, at first filled with serum, then with bloody serum, all of them threaten- ing mortification. Even when in the state of approaching death, we often find a soft, quiet, and regular pulse, having not the least degree of irritability in it, and this when there is every other sign of approaching death; such as entire loss of appetite, no rest, hiccup, the feet cold and partial, cold, clammy sweats, etc. A lady appeared to have lost all diseased action, only the consequences of disease remaining, viz. weakness, with swelled legs; she made little or no water; at length she became so weak, as hardly to articulate; she lay in a kind of doze, was only roused to impression, and only took food by spoonfuls when desired; the pulse so small as hard- ly to be felt: her extremities were cold, and she had all the signs of approaching dissolution, which took place; yet within thirty-six hours before she died, the whole water in her legs and thighs was taken up, her urine increased, and about ten hours previous to her death, the legs, etc. were as small as ever. As I consider the dropsy to be a disease, and not simply weakness, which this case would in some measure shew from the result, I should wish to ask, whether the absorption of water was not owing to the dis- ease being gone, and whether the disease being gone, the absorbents did not set to work? If so, then dissolution may be a cessation of disease, and persons die of weakness sim- ply; or simply, either the want of powers to act, or the want of that stimulus of necessity to act, by which means a cessation of action takes place. Since bodies of persons who die suddenly, and even by violent death, as well as those who die soon after a considerable operation, are not capable of being preserved so long as those who have been ill for some time; and as those who have a considerable operation performed upon them, as the amputation of a leg, do not so readily reco- ver as those who have been long ill, may not the more rea- dy production of death, and the more ready production of putrefaction be owing to the same principle? one more readily running into the action of death, as also more rea- dily into the action of putrefaction; but it is very probable that the action producing quick putrefaction, is an action prior to absolute death. [231] PART III. CHAPTER I. THE TREATMENT OF ABSCESSES. I HAVE endeavoured to lay down the general princi- ples of suppuration, which principles of themselves lead to a general method of cure; but as it is only the proper ap- plication of art, to those principles which completes the surgeon, and since it is the most difficult part to apply our knowledge of the first principles to practice with readiness, especially when there appear some peculiarities, it will be necessary to bring the beginner from first principles to the practical part. Abscesses are in general consequences of spontaneous in- flammation, but not always so; for they may be consequences of some violence, as strains or bruises from some external violence, which has hurt deeper seated parts than the skin over them, which inflame and form an abscess, as was de- scribed in treating of accidents; as also from the introduc- tion of extraneous bodies, over which the parts have heal- ed. Even when they appear to be spontaneous, they arise from so many causes, and from thence have so many dis- positions, or are of so many kinds, that in general they be- come one of the greatest objects in surgery; because, from these circumstances, they require a vast variety in the man- ner of treatment. 232 Treatment of abscesses. I do not mean at present to enter into a full discussion of the cause, effect, and cure of every abscess, because that would be treating of every disease which is capable of pro- ducing such complaints, many of which would come under the article of specific diseases, which must be treated of se- parately; yet I mean here to lay down such general surgi- cal rules for their treatment and many of their consequen- ces, as will include almost every kind of disease of this kind, considered as an abscess simply; so that the specific treat- ment of any specific abscess will be principally confined to the medicinal treatment of the part and the constitution; thereby the treatment of the local complaint so produced, abstracted from the specific disposition, will for the most part come under our general rules. As most spontaneous suppurations, from whatever cause, are deeper seated than the surface of the body, such of course must form what are called abscesses, or collections of pus; therefore we have abscesses of all depths, from the pimple in the skin to the boil; and from the boil to deep- seated abscesses, among the muscles, or in any other deep- seated part. Abscesses are commonly formed where matter is found, especially the more superficial ones, and such may be justly called abscesses of this part; but collections of matter are often found in parts where not formed, more especially in the deeper seated ones, the matter moving from the seat where it was formed to some more depending part, or hav- ing met with some obstruction in its course, it takes anoth- er direction and therefore may be called an abscess in this part; and I shall call them so in my descriptious of them; I believe such abscesses do not arise from inflammation, but are of the scrofulous kind, and therefore not so much to our present purpose. It will be difficult to divide abscesses into absolutely dis- tinct classes; but, similar to inflammation, they may be divided into two kinds, the sound and the unsound; for I imagine these two first principles might lead to the method of cure; but at present I only mean to lay down the prin- ciples of an abscess. The appearances which distinguish the sound from the unsound abscess are several; although there are many ab- scesses of particular kinds that give little or no informa- tion. They often differ from one another in their first ap- The treatment of abscesses. 233 pearance, from the kind of inflammation, as also in their course, but more particularly in their efforts towards a cure. Thus we judge of the consequences of the small pox, from the first appearance of the arm after inoculation; for if the beginning inflammation is small, pretty much cir- cumscribed, and of the florid red with some rising, then we may in our own minds expect a good kind; the same upon the first appearance of the small pox themselves; as also the first appearance of a chancre, etc. or almost of a- ny other disease, either beginning with, or attended by in- flammation; for it is by the kind of inflammation we are to judge of the future event. It might be thought almost unnecessary here to treat of sound abscesses, because in such our first principles will readily take place, and often little or no assistance is requir- ed; but abscesses may be attended with circumstances which may retard the cure, and which have nothing to do with unsoundness; such as extraneous bodies in sound parts and these will most probably come under our general principles of cure; that is, require something to be done, because they will in many cases, relieve themselves of the extraneous matter, and then they require but little assist- ance. I. THE PROGRESS OF ABSCESSES TO THE SKIN. WHAT I mean by a sound abscess, is, where there is a sound constitution, the parts affected having all the dispo- sition and powers to heal; those dispositions and powers allowed to take place, which will take place more readily if in structures of the body which have naturally a ready disposition to heal; so situated in the body as to be able to support its actions, and not of a specific kind, for which Vol. II Gg 234 The treatment of abscesses. we have no cure; for any specific disease, for which we have a cure, will come within our first division*. The inflammation in a sound and active part, and of a sound constitution, in general is pretty violent, attended from the very beginning with a considerable deal of pain †, suppuration takes place quickly; the parts between the ab- scess and the skin are readily affected, and ulceration goes on fast, the skin becomes of the florid red, the matter comes soon to it, especially at a point*, and it bursts; all this is done with great rapidity. These symptoms show such a degree of health in the constitution and the parts, that little is necessary for the surgeon to do in the first stages of the disease. Poultices are recommended in such cases to assist that disposition which the parts have to give way between the skin and the abscess; but I have already observed, that they certainly can have no effect of this kind; however, they have their uses when the inflammation has reached the skin, for they keep it soft, allow the cuticle to distend, and give way to the swelling underneath; which cases the pa- tient; warmth and moisture act in many cases as sedatives to our sensations, although not always; and the distinction between those where they give ease, and where they rather give pain, I have not been able to make out. * Viz. If a venereal abscess has its specific quality destroyed, it admits of cure as readily as any other, and the same treat- ment becomes necessary. † Vide symptoms or suppurative inflammation. * This very appearance makes a material difference be- tween an abscess arising from brisk inflammation, and one that is slow in its progress; it is so remarkable, that I have seen this effect where the matter was at such distance as not to be felt in the least, and where I have doubted whether there was matter or not, almost conceiving that it preceded suppuration. It cer- tainly has this effect long before there is any distention: besides, this of a pointing taking place, there is another effect of deep suppurations in consequence of inflammation, which is an œde- matous appearance, or thickening of the superficial parts. This was taken notice of by Le Dran, in internal abscess of the abdomen, where adhesions had taken place, between the sup- purating part and parietes of the abdomen, and by Mr. Pott, in suppuration of the brain; whether in such there is a point- ing I do not know. The treatment of abscesses. 235 As an abscess of the healthy kind requires but little surgi- cal treatment, between its commencement and opening, it also requires but very little attention afterwards for the cure, or the restoring the parts. It depends on the operation of the powers, or abilities the machine is in possession of more than any assistance the surgeon can give; however, abscesses may have other cir- cumstances attending them, besides soundness and unsound- ness, which will require surgical treatment; such as the ex- traction of exfoliated bones, which by their stay retard the cure. Farther, as few inflammations arise in perfectly sound parts and constitutions, it will generally be necessary to treat them in some degree as if they had an unfound ten- dency, and also according to other circumstances; as no abscess can set about a cure till the matter is discharged, the first process, therefore, is the discharge of the matter; but simply discharge is not always sufficient; therefore it be- comes necessary to consider whether or not, almost in eve- ry case it would not be proper to do more; and I am in- clined to believe that whatever would in general assist an unsound abscess, would also do the same to a sound one; but this practice should be followed with great caution, and not carried too far; for in many it will be perfectly unne- cessary, therefore it should not be practised; in others it will only be necessary in part; besides, in many cases it may do harm, for many abscesses may have tolerable dis- positions under the present treatment, yet may be in such a state as very readily to fall into an unsound one, of some kind or other, when too much violence is committed; some having a tendency to irritability. On the other hand, our practice may fall short of the intention, as many parts have a strong tendency to indolence; and if the stimulat- ing method is applied to the first it would be unlucky, and vice versâ. It will be generally more in the power of the parts to perform a cure if certain operations are done, which even dispose the most active and healthy disposition, both of con- stitution and of parts to heal sooner; but this does not hold of the irritable. The first of these operations will be the mode of exposing abscesses, by opening them sufficiently, which will make any particular treatment afterwards, either less necessary, or more easy of application, if necessary; so that the first principle of the cure, even of sound abscesses, may 236 The treatment of abscesses. be the freedom of opening them in the beginning; how- ever, the more sound they are, there is the less necessity for such treatment; for if it does not give new powers to the parts, it keeps up those of which they are already in pos- session, and obliges them to go on towards a cure; for the living principle in parts seems uneasy under the circum- stance of exposure, and of having no skin, more especially sound parts, therefore is roused to action, acting with a view to cover the part. It has no alternative; and as I have just now observed that few spontaneous abscesses take place from so slight a cause as simple violence produces, there must be a something to be got the better of. This is per- haps, as well illustrated in the fistula in ano, as in any o- ther; for without dividing along the gut to the bottom, which is where the disease is, and where the abscess formed, it seldom or never heals; however, all this will be accord- ing to circumstances, for if the suppuration is quick and comes fast to the skin, the parts will heal in the same pro- portion more readily, either with or without opening; there- fore, in such instances, it is not so necessary to open freely, though as it is not the method nature commonly takes, it has by many been objected to; but let us observe, that where an abscess opens of itself by a small orifice, the parts are commonly very sound where the opening is, although the bottom may be diseased; but if it be diseased where it opens, then ulceration commonly takes place at this orifice, which effect what should be done by art. To illustrate that a large opening is not detrimental to the healing of a sore, let us observe that there is no difference between an abscess open- ed largely, and a wound in consequence of an operation which is not healed by the first intention, such as an ampu- tation, etc. for in such cases there is a breach in the conti- nuity of the parts communicating with the skin, as large, if not larger, than at the bottom, and it heals readily; we endeavour, however, to remedy this as much as possible by saving skin, which, in some degree, answers to a small open- ing; and we may also observe that where there is only a small opening leading to a large cavity, which is to suppu- rate, as in the case of an hydrocele treated by a caustic or seaton, (which, when come to suppuration, is in all respects similar to an abscess) that the whole so far as suppuration extends, heals equally well with those that are wholly ex- posed; but I do not know that they do better; and where The treatment of abscesses. 237 the sack is not very sound, I do believe they do not do so well, as when more fully enlarged; and we may also ob- serve, that opening largely in the scrotum is not subject to the same inconvenience as in many other parts, for here there is so much loose skin as to remove any retardment to the healing that might arise in other parts from opening largely; however, after viewing this in every light, there seems but little advantage gained in the one way or the other. The opening more or less freely must be directed by some other circumstance, by which the surgeon must be guided. But as most abscesses owe some of their size to distention, and as this will be more or less according to circumstances, it becomes necessary to distinguish the one kind from the other, for the one will require a freer opening than the other. Abscesses in soft parts will owe more of their size to dis- tention than those in hard parts, such as bones, joints, etc. Abscesses in soft parts, not connected with the hard, will owe more of their size to distention than those in soft parts connected with the hard; for instance, an abscess in the calf of the leg, thick of the thigh, buttock, etc. will owe more of its size to distention than an abscess on the shin- bone, on the head, etc. Therefore an abscess, whose size is in some degree owing to distention, need not be so free- ly opened as one that is not; because when the distention is taken off by the discharge of the pus, the parts will con- tract, or fall into their natural position, which cannot so easily happen in the other case. Besides, the granulations will also be allowed to contract in the one much more than the other. However, we find many abscesses healing ve- ry readily without any other opening than what was at first made by ulceration, and this will be more readily effected if the abscess had been allowed to break of itself; which I shall now more fully explain. 