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MEDICAL  DISSERTATIONS
MlMKTOIie
OR
THE SPITTING OF BLOOD,
WHICH OBTAINED THE BOYLSTON PREMIUMS FOR THE YEARS




                1818 & 1820.        #





                    -/
           BY JOHN WARE, M. D.
                    ■an    '

      FEILOW OF THE MASSACHtJSETTS MEDICAL SOCIETY.
.4^
boston:    H>i;*n
PUBLISHED BY CUMMINGS AND HILLIARD,

      Boston Bookstore, No. 1 Cornhill.


            1820. 
 
ON HEMOPTYSIS.
   Hemoptysis signifies literally, a spitting of blood,
being compounded of the Greek words utpa, blood, and
xrva, I spit; but does not embrace, as commonly em-
ployed, every case  in  which the blood is spit from
the  mouth.  Blood may pass from the mouth in con-
sequence of bleeding from the nose, the fauces, throat
or stomach, and be spit out as in  Hemoptysis.   But
the  term  is  restricted to  those cases in which the
hemorrhage  is from the lungs, and embraces diseases
of  much   more consequence  and  danger than the
others which have this symptom in common.   Scarce-
ly any one disease excites so much alarm in the mind
of a patient, or those of his friends, as pulmonary
hemorrhage ; and this not on  account of any present
and  urgent danger which is to be  apprehended on
its  first attack, but from the  terrible  nature of that
disease of  which it is so often the precursor.  Phthi-
sis Pulmonalis  so  seldom  goes through its course
without the appearance of some blood from the lungs,
that we are apt to look on Consumption as the  inev-
itable  consequence of  Hemoptysis,  and  hence the
terror which  is almost  universally  excited by its ex-
istence.  And when it  is reflected,  that  almost the
only chance  for combating Phthisis  successfully,  is 
4
by resisting its very first approaches : the treatment
of hemoptysis, whether we consider it as a cause, or
a symptom of this disease, becomes an object of the
greatest  consequence,  and demands a corresponding
degree of attention.
  If we  reflect for a moment on  the structure, situa-
tion, and circulation of the lungs, we shall not  be at
a loss to discover  why hemorrhage so much  more
frequently  takes  place  from  them,  than  from  any
other part of the system ; and why indeed,—to  carry
our remarks still  farther—disease  more frequently
occurs in the lungs, than in  any other single organ.
Their inierual surface is exposed  to all the alterations
of the atmosphere, and is m'ore  liable to be affected
by  them, than if, like the skin, it  were  constantly
subjected to their influence.   These organs are, from
their  structure, more full of  blood, than  any others.
Their  blood-vessels  are more   numerous,  and the
trunks of them larger in size.  They are more imme-
diately subdivided  into  vessels of  the smallest  size,
and these are spread out amid the cellular  membrane
covered by a very thin tunic.   The  different functions
of these organs and of the rest of the body, are con-
stantly  throwing into  them  an   unusual quantity of
blood, with  which they become gorged—as in active
exercise, coughing, speaking, singing, &c.   In  addi-
tion to  these causes,  we may include  the  relation
which the circulation of  the lungs benrs to that of the
general system.   In speaking of this relation we have
regard to the old division of  the  circulation, into the
greater and the less ;  and not to  the modern, into the
circulation of the red  and  that  of the  black blood. 
                         5

The two circulations first mentioned are,  as it were,
placed in opposite  scales and  balance  one another ;
and although one is more extensive and widely diffus-
ed  than the other, yet they are so  adapted by their
peculiar arrangement, as to maintain an equilibrium.
The general  system necessarily  contains the most
blood ; but  its quantity does not so much exceed that
of the pulmonary as a first  impression  would  incline
us to believe.   There are many parts of it, in which
the blood is nearly stagnant, or exceedingly slow and
dilatory in its motion—and others to which it is very
sparingly supplied.   This system  is also at a  greater
distance from  the heart, the blood  must therefore be
sent farther and is of course longer before it returns,
than in the  vessels of the lungs.   For there, although
the force of impulsion  to the circulating  fluid from
the ventricle  is less ; yet the  distance which it has
to run and  the obstacles which it has to surmount,
being less in a  greater proportion, the circulation is
actually accomplished in a  shorter  time.  The two
systems  may  be compared  to the arms  of a  balance
unequal in length, of which the heart  represents the
centre of motion;   the  shorter arm  making  up  by
its  greater  weight for the advantage  which, by  its
length, the  other would have had over it.
   It is. obvious from these remarks, if  they  be  well
founded,  that any  derangement  in either of these
systems, will  affect  the  circulation of the  other.   It
is consequently the case,  that any  circumstance, which
shall cause a less quantity  of blood to exist  in  the
general system, will  produce an engorgement of the
vessels of the lungs.  % And  the opposite effect is pro- 
G
duced—that is, the quantity of blood in the pulmonary
system  is lessened—by causes  which determine it to
fill  the vessels of the general system more abundantly
than usual;  as  is done by warm bathing, friction, &.c.
  There are four ways in which it has been supposed
that hemorrhage might take place.   1.  By a rupture
of vessels either large or small—this  received the
name of rexis.   2.  By an erosion of the vessels from
the  acrimony of their contained  fluids,  which  was
diabrosis.  3. By anastomosis,  or a mere  dilation oi
the mouths of the extreme vessels.  4. By diapedesis,
or  the  transudation of the blood through the mem-
branes of which the  vessels are  composed.
  Hemoptysis  is undoubtedly  sometimes occasioned
in the first of these  ways, by  a mechanical rupture
of the coats  of  the vessels.  And it has been the pre-
vailing  opinion, that it is commonly  produced in this
way.  The grounds for a different belief will be given
shortly, and in the mean time it  may be observed, that
only those cases of  hemoptysis  are produced by rup-
ture in which some external violence has been applied,
or where there has been some very violent offorts of
respiration,  as in coughing.
   The  existence of such a species  of hemorrhage as
diabrosis is extremely doubtful.   We know of no such
acrimonious states of the fluids as should make them
sufficiently corrosive to destroy the coats of  a vessel.
The only cases which can possibly come under  this
division, are those  occurring in the  advanced stages
of pulmonary consumption, where it has been supposed
that the process of ulceration destroyed the coats  of
the vessels so as to give passage  to the fluid  which 
/
they contained.   But  one fact  relating to the phe-
nomena of ulceration  overthrows this  opinion—viz.
that  the  adhesive always precedes the  ulcerative
process of inflammation, and consequently  the cavity
of the vessel would be closed up, before  the ulceration
could penetrate into it.
  The  occurrence of  hemorrhage by  diapedesis ap-
pears equally improbable.  It  is inconsistent with all
our  knowledge on the subject  of the animal system,
that  the  membranes,  while life continues,   should
permit fluids to pass through inorganic  pores.   If the
pores are not inorganic, then this kind of hemorrhage
would amount to no  more than  anastomosis,  for the
pores would  be  themselves small  vessels  from the
mouths  of which the blood issued.  This explanation
suggested itself even  to  Galen, who  was the  first to
take  notice  of this species  of hemorrhage; and he
was therefore less confident in  describing  this, than
the other kinds of hemorrhage.
  The theory which best agrees with both physiolog-
ical and pathological observations, is that which refers
hemoptysis, as it  commonly occurs, to anastomosis—
that is, to  an effusion of blood from  the  mouths of
the exhalant vessels of the lungs.  The mucous mem-
branes  are  generally  the seat of hemorrhages,  and
their occurrence may almost be considered as peculiar
to  those surfaces.  I  shall endeavour  to  show  that
the  effusion  of  blood  from  these surfaces does not
proceed from a rupture, but from an affection of the
small vessels  entirely  different.  This opinion has
been advanced and defended by many distinguished
physiologists and physicians.  Let us state in the first 
8
place, a few considerations which  are  offered by Bi
chat in defence of the position that hemorrhage  is
really an exhalation, and not the consequence either
of erosion or of rupture.
  He observes, 1.  That in no instance, where he has
opened the bodies of those who have died of hemorrh-
age, has he  discovered any traces of erosion, although
he employed the nicest care in washing and macerat-
ing the  surfaces and  examining them with a micro-
scope.  2. That in squeezing the mucous surface of the
uterus in women who have died during menstruation,
a number of small drops of blood may be pressed out,
which manifestly  correspond to  the  extremities  of
exhalant vessels ; but no sign whatever of erosion can
be discovered.   3.  That hemorrhages sometimes take
place from free surfaces, as the skin, in which the
blood manifestly comes from  the exhalant vessels ;
this renders it  probable that the same is the case with
the mucous membranes.   4. That if rupture always
preceded hemorrhage, the internal surface of the womb
would be a mere collection of cicatrices, as we must
suppose one or more ruptures to occur at every month-
ly period of the catamenia.  5.  That even if in active
hemorrhages where there is evidently a previous con-
gestion of blood, we should admit the possibility of a
rupture, how can we suppose it to take place in passive
hemorrhage, where the powers of the vessels, almost
destroyed by disease, permit the blood to  pass  freely
from their orifices.  6. That it is difficult to reconcile
many of the phenomena of hemorrhage—such as the
extreme rapidity with which it is  sometimes produced
__its appearance in an other part, when it has disap- 
9
 peared from  that in which it previously  existed, and
 its subjection to the influence of sympathy—with the
 supposition that it is produced  by  rupture.  7. The
 irregularity of the appearance of the blood  in the
 course of menstruation, its copious flow in one in-
 stant and  its complete  cessation  the next, and so
 alternately many times in the course of  one period,
 are difficult to be accounted for on the principle of
 rupture, for we must suppose the wounds to be opened
 and closed again at every alternation of the discharge.
 8. If  we compare hemorrhages allowedly  proceed-
 ing from rupture,  with others, they  do not resem-
 ble them  either in their  phenomena or  duration.
 Their cessation does not give rise to others ; they are
 independent of all influence  from sympathy  ; and the
 passions, which have a considerable effect on the com-
 mon kinds, have none on these.
   These are  the  arguments which are adduced by
 Bichat in  support of  this theory.   There  are other
 observations  which may  be offered that favour the
 same opinion.  If we believe hemorrhage to arise in
 consequence of rupture, the  quantity of blood which is
 sometimes suddenly effused makes it necessary to sup-
 pose either that a  large  vessel or a large number of
 small  ones  are  ruptured.   If a  large  vessel  were
 ruptured, we ought, as Bichat observes, to discover it
 on the dissection of those who die  from hemorrhage ;
and besides,  this disease exists frequently in  those
 mucous membranes which have no large vessels, as in
those of the nose, ears,  &c.  In  addition  to  these
objections we may ask, how, if the blood be effused
from a large  vessel,  can we account for  its  being
               2 
1U
 arrested by bleeding and astringents taken internally,
 remedies which have no effect on the orifices of vessels
 wounded in any other way ?
   If we recur to the other explanation, that the small ves-
 sels are ruptured, we shall  not find this more satisfac-
 tory.  The  rupture must be produced by some internal
 cause, and  the congestion of blood in the vessels is usu-
 ally supposed to be this cause; even Bichat allows that
 this might  possibly be the  case.   But how and why
 is this congestion  to rupture the  coats of the  small
 vessels ?   To  do this,  it ought to be formed and sup-
 ported by the vis a tergo of the large.   But it is not
 probable that  the large vessels can produce a conges-
 tion in any part, unless an affection of the small vessels
themselves  exist  at the  same time.   The increased
 action of the large  vessels is a consequence  and not
 a cause of the  engorgement of the small ones, and will
 therefore be only proportionate to the increased quan-
tity of blood, which is demanded by them,  to support
 their altered state of action.   Since  the congestion,
 then,  is  a  consequence of the  state of action,  or of
 same modification of the vital properties of the extreme
 vessels themselves, it appears incredible to suppose,
 that an affection of their own should draw into them
 a quantity of blood sufficient to rupture their coats.