238 The treatment of abscesses. II. OF THE TIME WHEN ABSCESSES SHOULD BE OPENED. THE natural process that abscesses are obliged to go through for the discharge of their contents is in general the most proper, and it is so much so, as to be in most cases allowed to go on; and this process becomes more necessa- ry in unsound abscesses than in sound ones, as it exposes them more fully, from ulceration having destroyed more of the parts between the seat of the abscess and the external parts. As abscesses, wherever formed, must increase as they approach the skin, and therefore increase that part of their cavity next to the skin, faster than at the bottom, so that they become in some degree tapering towards the bottom, with a wide part immediately under the skin, and this will be more or less so, according to its depth, its meeting with different substances, which give a resistance to the pus, or its coming fast or slowly to the skin. This shape of the abscess, when allowed to take place is well adapted for healing, for it puts the bottom, which is the seat of the disease, more upon a footing with the mouth of the abscess, than it otherwise could be. When these two are not well proportioned, there is a retardment in the cure; for as the bottom, or part where the abscess begun, is more or less in a diseased state, and as the parts between the seat of the abscess and the external surface are found parts, having only allowed a passage for the pus, they of course have a stronger disposition to heal than the bottom has; and we commonly find this to be the case. If there could be made at any time a difference in the powers of healing between the mouth of the abscess and its bottom, it ought to be made the most defective at the mouth of the abscess, as that part is the easiest of manage- ment. To have this effect produced as much as possible, abscesses should be allowed to go on till they break or open of themselves; for although abscesses in general only open by a small orifice, more especially when sound, yet it is to be remarked, that the skin over the general cavity of the ab- scess is in such cases so much thinned as to have but very The treatment of abscesses. 239 little disposition to heal, and is often so much so, as to ul- cerate and make a free opening; and if it does not, an o- pening is more easily procured by art. It is a curious circumstance in the œconomy of abscess, that those that have the best dispositions to heal come fast- est to the skin; the lead takes place almost at a point, it does not swell so much into that conical form, above-de- scribed, not being under the same necessity in point of healing, and it opens by a small orifice; while, on the o- ther hand, if there is an indolence in the progress of the abscess, it will spread more, or distend the surrounding parts from their not being so firmly united by inflammation in the one as they were in the other; nor will ulceration so readily take the lead, and it will come to the skin by a broad surface, so as to thin a large portion of the skin. But abscesses should only be allowed to open of themselves where the confinement of the matter can do no mischief, which will generally be in such as ought to heal up from the bottom; but in the reduction of circumscribed cavities to the state of an abscess, it will be in most cases proper to open early, as abscesses of the abdomen or thorax; those within the cranium; those of the eye; and those in joints. In the abscess of the tunica vaginalis testis it would be better to let it open of itself, as it should be allowed to heal up from the bottom, similar to an abscess in the cellular membrane. If it should be unnecessary to open freely, or if from cir- cumstances this should be impossible, it will in either case be very proper to make the opening which is necessary or practicable at the most depending part, with a view to remove the pressure arising from the matter collected, which is com- monly called confinement or lodgement of matter, which will otherwise happen; for I shall observe, that a very small pressure on that side of the abscess, next to the skin, may produce ulceration there; and although this pressure in many cases might not be so great as to produce ulceration at the bottom of the abscess, yet it may be so great as to prevent granulations from forming on that side, and there- by retard the cure, as no union can take place but by means of granulations; or if it should not prevent granulations from forming, yet it might retard their growth, so that the cure would be more tedious than if the pressure did not 240 The treatment of abscesses. exist; and this retardation will be greatest where the pres- sure is the greatest, which will be at the most depending part of the abscess; so that its upper part will readily heal to a small point, and be reduced to the state of a fistula. But it is not always possible to open at the most depend- ing part of an abscess, and when possible, often very im- proper. When impossible, perhaps, nothing more can be done than to evacuate the matter as often as necessary, and by gentle pressure keep the sides of the sinus together, to allow their growing into one another; but the situation will not in all cases allow this. The inexpediency of opening at the most depending part of an abscess will in general arise from the distance between the matter and the skin at this part, for if the abscess is pretty deeply seated, and points at a part superior to that of its seat, which it sometimes does from the parts above, being such as more easily give way, in such a case it will be proper to open it where it points; for instance, if an ab- scess is formed in the centre of the breast, and opens at the upper part, (which is often the case) it would be improper to cut through the lower half, to allow the matter to pass that way, although it may make its way there after- wards, from the pressure of the matter, as was just now observed; which I have seen happen more than once. If an abscess forms on the upper part of the foot, it is improper to open through the sole of the foot to get at the most depending part of the abscess; for besides cutting such a depth of sound parts, which is an objection, it would be destroying a great many useful parts. It would also be impossible to keep it open, the sound parts having such a disposition to heal; and it would be contradictory to my first position, which was to have parts as thin as possible before they are opened, in order to destroy the healing dis- position there*. As in such cases, the place where the matter threatens to open a passage for itself, is where the future opening is most likely to be, and as the situation is disadvantageous to the healing of the seat of the abscess, it will be more neces- sary to let it first open of itself, because the abscess just un- * One would imagine that this last caption was hardly neces- sary; but I once saw a case where it was advised upon the ge- neral principles of opening in the most depending part. The treatment of abscesses. 241 der the skin will be increased in width, as was observed, and then to dilate it as freely as may be thought necessary; for by allowing abscesses to open of themselves, the open- ing has a less disposition to heal than if it had been open- ed early by art, therefore is more desirable in such situa- tions. III. OF THE METHODS OF OPENING AB- SCESSES, AND TREATING THEM AFTER- WARDS. ALL abscesses, I have already observed, will open of themselves, excepting where the matter is re-absorbed; and I have also observed, that in general they ought to be al- lowed to open of themselves, excepting some particular circumstance calls for an early opening; but when the skin over the abscess is very thin, it is not of so much con- sequence whether it is allowed to open of itself, or is o- pened at first by art. In large abscesses it will generally be necessary to open them by art, whether they have opened of themselves or not; for the natural opening will seldom be sufficient for the complete cure; and although it may be sufficient for the free discharge of the matter, yet they will heal much more readily if sufficiently opened; for the skin over the cavity granulates but indifferently, and there- fore unites but slowly with the parts underneath. Where the skin is very thin, loose, and much of it, it may be necessary to remove an oval piece from the centre, where it is generally thinnest. A question naturally oc- curs, in what way should these be opened? The methods recommended and used are by incision and caustic. Incision may or may not remove a piece of the skin, but the caustic always will. I believe, as a gene- ral practice, there is no preference to be given to either; VOL. II. Hh 242 The treatment of abscesses. but under circumstances, the incision is best; for in- stance, where there is but little skin to spare, as on the skin, scalp, etc. but where there is skin to spare, either ari- sing from situation, as in the scrotum, or where a great deal of skin was thinned, as in a great extent of inflam- mation and suppuration under the skin, a caustic will an- swer equally well; therefore I should be very apt to be di- rected by my patients, if they had any fears or opinions about the matter; for some have a terror at the idea of a cutting instrument, while others hate the idea of a contin- ued pain. If a caustic is approved of, then I should prefer the lapis infernalis, or septicus, to the common caustic; the method of application I described, when speaking of the methods of producing death by art: but if left entirely to myself, I should prefer the incision to the caustic, be- cause it is immediately done. If an abscess is allowed to open of itself, and this o- pening is not enlarged, no dressing is necessary, nor any thing but to keep the surrounding parts clean; the conti- nuation of the poultice, which was before applied, (if con- venient) is perhaps as good an application as any; and when the tenderness arising from inflammation is over, then lint and a pledget; but an abscess opened by a cutting in- strument, may be called a mixed case, being both a wound and a sore, and is more of the nature of a fresh wound in proportion to the thickness of the parts cut; and there- fore the dressing should be somewhat similar to that of a fresh wound. It is necessary that something should be put into the opening, to keep it from healing by the first in- tention; if it is lint, it should be dipt into some salve, which will answer better than lint alone, as it will allow of more early extraction; for such sores should be dressed the second time the next day, or the second day at latest; be- cause there is a suppurating sore at the bottom, and the pus requires being discharged much sooner than if wholly either a fresh wound or a circumscribed cavity, which is to suppurate, as the tunica vaginalis in the case of the radical cure of the hydrocele. This pus keeps the lint (if dressed with lint) moist, so that it does not dry, as in fresh wounds in common. When the cut edges have come to suppura- tion, which will be in a few days, then the dressing after- wards may be as simple as possible, for nature will in gene- ral perform the cure. The treatment of abscesses. 243 If the abscess has been opened by caustic, and the slough is either cut out, or allowed to slough out, then it is to be considered as an entire suppurating sore, and may be dress- ed accordingly; perhaps dry lint is as good as any thing, till the nature of the sore is known; if of a good kind, the same dressing may be continued, but if not, then it must be dressed accordingly; for nature cannot always perform a cure; for parts which were at first sound, or appeared so, from their readiness to go through the first stages, will sub- sequently take on every species of disease, whether from in- dolence, from irritability, from scrofulous, or other dispo- sitions which in some cases are produced from the nature of the parts diseased, such as bone, ligament, etc.  [245] PART IV. CHAPTER I. OF GUN-SHOT WOUNDS. GUN-SHOT wounds may be said to be an effect of a modern improvement in offence and defence, unknown in the former mode of war, which is still practised where Eu- ropean improvements are not known; and it is curious to observe that fire-arms and spirits are the first of our refine- ment that are adopted in uncivilized countries; and, in- deed, for ages they have been the only objects that have been at all noticed or sought after by rude nations. It was not till the fourteenth century that gunpowder was made, or rather compounded; but it was not till afterwards, applied to the purpose of projecting bodies. But even now, the wounds received in war are not all gun-shot wounds: some, therefore, are similar in many respects to those re- ceived in former times. The knowledge of the effect of gunpowder, and its application to the art of war, or the projection of bodies for the destruction of men, has been in some degree ac- companied by improvements in the arts and sciences in gen- eral, and among others, that of surgery, in which art, the healing of wounds so produced, makes a material part. In France, more especially, the study of both were carried to considerable lengths; but though the art of destruction has been there improved and illustrated by writings, it is rather surprising that the art of healing should not have been equally illustrated in the same manner. Little has been written on this subject, although, perhaps when we take every circumstance into consideration, it requires particu- 246 Of gun-shot wounds. lar discussion; and what has been written is so superficial, that it deserves but little attention. Practice, not precept, seemed to be the guide of all who studied in this branch; and, if we observe the practice hitherto pursued, we shall find it very confined, being hardly reduced to the common rules of surgery, and therefore it was hardly necessary for a man to be a surgeon to practice in the army. I. THE DIFFERENCE BETWEEN GUN-SHOT WOUNDS AND COMMON WOUNDS. GUN-SHOT wounds are named, as is evident, from the manner in which they are produced. From the frequency of their happening in the time of battle to a set of men ap- propriated for war, both by sea and land: and from the appointment of particular surgeons for their cure, they have been considered apart from other wounds, and are now be- come almost a distinct branch of surgery. Gun-shot wounds are made by the projection of hard obtuse bodies, the greatest number of which are musket-balls; for can- non-balls, pieces of shells and stones from ramparts in sieges, or splinters of wood, etc. when on board of a ship in an en- gagement at sea, can hardly have their effects ranked among gun-shot wounds, they will come in more properly with wounds in general. As the wounds themselves made by those very different modes will in general differ very consi- derably; any peculiarity that may be necessary in the treat- ment of gun-shot wounds, from those made by cannon-balls, shells, etc. or even common wounds, will generally belong to those made by musket-balls. The whole of gun-shot wounds will come within the de- finition of accidents. They are a recent violence com- mitted on the body; but they often become the cause of, or degenerate into a thousand complaints, which are the objects of surgery or physic, many of which are common to accidents in general, and to many other diseases; of this kind are abscesses, ulcerating bones, fistulæ; but some are peculiar to gun-shot wounds, as calculi in the bladder from Of gun-shot wounds. 247 the ball entering that viscus, consumption from wounds in the lungs, which I believe rarely happens; for I cannot say I ever saw a case where such an effect took place. But it is the recent state in which they are distinguished, and in which they are to be considered as a distinct object of treat- ment. Wounds of this kind vary from one another, which will happen according to circumstances; these variations will be in general according to the kind of body projected, the velocity of the body, with the nature and peculiarities of the parts injured. The kind of body projected, I have ob- served, is principally musket-balls, sometimes cannon-balls, sometimes pieces of broken shells, and very often on board of ship, splinters of wood. Indeed the effects of cannon- balls on different parts of the ship, either the containing parts, as the hull of the ship itself, or the contained, are the principal causes of wounds in the sailor; for a cannon- ball must go through the timbers of the ship before it can do more execution than simply as a ball, (which makes it a spent ball) and which splinters the inside of the ship very considerably, and moves other bodies in the ship, neither of which it would do if moving with sufficient velocity; musket or cannon-balls seldom doing immediate injury to those of that profession. The wounds produced by the three last bodies will be more like many common and violent ac- cidents, attended with much contusion and laceration of parts. Gun-shot wounds, from whatever cause, whether from a musket-ball, cannon-ball, or shell, etc. are in general con- tused wounds, from which contusion there is most com- monly a part of the solids surrounding the wound deaden- ed, as the projecting body forced its way through these so- lids, which is afterwards thrown off in form of a slough, and which prevents such wounds from healing by the first intention, or by means of the adhesive inflammation, from which circumstance most of them must be allowed to sup- purate. This does not always take place equally in every gun-shot wound, nor in every part of the same wound; and the difference commonly arises from the variety in the velo- city of the body projected; for we find in many cases, where the ball has passed with little velocity, which is often the case with balls, even at their entrance, but most common- 248 Of gun-shot wounds. ly at the part last wounded by the ball, that the wounds are often healed by the first intention. Gun-shot wounds, from the circumstance of commonly having a part killed, in general do not inflame so readily as those from other accidents; this backwardness to inflame will be in the proportion that the quantity of deadened parts bear to the extent of the wound; from which circumstance the inflammation is later in coming on, more especially when a ball passes through a fleshy part with great velocity; because there will be a great deal deadened, in proportion to the size of the wound; therefore inflammation in gun- shot wounds is less than in wounds in general, where the same quantity of mischief has been done; and this, also, is in an inverse proportion to the quantity of the parts deaden- ed, as I have already explained in my introduction to in- flammation, viz. that inflammation is less where parts are to slough, than where parts have been destroyed by other means. On the other hand, where the ball has fractured some bone, which fracture in the bone has done considerable mischief to the soft parts, independent of the ball, then there will be nearly as quick inflammation as in a compound fracture of the same bone, because the deadened part bears no proportion to the laceration or wound in general. From this circumstance, of a part being often deadened, a gun-shot wound is often not completely understood at first; for it is at first, in many cases, impossible to know what parts are killed, whether bone, tendon, or soft part, till the deadened part has separated, which often makes it a much more complicated wound than at first was known or ima- gined; for it very often happens, that some viscus, or a part of some viscus, or a part of a large artery, or even a bone, has been killed by the blow, which does not show itself till the slough comes away. If, for instance, it is a part of an intestine that has received a contusion, so as to kill it, and which is to slough, a new symptom will most probably appear from the sloughs being separated, the con- tents of the intestine will most probably come through the wound; and probably the same thing will happen when any other containing viscus is in part deadened; but those cases will not be so dangerous, as if the same loss had been produced at first, for by this time all communication will be cut off between the containing and contained parts; nor will it be so dangerous as when a considerable blood-ves- Of gun-shot wounds. 249 sel is deadened; for in this case, when the slough comes off' the blood, getting a free passage into the wound, as also out of it, probably death will immediately follow. If this artery is internal, nothing can be done; if in an extremity the vessel may be either taken up, or probably amputation may be necessary to save the person's life; therefore an ear- ly attention should be paid to accidents, where such an e- vent is possible. In case of a bone being deadened, an ex- foliation takes place. Gun-shot wounds are often such as do much mischief to vital parts, the effects of which will be according to the na- ture of the parts wounded, and the violence of the wound; and also to parts, the soundness of which are essential ei- ther to the health of the whole, or to the uses of the parts wounded; such as some viscus, whose contents are voided through the opening, or joints, the disposition of which is slow to heal, and whose uses are impeded when healed. Gun-shot wounds often admit of being classed with the small and deep seated wounds, which are always of a par- ticular kind respecting the cure. The variety of circumstances attending gun-shot wounds is almost endless; the following case may be given as an example. An officer in the navy was wounded by a pistol-ball, in the right side, about the last rib; it entered about five in- ches from the navel, and appeared on the inside of the skin about two inches from the spinal process, having passed, I believe, in among the abdominal muscles. The only re- markable thing that occurred was, that the cellular mem- brane for some way about the passage of the ball was œde- matous, and when I cut out the ball, air came out with it. II. OF THE DIFFERENT EFFECTS ARISING FROM THE DIFFERENCE IN THE VELO- CITY OF THE BALL. MANY of the varieties between one gun-shot wound and another, arise from the difference in the velocity of the bo- dy projected; and they are principally the following. VOL. II. Ii 250 Of gun-shot wounds. If the velocity of the ball is small, then the mischief is less in all of them; there is not so great a chance of their being compounded with fractures of the bones, etc. but if the ve- locity is sufficient to break the bone it hits, the bone will be much more splintered than if the velocity had been very considerable; for where the velocity is very great, the ball, as it were, takes a piece out; however, all this will also vary according to the hardness of the bone. In a hard bone the splinters will be the most frequent. When the velocity is small, the direction of the wound produced by the ball, will, in common, not be so strait, therefore its direction not so readily ascertained, arising from the easy turn of the ball. When the velocity is small, the deadened part or slough is always less; for with a small velocity, a ball would seem only to divide parts, while when the velocity is great, the contrary must happen; from this circumstance it is, that the slough is larger at that orifice where the ball enters than where it comes out; and if the ball meets with a great deal of resistance in its passage through, there will very probably be no slough at all at its exit, which will be therefore only a lacerated wound. The greater the velocity of the ball, the cleaner it wounds the part, so much so as almost to be similar to a cut with a sharp instrument; from which circumstance it might be imagined, that there should be a smaller slough; but I suspect, that a certain velocity given to the best cutting in- strument, would produce a slough on the cut edges of the divided parts; for the divided parts not giving way equal- ly to the velocity of the dividing body, must of course be proportionally bruised. Gun-shot wounds are attended with less bleeding than most others; however, some will be attended with this symp- tom more than others, even in the same part; this arises from the manner in which the wound is produced: bleeding arises from a vessel being cut or broken; but the freedom of bleeding arises from the manner in which this is done: if the artery is cut directly across, and it is done by a ball passing with a considerable velocity, it will bleed pretty free- ly; if bruised, and in some degree torn, then it will bleed less. When the velocity of the ball is small, the vessel will be principally torn, for, they will have time to stretch Of Gun-shot wounds. 251 before the continuity of their parts gives way; but if it is great, they will bleed more freely, because velocity will make up for want of sharpness. According to the velocity of the ball so is the direction. When the velocity is great, the direction of the ball will be in general more in a straight line than when it is small; for under such circumstances the ball more easily overcomes obstructions; and therefore passes on in its first direction. Velocity in the ball makes parts less capable of healing than when it moves with a small velocity; therefore gun- shot wounds in pretty thick parts are in general later of heal- ing at the orifice where the ball enters, than at the orifice where it passes out; because it becomes in some degree a spent ball, the part having less slough, being only torn, which will often admit of being healed by the first inten- tion. In cases where the ball passes through, and in such a di- rection as to have one orifice more depending than the o- ther, I have always found that the depending orifice healed soonest, and more certainly so if the ball came out that way, and also if the ball had been pretty much spent in its pas- sage; therefore it will require art to keep the depending orifice open, if thought necessary; but this circumstance of its being a spent ball, will not always happen, because if the person is near the gun when fired, the velocity of the ball will be very little diminished in its progress through the soft parts; and therefore it will have nearly the same ve- locity on both sides. This fact of the lower orifice healing soonest, is common to all wounds, and I believe is owing to the tumefaction which generally arises from the extravasated fluid always descending to the lower part, and being retarded at the lower orifice, it is as it were stopped there, and presses the sides of the wound together, obliging it to heal, if the parts have not been deadened; this is evidently the case after the introduction of the seaton in the hydrocele, especially is the two orifices of the seaton are at some distance; but in the hydrocele, there is a more striking reason for it; for in this disease, the extravasated fluids are wholly detained about the lower orifice, as there is no depending part for the fluid to descend to. 252 Of Gun-shot wounds. III. OF THE DIFFERENT KINDS OF GUN- SHOT WOUNDS. GUN-SHOT wounds may be divided into the simple, and the compound. Simple, when the ball passes into, or through the soft parts only: the compound will be accord- ing to the other parts wounded. The first species of compound, are those attended with fractures of the bones, or with the wound of some large ar- tery. The second species of compound wounds is, where the ball penetrates into some of the larger circumscribed cavi- ties. This last, or penetrating wound, may be doubly complicated, or may be divided into two. First, simply penetrating; and, secondly, where some viscus or con- tained part, as the brain, lungs, heart, abdominal viscera, etc. is injured; all which cases will be taken notice of in their proper places. [253] CHAPTER II. OF THE TREATMENT OF GUN-SHOT WOUNDS. IT has been hitherto recommended, and universally practised by almost every surgeon, to open immediately upon their being received, or as soon as possible, the ex- ternal orifice of all gun-shot wounds made by musket-balls; so much has this practice ben recommended, that they have made no discrimination between one gun-shot wound and another; this would appear to have arisen, and to be still continued, from an opinion that gun-shot wounds have a something peculiar to them, and of course are different from all other wounds, and that this peculiarity is removed by the opening; I own that I do not see any peculiarity. The most probable way of accounting for the first introduc- tion of this practice, is from the wound in general being small, and nearly of a size from one end to the other; also the frequency of extraneous bodies being forced into these wounds by the ball, or the ball itself remaining there; for the way in which these wounds are made, is by the in- troduction of an extraneous body which is left there, if it has not made its way through, so that the immediate cause of the wound makes a lodgment for itself; often car- rying before it clothes, and even the parts of the body wounded, such as the skin, etc. from hence it would na- turally appear at first view, that there was an immediate ne- cessity to search after those extraneous bodies, which very probably led the surgeon to do it; and in general the im- possibility of finding them, and even of extracting them 254 Of the treatment of gun-shot wounds. when found, without dilatation, gave the first idea of o- pening the mouths of the wounds; but from experience, they altered this practice in part, and became not so desi- rous of searching after these extraneous bodies; for they found that it was oftner impossible to find them than could at first have been imagined, and when found that it was not possible to extract them, and that afterwards these bodies were brought to the skin by the parts themselves, and those that could not be brought to the external surface in this way, were such as gave little or no trouble afterwards, such as balls; yet they altered this practice only so far as respected the attempt to extract extraneous bodies, for when they found from experience, that it was not necessa- ry nor possible to extract these immediately, yet they did not see that it therefore was not necessary to take the previ- ous or leading steps towards it. The circumstance I have mentioned, of gun-shot wounds being contused, obliges most of them to suppurate, because in such cases there is more or less of a slough to be thrown off, especially at the orifice made by the entrance of the ball; there is, therefore, a freer passage for the matter, or any other extraneous substance, than the same sized wound would have, if made by a clean cutting instrument, even if not allowed to heal by the first intention. From all which, if there is no peculiarity in a gun-shot wound, I think this of dilating them as a general practice should be rejected at once, even were it only for this rea- son, that few gun-shot wounds are alike, and therefore the same practice cannot apply to all. This treatment of gun-shot wounds is diametrically op- posite to a principle which is generally adopted in other cases, although not understood as a general rule, which is, that very few wounds of any kind require surgical treatment at their commencement, excepting with an opposite view from the above, viz. to heal them by the first intention. It is contrary to all the rules of surgery founded on our knowledge of the animal œconomy to enlarge wounds sim- ply as wounds; no wound, let it be ever so small, should be made larger, excepting when preparatory to something else, which will imply a complicated wound, and which is to be treated accordingly; it should not be opened because it is a wound, but because there is something necessary to Of the treatment of gun-shot wounds. 