   We do not meet with so much difficulty, if  we
 ascribe the effusion of blood to the mouths of the exha-
lants.   In  their ordinary  state, they have the power
 of separating  and pouring out a mucous   or aqueous
fluid ;  this  power depends,  probably, on a peculiar
modification of the vital properties which these vessels
possess.  An alteration in these properties would alter 
11
or take away their function.   The affection of the
vessels in hemorrhage, probably consists in such an
alteration, which draws to them an additional quantity
of blood, and gives to their  extremities the  power of
transmitting  that fluid, instead of  their accustomed
exhalation.   This  change in the state of the vessels
concerned in the disease  would not be  greater than
takes place in inflammation.   And indeed a strong and
well grounded analogy has been pointed out between
hemorrhage and inflammation.  The two diseases seem
to border  upon, and  run into one  another.   In an
inflammation  of the  lungs, hemoptysis  to  a certain
degree is a  very common symptom ; and after a he-
morrhage has occurred, inflammation and suppuration
succeed it so closely, that the line of separation cannot
be drawn between the  two diseases.
   The phenomena in hemorrhage, and their expla-
nation, resemble very closely  those of inflammation.
There is  every mark of preceding  irritation and con-
gestion, as is evident from the  symptoms of hemopty-
 sis.   Indeed, the first approaches  of  pulmonary he-
morrhage  might easily be  mistaken for those of an
inflammation of the lungs.  The local  affection differs
 principally in the circumstance of the effusion of blood,
 and were it not for this,  the  two diseases  would be
 nearly the same.  But is not the passage of the blood
from the mouths of the exhalants a  phenomenon of
almost exactly the same kind, with some of those which
take place in inflammation ? In the  serous membranes,
for  instance, the small vessels do not naturally  give
passage to red blood.   Irritate them  so as produce
inflammation,* and  this fluid immediately  penetrates 
12
them.  Now, would not a similar change, in the state
of the exhalant vessels  of the mucous membranes
permit the effusion of blood, instead of that of mucus?
These circumstances seem to me to stand on precisely
the same ground, except that in the serous membranes,
the vessels, whose vital state is thus altered, do not ter-
minate in  open  mouths, as those of the mucous mem-
branes do. A similar comparison might be made with
respect to many other phenomena of inflammation;
but I would only observe, that there seem to be sufficient
grounds for  regarding the admission of blood  into
vessels  which do  not commonly transmit it, the ef-
fusion of  coagulable lymph and  the secretion of pus,
as circumstances of the same kind with the exhalation
of blood from mucous membranes, and depending on
a like cause.   This cause, probably, consists in some
increase,  or  alteration (of the nature of which we
are entirely  ignorant) in the vital properties of the
part  affected.  These  observations are confirmed  in
some measure  by  a symptom which has been  often
observed  to  precede  hemorrhages.   Before the dis-
charge  of blood  commences, there  is  an effusion
of  a serous or mucous fluid in unusual quantity  ; and
this seems to denote that a gradual  change is taking
place in the state of the  vessels, from their ordinary
degree of vital power, to that which enables them to
discharge blood.   This  circumstance  has been re-
marked in hemoptysis and with respect  to the  men-
strual discharge.   I  have also observed it twice in
bleeding  from  the nose.  Dysentery affords  much
to confirm what has been remarked.   The  different
appearances of the evacuations in this disease,  vary- 
13
ing from  pure mucus to almost pure blood, with all
the intermediate degrees of mixture, seem to be a
consequence  of the  different  degrees of alteration
which  the exhalant  vessels  have undergone in diffe-
rent portions of the  intestinal canal.   In this disease
hemorrhage  seems  clearly  to  be only. one  among
the symptoms of inflammation.   Are we not therefore
justified  in adopting the same  opinion with  respect
to hemoptysis, to say nothing  of any other hemor-
rhage ?  This view need not interfere with any prac-
tical distinctions, which  will continue as well  defined
as they are now.
   These  observations,  it is  obvious,  refer  only to
active hemorrhage.   The distinction of hemorrhages
into active and passive  is founded on the  same prin-
ciple,  as a similar division  of  the exhalations.*  In
active exhalation  the life of a  part  is vigorous and
it is full of  blood.   In  passive, the vital  power and
the quantity of blood  are  both diminished.   The
same  is  the  case  with hemorrhages.  Passive  he-
morrhage arises from an adynamic state of the vessels
of the surface, whence it proceeds, and is  not accom-
panied by   that congestion,  or those symptoms  of
fulness, which attend on active hemorrhage.   The
vessels seem to  let  the  blood  pass  out of them,  in
consequence of their complete apathy, and  want of
power to retain it.   Passive  hemoptysis occurs in
the lungs, in the advanced  stages of  chronic  diseases
of those organs; but I  am  not in the possession of
experience or authorities on the subject, which would
    * Bichat Anat. General, vol.  ii. 
14
enable me  to  speak with decision or confidence of
these cases.
  This view of the  proximate cause of  hemorrhage
applies  to  the disease in general;  but no particular
remarks will  be necessary to adapt it to the present
subject.  The phenomena of the disease  are  as  dis-
tinctly and clearly marked  in hemoptysis as  in  any
hemorrhage, and  like inflammation, the  disease  has
the same  general character  wherever it is situated,
though  the structure and  constitution of each  par-
ticular organ  may  produce some slight  varieties of
symptom.
  Having treated of the proximate, we proceed  next
to the remote causes of hemoptysis,  which  are in
many respects the same as  those  of hemorrhage in
general.    It has been  a common  opinion  that  this
disease  was a sign of a  plethoric state of  the system.
The effusion of blood was considered  as a proof  that
there was too  much of  that fluid in the  vessels,  and
that nature took this method to rid herself of the
incumbrance.   There can be little doubt, that the
discharge  is   the  natural means  of relief for  some
difficulty;  but it does not  follow of course that  this
difficulty consists in  the presence of too much blood.
The  congestion  and  derangement  is local, and the
discharge  relieves  these ;  and  they may certainly
be  produced  without the existence of a general  ple-
thora.  Hemorrhage is doubtless sometimes occasion-
ed by plethora, but not commonly ; and hemoptysis
seldom.   Individuals subject to hemorrhage  have it
generally in some particular part; which circumstance
indicates a predisposition in that part to  the disease, 
15
without implying any affection of the system at large,
The part thus affected may perhaps be said  to have
a plethoric disposition of itself, which does not extend
to other organs.  It is thus that very slender women,
who are far  from a plethoric habit, have frequently
profuse catamenia ;  a peculiar irritability of the ves-
sels of the uterus drawing to them a disproportionate
quantity of  blood.   An abundance of  blood in  the
body will not be apt to  produce hemorrhage, if it be
equally distributed and properly  balanced.   It is
only when the balance is destroyed that injury ensues,
and although this is, perhaps, more easily  done in a
plethoric  habit, yet it may take place under any cir-
cumstances and produce the same effects.
   In hemoptysis the  local tendency to the disease
appears  to be  far more  instrumental in producing it,
than any  circumstances  relating to the  general  cir-
culation. We cannot separate the predisposition to this
disease, from the predisposition to phthisis pulmona-
lis.  In fact we may generally consider it as the pre-
disposition to phthisis, of  which hemoptysis is one of
the first effects.  The existence of this predisposition
may be often observed long before it is matured into dis-
ease.  We can see it in thousands almost from their in-
fancy ; and we daily meet those who appear destined,
by their very form and appearance, to become the victims
of this destructive disease.  Many, no^loubt, go through
a  long life with  this tendency? and are  so fortunate
as  never  to  have it called into action; while others
are cut off at the very threshold of existence.  This
predisposition of the lungs to pulmonary consumption
consists  probably in  some peculiar modification of 
1G
the vital powers of those organs.  It is. as it respects
the lungs, what the  temperament or constitution is
as it regards the  whole system, a peculiar mode of
exercising the  functions of life, which, though per-
fectly distinct and characteristic, cannot be accurate-
ly defined or described.   We  can arrive nearer the
truth probably, if we defer  an examination  of the
nature  of this tendency  in the lungs, till  we  have
inquired  a  little into its origin and external signs;
for it is usually accompanied by a certain  habit and
appearance  in the rest of the  body, and by visible
peculiarities of the whole  constitution as  well as of
the lungs.  A  general delicacy of  habit—a fair and
rosy  complexion—the  skin thin  and transparent—a
long neck, depressed shoulders, and  flat and  narrow
chest—a flaccidky and softness of the muscular parts,
are all  marks of a predisposition to hemoptysis and
consumption.    Persons of this habit  are apt  to be
peculiarly affected by any cause which produces an
alteration in the state of the circulation.  Hence any
considerable degree of exercise renders their respira-
tion  laborious—digestion is  accompanied  with some
 sympathetic effect on the system, and there is a pro-
 pensity to  nocturnal sweats.  A peculiar acuteness
 of intellect has also been ascribed to persons of this
 constitution.   The predisposition, marked by these
 signs,  is frequently accompanied, and rendered more
 alarming and inveterate, by a scrophulous taint of the
 constitution.   Where this is  the case, the evil  is usu-
 ally hereditary,  and always  where these peculiarities
 are present they are a part of the original constitution.
 But causes may  operate after birth, so as to produce 
17
 a predisposition to consumption  in those who were at
 first  entirely free from it.   Like other parts of the
 system,  the  lungs may be permanently affected by
 circumstances occurring in the  early stages of life.
 Violent  and  long  continued diseases,  affecting the
 general system,  sometimes produce consequences from
 which it never  recovers.  According to the  common
 expression, the  constitution  is ruined  or impaired;
 the individual is completely altered; his life and its
 functions have  taken on  themselves a new character.
 Similar  to this may  be the effect of disease on the
 constitution of the  lungs.  Accidental  causes induce
 pulmonary disease  in  a child, which, though cured,
 leaves behind it a tendency, never to be eradicated,
 that  finally  brings on hemoptysis, consumption and
 death.
   In the same  way  there  are many causes, which,
 taken separately, are only capable of slightly affecting
 the lungs, yet long continued, produce a permanent
 change in their constitution.  We may adduce the
 case  of  public  speakers; of whose disproportionate
 liability to pulmonary consumption, we  have so  many
 and  such melancholy examples.  It is true,  these in-
 stances  may possibly  be only the  development  of
 original  tendencies;  but it  appears reasonable  to
 conclude, that a cause, which applied in a certain de-
 gree is capable  of developing a predisposition,  may,
 if applied in a greater, produce the predisposition
 itself.
   Having described  the origin and signs of  the pre-
disposition in question, we return to the inquiry into
its nature.   Of  this,  I  think  we must  judge rather
              3 
18
from  phenomena which take  place when phthisis al-
ready exists, than from any which occur previously.  In
this disease, processes are carried on similar to those.
which in other organs  are preparatory to  the resto-
ration of health—viz. inflammation and  suppuration.
The inference then is, that there  is in  the lungs an
attempt  to cure the  disease, but not power sufficient
to carry  through  all the processes which are  neces-
sary.   Or if  there  be sufficient  power, that it is not
rightly directed,  but  expends  itself in  useless and
excessive suppuration.  The  labour is  rightly com-
menced,  but  not  rightly finished.  We may compare
this  state of things in the lungs to  what  occurs  in
irritable  and  phagedenic ulcers.  The processes are
formed and carried on  by  the same  rules and on the
same  plan as in healthy ones, but there  is a want of
power to complete the plan, or else the power is mis-
applied.   From these remarks  we may  derive some
idea of the nature of that affection of the  lungs, which
constitutes a predisposition to  phthisis pulmonalis.   It
appears to me to consist in a tendency to excessive ac-
tion, without a  proportionate power of supporting ac-
tion ; in  a great degree of irritability, without corres-
ponding  strength.   It is the result  of  such a dis-
position,  that slight  causes excite the vessels of the
lungs to a degree  of action, which their  structure and
organization are not capable of supporting; and the
consequence is, that they are  destroyed by the vio-
lence of their own efforts.
   In  those who are thus predisposed  to the disease,
hemoptysis is easily brought on  by  various exciting
causes.   These causes are  generally such as produce 
19
an increase  in the rapidity of the circulation in gen-
eral, or of that  of the  lungs in  particular.  Among
the former, we may reckon exposure to great external
heat, as in manufactories, glass houses, etc. all violent
straining, or exercise of the muscles, as in  running,
jumping,  and  walking  for a long time.  Among the
latter,  public  speaking  or singing, shouting loudly,
playing  on  wind  instruments.   In  many  of  these
cases,  the extreme congestion  of the vessels  of the
lungs is shown by the short and laborious breathing—
a sense of oppression and suffocation—and  the vio-
lent efforts  of the  chest to overcome this  difficulty.