255 be done, which cannot be executed unless the wound is en- larged. This is common surgery, and ought also to be military sur- gery respecting gun-shot wounds. As a proof of the inutility of opening gun-shot wounds as a general practice, I shall mention the cases of four Frenchmen, and a British soldier, wounded on the day of the landing of our army on the island of Bellisle; and as this neglect rather arose from accident than design, there is no merit claimed from the mode of treatment. Case I. A. B. was wounded in the thigh by two balls, one went quite through, the other lodged somewhere in the thigh, and was not found while he was under our care. II. B. C. was shot through the chest; he spit blood for some little time. III. C. D. was shot through the joint of the knee: the ball entered at the outer edge of the patella, crossed the joint under that bone, and came out through the inner condyle of the os femoris. IV. D. E. was shot in the arm: the ball entered at the inside of the insertion of the deltoid muscle, passed towards the head of the os humeris, then between the scapula and ribs, and lodged between the basis of the scapula and spinal processes, and was afterwards extracted. The man's arm was extended horizontally when the ball entered, which ac- counts for this direction. These four men had not any thing done to their wounds for four days after receiving them, as they had hid them- selves in a farm-house all that time after we had taken pos- session of the island; and when they were brought to the hospital, their wounds were only dressed superficially, and they all got well. A grenadier of the 30th regiment was shot through the arm, the ball seemed to pass between the biceps muscle and the bone; he was taken prisoner by the French. The arm swelled considerably, they fomented it freely, and a su- perficial dressing only was applied. About a fortnight after the accident he made his escape, and came to our hos- pital; but by that time the swelling had quite subsided, and the wounds healed; there only remained a stiffness in the joint of the elbow, which went off by moving it. 256 Of the treatment of gun-shot wounds. I. OF THE PROPRIETY OF DILATING GUN-SHOT WOUNDS. IT would be absurd for any one to suppose that there is never occasion to dilate gun-shot wounds at all; but it is certain there are very few in which it is necessary. It will be impossible to determine by any general description what those are that ought to be opened, and what those are that ought not, that must be left in a great measure to the dis- cretion of the surgeon, when once he is master of the argu- ments on both sides. Some general rules may be given with regard to the more simple cases; but with regard to the more complicated, the particular circumstances of each case are the only guide; and they must be treated according to the general principles of surgery. Let us first give an idea of the wound that would appear to receive no benefit from being dilated; and first of the most simple wounds. If a ball passes through a fleshy part where it can hurt no bone in its way, such as the thick of the thigh, I own, in such a simple wound, I see no reason for opening it; be- cause I see no purpose that can be answered by it, except the shortening of the depth of the wound made by the ball, which can be productive of no benefit. If the ball does not pass through, and is not to be found, opening can be of as little service. If the opening in the skin should be objected to, as being too small, and thereby forming an obstruction to the exit of the slough, etc. I think that in general it is not; for the skin is kept open by its own elasticity, as we see in all wounds; this elasticity, muscles and many other parts have not; and in general the opening made by a ball is much larger than those made by pointed instruments; for I have already observed, that there is often a piece of the skin car- ried in before the ball, especially if it passed with consider- able velocity, besides the circular slough; so that there is really in such cases a greater loss of substance; therefore, whatever matter or extraneous body there is, when it comes to the skin, it will find a free passage out. Nor does the wound in the skin in general heal sooner than the bottom; and, indeed, in many cases not so soon, because the skin is generally the part that has suffered most. Of the treatment of gun-shot wounds. 257 However, this is not an absolute rule, for the skin sometimes heals first; but I have found this to be the case as often where openings had been made, as in those where they had not; and this will depend upon circumstances or peculiarities; such as the bottom being at a considerable distance, with extraneous bodies, and having no disposi- tion to heal, tending to a fistula; and I have observed in those cases, that the wound or opening made by the sur- geon generally skinned to a small hole before the bottom of the wound was closed, which brings it to the state it would have been in, if it had not been dilated at all, especially if there are extraneous bodies still remaining; for an extra- neous body causes and keeps up the secretion of matter, or rather keeps up the disease at the bottom of the wound, by which means the healing disposition of its mouth is in some degree destroyed. Let me state a case of this last description. Suppose a wound made with a ball; that wound (from circumstances) is not to heal in six months, because the extrane- ous bodies, etc. cannot be extracted, or worked out sooner, or some other circumstance prevents the cure in a shorter time; open that wound as freely as may be thought neces- sary, I will engage that it will be in a month's time in the same state with a similar wound that has not been opened, so that the whole advantage (if there is any) must be before it comes to this state; but it is very seldom that any thing of consequence can be done in that time, because the extra- neous bodies do not come out at first so readily as they do at last, for the inflammation and tumefaction, which ex- tends beyond that very opening, generally keeps them in; and if the wound is opened on their account at first, it ought to be continued to the very last. Upon the same principle, opening on account of extraneous bodies at first cannot be of so much service as opening some time after; for the suppuration, with its leading causes, viz. inflam- mation and sloughing, all along the passage of the ball, makes the passage itself much more determined and more easily followed; for the want of which, few extraneous bodies are ever extracted at the beginning, excepting what are superficial, small, and loose. VOL. II. Kk 258 Of the treatment of gun-shot wounds. If the extraneous bodies are broken bones, it seldom hap- pens that they are entirely detached, and therefore must loosen before they can come away; also the bones in many cases are rendered dead, either by the blow or by being exposed, which must exfoliate, and this requires some time; for in gun-shot wounds, where bones are either bruised or broke, there is most commonly an exfoliation, because some part of the bone is deadened, similar to the slough in the soft parts. A reason given for opening gun-shot wounds is, that it takes off the tention arising from the inflammation, and gives the part liberty; this would be very good practice if tention or inflammation were not a consequence of wounds; or it would be very good practice, if they could prove that the effects from dilating a part that was already wounded were very different, if not quite the reverse of those of the first wound, but as this must always be considered as an extension of the first mischief, we must suppose it to pro- duce an increase of the effects arising from that mischief; therefore this practice is contradictory to common sense and common observation. They are principally the compound wounds that require surgical operations, and certain precautions are necessary with regard to them, which I shall here lay down. As the dilatation of gun-shot wounds is a violence, it will be necessary to consider well what relief can be given to the parts or patient by such an operation; and whether without it more mischief would ensue; it should also be considered what is the proper time for dilating. But it will be almost impossible to state what wound ought, and what ought not be opened; this must always be determined by the surgeon, after he is acquainted with the true state of the case and the general principles; but from what has been already said, we may in some measure judge what those wounds are that should be opened, in or- der to produce either immediate relief, or to assist in the cure: we must have some other views than those objected to, we must see plainly something to be done for the relief of the patient by this opening, which cannot be procured without it, and if not procured, that the part cannot heal, or that the patient most probably must loose his life. Of the treatment of gun-shot wounds. 259 The practice to be recommended here will be exactly si- milar to the common practice of surgery, without paying any attention to the cause as a gun-shot wound. One of the principal points of practice will be to deter- mine at what period of time the dilatation should be made. First, if the wound should be a slight one, and should require opening, it will be better to do it at the beginning, before inflammation comes on; for the inflammation, in consequence of both, will be slight; but in slight cases dila- tation will never be necessary, except to allow of the ex- traction of some extraneous body that is near. But if the wound is a considerable one, and it should appear upon consideration, that you cannot relieve immediately any par- ticular part, or the constitution, then you can gain no- thing by opening immediately, but will only increase the inflammation, and in some cases the inflammation arising from the accident and opening together, may be too much for the patient; under this last circumstance, it would be more advisable to wait till the first inflammation ceases, by which means the patient will stand a much better chance of a cure, if not of his life; therefore it is much better to di- vide the inflammations; however, it is possible that the in- flammation may arise from some circumstance in the wound, which could be removed by opening it; for instance, a ball, or broken bone pressing upon some parts whose actions are either essential to the life of the part or the whole, as some large artery, nerve, or vital part; in such the case will determine for itself. On the other hand, it may, in many cases be better to remove the whole by an operation, when in such parts as will admit of it, which will be taken notice of. Secondly, if an artery is wounded, where the patient is likely to become either too weak, or to loose his life from the loss of blood; then, certainly the vessel is to be tied, and most probably this cannot be done without previously opening the external parts, and often freely. Or thirdly, in a wound of the head, where there is rea- son to suspect a fracture of the scull, it is necessary to open the scalp, as in any other common injury done to the head where there was reason to suspect a fracture, and when opened, if a fracture is found, it is to be treated as any o- ther fractured scull. 260 Of the treatment of gun-shot wounds. Fourthly, where there are fractured bones in any part of the body that can be immediately extracted with advantage, and which would do much mischief if left, this becomes a compound fracture wherever it is, and it makes no difference in the treatment, whether the wound in the skin was made by a ball, or the bone itself, at least where the compound fracture is allowed to suppurate; for there is often a possibility of treating a compound fracture as a simple one which gun-shot fractures, if I may be allowed the expression, seldom will allow of; but where the compound fracture must suppurate, there they are ve- ry similar. However, there have been instances where a fracture of the thigh-bone made by a ball has healed in the same way as a compound simple fracture. Fifthly, where there is some extraneous body which can with very little trouble be extracted, and where the mis- chief by delay will probably be greater than that arising from the dilatation. Sixthly, where some internal part is misplaced, which can be replaced immediately in its former position, such as in wounds in the belly, where some of the viscera are pro- truded, and it becomes necessary to perform the operation of gastroraphia; which is to be done in this case in the same manner as if the accident arose from any other cause; but the treatment should be different; for gun-shot cases cannot heal by the first intention, on account of the slough that is to ensue. Or, seventhly, when some vital part is pressed, so that its functions are lost or much impaired, such as will often happen from fractures of the scull, fractures of the ribs, sternum, etc. in short, when any thing can be done to the part after the opening is made for the present relief of the patient, or the future good arising from it. If none of these circumstances has happened, then I think we should be very quiet. Balls that enter any of the larger cavities, such as the abdomen or thorax, need not have their wounds dilated, except something else is necessary to be done to the contained parts, for it is impossible to follow the ball; there- fore they are commonly not opened, and yet we find them do very well. Balls that enter any part where they cannot be followed such as into the bones of the face need not have the wound in the skin in the least enlarged, as it can give no assistance Of the treatment of gun-shot wounds. 261 to the other part of the wound, which is a bony canal. The following cases are strongly in proof of this, being respec- tively instances of both modes of practice. CASE FIRST. I was sent for to an officer who was wounded in the cheek by a ball, and who had all the symptoms of an in- jured brain; upon examining the parts, I found that the ball had passed directly backwards through the cheek-bone; therefore, from the symptoms and from the direction of the wound, I suspected that the ball had gone through the basis of the scull into the brain, or at least had produced a depression of the scull there: I enlarged the external wound, and with my fingers could feel the coronoid process of the lower jaw; I found that the ball had not entered the scull, but had struck against about the temporal process of the sphenoid bone, which it had broke, and afterwards passed down on the inside of the lower jaw. With small forceps I extracted all I could of the loose pieces of bone; he soon recovered from his stupor, and also from his wound. The ball afterwards caused an inflammation at the angle of the lower jaw, and was extracted. The good which I propos- ed by opening and searching for extraneous bodies and loose pieces of bone was the relieving of the brain; but as the ball had not entered the scull, and as none of the bones had been driven into the brain, it is most probable that I did no good by my opening; but that I could not foresee. CASE SECOND. An officer received a wound by a ball in the cheek, (which in this case was on the opposite side) the wound led back- wards, as in the other; by putting my finger into the wound I felt the coronoid process of the lower jaw, as in the former; but he had no symptoms of an injured brain; I therefore advised not to open it, because the reason for opening in the preceding case did not exist here; my advice was complied with, and the wound did well, and rather better than the former, by healing sooner. The ball was never found, so far as I know. The present practice is not to regard the balls themselves, and seldom or ever to dilate upon their account, nor even to search much after them when the wound is dilated, which 262 Of the treatment of gun-shot wounds. shews that opening is not necessary, or at least not made upon account of extraneous bodies. This practice has arisen from experience; for it was found that balls, when obliged to be left, seldom or ever did any harm when at rest, and when not in a vital part; for balls have been known to lie in the body for years, and and are often never found at all, and yet the person has found no inconvenience. This knowledge of the want of power in balls to promote inflammation when left in the body, arose from the diffi- culty of finding them, or extracting them when found; and therefore in many cases they were obliged to leave them. One reason for not readily finding the ball at first is be- cause the parts are only torn and divided, without any loss of substance, (till the slough comes off) by which means the parts collapse and fall into their places again, which makes it difficult to pass any thing in the direction of the ball, or even to know its direction. The different courses they take, by being turned aside by some resisting body, and also to the difficulty; as will be explained. But the course of a ball, if not perpendicular, but passing obliquely and not very deep a little way under the skin, probably an inch or more, is easy to be traced through its whole course, for the skin over the whole passage of the ball generally is marked by a reddish line. I have seen this redness, even when the ball has gone pretty deep; it has none of the appearances of inflammation, nor of extravasa- tion, for extravasation is of a darker colour, and what it is owing to, I have not been able to discover. I can conceive it to be something similar to a blush; only the small vessels allowing the red particles of the blood to flow more easily. II. OF THE STRANGE COURSE OF SOME BALLS. THE difficulty of finding balls, I have just observed, of- ten arises from the irregular course they take. The regu- larity of the passage of a ball will in general be in proportion to its velocity, and want of resistance: for balls are turned aside in an inverse proportion to the force that they come with; and this is the reason why we seldom find them take Of the treatment of gun-shot wounds. 263 a strait course; for if they are spent balls, the soft parts alone is capable of turning them; and if they come with a con- siderable velocity, it is a chance they may hit some bone obliquely, and then they are also turned aside, for any body that gives a ball the least oblique resistance, throws it out of its direct course; therefore, the balls that do not pass through and through (which are the only ones that are searched after) will be in general spent ones, excepting those that come directly against some considerable bone, as the thigh-bone, etc. As a proof that balls are easily thrown off obliquely, we often find that a ball shall enter the skin of the breast obliquely, and afterwards shall pass almost round the whole body under the skin. The skin here is strong enough to stop the balls coming out again, so that it turns it inwards, which meeting with the ribs, it is again turned out against the skin, and so on, alternately, as long as it has force to go on; however, in many cases, the ball goes a little way after it has through the skin, and when it meets with any hard body on that side next the centre of the body, such as a rib, its course is directed outwards, and it pierces the skin a second time; but the velocity of such balls must have been considerable. I have seen a ball pass in at one side of the shin-bone, and run across it under the skin, without either cutting the skin across, or hurting the bone; which shows that the ve- locity could not be great; for we know that there is not sufficient room between these two parts in a natural state for a ball to pass; but the ball, after it had got under the skin, where there was room for it to cover itself, then came against the tibia, which threw it outwards, and the skin counteracting, it only raised the skin from the tibia, and passed on between them; but if this ball had had a sufficient velocity, it would have either cut the skin across, or taken a piece out of the bone, or most probably both. Another circumstance in favour of the uncertainty of their direction is, that the parts wounded are often not in the same position that they were when they received the ball. The French soldier who was wounded in the arm, was a striking instance of this. The ball entered the arm about its middle, on the inside of the biceps muscle, and it was extract- ed from between the two scapulæ, close on one side of the spinal process of the back-bone. The reason of this strange course, I have already observed in the case, was owing to 264 Of the treatment of gun-shot wounds. his having had his arm stretched out horizontally at the time he was wounded, and the ball passed on in a straight line. These uncertainties in the direction of the balls above- mentioned, have made the common bullet-forceps almost useless; yet forceps are not to be entirely thrown aside, for it will often happen, that a ball will be found to lie pretty near the external wound, which, if the ball was removed, would heal, probably, by the first intention; for in such superficial wounds they must have passed with little velo- city; or if there was a part killed, it would heal immedi- ately; but if there is a slough, this is best done after all in- flammation, and the separation of the slough is over, for then the passage of the ball is better ascertained, in conse- quence of the surrounding adhesive inflammation; and, moreover, the granulations are beginning to push the ex- traneous body towards the surface; but the operation of ul- ceration, which brings it to the skin, being often too slow, the ball, etc. had better be extracted, and even the part might be dilated. However, I would be very cautious how far I carried this practice, and only do it when all circum- stances favoured. For the same reasons probes are become of little use; in- deed, I think that they should never be used but by way of satisfaction, in knowing sometimes what mischief is done; we can perhaps feel if a bone is touched, or if a ball is near, etc. but when all this is known, it is an hundred to one if we can vary our practice in consequence of it. If the wound will admit of it, the finger is the best instrument. In cases where the ball passes a considerable way under the skin, and near to it, I think it would be advisable to make an opening midway between the two orifices which were made by the ball (especially when the orifices are at a very great distance) that fractured bones, or extraneous bodies may now, or hereafter be better extracted; for if this is not done, we have often an abscess forming between them; which, indeed, answers the same purpose, and often better; but sometimes it should not be delayed for such an event to take place. Where the ball has passed immediately under the skin, as in the case where the ball passed between the skin and tibia, it will be often proper to open the whole length of the passage of the ball, the necessity of which I think aris- Of the treatment of gun-shot wounds. 265 es from the skin not so readily uniting with the parts under- neath, as muscles do with one another. Although we have given up in a great measure the prac- tice of searching after the ball, broken bones, or any other extraneous bodies, yet it often happens that a ball shall pass on till it comes in contact with the skin of some o- ther part, and where it can be readily felt; the question is, should such a ball be cut out? if the skin is bruised by the ball coming against it, so that we may imagine that this part will slough off, in that case, I see nothing to hinder opening it, because the part is dead; therefore no more inflammation can arise from the opening than otherwise would take place upon allowing the slough to be thrown off; while, on the other hand, I should also suppose as lit- tle good to arise from it, because the ball will come out of itself when the part sloughs off; however, it may be sus- pected that before the slough falls off, the ball may so alter its situation, that it will be impossible to extract it by that opening; however, I should very much suspect the ball altering its course under such circumstances, for if the skin was so much bruised as to slough, inflammation would soon come on, and confine the ball to that place; however, it always gives comfort to the patient to have the ball ex- tracted. But if the ball is only to be felt, and the skin quite sound, I would in that case advise letting it alone, till the wound made by the entrance of the ball had inflam- ed and was suppurating; my reasons for it are these: First, we find that most wounds get well when the ball is left in (excepting it has done other mischief than simply passing through the soft parts) and that very little inflamma- tion attends the wound where the ball lodges, only that where it enters; the inflammation not arising so much from the injury done by the ball, as from the parts being there exposed to the suppurative inflammation, if it is im- mediately removed. There is always a greater chance of a slough where the ball enters than where it rests, arising from the greater velocity of the ball; for, beyond where the slough is, the parts unite by the first intention. Secondly, in those cases where the ball passes through and through, we have two inflammations, one at each ori- fice, instead of the one at the entrance; or a continued in- flammation through and through, if the ball has passed with VOL. II. Ll 266 Of the treatment of gun-shot wounds. great velocity. Where the ball makes its exit, the inflam- mation passes further along the passage of the ball, than when the wound has been healed up to the ball, and then cut out afterwards; so that by opening immediately, the irritation will be extended further, and of course the dispo- sition for healing will be prevented. If this is the case, I think that two wounds should not be made at the same time; and what convinces me more of it is, that I have seen cases where the balls were not found at first, nor even till after the patients had got well of their wounds; and these balls were found very near the skin. They gave no trouble (or else they would have been found sooner); no inflammation came upon the parts, and they were afterwards extracted and did well. Again, I have seen cases where the balls were found at first, and cut out immediately, which were similar to balls passing through and through; the same inflammation came on the cut wounds that came on the wounds made by the entrance of the ball. III. PENETRATING WOUNDS OF THE AB- DOMEN. WOUNDS leading into the different cavities of the body are very common in the army, and in a great measure pe- culiar to war; they are mostly gun-shot wounds, but not always; some being made with sharp-pointed weapons, as swords, bayonets, etc. they are pretty similar in whatever way they are made; and I have given them a name ex- pressive of the nature of the wound. I shall not take no- tice of any of this kind, but those which penetrate into the larger cavities, as the abdomen, thorax, and scull; but those into the scull are made most commonly by balls, shells, etc. Of the treatment of gun-shot wounds. 267 These wounds become more or less dangerous, accord- ing to the mischief done to the contents of the cavity into which they penetrate. These wounds may be distinguished according as they are simply penetrating, without extending to the contained parts, or, as they affect these parts; and the event of these two kinds of wounds is very different; for in the first, little danger is to be expected if properly treated; but in the second, the success will be very uncertain; for very often nothing can be done for the patient under such wounds; and very often a good deal of art can be made use of with advantage. Wounds of the parietes of the abdomen, not immediately inflicted on such a viscus as has the power of containing other matter, will in general do well, let the instrument that made the wound be what it will*. There will be a great difference, however, should that instrument be a ball passing with great velocity, for in this case a slough will be produced. But if it should pass with little velocity, then there will be less sloughing, and the parts will in some degree heal by the first intention, similar to those made by a cutting instrument; but although the ball has passed with such velocity as to produce a slough, yet that wound shall do well, for the adhesive inflammation will take place on the peritonæum all round the wound, which will exclude the general cavity from taking part in the inflammation, although the ball has not only penetrated, but has wound- ed parts which are not immediately essential to life, such as the epiploon, mesentery, etc. and perhaps gone quite through the body; yet it is to be observed, that wherever there is a wound, and whatever solid viscus may be pene- trated, the surfaces in contact, surrounding every orifice, will unite by the adhesive inflammation, so as to exclude entirely the general cavity, by which means there is one continued canal wherever the ball or instrument has passed; or if any extraneous body should have been carried in, such as clothes, etc. they will also be included in these adhesions, and both these and the slough will be conducted to the ex- ternal surface by either orifice. * What I mean by a containing viscus, is a viscus that con- tains some foreign mattter, as the stomach, bladder, ureters, gall-bladder, etc. to which I may add blood vessels. 268 Of the treatment of gun-shot wounds. All wounds that enter the belly, which have injured some viscus, are to be treated according to the nature of the wounded part, with its complications; which will be many, because the belly contains more parts of very dissimilar uses than any other cavity in the body; each of which will produce symptoms peculiar to itself, and the nature of the wound. The wounding of the several viscera will often produce what may be called immediate and secondary symptoms, which will be peculiar to themselves, besides what are common to simple wounds, such as bleeding, which is immediate; and inflammation and suppuration, which are secondary. Sensations alone will often lead to the vis- cus wounded, and this is frequently one of the first symp- toms. The immediate symptoms arising from wounds in the different viscera are as follows; From a wound in the liver there will be pain in the part, of the sickly or depressing kind; and if it is in the right lobe, there will be a delusive pain in the right shoulder, or in the left shoulder, from a wound in the left lobe. A wound in the stomach will produce great sickness and vomiting of blood, and sometimes a delirium; a case of which I once saw in a soldier in Portugal, who was stabbed into the stomach with a stiletto by a Portuguese. Blood in the stools will arise from a wound in the in- testines, and according to the intestine wounded, it will be more or less pure; if the blood is from a high part of an intestine it will be mixed with fœces, and of a dark colour; if low, as the colon, the blood will be less mixed, and give the tinge of blood; and the pain or sensation will be more or less acute, according to the intestine wounded: more of the sickly pain, the higher the intestine, and more acute the lower. There will be bloody urine from a wound in the kidnies or bladder; and if made by shot or ball, and a lodgment made, these bodies will sometimes become the cause of a stone. The sensation will be trifling. A wound of the spleen will produce no symptoms that I know of, excepting, probably, sickness, from its connexion with the nerves belonging to the stomach, etc. Extravasations of blood into the cavity of the abdomen will take place, more or less, in all penetrating wounds, Of the treatment of gun-shot wounds. 