In  addition to  these causes, we  might mention some
others which  operate  in a different way.   Any cir-
cumstances, which, without increasing the rapidity in
the circulation, destroy the balance between that of the
lungs  and the  rest  of  the  body, will often produce
hemoptysis; and likewise causes,  that dp not affect the
circulation  immediately, but  are applied  to some
other part of the system, produce disease  in the lungs
by  sympathy; as cold  applied to  the  surface of the
body,  and  probably some states of the  alimentary
canal.
  The suppression of accustomed discharges (such  as
the catamenia, piles, &c.) is often a cause of hemop-
tysis ;  from this it more frequently  comes on without
predisposition, than from any other, and  is  conse-
quently  attended  with  less  danger, though still an
important disease.   These  discharges were  looked
upon by the ancient physicians, as serving to evacuate
morbific and injurious humors, which, when they were
suppressed, sought  some  other  outlet  and  thus fell 
ao
upon the lungs,  the stomach,  or  the  head.   This
explanation is hardly  admissible in the present state
of our  knowledge;—can we discover any that  is
more satisfactory ?   There  are some observations of
Bichat,  when speaking of the  distribution  of the
vital  powers,  which  appear to me  to have a bearing
not only on this question, but also  on others relating
both to  healthy processes,  and  to  those of disease.
These observations with  their illustrations and ap-
plication, will be introduced  here,  not because the
explanation of this circumstance is of very great impor-
tance, but  because the principles quoted  will be ap-
plicable  not only here, but elsewhere in the course
of our inquiry.  The amount of the ideas he advances
is as follows.  " It  is  an invariable law  of the vital
powers, that if they are augmented in  one direction,
they are proportionally diminished in another.  There
is only a certain sum  of these  powers apportioned
to the system at any one time.  There  may be much
difference  in  the proportions  in which  this sum  is
distributed, but not a difference in the whole quantity.
One part of  the system then  augments its  actions
only at the expense of some other."  Wherever there
is an increase in the energy of action  of any one
organ,  there  is  a  corresponding  decrease  in  some
other organ,  or  in the system in general.   These
remarks  do  not  imply  that  there  is  a  certain
quantity of vital power given  to  the  system which
is always to  supply  it.    There  is undoubtedly a
constant development,  as there is a  constant con-
sumption.    But the  supply  is,  at any particular
period,  in  a  definite  quantity.   If the  circumstan- 
l\
ces of any  particular part oi  .»e body call  for an
unusual  proportion of vital power, this  is furnished
by depriving other parts of it, and not by an absolute
production  of  the requisite  quantity de novo, as is
commonly supposed.   We may infer from these prin-
ciples, that many  of  the  diseases to which  we  are
liable, arise from an inequality and disproportion in
the distribution of the  vital  powers;  especially, as
an unequal  distribution  of the  blood usually accom-
panies, and is indeed  a natural  consequence of this
occurrence.   It is obvious, ithat if  any cause  attracts
to a  particular organ,  a larger proportion of vital
power than  is  sufficient to  perform  its ordinary
functions,   some derangement  and  the production
of some  unnatural function will  be the consequence.
For,  since the structure and  strength of the  part is
exactly adapted to the degree  of  life and  action
which it is  destined  to  support, any increase in the
latter, as it must  destroy the proportion that ought
to exist  between  these  circumstances, necessarily
produces a  derangement.  Morbid processes, or  the
functions  of  disease,  are  supported  by  the same
means as those of health, but they require an increase
in the powers, or at least in some of the powers of the
part;  or else  a  different proportion  and relation
among them.   In the production  of any discharge,
whether sanguineous or suppurative, the part in which
it exists  draws  on  the rest of the system  for an in-
crease of its vital  energy.   If this discharge is habit-
ual, the system  is able by degrees  to furnish an addi-
tional supply in order to compensate for this demand.
But should  any  cause suddenly  suppress  the  evacua 
22
tion, the powers which had been  previously  appro-
priated to its  production are thrown loose upon  the
system.  In constitutions  universally vigorous, they
are probably distributed equally among all the organs
and  not felt; but where there is some particular  one
weaker in  its structure than others, and  predisposed
to take on itself diseased action, they concentrate there,
and  exhaust themselves  in the production of some
derangement.
  Upon these principles, if they be well  founded, we
may, I think, account for the production of hemopty-
sis  by the suppression of  an  accustomed discharge.
And indeed, with proper adaptation to different cases,
they will explain a great many other phenomena, both
in health and disease.
  In whatever manner hemoptysis is occasioned, it
generally comes on with very nearly the same symp-
toms.   The discharge of blood  is preceded by  a
weariness and lassitude affecting the organs of motion,
a shivering sensation and  constriction of the skin—
by a coldness of the extremities—a sense of weight or
anxiety about the precordia—a slight degree of pain in
some part of the  chest—a sensation  of heat or of
burning  under the sternum—and  by a shortness  and
difficulty of breathing increased by moderate exercise.
These symptoms may have existed for a longer or
shorter time before the hemorrhage occurs, but some-
times it comes on suddenly without any such  warning,
the flow of the blood  being the first symptom observed.
This is said frequently to  be  immediately preceded
by a saltish  or brackish taste in the mouth, the cause
of which, if it be any thing more than the fancy of the 
23
patient,  is  probably  owing  to  a sympathy  of  the
organ  of taste  with  the diseased part.    A  slight
tickling  is felt  at the  top  of the windpipe,  which
excites  a coughing to  relieve it.   This  brings  up
the blood from the lungs, of a florid, arterial colour,
and of a frothy appearance, at first in a small  quan-
tity, but  the  irritation continuing, more  is brought
up  in  the same way, with  a rattling noise in  the
windpipe, as of air passing through a fluid.   In some
instances, only a few mouthfuls are thrown up,  before
the hemorrhage ceases; in  others, a  slight spitting
continues for  several  days  together, and  sometimes,
especially when  it has repeatedly occurred, it is in
great quantity, and the blood is  thrown out so copi-
ously, that the patient  seems rather to be vomiting
than coughing it up.   It is seldom that the hemor-
rhage  is  so abundant  as to cause death  either  by
suffocation or  exhaustion.  It generally ceases spon-
taneously, when  sufficient blood  has been  poured out
to relieve the vessels of the lungs; or it is checked
by the use of  remedies.
   Hemoptysis affects the system generally, and pro-
duces  symptoms of the same kind,  as those  which
accompany inflammations of  internal  organs.   These
are usually known by the name of the sympathetic fe-
ver, and are of two kinds, Symptoms of General Inflam-
mation, and Symptoms of Irritation.  The  differences
between them it is  not necessary to  describe, as it
has been so frequently and  so accurately done, as to
be sufficiently familiar to physicians.   The  latter,
Symptoms of Irritation, are  most usually  attendant
on the disease un^er consideration:  and  accompany 
II
 especially those eases which result  from predisposi-
 tion,  and  are introductory to phthisis  pulmonalis.
 The  former,  Symptoms  of  General  Inflammation,
 occur  oftener  in  those  instances arising  from  the
 common exciting  causes  of disease, and  which  are
 therefore less likely to terminate  in pulmonary con-
 sumption.
   Having  thus taken a general view of the  charac-
 teristics of hemoptysis,  as  they  ordinarily  appear,
 we turn to consider the varieties to which it is liable.
 As it  is produced by different causes, in different
 states of the system, and in a variety of constitutions,
 we ought to examine if there be any  essential diffe-
 rences which require diversity of treatment.
   Hemoptysis may be caused, in  the first  place, by
 some external violence. In such a case, the precursory
 symptoms,  which  have been above   enumerated,  of
 course do not occur, and if there be any constitutional
 effect, it follows the hemorrhage.   It is easy to deter-
 mine this kind of  hemoptysis, because we  can ascer-
 tain whether any  cause capable of having  produced
 it has preceded.  The degree of danger to be appre-
hended depends more on the previous state of the
lungs and of the system, than of the actual extent of
 injury done to the organ itself.  If the  health is good,
and especially if the lungs be sound  and without any
 predisposition to   disease,  a very serious  injury  is
frequently  recovered  from.    But  even  under  the
most favourable circumstances the danger is  consid-
erable.   The lungs at  best possess but feeble  powers
of restoring themselves after an injury has  been  in-
flicted. 
25
  In the second place, we rank those eases of hemop-
tysis, which are produced in consequence of some of
the ordinary causes of inflammatory disease, are ac-
companied by the symptoms of General Inflammation,
occur in healthy,  perhaps  plethoric habits,  where
there has been no predisposition to pulmonary disease,
and  are more  easily relieved by remedies  than any
other kind, without leaving an  unpleasant affection
behind.  It is impossible, in actual  practice, to draw
a line between  this  kind and that which  will next be
attended to ; but theoretically, at least, there appears
to be a clear distinction between these cases and those
in which signs  of predisposition  and disease precede
the bleeding.   The difference consists  in  this, that
when phthisis  follows this variety  of hemorrhage, it
is as clearly produced by it, as if the disease had been
a  common inflammation ending in  suppuration; but
when, on  the other hand, it  follows a  hemorrhage,
which is manifestly the  consequence of a predisposi-
tion,  the hemoptysis is  to  be  regarded  as  only a
symptom of incipient phthisis, and this forms the third
kind.
   This kind, the  third, is only one of a series of
morbid phenomena, constituting pulmonary consump-
tion, and  may  be either the  first symptom, or it may
occur after the disease  has  made  considerable pro-
gress, and when ulceration has far advanced.
   As the fourth kind of hemoptysis, we may  reckon
that which  proceeds from  a suppressed  discharge.
Of the nature and  causes of this variety we have  al-
ready spoken, and nothing need be  added here.  We
can only observe that hemorrhages, produced  in this
             4 
26
 way, are often perfectly  innocent.   A  spitting of
 blood, which is vicarious of suppressed menstruation
 will frequently go off with as little subsequent derange-
 ment,  as if the discharge  had been accomplished in
 the natural manner;  and the accompanying symptoms
 are not more unpleasant than those which frequently
 accompany menstruation.
   In the fifth place are passive hemorrhages of the
 lungs, which, as before remarked,  occur  in  the ad-
vanced stages  of  chronic  diseases of those organs.
They are to be regarded merely in the light of symp-
 toms of those diseases, as  they are not of sufficient
importance to require a separate treatment.
   The degree  of danger  to  be apprehended  from
hemoptysis  depends on circumstances, which   must
suggest themselves to every one who  has considered
the disease  attentively.    Since scarcely  any cases
terminate fatally from the bleeding, the only thing to be
regarded is the degree of  probability that  the  case
will  terminate  in  phthisis.   On  this  subject  it is
unnecessary to dwell.   It will  be sufficiently  obvious
from what has been already said, in what cases  this
termination is to  be apprehended, and so far as we
can ever decide, what the degree of danger is.
   As in inflammation of the lungs, the first and  most
important remedy for hemoptysis  is bleeding.   The
propriety of this practice has been generally acknowl-
edged, though there have been  those who have  ad-
vanced many objections to  its adoption.  It will not
be pretended  that blood-letting is to  be  indiscrimi-
nately employed, wherever  a spitting of blood exists ;
but in the greater number  of cases it appears to be 
27
a remedy of the first  consequence.   The  objection
which  would be thought the greatest against its em-
ployment is, that  it tends  to increase and aggravate
the debility which follows the disease, and thus lessen
their chance of recovery, who are so unfortunate  as
not to have the symptoms of phthisis removed  with
the hemoptysis, where  the bleeding proceeds from a
predisposition to  that   disease.   But, if it appears
satisfactorily, from the  experience of most physicians,
that the adoption  of seasonable and  sufficient blood-
letting affords  the best prospect  of preventing the
hemoptysis  from  passing into  phthisis, ought it not
to be  employed ?   For even if we admit, that it may
hasten the fatal event  in those, who, notwithstanding
its  use,  do  fall into consumptions; yet  if it  does
actually  preserve  many from this issue  to their dis-
order,  it on the whole is of advantage.
  Blood-letting is  indicated by every  view which
we  take  of the nature, the symptoms and  course of
this disease.  As a remedy for inflammation, it seems
best calculated to remove  the danger, that suppura-
tion and  ulceration will follow the hemorrhage.   Wri-
ters in general  have recommended  to confine  its use
to strong and plethoric habits ; but I do not see why
this should be  thought to  make so  much difference.
Do we find  that those  of weak and slender habits are
more  debilitated  by bleeding, than those  who  are
stronger  ?   At any rate,  are  the bad  consequences
of the  operation  so grave and  dangerous, as  those
which ensue  from hemoptysis?  And  does it not  as
often prevent these consequences  from taking  place
in those  who seem  to have no blood to  spare, as  in 
28
those who are full of it.   If they are not able to bear
the operation of the remedy ;  they are still less able
to support the disease.   It may be  said  that  our
opinions are derived  from theoretical  views  with
respect to  the  nature of hemorrhage : but  is it not
theory which restricts  bleeding  to those who  are in
vigorous health?   We ought  undoubtedly to have
some  regard  to the power  of the system to  repair
the loss of blood.   There are certainly cases in which
this  remedy  is improper ; but in any subjects, with
respect to  whom  it would be  adopted  were  they
attacked with inflammation of  the lungs, there seems
to be no danger in resorting  to  it in hemoptysis.
  The degree  and extent of  the bleeding must  be
regulated in  every case by the  symptoms and  the
effects of the remedy.   More  copious depletion  can
generally be  borne in the first, second, and  fourth
kinds of hemoptysis, than in the third, although the
actual advantage to be derived  from the  operation
may not be  less.   When  hemoptysis occurs after
phthisis has made considerable progress, it is evident,
that, as we cannot promise ourselves  a cure from it,
many of the above arguments in favour of its employ-
ment  do not apply, and the debility which it might
produce would  perhaps hasten the fatal event.   Still,
even in this situation, if the digestive powers continue
in considerable  vigour, small and  frequent bleedings
will  often serve to remove some  urgent symptoms,
without much  fear of  any injurious  consequences.
Should this, however, not  be the case,  this  treatment
becomes of very hazardous application, and it is safer 
29
to confide in some measures of  a milder and perhaps
as effectual nature.
  We are however  to be governed in our  treatment
of hemoptysis, rather by a regard to the state of the
general health and the other indications  of pulmonary
affection,  than to the simple occurrence of hemor-
rhage.  If we  consider  this as merely  one symptom
out  of many, which collectively indicate some disease
of the lungs, there is no reason  why we  should direct
our practice wholly  by  an attention to this  partic-
ular.   Does the spitting  of blood  ensue from a  sup-
pression of the catamenia ? There is no more urgent call
for  vigorous practice, than if the hemorrhage were
from  the nose  or  the stomach ; unless,  at the same
time,  there  are circumstances leading to the belief,
that the disordered state  of the catamenia has produc-
ed,  not merely a  vicarious discharge of blood  from
the lungs, but  has likewise impressed  upon  them a
tendency ?o disease.  Does it  arise in  the course of
pulmonary consumption, at an earlier or later stage ?
There seems to be no sufficient reason why we should
bleed  for this  symptom, more  than for any  other of
equal  importance  which may arise  in the course of
the  disease.  And we may perhaps  fairly say,  that
where we should think  it right to  bleed  for an in-
crease of cough, a  pain in the side, a difficulty of
breathing and  expectoration-, when these are urgent,
we should  also be justified  in bleeding  for such  spit-
tings of blood  as occur  in the  course of pulmonary
consumption.
  These remarks, it will be observed, are not intended
to deter from  venesection,  when  hemoptysis is the 
30
leading symptom of phthisis, or when  it arises from
ordinary causes.   In these cases,  though not even
in these without  exception, it is eminently applicable ;
not simply because of the spitting of blood, but  be-
cause there is generally a state of system and of local
disorder, which would demand  the remedy, were  not
blood effused.
  The same principles are to guide us in the choice of
other remedies.  The state of the prima via, generally
claims our attention next  to that of the circulating
system.   Emetics have  been  highly recommended,
and  sometimes to the exclusion of the remedy  last
spoken of. Of their great importance there is no doubt,
and  they seem to be called for in  the  majority of
cases.    They may  be useful  in two ways;  first,
when the stomach is deranged  either from previous
disorder or from the attack itself,  by putting it in
good  order;  for  the system never acts to advantage
under any difficulty, if this is not done 5 and secondly,
by the sympathetic  operation, which  vomiting  has
upon the capillary circulation  of every  organ, par-
ticularly of the  lungs and skin.  The remedy is to
be administered upon the same principle and operates
in the  same  way, in this, as  in other  pulmonary
complaints, especially those which affect  the  mucous
membrane.
  The  emetics,  which have been most highly recom-
mended, are those of a metallic and astringent nature,
such  as the sulphates of  copper and  of zinc.   It is
somewhat  questionable,  when  they  are employed,
whether part of their  superior efficacy  may not be
ascribed to their astringency, and this probably is the 
31
case, but the vomiting is itself of much service, since
the exhibition of other articles is also attended with
advantage.
  The state of the bowels, as in every other disorder,
demands special attention.  In  most instances, thor-
ough purging in the first place, with  the subsequent
use of laxative medicines, is sufficient; but there are
some  cases  connected with a constipated state of the
alimentary canal, and in some degree caused by it,
which  require a more  continued  use of purgatives.
These cases are to be determined by a reference to
their history.   During the continuance of the bleeding
and the immediate symptoms which follow it, those
cathartics which operate  with least  irritation are to
be preferred ; such are the neutral salts.  But in indi-
viduals, where there is a combination of the pulmona-
ry disease with  some affection of  the stomach,  liver,
or  alimentary canal, other articles will often  demand
the preference.   But this subject will be more par-
ticularly attended to hereafter.
  The well  known power of astringents in stopping
hemorrhage, when applied  to wounded vessels, natu-
rally  suggested the  same application to the vessels
supposed to be  ruptured in internal hemorrhages.
It is obviously impossible to  do this  in hemoptysis,
unless the remedy  be introduced in the form of va-
pour ; but it is probable that such evil would arise from
the irritation excited in  this way as would counter-
balance  any other benefit that might ensue.   Astrin-
gents have therefore been introduced into the stomach,
and operating sympathetically, they will  frequently
stop a  hemorrhage  in  the lungs.    But this is not 
:v.2
the same kind of operation, as that produced by their
immediate application to bleeding vessels.  If astrin-
gents were  thrown into the  stomach, when a  wound
is  bleeding, we should not expect them to have any
effect j and besides we suppose the state of the  vessels
in hemorrhage to  be very different from that which
exists in a  wound.  The effect of astringents is of
the same kind  as  that  which they produce  in sup-
pressing increased secretions : they probably remove
that state of action in the part on which the disorder
depends.  Their  use is indicated principally in those
cases where bleeding and the other measures employ-
ed do not succeed ; where any particular circumstance
prevents their employment;  or where  the effusion of
blood is so sudden and  profuse  as  to  threaten  im-
mediate loss of life from the hemorrhage.
   It does not appear to be  a matter of great  impor-
tance what article of this kind we  prefer.    It is
sometimes necessary  to try several before we succeed.
The mineral astringents, such as the acetate of lead,
the sulphates of zinc and of copper, the super-sulphate
of  alumina and potash, and  the  sulphuric acid,  are
the most powerful, and the most commonly employed.
The vegetable astringents, such  as kino and catechu,
though  possessed of  considerable power when intend-
ed  to act on the alimentary canal, are less efficacious
than the mineral,  when their effect is  to be produced
in  distant  organs.   Dr.  Rush  relates, that  he  has
found a quantity  of common  salt  effectual,  when
other means of arresting the bleeding had failed.
   Counter irritation  by means of  blisters  should  be
early adopted and pnticntly continued.  It is one of 
33
the most  effectual  means  of  preventing termination
in phthisis  pulmonalis.   Where the hemorrhage is
sudden, rapid, and of short  continuance, we cannot
expect by vesication to controul  the  flow  of blood,
unless, as he has  been recommended  in  some other
cases, we  should  produce  it immediately  by the ap-
plication  of boiling water.   But in cases where the
spitting  of  blood  continues,  at short intervals, for
some  time ; which  are  accompanied by a slight  dry
cough, pain in the side and across the chest, and short-
ness of breath ; counter-irritation, either by blisters,
setons, or issues, becomes a remedy of great power,
and is perhaps the most certain we can employ.
   Digitalis  is an  article  well worthy of a trial, in
cases which  do not yield to the  measures already
recommended.   Though  far  from doing good  in  a
majority of instances, it is in some, of such evident
advantage,  that one would  hardly feel justified in
omitting its  employment, where the usual  remedies
had failed to check the hemorrhage, or where serious
symptoms  of  pulmonary disease continued,  after the
violence of the first attack has been subdued.  I know
of no particular circumstances  by which we are ena-
bled to distinguish the cases in which this remedy
will  be of service, though such a  power of discrim-
ination would be of great value.  On subjects, to all
appearance affected  in the  same  way, it  produces
entirely different effects,  without  affording  any clue
to the principle on  which this difference is founded.
It is  possible, that it may  have some connexion with
the very marked  and  powerful influence  possessed
by Digitalis  over the  lymphatic system,  in Dropsy.
              5 
34
   When by these, or any other measures, or  by the
natural relief produced  by the flow of blood, hemop-
tysis ceases, it becomes  the principal object to pre-
vent those changes from taking place  in the lungs,
to which there is a strong tendency, and which end
in  consumption.   The measures,  already  recom-
mended, if they have their due  effect, are the most
likely  to  prevent this  unfortunate  event.   But it
is not merely necessary to employ them  while the
spitting of  blood is actually  present; either  the
same  or  some other measures  should  be continued
after  it has ceased, and until its  effects upon  the
lungs have been removed.
  For this  purpose frequent bleeding  has been  re-
commended.   It  should not, however,  be  regularly
and periodically employed, as was  done by  some of
the older  physicians.    It  is  sufficient, that  it be
practised whenever symptoms indicate that the lungs
are disposed to hemorrhage.   In this way, by sea-
sonably arresting  the processes  of disease, it may be
of important benefit;  and  when some marks of  de-
rangement  remain, after a spitting of blood  has
ceased, the  repetition  of the  bleeding is often  ne-
cessary, and its propriety is to be determined  by the
nature and urgency of the symptoms, and the ability
of the patient to bear depletion.
  The production and  continuance of  an  external
discharge, by means of blisters, issues,  or setons, is
a most important measure  in  these cases.    Some
observations  have  been  previously  made,  on  the
mode  in which  the suppression of an accustomed
discharge operates to  produce  an  effusion  of blood 
35
from the lungs.  If we reverse the application of the
same  principle, we find the way  in  which  the pro-
duction of a discharge removes the effusion.   So far
as I have observed, this remedy  has  prevented more
cases of diseased lungs,  as well those  proceeding from
other causes, as from hemoptysis, from  passing  into
confirmed consumptions, than any  thing else.
   But of equal, or even of greater efficacy, than any
medical  means, is  a strict attention  to  the  general
health;   and   indeed, without   this,   little  more
than  temporary benefit can be expected from med-
icine alone.   If the general health be impaired, if the
digestive system become disordered, a recurrence of
the difficulty in the lungs  is almost  inevitable.   To
this subject  I  intend however more particularly to
direct attention in considering the liability and  ten-
dency of a certain class of  individuals to hemoptysis,
and the best means of  preventing so unfortunate an
event.
   I allude  to  public  speakers,   especially  those of
the  clerical  profession.    The many and  valuable
lives, which  have among us fallen apparently a sac-
rifice  to the duties of this  profession, have  given to
the subject  a  painful  degree  of  interest.   So little
can be done with  the  hope of restoring those  who
have  once suffered  from hemoptysis  with a tendency
to phthisis, that it seems of the first  consequence  to
ascertain what the exact circumstances are, in  the
life, habits, and duties of a clergyman, which render
him peculiarly liable to  such an attack and to  the
consequences it brings in its train. 
3(i
   The most  obvious cause of this liability  to pulmo-
nary  disease  in  clergymen, is the great  and  long
continued  exercise  of the  lungs, required in  the
performance  of public worship.    To  this, as  the
peculiar duty of the profession, our attention is  apt
to be  principally and almost exclusively  devoted;
we are  too ready  to consider it as a sufficient  cause
in itself,  and  to  avoid examining the influence of
other circumstances.   It is not found  that members
of other professions, who are in the habit of exerting
their  lungs,  are more liable  than the  average  of
mankind to  pulmomiry disease.    We do  not hear
of any extraordinary proportion of deaths  from con-
sumption  among lawyers,  public  actors, public sing-
ers,  &c.  We must therefore look to other circum-
stances  in the mode of speaking, the life and habits
of our clergy, for the  causes of this tendency among
them to affections of the lungs, and derive  from our
investigation  the  best methods   of   counteracting
their  operation, and of avoiding  the  fatal issue  to
which they lead.