269 and more especially if some viscus is wounded, as they are all extremely vascular; and this will prove dangerous or not, according to the quantity. These are the immediate and general symptoms upon such parts being wounded; but other symptoms may arise in consequence of some of those viscera being wounded, which require particular attention. There may be wounds of the liver and spleen, which produce no symptoms but what are immediate, and may soon take on the healing dis- position; but wounds in those viscera which contain ex- traneous matter, such as the stomach, intestines, kidnies, ureters, and bladder, may produce secondary symptoms of a distinctive kind. If the injury is done by a ball to any of those viscera, the effect may be of two kinds; one where it makes a wound, as stated above, the other where it only produces death in a part of any of them; these will pro- duce very different effects. The first will most probably be always dangerous; the second will hardly ever be so. The first is, where the ball has wounded some one of the abovementioned viscera in such a manner as not to produce the symptoms already described, but produce one common to them all, viz. their contents or extraneous matter im- mediately escaping into the cavity of the abdomen. Such cases will seldom or ever do well, as their effect will hinder the abovementioned adhesions taking place. The con- sequence of this will be, that universal inflammation on the peritonæum will take place, attended with great pain, tension, and death. But all this will be in proportion to the quantity of wound in the part, and quantity of con- tents capable of escaping into the cavity of the abdomen; for if the wound is small, and the bowels not full, then adhesions may take place all round the wound, which will confine the contained matter, and make it go on in its right channel. These adhesions may take place very early, as the following case shews. The case of an officer who died of a wound which he received in a duel. On Thursday morning, the 4th of September, 1783, about seven o'clock, an officer fought a duel in the Ring in Hyde-park, in which he exchanged three shot with his antagonist, whose last shot struck him on the right side, just below the last rib, and appeared under the skin on the 270 Of the treatment of gun-shot wounds. opposite side, exactly in the corresponding place, and was immediately cut out by Mr. Grant. About three hours after receiving this wound, I saw him with Mr. Grant. He was pretty quiet, not in much pain, rather low, pulse not quick, nor full, and a sleepy languid- ness in the eye, which made me suspect something more than a common wound. He then had had neither a stool nor made water, therefore it could not be said what viscera might be wounded. His belly had been fomented, a clyster of warm water was ordered, and a draught with confec: card: as a cordial, with twenty drops of laudanum, to procure sleep, as he wished to have some. We saw him again at three o'clock; the draught had come up. Had no stool from the clyster, nor any sleep; had made water, and no blood being found in it we conjectured that the kidnies, etc. were not hurt. He was now rather lower, pulse smaller, more restless, a good deal of tension in the belly, which made him uneasy, and made him wish to have a stool. It was at first imagined that this tension might be owing to extravasated blood; but on patting the belly, especially along the course of the transverse arch of the colon, it plainly gave the sound and vibration of air, there- fore we wished to procure a motion, to see if we could not by that means have some of that air expelled; we wished, also, to repeat the cordial and the opium, but the stomach was become now too irritable to contain any thing, and was at times vomiting, independent of any thing he took; a clyster was given, but nothing returned or came away. We saw him again at nine o'clock in the evening. His pulse was now low and more frequent; coldness at times; vomiting very frequent, which appeared to be chiefly bile, with small bits of something that was of some consistence; the belly very tense, which made him extremely uneasy; no stool. From nothing passing downwards, and the colon continuing to fill, we began to suspect that it was becoming paralitic, probably, from the ball having divided some of its nerves. Fumes of tobacco by clyster were proposed, but we were loath to use it too hastily, as it would tend to increase the disease, if it did not relieve; however, we were prepared for it. Mr. Grant stayed with him the whole night; all the a- bove symptoms continued increasing, and about seven Of the treatment of gun-shot wounds. 271 o'clock in the morning he died, viz. about twenty-four hours after receiving the wound. He was opened next day at ten o'clock, twenty-seven hours after death, when we found the body considerably putrid, although the weather was cold for the season, the blood having transuded all over the face, neck, shoulders, and breast, with a bloody fluid coming out of his mouth, with an offensive smell; below this the body was not so far gone. On opening the abdomen, a good deal of putrid air rush- ed out; then we observed a good deal of fluid blood, prin- cipally on each side of the abdomen, with some coagulum upon the intestines; when sponged up it might be about a quart. The small intestines were slightly inflamed in many places and there adhered. We immediately searched for the pas- sage of the ball. On searching for the course of the ball, we found that it had passed directly in, pierced the peritonæum, entered again the peritonæum, where it attaches the colon to the loins, passed behind the ascending colon, and just appeared at the right side of the root of the mesentery where the co- lon is attached; passed behind the root of the mesentery, and entered the lower turn of the duodenum as it crosses the spine; then passed out of that gut on the left of the mesentery, and in its course to the left side, it went through the jejunum, about a foot from its beginning, then through between two folds of the lower part of the jejunum, taking a piece out of each, then passed before the descending part of the colon, and pierced the peritonæum of the left side, as also some of the muscles, but not the skin, and was im- mediately cut out, exactly in the same place on the left, where it entered out the right; so it must have passed per- fectly in an horizontal direction. There was no appearance of extravasation of any of the contents of the intestines loose in the cavity of the abdo- men. The intestines in many places were adhering to one another, especially near to the wounds, which adhesions were recent, and of course very slight; yet they shewed a ready disposition for union, to prevent the secondary symp- toms, or what may be called the consequent, which would also prove fatal. 272 Of the treatment of gun-shot wounds. There was little or no fluid in the small intestines; but there was a good deal of substance in consistence like fœces, in broken pieces, about the size of a nut through the whole track of the intestine, even in the stomach, which he vo- mited up; but in the upper end of the jejunum, as also in the duodenum, there was some fluid mixed with the o- ther; but that fluid seemed to be rather bile. If this solid part was excrement then the valve of the colon must not have done its duty. Was all the thin part absorbed to hin- der extravasation into the belly? or was it all brought back into the stomach to be vomited up? There was a good deal of air in the ascending, but more especially in the transverse turn of the colon. This case admits of several observations and queries. First, the lowness and gradual sinking, with the vomit- ing without blood, bespoke wounded intestines, and those pretty high up. It shews how ready nature is to secure all unnatural passages, according to the necessity. Query, what could be the cause of his having no stool, even from the clyster? Were the intestines inclinable to be quiet under such circumstances? Would not he have lived if the immediate mischief had not been too much? I think that if the immediate cause of death had not been so violent, nature would have secured the parts from the se- condary, viz. the extravasation of the fœces. What is the best practice where it is supposed an intes- tine may be wounded? I should suppose the very best prac- tice would be, to be quiet and do nothing, except bleeding, which in cases of wounded intestines is seldom necessary. As he was extremely thirsty, and could not retain any thing in his stomach, which if he could, it would have been probably productive of mischief, by giving a greater chance of extravasation; would not the tepid bath have been of service, to have allowed of fluids to enter the con- stitution? It is very possible that a wound of the gall-bladder, but more readily of the ductus communis, and also of the pan- creatic duct, will produce the same effects, although not so quickly; and it may be observed, that a wound in them could not be benefited by any adhesions that could take place, because the secreted fluids could never, most proba- bly, get into the right channel again, and would therefore be the cause of keeping the external wound open, to dis- Of the treatment of gun-shot wounds. 273 charge the contents, as we find to be the case in the diseases called fistula lacrimalis; as also when the duct of the paro- tid gland is divided. Of parts that have been only deadened. Wounds will be very similar to the above stated pene- trating wounds, but they will differ from them in effects, arising from a slough separating from a containing viscus; for whenever the slough comes away, the extraneous or contained matter of that viscus will escape by the wound; such as the contents of the stomach, intestines, ureters, bladder, etc. the two last of which will be similar, or the slough may escape by either of these outlets; whereas, in the last kind of wounds, any of the contents that could pos- sibly escape would immediately pass into the cavity of the abdomen. The periods of these symptoms appearing after the acci- dent, will be according to the time of separation; which may be in eight, ten, twelve, or fourteen days. This new symptom, although in general very disagree- able, will not be dangerous*, for all the danger is over before it can appear; but that the orifice should afterwards continue, and become either an artificial anus, or urethra, is a thing to be avoided; though they commonly close up, and the contents are directed the right way; in such case nothing is to be done, but dressing the wounds superficial- ly, and when the contents of the wounded viscus become less, we may hope for a cure. The following case explains the foregoing remarks. A young gentleman was shot through the body. The musket was loaded with three balls, but there were only two orifices where they entered, and also only two where they came out, one of the balls having followed one of the others; that there were three that went through him was evident, for they afterwards made three holes in the wain- scot behind him, but two very near one another. The balls entered upon the left side of the navel, one a little further out than the other, and they came out behind * How far the contents of the stomach escaping through a wound might not be attended with bad consequences, I cannot pretend to say. VOL. II. Mm 274 Of the treatment gun-shot wounds. pretty near the spinal processes, about the superior vertebræ of the loins. From the closeness of the gun to the man when fired, which of course made it pass with great veloci- ty, as also from the direction of the innermost, which we supposed to be the double one, we were pretty certain that it had penetrated the cavity of the abdomen, but could not be so certain of the course of the other. The first water he made after the accident was bloody, from which we knew the kidney was wounded; but that symptom soon left him. He had no blood in his stools, from which we concluded that none of the intestines were wounded; and no symptoms of extravasation of the contents of any viscus taking place, such as the symptoms of in- flammation of the peritonæum, we were still more confirm- ed in our opinion. The symptomatic fever did not run higher than could have been expected; nor was there more pain in the track of the ball than might be imagined. These consequent symptoms of the immediate injury a- bated as soon as could be expected; and in less than a fort- night, I pronounced him out of danger from the wound; for no immediate secondary symptoms having taken place, I concluded that whatever cavities the balls had entered, there the surrounding parts had adhered, so that the pas- sage of the ball was by this means become a complete canal; and therefore that neither any extraneous bodies that had been carried in with the balls, and had not been carried through, nor any slough that might separate from the sides of the canal, nor the matter formed in it, could now get into the cavity of the abdomen, but must be conducted to the external surface of the body, either through the wounds or from an abscess forming for itself, which would work its own exit somewhere. But this conclusion was supposed to be too hasty, and soon after a new symptom arose, which alarmed those who did not see the propriety of my reasoning; which was some fœces coming through the wound; this new symptom did not alter my opinion, respecting the whole operations of na- ture to secure the cavity of the abdomen, but it confirmed it, (if a further confirmation had been necessary) and there- fore I conceived it could not effect life; but as I saw the possibility of this wound becoming an artificial anus, I was sorry for it. It was not difficult to account for the cause of Of the treatment of gun-shot wounds. 275 this new symptom; it was plain that an intestine, (the des- cending part of the colon most probably) had only received a bruise from the ball, but sufficient to kill it at this part, and till the separation of the slough had taken place, that both the intestine and canal were still complete, and there- fore did not communicate with each other; but when the slough was thrown off, the two were laid into one at this part, therefore the contents of the intestine got into the wound, and the matter from the wound might have got into the intestine. However, this symptom gradually decreas- ed, by (we may suppose) the gradual contraction of this opening, and an entire stop to the course of the fœces took place, and the wounds healed very kindly up. But the inflammation, the sympathetic fever, the reducing treatment, and the spare regimen, all tended to weaken him very much. IV. OF PENETRATING WOUNDS IN THE CHEST. LITTLE notice has been taken of wounds in the chest and lungs: indeed it would appear at first, that little or nothing could be done; yet, in many cases a great deal may be done for the good of the patient. It is possible a wound in the chest may be of the first kind, viz. only penetrating; yet from circumstances may prove fatal, as will be explained in the second or compli- cated, viz. a wound of the lungs. It is pretty well known, that wounds of the lungs (ab- stracted from other mischief) are not mortal. I have seen several cases where the patient has got well after being shot quite through the body and lungs, while from a very small wound made by a sword or bayonet into the lungs, the pa- tients have died; from which I should readily suppose, that a wound in the lungs from a ball, would in general do better than a wound in the same part with a pointed instrument; and this difference in effects would appears in many cases to arise from the difference in the quantity of blood extra- vasated; because the bleeding from a ball is very inconside- 276 Of the treatment of gun-shot wounds. rable in comparison to that from a cut; and there is there- fore a less chance of extravasated blood, either in the cavity of the thorax, or the cells of the lungs; another scum- stance that favours the gun-shot wounds in these parts, is, that they seldom heal up externally by the first intention, on account of the slough, especially at the wound made by the entrance of the ball, so that the external wound remains open for a considerable time, by which means any extravasat- ed matter may escape; but even this has often its disadvan- tages, for by keeping open the external wound, which leads into the cavity, we give a chance to produce the suppurative inflammation through the whole surface of that cavity, which most probably would prove fatal, and which would be e- qually so if no viscus was wounded; but it would appear that the cavity of the thorax does not so readily fall into this inflammation from a gun-shot wound as we should at first imagine; nor can we suppose that the adhesive in- flammation readily takes place between the lungs and pleura round the orifice, as we described in the wounds of the ab- domen, because these parts are not under the same circum- stances that other contained, and containing parts are; for in every other case, the contained and containing have the same degree of flexibility, or proportion in size. The brain and the scull have not the same flexibility, but they bear the same proportion in size. From this circumstance, the lungs immediately collapse, when either wounded them- selves or when a wound is made into the chest, and not al- lowed heal by the first intention, and become by much too small for the cavity of the thorax, which space, must be filled either with air or blood, or both, therefore adhesion cannot readily take place; but it very often happens that the lungs have previously adhered, which will frequently be an advantage. In the cases of stabs, especially if with a sharp instrument, the vessels will bleed freely, but the external wound will collapse, and cut off all external communication. If the lungs are wounded in the same manner, we must expect a considerable bleeding from them, this bleeding will be in the general cavity of the thorax (if the lungs at this part have not previously adhered there) and likewise into the cells of the lungs or bronchia, which will be known by pro- ducing a cough, and in consequence of it a bleeding at the mouth; for the blood that is extravasated into the air-cells Of the treatment of gun-shot wounds. 