   It has usually been admitted by physiologists, that
the exercise of any organ, if  not  carried  to an ex-
traordinary   or  unnatural  degree,  and if it be  in a
healthy state,  contributes  to increase  its  strength,
and  render  it capable  of sustaining  an  increased
degree of labour without injury.   This, under  some
circumstances,  is  true  of  the  lungs, though not  to
the same extent that it is with regard to the external
voluntary organs.   Public singers, and performers
upon wind instruments, acquire by habit  the  power
of exercising their lungs in a pretty violent manner 
37
for a length of time, to which at first they were totally
inadequate.   This partly depends, without  doubt,
upon the facility which  they acquire of producing
the same  effect with a less exertion of strength ; but
it cannot  be entirely attributed  to this circumstance.
A few moments  will exhaust a  beginner  upon wind
instruments ; but almost any individual may gradually
become able to play upon them for some hours with-
out injury.    Now  why  is  the case different with
regard to the  public  speaking of clergymen,  which
certainly  requires  a much less  violent exertion  on
the part of the lungs, than either singing  or playing
on  wind  instruments ?  The  reason I believe to be
this, that  the duties of the profession are  only occa-
sional, and  occur at  too  great intervals to allow  of
the formation of a habit;  whilst at the same time they
are sufficiently difficult to  over-exercise, fatigue, and
exhaust the organ.   They are from the first as long
and  as laborious as they will  ever be, and there is no
opportunity  for that slow and gradual increase which
enables one to acquire strength and facility of exertion.
In order  to strengthen  the  general habit, or any
particular part, by exercise, it  is  not  necessary  to
begin with any unusual or extraordinary efforts; this
is rather  injurious,  and  defeats the  object in view;
but it is necessary to keep up constantly some effect
from  the  exercise; to have the  organ or  the system
under  its  regular and equable influence.   It is only
in this way  that any benefit  is  to  be derived from
it in  the  treatment of disease.  Occasional extraor-
dinary exertion, carried  to the point of fatigue, and
then omitted until  the fatigue is entirely removed, 
38
ean only have the most injurious  effect; and it is
exactly  in this way that the  lungs  are exercised in
preaching.    They are wearied by  the  services of
the Sabbath,  and are then suffered  to remain per-
fectly at rest, through the interval of the week.
  But there  are other  circumstances which  give
force and certainty to the operation of this cause, and
which act by rendering the  system liable to become
diseased in any organ to which  the exciting causes
may happen to be applied.   They produce a general
state  of predisposition to  disorder,  which  becomes
developed in the  lungs, in  consequence of the unnat-
ural exertions  which they  are occasionally  obliged
to  make, and would, under similar  circumstances,
be  developed in any  other  organ.   I refer to the
habits of studying and living among the greater part
of our literary men.
   They are, in the first place, accustomed to use but
little exercise, and to devote a good deal of time to
sedentary occupation.   Their relaxation  is  too often
of  an inactive kind.  Their  exercise, if  they are in-
duced to attend  to it at all, is seldom judiciously
arranged ; it is not regular and equal, but sometimes
entirely omitted, and sometimes carried to excess.  To
the state  of  system  produced  by  this inactivity,
is  added the effect of improper diet  and improper
quantity of food.   In  order  to perfect health, it is
necessary there should be a certain proportion between
the demand  for nourishment, and the supply provid-
ed.    Other things   being   equal,  the  quantity  of
healthy exercise  in  the  system  determines  the
quantity of nourishment requisite for its necessities, 
39
and the quantity which the stomach can  perfectly
digest.   If the  exercise increase, the food must also
increase; and vice versa.   He, therefore, who leads
a  sedentary,  and as  it  respects  the body,  an in-
dolent life, does not require so much  food,  as one
engaged in active occupation, and  it is not necessarv
that it should be of so nutritious a quality.   V>c>'  '^
opposite course is in fact pursued by students,   "i -wii
appetites, at  least till they are become the  subjects
of disease, are not affected ;  or if so, are excited  by
delicacies  or  stimulants, and  are  indulged to an im-
proper  extent.   The  consequence is,  that  digestion
is impeded;  is performed  for a while with  difficulty
and labour, then imperfectly  in  a greater  or less
degree, and, at last, almost entirely destroyed.   This
of course is the case with only a part of the individ-
uals to  whom I  refer;  the constitutions of  perhaps
a majority, are  sufficiently pliable to become accom-
modated to this manner of life sooner or later; but
I  apprehend  I  am  correct  in  saying,  that a great
proportion of professional students  in  our vicinity,
especially  theological  students, are  affected,  at one
time or another, by some serious disorder of the diges-
tive organs.
   It is no part of my plan to describe these disorders,
except so far  as they are  connected with affections
of the lungs.  Yet, so insidious are their approaches,
so latent their symptoms,  that  hemoptysis may  be
produced as an indirect consequence, long before their
existence is even suspected by the individual affected.
I say an indirect consequence, because I believe the
disordered digestion operates by impairing  the  gen- 
40
eral powers of the whole  system, thus  lessening the
vital energy of all the organs, and of course rendering
them  less able to  resist the causes of disease.   If
then there  be any predisposition to phthisis,  or  if
the lungs  be subjected  to  extraordinary  irritation
from excessive exercise or  any other  cause ;  they
cannot resist, as  in a state of health, but are  excited
to the actions of  disease.  The same is true of every
other part.   A  disordered  state  of the  digestive
system, or as  it has been denominated by  a distin-
guished  writer*  on  this  subject,  a  constitutional
disorder, influences local disease wherever it is situ-
ated.   A scratch over  the  tibia, which, in a healthy
individual,  scabs and  heals over  in  a  few  days;  in
another, the subject of such a  disorder  may  spread
into a large,  foul, irritable  ulcer, that  will yield  to
no  remedy  except such  as removes that  disorder.
Such ulcers will sometimes spontaneously arise ;  and
they afford a true index of the state of  the  constitu-
tional  health, amending or growing  worse as  that
improves or deteriorates.  This is no bad illustration
of what I  believe takes place  in  the  lungs, when
hemoptysis is a consequence of constitutional disorder;
the exciting cause,  whatever it be, inflicts an  injury,
or produces a state of  action in  those  organs, from
which, on account of  their deteriorated  powers, they
cannot  restore   themselves,  and  inflammation  and
ulceration become established.
   It becomes of the highest importance then, to point
out those circumstances which indicate  the existence of
such a digestive  derangement, while it is yet  latent,
   * On the constitutional origin  and treatment of local dis-
eases, by John Abernethy, Esq. F. R. S. 
41
and before it has  produced irreparable disease.   It
is first sensibly felt, only whilst  digestion is actually
going  on.   There is a  sensation  of  fulness,  rather
than  oppression,  in the epigastrium after a  meal,
even  if  it  has been a  sparing one.    This fulness
affects the respiration;  it is  difficult to draw a  full
breath, though there is  a constant inclination to c
it.  Any change of posture,  especially such as com
presses  or  contracts the abdomen, as in stooping,
or even in bending forward over  a  desk to write,
 renders  the  respiration short and hurried;  there
 is an  unusual lassitude, want of disposition to mus-
 cular exertion, and drowsiness, which  continue while
 digestion is going on.   For a while these symptoms
 only  exist during  the period the stomach is perform-
 ing its function.   This  is actually  as well, or nearly
 as well  performed, as in health,  but the  symptoms,
 which have been described, show that the stomach
 labours  in the performance of its office, and exercises
 an unnatural  degree of  power.  Other consequences,
 however,  soon become developed.   The mouth in
 the morning  has  a filthy  and nauseous  taste; it is
 dryer   than  .is   natural  and  coated   with  a thick
 adhesive mucus ; the tongue  is furred at the root,
 and  there is  a sensation of faintness, emptiness, and
 sinking  at  the stomach; a sensation resembling  that
 of hunger, so as at first to  be mistaken  for it.   It
 is removed by eating, but occurs  repeatedly during
 the day,  and always  seems to  demand food for its
 relief.   The food now really  oppresses ; it is  felt
 sometimes  like lead in the  stomach,  sometimes like
 a bar laying directly  across it; the  patient thinks
               6 
42
his clothes too tight and expects to be relieved  by
loosening  them; the relief is, however, only partial.
Digestion   is  accompanied  with  much  sympathetic
irritation of the system, the pulse is quickened, there
is  head-ach, sometimes shivering, and burning of the
palms of the hands and  soles of the feet.  Chemical
changes take place in the stomach; the food  under-
goes fermentation in part, instead of being digested ;
and this is known by  heart-burnings, and eructation of
gas.   The bowels become affected, they are costive
or relaxed;  food  passes in an undigested state, the
stools are  altered from their natural appearance and
become  dark and discoloured.
   This  is only a slight and  superficial sketch of the
incipient  stages of this  disordered state of  the  di-
gestive  system.  A  full detail  of the  symptoms  is
wholly  out of my  plan.   It  is at  this early  period,
that the  complaint  is  most  apt  to be overlooked.
The appetite frequently ramains  good ; it is some-
times even greater than natural;  there is an almost
insatiable  longing for food;  and the patient is apt
to imagine,  that when  this is the case, he must  be
in good health.  Every physician, however, is aware,
that this is the case in some of the last stages of dis-
ease, when the stomach is  totally  incapable of  di-
gestion, and the food passed off is but little changed
by the bowels.   The  sensation of hunger  in this
ease, is probably produced by  the sympathy of  the
stomach with the  state  of the whole  system.  The
nutritient  vessels in  the surface  and  extremities,
retain  their powers of  action,  and  of course feel
the  want of their  ordinary supply of  materials,  of 
43
which  the failure of digestion deprives  them.  This
hunger then  is  in  fact the hunger of  the whole
system, and in its  nature is like that following a
fever,  which  continues unsatiated,  even when  the
stomach is distended with food.
   This is a state of  constitution, which renders us
liable to  local disease  in any  part already predispos-
ed,  or in any to which a  sufficient exciting  cause
is applied.  Even those, in whom phthisis pulmonalis
is a hereditary disease, frequently perceive  the first
warnings  of its approach, in  an affection of the diges-
tive organs, which develops  and brings into action
the predisposition, of which  they are  the  subjects.
When a  public speaker becomes  disordered in this
way, he  has  reason to apprehend  the production,
sooner or later,  of some  disease  in his lungs, and
should at once take  measures for the  restoration of
his  general health, and removing any tendency to
a pulmonary  affection.    If  this  be not done,  the
symptoms progress, there is some cough  and  pain
in the side, and  hemoptysis, if the disease takes this
course, comes  on, preceded  by such symptoms and
followed  by such  consequences, as I have described
in the previous part of this dissertation.  The treat-
ment  in  this  case,  during its continuance, is  to be
conducted according to the rules already  laid down;
but a good deal  may  be done to prevent this unfor-
tunate issue,  by a strict and seasonable attention to
the health of the  constitution;   and  the measures
to  be adopted  with  this view  I now proceed to
describe. 
44
  It is sometimes sufficient, especially  in the earlier
stage,  to counteract the  operation  of those causes
which I  have pointed out  as producing this state of
the health,  by a strict attention to regular exercise,
and the observance of  rigid rules with regard to diet*
In the  more advanced  periods of the  disorder, par-
ticularly if it have  produced and  become  combined
with local disease of the lungs, the treatment becomes
complicated, and  requires the  interference of med-
icine.  It is not necessary, however, to discriminate
particularly, in the consideration  of  the treatment,
between  these different stages.
  " There are  three things," says Mr. Abernethy in
a work  to which I  have previously referred, and to
which  the  profession  have  to acknowledge  much
information  on  this subject; " there are three things
which  I consider as right  and  necessary to  the
cure of  this disorder.     First. That the  stomach
should thoroughly digest all the food that is put into
it.   Secondly. That the residue of the food should
be daily discharged from the bowels.   Thirdly.  That
the secretion of bile should be  right both in quantity
and  quality."   These three heads include all  the
treatment which  applies  to the  digestive  organs
themselves.    The first embraces  the  quantity and
quality of nourishment.  We are most apt to err in
the quantity of  our food.  This point must be par-
ticularly  attended to  where  disorder exists.    No
more should be  put into  the  stomach, than it  can
entirely  and comfortably dispose of within the proper
time.  This organ should not be overworked.   Noth-
ing contributes  more to strengthen it, than  to give 
45
it  as  little  to  perform as is consistent with  a due
supply of nourishment to the system,  and let it have
periods of entire rest.  Where the appetite has failed,
the patient is apt to imagine it to be absolutely necessa-
ry for him to eat  something, even if he does not relish
it.   This is a  mistake.   He  should not, till he has a
strong inclination.  Let  him  go without food  till  he
becomes hungry ; and this will unquestionably hap-
pen in a short time, if complete abstinence be adhered ,
to.    By constantly  throwing  in  food against  the
inclination, the appetite  is prevented  from returning,
as it would, if left entirely to itself.  I have previous-
ly described a  sensation of faintness &c. at the stom-
ach, which  is  mistaken for  hunger and relieved  by
food.   This is a deceptive feeling; for it comes  on
immediately after a  meal has  been digested, and
arises rather from the exhaustion of the stomach  by
the labour  it has gone  through.   It is  best relieved
by  some gentle  stimulant,  or light  tonic, such  as
Infusion of  Columbo, Cascarilla or Quassia.  When
the appetite remains good,  it is equally necessary,
though far more  difficult, to enforce strict abstinence;
the  desire  for food  being frequently voracious, and
seeming rather  to be increased than diminished  by
the disorder.
   It is extremely difficult to give any  directions with
regard to the quality of food, which shall be univer-
sally  applicable,  so different are the digestive powers
in different individuals.   Every one, with  sufficient
attention, may  become the best judge of that which
agrees best  with himself;  and this is  to be  done  by
a careful observation of the   effects produced during 
46
digestion by various articles of food, and the degree
to which  they are  digested.   If any  thing which
has been eaten is found  to pass off unchanged, it is
a proof that  the stomach cannot  digest  it, and it
should therefore  be avoided.  I am inclined to  be-
lieve, that  where there is danger that the digestive
disorder will  terminate  in an affection of  the lungs,
a simple vegetable  and  milk diet is best, with very
little variety.   There is one kind of food, which I par-
ticularly mention to be avoided, because of its frequen-
cy, its delicacy, and  the common  impression that it
is simple  and  not  injurious.   I  refer  to bread or
pastry in which flour is baked or fried with butter
or any  other oil.   This, whether in the shape of
pie or cake, is always, to the invalid, an indigestible
and  pernicious species of nourishment.
  Food should not  be thrown in at too short inter-
vals.  The  stomach ought not only entirely to finish
digesting one meal before another is eaten, but have
time to rest for a considerable period.  Three meals
each  day  are sufficient,  and  neither of them  late
in the evening.  They had better be at least six hours
apart, and  nothing  should be taken between them.
   The  second  object to be  attended to  is,  that
there should  be daily  a sufficient discharge from
the bowels.  This is  best effected  by the formation
of a habit of regular evacuation ; but in failure of this,
resort is to be had  to medicine.   It  makes no great
difference what article is used, if  the proper quantity
is taken, i. e.  enough to produce a discharge, but not
enough to bring on purging.  Two drams of a mixture
of one ounce of the Tinct. of Aloes and  Myrrh, with 
47
half a dram of powdered Jalap or Rhubarb, is an easy
and effectual  medicine and  does not interfere with
the patient's nourishment; this quantity, two  drams,
is to be  repeated once, twice, or thrice  every day,
according to circumstances.  But I  have been better
satisfied  with  the effect of pills made according *to
the following  formula, than any other  preparation.
&.  Pulv.  Aloes 5j. Pulv. Jalap,  et  Ipecacuanhie, ~i
3ss. Tart. Antimonii gr. xv. M.   This mass  I have
usually made into about an hundred and twenty pills,
varying their size, however, according to the habits of
the patient, and directing one or more to be taken with
every  meal.   In  a  majority of  cases, I  have found
this very  minute quantity of medicine  answer  the
intended  purpose better than  larger doses, and it
seems, when  thus taken with  the  food,  tp  act by
mingling with it, and imparting  to the feces a gently
stimulating power, which  ensures their  own  evacu-
ation.     But  the  patient  ought at  the  same  time
to  endeavour to form a habit of daily  evacuation,
which may prevent the necessity of medicine.
   The third  object  is to regulate the state  of the
liver and insure the  secretion of bile, both in  proper
quantity and of a proper quality.   The  state of the
liver is to be determined  by that of the feces.  Their
natural,  healthy colour is a dark, concentrated  brown,
or, as Mr. Abernethy describes it, a wet rhubarb
colour;  but  a derangement of the the liver, which
produces a diminution in quantity or an alteration
in  the quality  of this secretion, renders  them light
coloured,  black,  green,  clayey,  &c. according  to
circumstances.   The  appropriate  remedy  in any 
48
of these cases is mercury in small, alterative doses;
very  seldom carried so as to affect the mouth ;  and
by  far the  best  preparation  of mercury  for  this
purpose, is the Pilula Hydrargyri, or Blue pill.  This
preparation is  very uncertain in quality,  from the
different modes of preparing  it.   The London pill
has been  extolled as far superior  to that  prepared
in this country.    I have  carefully  examined the
imported and the domestic article, and have uniformly
found the latter, if made  by a careful  apothecary, as
good, and often better, than  the foreign as we have it.
  Mr. Abernethy recommends,  that  one   pill, con-
taining five grains of the mass, and  one of mercury,
should be taken every day or every other day, accor-
ding to circumstances, and continued till the difficulty
is removed.  If this do  not agree with the patient,
a corresponding dose of some other mercurial is to be
substituted.
  But besides  these organs, the immediate seats of
disorder, the rest of the system demands strict  atten-
tion.   The tendency of the complaint is, to paralyze
the nutritient actions of the  body  ; and our indication
is, to  counteract  this tendency by exciting those ac-
tions ;  and thus by creating a demand for  nourish-
ment,  stimulate  the  digestive organs  to  furnish  it.
A medical gentleman once  informed me, that while
afflicted by Dyspepsia, he had  occasion to lose blood
for some local inflammation.  The consequence was,
for a  few  days, an increase of appetite,  a  restored
power of digestion, and an  apparent amendment.
In this case the sudden loss of  blood  excited  in the
stomach an effort to repair the deficiency, and  hence 
49
the increased appetite &c. which ceased when this
object was effected.  It is in this way that travelling,
exercise of all kinds, friction and abstinence appear to
me to operate to amend this disorder ;  and by keep-
ing* up in this way a constant demand,  the organs  of
digestion  may be finally restored to  their original
powers.
   Exercise should  be  so regulated as not to interfere
with the process of digestion.  It ought  not  imme-
diately  to precede a  meal; there should  always be
time allowed, for the body  to become rested and the
increased rapidity of  the  circulation to subside be-
fore food is taken; and afterwards it should be delayed
till digestion is accomplished.  With these restrictions,
it had  better precede every meal,  or at least two
meals in the day.   It  ought not to be carried so far
as to induce fatigue, nor should  it be taken  in the
heat  of the  day during summer.   There are some
states of  the  complaint, when  exercise will  at  best
do no good; when the digestive organs require con-
siderable  preparation  from medicine  before they can
be benefited by it.
   It is  impossible  here to offer any thing more than
this very general sketch.   To  enter into  the  nume-
rous  details of the subject would  require a volume.
I  pass  therefore to a few observations  relative to
the particular measures which may be taken  to pre-
vent  or remove local  disease in  the lungs, whether
produced simply  by  the  exercise required  by the
duties of a clergyman, or  by the operation  of this
cause, combined with and  rendered more  certain  by
such  a  disorder of  the constitution,  as has  beeu
              7 
50
described.   The object is to  lessen the susceptibility
of these organs to  fatigue ;  in other words, to give
them strength.
  I  am convinced  that  the evil  against  which  we
wish  to guard,  arises rather  from the infrequeucy
and  inequality of  the exercise of  the lungs, than
from  its essential bad tendency.   I  have  previously
stated some reasons for  believing that these organs,
like  all others, are capable of being  influenced by
habit, and made able  to bear by exercise more exer-
tion ; and if clergymen could be induced to attend to
the formation of such a habit, that they would be no
more liable to  a pulmonary affection than other men.
It should be a first object with one who engages in the
clerical profession—especially  if  he  has any  of  the
marks of weak lungs, if he is hereditarily  or  consti-
tutionally  liable to pulmonary complaints,  if  he is
the subject of a disorder of  the  digestive organs or
has  a tendency to it—to accustom himself  gradually
to that kind of exertion which will be required by
the  duties of his future profession.    This is to  be
attempted  by  the  constant  daily practice of loud
speaking or reading.   This need  waste no time, and
may be made to  answer other  good  purposes.   It
will  be best to begin gradually, to continue the exer-
tion  for a short  time  at first, to stop  always before
it becomes fatiguing, but  to increase every day until
it equal that required for public worship.  If this kind
of exercise be persevered in, it seems  almost certain
that all, except those whose lungs are radically  infirm,
may acquire the habit of going through their profession-
al performances without  injury ; and as for those who 
51
fail, it is far better for them to know at once their
incapacity,  than  to  spend the best years of their
youth in qualifying themselves  for a profession which
they must finally relinquish.
  Bodily  exercise  of  any  kind, besides  its general
effect on  the system,  contributes  in particular i*»
strengthen the  lungs, by increasing  the circulation o?
blood through them and calling forth a more vigorous
performance of  their function.   Exercise of a violent
kind, in one unused to it, produces great efforts of
respiration—if carried to  excess, pain in the  breast,
shortness  and difficulty of breathing—and it might
sometimes  possibly  prove fatal.   But habit  soon
enables one to bear  the  same  degree  of exertion
without inconvenience; and  this  is to be attributed
in some measure to an increased power on the part
of the lungs, as well as in the muscular system.
  .Pain in  the  side  is a  common  symptom  among
students whose health is in any way disordered, but
is more particularly so in those inclined to pulmonary
disorder or  exercised  in public speaking.   Unaccom-
panied by  other  symptoms, it  is not alarming,  but
when occurring with them, it becomes important.   It
is frequently the  first  symptom which leads  to the
suspicion  that the  lungs are in danger.  The attention
of patients is  too  apt to be confined to this symptom
alone; they imagine  if they can remove this, there
is nothing to  apprehend.  It  ought undoubtedly to
receive attention,  but  not to the exclusion of other
symptoms,  for this may be removed, and yet others
of  more consequence, but less obvious, remain.  The
best remedy for the teasing habitual pain in the side 
52
to which so many are subject, I believe to be a plaster
spread  from Burgundy  Pitch, with  the  addition of
from two to four grains to the ounce of the Tartrite of
Antimony.
  It is  difficult  to determine how far it is proper for
the persons of whom I  have been speaking, to take
particular precautions against exposure to  weather.
1 suspect the error has been on the side of  too much
caution.  The question  is, whether; we shall always
be obliged to guard against taking  cold  from the
slightest alterations  of  temperature,  or enable our-
selves by habit  to meet  them without injury.  When
it is considered, that great care renders  the system
more susceptible, and that no care can prevent  occa-
sional accidental exposures, it seems  most adviseable
to adopt a course which shall render us able to resist
those causes,  to which  we are all of us sometimes
exposed, and which fall with  their  heaviest effects
upon  those  who are accustomed to shield themselves
from  their influence.   It  is  probably best to pay
little regard to weather in the  pursuit of occupation
or exercise; to avoid the extreme of caution on the
one hand  and of foolhardiness on  the other.   If we
keep  within doors  in  a snow  storm, whenever it
is possible, we  shall inevitably take cold  if we ever
happen to  be exposed ; and  this must be sometimes
the case with every man.   If we  always  protect our
lungs from the  air by  wearing some covering over
the mouth, we shall  suffer  should  this ever be omit-
ted ;  and  this must sometimes happen.  The injury
moreover in these  cases  will  fall  upon  enervated
organs, incapable of  resisting  the  attack, and of 
53
course more liable to be seriously  and permanently
affected.  Unless  then the precautionary  habit have
been long established, it is better to pay little  regard
to weather.    Exercise  should be  taken  as  before
described, without any reference  to  the state of  the
atmosphere, at all  seasons and under all circumstances.