277 of the lungs, will be coughed up by the trachea, and by that means will become a certain symptom of the lungs being wounded; but that which gets into the cavity of the thorax cannot escape, and therefore must remain till the absorbents take it up; which they will do, if it is only in small quantity; but if in large quantity, this extravasated blood will produce symptoms of another kind. The symptoms of these accidents are, First, a great lowness, which proceeds from the nature of the parts wounded, and perhaps a fainting from the quantity of blood lost to the circulation; but this will be in proportion to the quantity, and quickness with which it was lost. A load in the breast will be felt, but more from a sensation of this kind, than from any real weight; and a considerable difficulty in breathing. This difficulty in breathing will arise from the pain the patient will have in expanding the lungs in inspiration, and will also proceed from the muscles of respiration of that side being wounded, and this will continue for some time, from the succeeding inflammation; it will hinder the ex- pansion of the thorax on that side, and of course in some degree of the other side; as we have not the power of raising one side without raising the other *; and if wound- ed by a cutting instrument, the lungs of that side not being able to expand fully, by the cavity of the thorax being in part filled with blood, will also give the symptoms of dif- ficulty of breathing. The patient will not be able to lie down, but must sit upright, that the position may allow of the descent of the diaphragm, to give room in the chest; all which symptoms were strongly marked in the following case. A person received a stab behind the left breast with a small sword; the wound in the skin was very small. He was almost immediately seized with a considerable discharge of blood from the lungs, to near a quart, by the mouth, which shewed that the lungs were considerably wounded, for from the situation of the external wound we were sure that the stomach could not be injured. His breathing soon became difficult and painful, and his pulse quick; he was * I have often thought it a great pity, that we do not ac- custom ourselves to move one side of our thorax independent of the other, as we from habit move one eye-lid independent of the other. 278 Of the treatment of gun-shot wounds. bled; these symptoms increased so fast, that every one thought him dying. He could only lie on his back, for if he lay on the sound side, he could not breathe in the least, and the pain would not let him lie on the unsound side; the easiest position was an erect posture, which obliged him to sit in a chair for several days; when he coughed he was in great pain, very seldom spit with the cough, and never discharged any blood after the second day, by which we supposed that the bleeding was stopped in the lungs. While the parts were in a state of inflammation he was in great pain, his breathing excessively quick, and his pulse hard and extremely quick; but as the inflammation went off, he drew his breath in longer strokes, his pain became less, and his pulse not so quick nor so hard; but this last circumstance varied as he moved his body, coughed, or put himself into a passion, which he often did. I suspected from both the wound and its effects, that there was a good deal of extravasated blood in the cavity of the thorax; for I considered that the blood which got out of the vessels of the lungs into the wound in the lungs, would find a readier passage into the cavity of the thorax, than into the cells of the lungs; and, indeed, every attempt to the dilatation of the thorax would rather act as a sucker upon the mouth of the wound in the lungs, as the pressure of the external air was taken off by that means; I proposed the operation for the empyema, because the extravasated blood must compress the lungs of that side, and hinder their expansion, and likewise irritate, and at last might pro- duce inflammation. He continued for some days with little variation, but upon the whole seemed getting better; but the day before he died, he became worse in his breathing, which we imputed to his stirring too much, and was rather better on the day that he did die: just before death he was taken with a sort of suffocation, and in half an hour he died. Through his whole illness he had a moist skin, and some- times sweat profusely, at last his legs swelled. At first he only took a spermaceti mixture with a little opium, which gave him relief; I wanted to increase the opium, but it was objected to, for fear it should bind the chest too much, as it often does in asthmas, therefore it was given with the squills. On the day that he died, we ordered him the bark with a sudorific. As this was very different from a common asthma, and Of the treatment of gun-shot wounds. 279 the difficulty of breathing arising entirely from the inflam- mation of the intercostal muscles and lungs, and likewise from having but one lung, I thought it advisable to give opium in this case, as it would take off the irritation of the inflamed parts, and therefore allow a greater stretch or ex- pansion; especially as we found whenever it was given, that it gave relief, and produced these effects. One might at first wonder why he should breathe with such difficulty, as he had one side whole or sound; for I have seen people breathe pretty freely who have had but one side to expand; but when we consider the case, we can easily account for this. After death we opened him; on raising the sternum I cut into the cavity of the thorax, and a great deal of blood gushed out at the incision: we sponged out of the left side of the thorax above three quarts of fluid blood; the coagu- lum appeared to have been attracted to the sides of the cavi- ty every where as if it had been furred over with the coagu- lating lymph which was no where floating in the fluid; but most probably the extravasated blood had never coagu- lated, and this thick buff crust was an exudation of coagu- lating lymph from the lungs and pleura which covers the ribs, as in all inflammations; if so, this is another instance, besides that of the inflammation of veins, in which the coagulating lymph coagulates immediately upon being thrown upon the surface, for if it had not, it then must have mixed with the blood in the chest, and only been found floating there. The lungs were collapsed into a very small substance, and therefore firmer than common; we observed the wound in them which corresponded to the wound in the pleura; I introduced a probe into the wound in the lungs, which passed near four inches, but was not certain whether it did not make some way for itself; however, I traced the wound by opening the lungs, and could easily distinguish the wounded part by the coagulated blood that lay in it. I found the heart and inside of the pericardium inflamed, and their surface furred over with coagulating lymph, similar to that on the lungs, the lungs of the right side had also become a little inflamed on their anterior edges. Wounds in the lungs generally become a cause of a quick pulse; this likewise may arise in some degree from the lungs being so immediately concerned in the circulation, 280 Of the treatment of gun-shot wounds. that any thing that gives a check to the blood's free motion through them, may affect the heart. But the pulse be- comes hard, which arises from the nature of the inflam- mation that attends, and also from the wound being in a vital part. In the cases arising from balls, nothing in general is to be done but to keep quiet, and dress the wounds superfici- ally; for any extravasated blood that might have got into the cavity of the thorax will generally make its escape by the external wound, as also any matter from suppuration. But in the cases of wounds made by cutting instruments, and where there is reason to suspect a considerable quantity of blood in the cavity of the thorax, then we may ask what should be done? and the natural answer is, that the ope- ration for the empyema should be performed. This opera- tion will relieve the patient and bring the disease to the sim- ple wound, and somewhat nearer to the gun-shot wound; it should be performed as soon as possible, before the blood can have time to coagulate; for the coagulum of the blood may be with difficulty extracted. The enlargement of the wound already made will often answer; but if that is in such a situation as to forbid dilata- tion, then the common directions for the empyema are to be followed here. When all symptoms appear, and we have great reason to suppose a considerable extravasation of blood into the ca- vity of the chest, I think that we should not hesitate in per- forming the operation for the empyema. V. OF CONCUSSIONS AND FRACTURES OF THE SCULL. THESE injuries, in consequence of a musquet-ball, dif- fer in nothing from the same accidents arising from any other cause, excepting the lodgement of the ball, which I imagine will require no peculiar mode of treatment. Of the treatment of gun-shot wounds. 281 VI. OF WOUNDS COMPOUNDED WITH FRAC- TURED BONES, OR CONTAINING EXTRA- NEOUS BODIES. THE compound gun-shot wounds, where bones are broke, or where there are extraneous bodies that continue the irritation, similar to compound fractures, seldom or e- ver heal at once, or by regular degrees, as in the former, but generally heal very quick at first, upon the going off of the inflammation, similar to the healing of simple gun-shot wounds; but when healed so far, as to be affected by the extraneous bodies, then they become slow in their progress, till at last they come to a stand, or become fistulous; in which state they continue till the irritating cause is remov- ed; and this takes place even if the dilatation should have been made at first as large as could be thought necessary; so that the opening at first, in such cases, can only let out those extraneous bodies or detached bones, that are perfect- ly loose, or becomes loose while the wound continues large; however, even this can only take place in superficial wounds; but in those that are deep, or where there is an exfolia- tion to take place, the dilated part always heals up long be- fore they are fit to make their exit; but before this happens the parts often acquire an indolent diseased state, and even when all extraneous bodies are extracted, the parts do not readily heal. When a wound comes to this stage, surgeons generally put in sponge or other tents in the opening, or apply some corroding medicine to keep it open, and also with a view to make it wider; but this practice is unnecessary, as a wound in such a state seldom heals entirely ever, nor do tents add much to the width of the wound, and always confine the matter between the two dressings. Where an exfoliation is expected, it is generally better to expose as much of the bone as possible; it keeps up a kind of inflammation, which I imagine gives a disposition for this process. This can only be done where the bone is pretty superficial; but in cases where the separation has already taken place, and it is now to make its way to the skin, like any other extraneous substance, then, in- VOL. II. Nn 282 Of the treatment of gun-shot wounds. stead of the practice of sponge tents, to keep the orifice in the skin open, it would be often better in such cases, to let the whole heal over, because the extraneous body would form an abscess round itself, which would enlarge the ca- vity, and produce the ulcerative inflammation quicker to- wards the surface; and when that was opened, the extra- neous body could be with more ease extracted, or would come out of itself; but this method of healing the mouths of fistulous sores is not always practicable. If this last practice has no inconveniences attending it, it has this advantage, that the patient has not the disagreeable trouble of having a sore to dress every day, till the extra- neous body comes away, which I think is no small conside- ration. This practice, however, is not to be followed in every case; for instance, if the wound should communi- cate with a joint, as is common to most sores in the foot and hand, where the bones are diseased, it would be, in such cases very imprudent to allow the wound to heal, as the confined matter would get more readily into the diffe- rent joints, and increase the disease; there may be other causes to forbid this, as a general practice. If wounds are to be kept open at their mouths, whose bottoms have not a disposition to heal, they should be kept open to that bottom; because, whenever they do heal at their mouths, it is most commonly owing to their sides un- derneath first uniting; for the skin will seldom unite when all beyond it is open. In wounds that become fistulous, where there is no ex- traneous body, there is always a diseased bottom, which is to be looked upon as having the same effect as an extrane- ous substance. To alter this diseased disposition, they should be opened freely, as large openings produce quick in- flammation, quick suppuration, and quick granulations, which are generally sound when they arise from such a cause; on the other hand, letting such wounds heal at their mouths, has often a salutary effect, as it becomes a means of destroying this diseased part by the formation of an abscess there, and in general, there can be no better way of coming at a part or extraneous body, than by the forma- tion of an abscess there. It is a natural way of opening to relieve diseased parts; but we often find in practice, that this method is not sufficient, either for the extraction of extraneous bodies, or to expose the diseased bottom, ex- Of the treatment of gun-shot wounds. 283 cepting these abscesses are opened very largely by art, so as to expose the whole of the diseased parts or extraneous body. VII. OF THE TIME PROPER FOR REMOV- ING INCURABLE PARTS. MANY gun-shot wounds are at the very first evidently in- curable, whether in a part that cannot be removed, or in one that will admit of being removed. When such wounds are in parts that will not admit of a removal of the parts in- jured, then nothing can be done by surgery; but when in a part that can be removed, then a removal of the injured part is to be put in practice; but even this is to be under certain restrictions; perhaps it should not be done immedi- ately upon the receiving of the injury, excepting where a considerable blood-vessel is wounded, so as to endanger the life of the person, and that it absolutely cannot be taken up; or it is suspected that the inflammation, in conse- quence of the accident will kill; by which means you have only the inflammation in consequence of the amputation; but this is a bad recourse, especially if it is a lower extre- mity this is to be amputated, and which is perhaps the on- ly part that can be removed of which the inflammation will kill. How far the same practice is to be followed in cases which we may suppose will not kill; but that the part is so hurt, as to all appearance not to be in the power of surgery to save, I will not now determine. This is a very different case from the former, and its consequences depend more upon contingences, so that the part should be removed on- ly when the state of the patient in other respects will ad- mit of it; but this is seldom the case, for few people in full health are in that state, and still less so those who are usu- ally the subjects of gun-shot wounds; the situation they are in at the time, from the hurry of mind, makes it here in general to be the very worst practice; it will in general therefore, be much better to wait till the inflammation, and 284 Of the treatment of gun-shot wounds. all the effects of both the irritation and inflammation shall be gone off. If these things are not sufficiently attended to, and the first inflammation, as in the first stated case, (for instance, that which is likely to prove mortal) is allowed to go on, the patient will most probably lose his life; or if the first inflammation is such as is likely to go off, according to the last stated case, then we should allow it to go off before we operate, and not run the risk of producing death by an operation; for I have already observed, few can support the consequences of the loss of a lower extremity when in full health and vigour: we know that a violent inflamma- tion will in few hours alter the healthy disposition, and give a turn to the constitution, especially if a considerable quan- tity of blood has been lost, which most probably will be the case where both accident and operation immediately succeed one another. The patient under such circumstances becomes low, sim- ply by the animal life losing its powers, and hardly ever recovers afterwards. After considering the curative treatment of gun-shot wounds, and other accidents common to the soldier, as also the sailor, let us further consider the treatment of those patients, whose wounds at the very first appear to be incu- rable, when they are in parts that will admit of being re- moved. The operation itself is the same as in other cases, and the only subjects of peculiar consideration here are the situation of the patient, and the proper time for performing the ope- ration after the injury. I have already given some directions with regard to the proper time of operating, in treating upon the dilatation of gun-shot wounds, which are in some degree applicable here; but we shall consider this now more fully, as the proper time of removing a part is often much shorter than that of dilating. Amputation of an extremity is almost the only operation that can, and is performed immediately on receiving the in- jury. As these injuries in the soldier are generally received at a distance from all care, excepting what may be called chirur- gical, it is proper we should consider how far the one should be practised without the other. In general, surgeons have not endeavoured to delay it till the patient has been Of the treatment of gun-shot wounds. 