The patient will  not take cold  more  frequently than
if he used all  the precautions  that prudence  or tim-
idity can  suggest;  and he will  on  the other hand
suffer  less from  the  complaint when it exists,  and
be  far  better  able to struggle  with it and throw it
out of his system. 
ON SUPPURATION.
  Suppuration is so important a part of the process
of Inflammation, and so intimately  connected with
its  other stages,  that  we  cannot enter upon the
consideration of the former, without embracing a view
of some of the general principles of the latter.   These,
it  is to be remarked, do not refer to  any particular
stage of the process, but to inflammation as a whole, as
consisting of a series of connected functions existing
for some  definite purpose; which  purpose is accom-
plished by different degrees, and  a different exercise
of the same powers, according to the nature  of the
purpose  and the powers of the  system and  of the
part.
   If we  would  attain  to a right understanding of
suppuration, we ought  to  understand  the  object
originally proposed  by  nature, in  the establishment
of such a function;  to what degree it is necessary, as
a general principle that it should take place in those
cases where there is an obvious tendency to produce
it; what is the state of  the parts which precedes it;
and  what the actions by which it is  accomplished.
These considerations embrace the  fundamental prin-
ciples of inflammation, and  those laws which regulate 
55
its progress from its mildest and simplest, to its most
severe and complicated forms.
  Supposing a  human body  in  a state of  the most
perfect health of which it is capable;  there seem  to
be  only two ways by which  we could imagine  that
disease should  be ever produced.  First, by a spon-
taneous imperfection in  the actions of some of its
organs,  which  deranges the natural  relations its
functions maintain with each other and  the reciprocal
influences  they exert.   Second,  by the operation  of
external causes  upon the different parts of the body;
which operation is of two kinds, and will produce dis-
ease in two different ways. 1. By an immediate primary
derangement, as is the case with all injuries, poisons,
indigestible  food,  &c. or 2.  by  exciting  trains  of
action in  the system, not essentially morbid, which
yet result, at a  greater or less distance of time, in the
establishment of disease.
   Disease is probably never established in the first
of  these  ways,  since  this  necessarily implies  an
original tendency in the system to its existence.  The
gradual decay  of the powers  and organs, in old age,
is the natural  provision  for the cessation of life, and
seems to be the only one had in view in the construc-
tion  of the system.   But this is something  very
different from an original  tendency to disease; this
would amount to a direct provision for the existence
of evil, of which I believe  there is  no  example in
the creation.   Considered abstractly, it is believed
that every  thing  in the human  body is  established
in the best possible manner  for its own well being,
 so far as  its own organs and powers are concerned. 
56
That if every natural appetite was naturally indulged,
the functions might be performed in the same degree
of perfection as at first, till exhausted by  old age,
were they not subject  to  the influence  of  external
causes.   It is  to  this influence,  combined  with the
unnatural  indulgence  of  our  appetites,  that we
are  to attribute our liability  to  disease :  and,  not
merely to these circumstances operating  upon  indi-
viduals, but to the influence  they have  exerted for
ages, upon  generation after generation, till the con-
stitution of  the species  has deteriorated  from its
original perfection,  so  that we  are now born with
a predisposition to  disease.  It is a consequence of
this, that we daily see individuals who come into
the world with such imperfections  of constitution,
or of particular parts, that  even when in  health, it
is obvious that  the regular series of  their  functions
will  finally  end in  the  establishment  of some fatal
malady.
  Considered merely in  relation to our  physical
constitutions, our habits of life in society are artificial
and  pernicious.    The temperature  in which we
live, our  food, our clothing,  our hours of  rest, our
exercise,  are all  unnatural.   As  we depart  from
civilized life, we find the quantity of disease  becoming
regularly less; the  savage  is free from  a  thousand
ailments under which we labour, and the  domestic
animals we  bring  up around us are  far more subject
to disease, than those of the same species  in a state
of nature.   Delicacy of  constitution, susceptibility
to disease, are the inheritance of eivilized society  ;
they are  the price we pay  for that refinement and 
57
elevation of  moral feeling,  that  enlargement  and
expansion  of the  mind, that  intellectual grandeur
which are only the rusults of social life.
   All disease,  then,  I  believe to  be introduced in
the  second of the ways before  mentioned,  Viz.  by
the  influence of external circumstances.  These, as
has been observed, produce their effects, 1. directly ;
2. indirectly;  and under their indirect  operation is
included that  deterioration from the original  perfec-
tion  of  the constitution of  the  species, and that
susceptibility to disease, of which I have just spoken.
   The powers exercised in the processes of  disease
are  the  same  as those which  maintain  the  system
in a state of health, diverted from their natural course
and  operation.   Every phenomenon may be  clearly
attributed  to the ordinary  vital laws, and there  is
in fact considerable resemblance between the pro-
cesses of,  disease  and  those  of  health, as  to the
general  plan on which they  proceed.   The  powers
of life have an instinctive  tendency  to  resist the
operation,  and  remove  the  effects of the operation,
of those  external agents which are disposed  to injure
the  organs, or  derange the functions.   This is a
general  principle  of action,  and  I believe  that all
disease,  except that which is produced by mechanical
injury, is  directly or  indirectly  the  result  of this
principle.
   To  judge of  the  original objects for which the
processes of disease are established, we are not alwavs
to look upon the effects which actually are, but  those
which there is a  tendency  to  produce.   It is a con-
sequence of the deteriorated state of constitution of
              8 
 which I  have spoken, that those  very efforts, whose
 original  tendency is  to  restore  the equilibrium of
 the system and amend  any local  derangement which
 may exist  after the  injurious operations  of an exter-
 nal cause  are turned aside from  the purposes they
 were intended to accomplish and end in the production
 of injury instead of benefit.
   I would start then  with this  principle, that all
 the actions of disease are, essentially and originally,
actions  instituted by  the system  with  the  intent
 of avoiding  or repairing injuries, either  from  the
 direct  or  indirect operation of external causes.   If
 we reflect  on  the   effects  produced  by  different
 agents, we find them to be such as serve  to resist
 injury, or to repair it if it has taken place.   Indiges-
 tible food  excites vomiting  and  diarrhea  for  its
 expulsion.    Poisons excite the  same actions  in a
more violent  degree ;  the secretion from the stomach
 and  bowels  is  more  copious,  and  inflammation is
produced,  which is   an attempt,  and  often, where
 the poison is not of a powerful  kind,  a successful
 attempt, to resist the progress of  the evil and  check
 any farther operation on the system.  To  the  same
 purpose, is the obvious tendency which the  processes
 of inflammation,  excited  by a  local injury, have to
 restore the  part affected to its original  integrity, or
 to such a degree  of  soundness as  the nature of  the
injury  allows.   The  degree of inflammation,  also,
 is adapted to the degree of injury; and it stops at
 that stage in  which its  object has been   properly
 accomplished.   If adhesion alone  is necessary, as
 in a recent wound, the adhesive inflammation alone 
59
takes place.   If suppuration be required, it ensues.
If the part be too much injured to be restored in
either of these ways, it is separated by  mortification,
and  its place supplied in the  best manner of which
the system is capable.
   Our reasonings with respect to inflammation, as
a primary affection intended for the repair of injuries,
must be principally  drawn from what we  see -in
external  parts,  where we  know  that it effects this
purpose.   Yet we  have a fair reason from analogy
to  judge—since  the processes in  spontaneous and
accidental inflammations are generally alike in symp-
tom, in  appearance, in  the organic changes taking
place, and in the  stages  through which they pass—
that  the  objects for which they are  instituted  are
also alike. " Suppuration being in cases of violence,"
says Mr. Hunter,  " a means  of restoration, affords
a presumption that it is a  like  instrument of nature in
spontaneous cases ;" " in  these it is almost impossible
to determine 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  process  of  nature
 to restore parts, whose functions, and perhaps texture
 has been destroyed by some previous and almost im-
 perceptible disease or cause.   If it  is the first, viz. a
 real disease, then two causes that are different in them-
 selves, can produce one effect or one mode of action,
 for the result of both is the same; but if it be the last,
 then suppuration  must be considered as depending
 on  exactly  the  same stimulus  being  given as in the
 above mentioned case of violence." 
60
  It is sufficiently evident that Mr. Hunter was of
opinion that inflammation was  originally a  salutary
process.   Yet I  should by no means contend, that it
actually is,  in all cases,  a salutary process.   The
natural operations intended for good purposes  have
been  modified and directed, by that infinite variety
of external circumstances which have been influencing
the  human  system  ever  since  its  creation.   The
consequence is, that  a thousand  processes take  place
without any object; or which fail  in attaining it, if
they  have  one, from a defect  or misdirection of  the
powers in operation, though we  can still  perceive,
that even in  these  cases, the actions are conducted
on the same general plan, as those which are really
prpductive of benefit; that their tendency is to  good,
though, from the circumstances of the case, good can-
not result.
  Having premised these remarks upon  the general
principles of action  in the system  from which disease
takes its origin, I proceed to treat  more  particularly
of inflammation  and especially of  that  part which
is connected with suppuration.   It is no part of my
plan to  describe, except  incidentally, the symptoms
or  causes of inflammation ; but, by an investigation
of the  general  nature and  objects of this  process,
and of the purposes  for which it is  varied  in its
different stages, to arrive at such views of the nature
and objects of suppuration in particular,  as will lead
us to the  most judicious and  philosophical principles
of treatment.
   Where the suppurative inflammation  follows  the
adhesive,  as  it does  in the  cellular  and serous 
61
membranes, the former cannot be  well  understood,
without a thorough  knowledge of the latter.  Indeed
the most common opinion among  mere practical  men
has probably  been,  that the  adhesive inflammation
is only a measure of preparation for the suppurative,
and  not sufficient of itself for the accomplishment
of any necessary purpose in the  system.  Inflamma-
tion  without suppuration,  they consider as only a
half  completed process, cut short in its progress by
a defect of the exertions of nature  or  by the success
of those of art.  That many cases of inflammation
have  a tendency in  the  first instance  to  go on  to
suppuration cannot be doubted ;  and in such cases
if art prevent this result, as it often does, the object
of the inflammation, whatever it was, remains unac-
complished.    Every  practitioner  must  have  seen
cases, in which inflammation  has begun in a part,
has  been  checked  and apparently  subdued;  has
notwithstanding returned once  or  twice more, and
been  as often resolved;  and nothing  has seemed
sufficient to relieve the morbid state cf the  part and
restore it to a quiet state, till an abscess has formed
and discharged.  The reason  of such a disposition we
may imagine to be this ; that a degree of imperfection
exists in the seat of the disease, which can only  be
remedied by such a change in the part as is produced
by the process of  suppuration ;  and,  that although
art can combat the steps taken to effect this purpose,
and  prevent the vessels concerned from going through
with  their  course  of action, yet  it  cannot remove
the  original imperfection.    This  continues to act
as a stimulus  to  inflammation, and finally brings  on 
62
a degree  of  it, which cannot be  allayed.  This ap-
pears to  me particularly  t9  be  the  case  with the
female breast.
  Yet this necessity of suppuration in some instances
does not  invalidate the opinion, that  adhesion alone
is  often fully sufficient for the  purpose of  repairing
the imperfection  for which  the  inflammation  was
produced.   If this  were not so, we ought in healthy
subjects to have no spontaneous resolutions, and our
artificial resolutions  ought to be  less perfect than
they are.    Adhesion is  sufficient  for  the cure  of
wounds and many external injuries ;  it  seems to  be
so also  in some internal  inflammations, particularly
of the pleura.   I  think  we are justified in  saying,
that under different circumstances the vessels of any
part take  on  themselves different degrees  of  the
restorative efforts,  proportioned to  the  necessity  of
the case, from  the slightest  blush produced  by a
gentle  stimulus  or  by simple friction,  to  the most
severe  and  aggravated   degrees  of  inflammatory
action.  And it will  be worth while briefly to trace
out in  order,  those processes established by the
system for the repair of injuries,  arranged  according
to the degree in which they depart from the ordinary
healthy functions of the same  parts.
  When  any organ, especially one of  a  muscular
structure, has been  excited to  extraordinary exertion,
whether  in  its usual or  in an  unusual  manner,  we
observe, after the exertion has ceased and the parts
have been for some  time in a  state of rest,  that they
arc affected by a degree  of soreness, varying  accor-
ding to the  violence of  the  preceding  excitement. 