285 housed, and put in the way of a cure; and, there- fore, it has been a common practice to amputate on the field of battle: nothing can be more improper than this practice, for the following reasons. In such a situation it is almost impossible for a surgeon, in many instances, to make himself sufficiently master of the case, so as to perform so capital an operation with propriety; and it admits of dis- pute, whether at any time, and in any place, amputation should be performed before the first inflammation is over: when a case is so violent as not to admit of a cure in any situation, it is a chance if the patient will be able to bear the consequent inflammation, therefore, in such a case it might appear, at first sight, that the best practice would be to ampu- tate at the very first; but if the patient is not able to support the inflammation arising from the accident, it is more than probable he would not be able to support the amputation and its consequences: on the other hand, if the case is such as will admit of being brought through the first inflammation, although not curable, we should certainly allow of it, for we may be assured, that the patient will be better able to bear the second. If the chances are so even, where common circumstances in life favour the amputation, how must it be where they do not? how must it be with a man, whose mind is in the height of agitation, arising from fatigue, fear, distress, etc.? These circumstances must add greatly to the consequent mis- chief, and cast the balance much in favor of forbearance. If it should be said, that agreeable to my argument, the same circumstances of agitation will render the accident itself more dangerous? I answer, that the amputation is a violence superadded to the injury; therefore, heightens the danger, and when the injury alone proves fatal it is by flower means. In the first case, it is only inflammation; in the second, it is inflammation, loss of substance, and most probably loss of more blood, as it is to be supposed that a good deal has been lost from the accident, not to mention the awkward manner in which it must be done. The only thing that can be said in favour of amputation on the field of battle is, that the patient may be moved with more ease without a limb, than with a shattered one; however, experience is the best guide; and I believe it is universally allowed by those whom we are to esteem the best judges, those who have had opportunity of making 286 Of the treatment of gun-shot wounds. comparative observations, with men who have been wound- ed in the same battle, some where amputation had been performed immediately, and others where it had been left till all circumstances favoured the operation; it has been found that few did well who had their limbs cut off on the field of battle; while a much greater proportion have done well, in similar cases, who were allowed to go on till the first inflammation was over, and underwent amputation afterwards. There will be exceptions to the above observations, which must be in a great measure left to the discretion of the surgeon; but a few of these objections may be mention- ed, so as to give a general idea of what is meant. First, it is of less consequence, whichsoever way it is treated, if the part to be amputated is an upper extremity; but it may be observed, that there will be little occasion in general to amputate an upper extremity upon the field, be- cause there will be less danger in moving such a patient, than if the injury had happened to the lower. Secondly, if the parts are very much torn, so that the limb only hangs by a small connexion, then the circum- stance of the loss of so much substance to the constitution cannot be an objection, as it takes place from the accident; and, indeed, every thing that can possibly attend an ampu- tation; therefore, in many cases, it may be more con- venient to remove the whole. In many cases it may be necessary to perform the operation to get at blood-vessels, which may be bleeding too freely; for the searching after them may do more mischief than the operation. I have already observed, that gun-shot wounds do not bleed so freely as those made by cutting instruments, and are, therefore, attended with less danger of that kind; however, it may often happen, that a considerable vessel shall be divided, and a considerable bleeding take place; in such cases no time is to be lost, the vessels must be taken up to prevent a greater evil: this operation may, in many cases, be attended with considerable trouble, especially as it will, in general, be on the field of action. Here the sailor has the advantage of the soldier. It will also be immediately necessary on the field to re- place many parts that would destroy the patient if their restoration was delayed, such as the bowels or lungs pro- truding out of their cavities; to remove large bodies, such Of the treatment of gun-shot wounds. 287 as a piece of shell sticking in the flesh, which would give great pain, and do mischief by moving the whole together. Very little can be done to relieve the brain in such a situation. VIII. OF THE TREATMENT OF THE CONSTITUTION. BLEEDING is recommended in gun-shot wounds, and in such a manner, as if of more service in them that wounds in general; but I do not see this necessity more than in other wounds that have done the same mischief, and where the same inflammation, and other consequences are ex- pected. Bleeding is certainly to be used here, as in all wounds where there is a strong and full habit, and where we ex- pect considerable inflammation and symptomatic fever; but if it is such a gun-shot wound, as not to produce con- siderable effects, either local or constitutional, I would not bleed merely because it is a gun-shot wound; and from what I have seen, I think that inflammation, etc. does not run so high in these wounds, as I should have at first expected. I believe this is the case with all contused wounds, where death in the part is a consequence: a con- tused wound is somewhat similar to the effects of a caustic; for while the separation of the dead part is forming, the suppurative inflammation is retarded, and therefore not so violent; but this can only be said of those wounds which are not complicated with any other injury, except what was produced by the balls passing through soft parts; for if a bone is broken, it will inflame like any other compound fracture. It is often of service in the time of inflammation to bleed in the part with leeches, or by punctures with a lancet; this helps to empty the vessels of the part to lessen the in- 288 Of the treatment of gun-shot wounds. flammation sooner, and of course to promote suppuration; but I must own that bleeding must be used with great caution, where inflammation and fever run very high, for to reduce the patient equal to the action at the time (which, whether an increased action, or an acquired one, is only temporary) will be reducing him often too much for the constitution to support life, when this action ceases; for the very worst thing that can happen, is the patient being reduced too low; we often afterwards find more difficulty in keeping up with cordials, bark, etc. than we find in lowering; and we may avail ourselves of observing those who have lost considerable quantities of blood from the ac- cident, which is always immediate, and we find too, that a second bleeding, by some other accident, although very small in quantity, often destroys our patient very quickly; but this will in a great measure depend upon the seat of the injury; for in cases of great violence done to some parts of our body, bleeding answers better than in others, because the symptoms of dissolution, and dissolution itself, come on sooner from mischief done to some parts, than when it is done to others. A man will bear bleeding better after an amputation of the arm than leg; better after a compound fracture of the arm than the leg; he will bear bleeding better after an in- jury done to the head, chest, the lungs, etc. than to either the arm or leg. We find that injuries done to inactive parts, such as joints, do worse, and are more susceptible of irritation than those in fleshy parts of the same situation. It would appear upon the whole, that the decay of ani- mal life is sooner brought on, when the inflammation is in a part whose circulation is not so strong, and where the nervous influence, or the force of the circulation is far removed. Bark is greatly recommended in gun-shot wounds, and with good reason; but it is ordered indiscriminately to all patients that have received such wounds, whatever the symptoms or constitution of the patient may be. That there is no better medicine for wounds in general; not only when the inflammation is gone off, but in the time of in- flammation, if the patient is rather low; and, indeed, be- Of the treatment of gun-shot wounds. 289 fore it comes on, experience daily shews. Bark is to be looked upon as a strengthener, or regulator of the system, and an antispasmodic, both of which destroy irritation; the bark and gentle bleedings, when the pulse begins to rise, are the best treatment that I know of in inflammations that arise either from accidents or operations; one lessens the volume of the blood, and the increased animal powers at the time, which makes the circulation more free; so that the heart labours less, and simple circulation goes on more freely; the other gives to the blood that which makes it less irritating; makes the blood-vessels do their proper offices, and gives to the nerves their proper sensations, which take off the fever. VOL. II. Oo Plate I. Fig. 1. Fig. 2. Fig. 3. E Trenchard fc.  Plate II. Fig. 1. Fig. 2. Vallance fc.  Plate III. Fig. 1. Fig. 2.  Plate IV. Fig. 1. Fig. 2. [291] EXPLANATION OF THE PLATES. PLATE FIRST. IN this plate is represented the embrio of the chick in the incubated egg, at three different stages of its formation, beginning with the earliest visible appearance of distinct or- ganization. The preparations from which these figures are taken form part of a complete series, contained in Mr. Hun- ter's collection of comparative anatomy. They are meant to illustrate two positions laid down in this work, viz. That the blood is formed before the vessels, and when coagulat- ed, the vessels appear to rise; that when new vessels are produced in a part, they are not always elongations from the original ones, but vessels newly formed, which after- wards open a communication with the original. FIRGURE I. In this figure the only parts that are distinctly formed, are two blood-vessels; on each side of these is a row of small dots or specks of coagulated blood, which are after- wards to become blood vessels. FIGURE II. The formation of the embrio is further advanced, vessels appear to be rising up spontaneously in different parts of the membrane; and the specks, out of which they are produc- ed, are in many parts very evident. FIGURE III. The number of blood-vessels is very considerably increas- ed; they now form a regular system of vessels, composed of larger trunks, and a vast number of ramifications going off from them. [292] PLATE SECOND. THIS plate represents a section of the human uterus in the first month after impregnation. The uterus itself is a little enlarged in size, and thickened in its substance; its cavity every where lined with a coagulum of blood, having a smooth internal surface, but adhering firmly to the uterus. The arteries are injected to shew that it is uncommonly vascular, and vessels are found to be injected in different parts of the coagulum. The object of this plate is to shew the readiness with which vessels are formed in coagulated blood, when attach- ed to a living surface, and its vascularity being to answer useful purposes in the machine; of which this is a remark- able instance, as it is to form the outer membrane of the fœ- tus or the connecting medium between it and the uterus. FIGURE I. A longitudinal section of the uterus, in which the cavi- ty is exposed. A. The os tincæ projecting into the vagina, of which there is a small portion, to shew the length to which the os tincæ projects. BB. The cervix uteri. CCC. The coagulated blood smooth upon its internal sur- face, although extremely irregular. DD. The cut surface of the substance of the uterus, which has so intimate a connexion with the coagulum that the one appears to be continued into the other. The laminated appearance is produced by the section of en- larged veins in a collapsed state, which are extremely numerous. FIGURE II. Is a thin slice of the substance of the uterus and the coag- ulum adhering to it, dried, and viewed in a microscope, to shew the vascularity of the uterus, whose vessels are dis- tinctly seen, continued into the coagulum, and passing a- bout half way through its substance. [293] PLATE THIRD. REPRESENTS two rabbits' ears, one in the natural state, the other in an inflamed state, in consequence of having been frozen and thawed. The vessels are injected, and as they belonged to the same head, the force applied, and other circumstances must have been exactly similar. The difference in the size of the vessels, and the diffe- rence in the thickness of the ears themselves, is very evi- dent; but there was an opacity in the inflamed ear com- pared with the other, which it was not possible to express. FIGURE. I. The ear is in its natural state. AA. The projecting part of the ear. B. That part which is covered by the skin of the head. CCC. The principal arterial trunk. FIGURE II. The inflamed ear. AA. B. CCC. represent the same parts as in figure one. D. A branch rather larger than the trunk, not distinguish- able in the natural state of the ear. [294] PLATE FOURTH. FIGURE I. A PORTION of the illium taken from the intestines of an ass. The intestine was in a state of inflammation, and shews the internal surface of the gut partly covered by a layer of coagulating lymph thrown out by the great degree of inflammation which the parts had undergone. The internal membrane was extremely vascular, and when injected, vessels were seen in portions of the coagu- lating lymph. AA. The inner surface of the intestine. BB. The coagulating lymph which adhered to it. FIGURE II. The peritoneal coat of a portion of the human intestine, in an inflamed state, to shew its vascularity, and to shew a small portion of coagulating lymph attached to it by a nar- row neck, which is supplied with vessels from it. FINIS.