63
This soreness, in some cases, shows  itself only when
an attempt  is made  to move the part, or when pres-
sure is applied to it.    In  others, there is  pain, or
at  least a  sensation of  uneasiness, even  during a
st itc of perfect  rest.   This soreness  we do not call
inflammation, and yet there seem to be good grounds
for considering it as only a less degree of the same
kind of action  in  the  small  vessels, as that  which
constitutes  inflammation.   Soreness, on pressure or
motion, is one of the  signs  of inflammation; and,
taking any  particular organ  as an example,  which
has  been exposed  to  unusual  action,  we can trace
out  all grades  of  this  symptom from  the  slightest
tenderness,  to the  most  exquisite  sensibility caused
by an acute inflammation.  The consequences which
follow  an  attack  of colic, in  different degrees of
severity,  illustrate  extremely well   the  gradual
blending of this  simple sensation with  that which is
produced  by inflammation.   The slightest form of
this  disease, or  even that action produced by the
operation of a very powerful cathartic, usually leaves
behind it a sensible tenderness;  in the severer grades,
this  becomes more and more remarkable, till in its
most violent and  long continued attacks, it terminatesr
in genuine  peritonitis.    The  same is true of the
uterus, after parturition, or when it  acts spasmod-
ically  in  dysmenorrhea,  or  from  any  other  cause.
Every  practitioner, in  the habit  of  observing  the
nice shades of difference in symptoms and in diseases,
must have  met  with cases where  the soreness, con-
sequent on  these affections, was so  great, as to lead
him to doubt whether  peritoneal or uterine inflam- 
64
mation was not coming  on, and  to  hesitate whether
he ought  not to adopt  the necessary  measures for
their  removal.   Now this approximation of cases
appears  to me to indicate  a  resemblance  in  the
functions  going on  in  the small  vessels  at  these
different times, or at least  in  the ultimate  objects
they  are  intended to  attain;   and to  prove that
the soreness is the consequence of an increased action
in these vessels,  by which they  are  making  up for
the wear  of  the  part  occasioned  by  the unusual
exercise  to which it  has been subjected.   Thus,
after any  extraordinary  exertion in running, walking
or jumping,  or  after  epileptic convulsions   or  an
attack of  spasm,  the muscles  called  into exercise
are for a few days tender and sore, and the sensation
is not very different from that  produced  in the same
parts by a slight rheumatic affection, or some external
injury;  in which  last  cases we cannot doubt that
a degree of inflammation exists.
  Next to  these,  which I  should consider  as the
most  simple cases of the exercise of the functions
of restoration, we  may  reckon the  slighter injuries,
which seem scarcely to excite the full adhesive inflam-
mation, and  yet are followed by an action approach-
ing to it,  before  the parts  concerned  are restored
to their former  state.   A  higher degree of injury
requires a higher degree of  inflammation, the adhe-
sive  is  established  and apparently  without  any
tendency   to  suppuration;  a  still  higher   degree
requires  and  excites  suppuration,  and,  one step
farther, if the texture  of the part be destroyed,  or
its vital  connexions cut off, the  proper action takes 
65
place and it is separated  from the system.  We set
in these cases of external injury particularly, because
in them  the processes are so entirely laid open to
our view, the admirable economy with which nature
husbands her resources ; doing no more  in any case,
than  is absolutely  necessary, but always  doing the
most that is possible, where the health of the subject
admits.  We cannot, in internal inflammations, trace
these things so distinctly, because the parts are hidden
from  our view, and because  they are not probably
so regularly, perfectly, and economically carried on,
since in the latter cases the constitution  is more
oppressed by the disease and cannot exert its energies
with the same effect.
  According to this view of the nature and general
objects of. inflammation,  we  are to  presume that
these  inflammations  are  intended   to  remedy  an
imperfection in the powers, or function of  some part,
or of the constitution, which  has  been produced by
the  remote  or  exciting  cause of the 'disease.   In
many cases where these causes are  known and their
modus operandi is capable of investigation, we can
trace  the course which is taken, and  attain to some
notion  of  the  state  of  imperfection, or defect in
structure, power, or function, which  precedes inflam-
mation, and  in fact affords the reason why inflamma-
tion  takes  place.   Thus a  severe  blow upon the
head  produces  an immediate and  powerful  effect
upon the functions, if  not upon the  structure of the
brain;  this effect  is not  inflammation, it  is the
fore-runner of inflammation;  it is a state of the organ
which cannot remain consistently with the  harmonious
              9 
(^
operations of the whole system, and a process is set up
to restore it from this state, and the principle on which
it is done  is  the  same, whether successful  or  not.
The same  is  true  of  injuries in other  parts; it  is
true of acrimonious gases  taken  into the  lungs, and
of poisons acting upon the stomach.   Now we may
reason from  analogy,  and  apply the knowledge we
acquire from these cases to the explanation of  others,
where the operations of nature are more inscrutable.
We may  conceive that  the causes of disease produce
an alteration  in the vital state and vital  relations  of
the organ  affected, which is inconsistent with  its
health, and that inflammation removes or is intended
to remove this state and restore the healthy relations.
  It is obvious to inquire, if  these remarks are well
founded,  whence it happens,  that we daily see, even
in the most healthy individuals, inflammations arising
which can have  no beneficial  tendency,  but must
inevitably result in the injury or destruction  of the
part or of the system.   In such cases, disease seems
to exist  for its own sake, and is situated in organs
and carried  on in a  manner which  precludes the
possibility of a favourable  termination.   These cases
may partly be accounted  for  upon  the principle,
that there is  in  the system  an  acquired tendency
to disease in general, if not to any particular disease.
This  is  applicable to those instances  where  the
inflammation  answers   no   good  purpose, although
there is no  essential   impossibility  that  it  should.
But there are others to which it will not ^pply.   As
examples, we  may adduce the  formation of  pus  in
the brain, of which the result is almost  necessarily 
67
Catal, although it may be  the regular consequence
of healthy  inflammation;   the destruction of vision,
which must  inevitably follow  a suppuration in the
ball  of the eye;  the  injury to the same organ  occa-
sioned by any degree  of the adhesive inflammation,
as in iritis, or of the effusion of coagulable lymph,
as in a speck upon the cornea ;  and the impediment
to the   functions of  the   heart occasioned  by  the
slightest  depositions about  that organ.  To account
for  cases of  this kind, we  are  to consider that the
processes of inflammation  are conducted throughout
the  system upon general  laws, that they are essen-
tially the same  in  all parts,  are adapted  by  slight
modifications to  the varieties of structure, but not to
the  varieties of function, to the performance of  which
those structures, differently combined in  the  com-
position  of different organs, are subservient.   The
tendency of these laws is  upon the whole to  produce
good; yet  their operation being universal, evil in
particular  instances will  be sometimes  their  effect.
 We readily  find among  the  phenomena of disease
 numerous instances directly illustrative of the opera-
 tion of these general laws.   The  adhesive inflam-
 mation  proceeds, on exactly  the  same principle in
 the iris and in  the serous membrane of the  testis,
 yet in  the former  case  the consequence is a great
 imperfection or  destruction of vision, whilst  in the
 latter no sensible defect remains after the inflammation
 has subsided.   Still  the  process itself is as  perfect
 in  the  one case as in the other, and the difference
 of  injury  does   not proceed  from  the difference of
 structure,  but   of  function.   The   deposition of 
68
 coagulable lymph  in the common cellular membrane,
 is a circumstance of trifling  importance; let  it take
 place between the laminae of the cornea of the eye,
 or upon one of the valves of the heart, and it produces
 the most  serious  injury to  the  functions of  either
 or^an.  The inflammation taking  place around what
 we  call  the core  of a bile is simply  painful  and
inconvenient,  but  around  a tubercle in the  lungs.,
it gives  rise to a  most dangerous  affection.  It  is
needless  to multiply illustrations  of this kind.    It
is to  be  explained  on the same  general principle,
that pain, which  is intended to warn  us of  danger
 and  direct  us where  that  danger  lies, is  often  a
much greater evil  than any which could  result from
the disease.   The  pain of  a decayed  tooth  is  fre-
quently as severe  and difficult to bear, as that  of
the most  severe diseases, yet in this case, it is simply
 an evil, without any tendency to good.
  Our first  reflections, it  appears to  me, in entering
upon  the  management of any case  of  inflammation,
should be directed to determine from what cause  and
for  what purpose,  if any, it has taken place ; how
 ar it is necessary  from the  nature of the cause &c.
 that the  inflammation  should proceed, and  what in-
jury or benefit may arise from arresting its progress
by the use of those  remedies which exercise a controul
 over it.
  From the operation of those general laws of action,
 of which  we have taken notice, inflammation  will
 take  place  in consequence of the imperfection of a
 part,  wherever it  exists, whatever be its cause,  and
 whether  it  be possible that it should  be remedied, 
69
or not.  Thus  in the  lungs, there  is often a predis-
position to  inflammation, arising from a natural or
acquired weakness, or from the presence and irrita-
tion of tubercles.   A slight cause will bring  this
predisposition into action, and inflammation becomes
established without the slightest prospect of ultimate
advantage.   In such  cases, there  can be no doubt,
that we  ought  to check the inflammation,  since  it
can do no good and may induce a fatal termination.
The best we can hope is to render the organ quiet
under  its imperfection;  and this  we are to do by
counteracting the causes which  make  the part sensi-
ble of  its defect, if I may so speak, and by abstract-
ing those  powers which support it in a state  of in-
flammation.
   When any of the internal viscera become inflamed
from taking cold, or without any determinate  cause,
it seems to me most probable, that this is a mode in
which  the constitution relieves  itself  of some  dispo-
sition not consistent  with its healthy functions.   The
remote cause appears, originally,  to have its opera-
ration  upon the vital machine as a  whole, rather  than
upon any particular  organ, and the system relieves
itself by concentrating the affection in a particular
part.   Perhaps the  reason why  vigorous  medical
interference  in these  cases  seems  so  entirely to re-
move  the  inflammation  and its immediate cause  is,
that the remedies are  capable of answering the same
good purpose to the constitution with the local inflam-
mation, and with much less danger  of  the lesion of an
important organ.  This suggests an important ques-
tion in all cases of  disease, which we believe to be 
70
of constitutional origin, or to be  produced  for con-
stitutional relief; whether we cannot substitute ope-
rations for those of nature, which shall answer equally
well for the necessities of the system, and divert the
diseased actions from an important organ.
  Inflammation  has frequently a tendency to proceed
greater lengths than the part affected can bear with-
out permanent  injury ; as in  the eyes, brjin,  lungs,
&c.   The  degree of this tendency is  important to
be taken into consideration, in making up our  minds
as to the general plan of treatment to be pursued in
any particular  case.   We  should adopt  the most
vigorous measures to prevent suppuration in  a degree
of inflammation of the lungs,  which we should suffer
to go unchecked in the external  cellular membrane.
   It  seems doubtful whether we are in the habit of
paying sufficient attention to considerations of this
kind in the treatment of  inflammation.   We are apt,
in every case, without much discrimination of causes,
classes, or kinds, to push at  once  our most  powerful
remedies, with the view to cut it short as speedily and
thoroughly as  possible.   Yet perhaps in many cases,
parts would more perfectly recover  from the effects
of external injuries, if their operations were left  a
little more in  the hands of nature; care being taken
to check or regulate any excesses  or irregularities of
 action.  In severe inflammations of important organs,
where  the probable termination  would  be death or
 permanent injury,  there can be  no  question about
 the propriety of our usual method of procedure, since
 the consequences of not permitting the inflammation
 to go thrpugh  its intended processes, whatever they 
71
may be, cannot  be worse  than those we  have to fear
from the inflammation itself.
  But where no very important  organ is concerned,
it should be considered at the commencement of the
disease, what processes it is necessary the part should
go through before it is completely  restored, or restored
as  far as  is possible.  In  illustrating this point, we
must take external injuries principally as our exam-
ples, since we  are not  sufficiently  familiar with the
causes  and  course of  spontaneous  inflammations.
Many  injuries require the  adhesive  inflammation
alone in its most simple form ; others run on  to sup-
puration,  and form either an abscess, or a suppurating
surface, in order that some portion of the organ may
be  renewed, or new modelled by granulation.  Wounds
simple, or complicated with other injuries, may some*
times  be  healed by the  first intention, sometimes by s.
the adhesive inflammation, and sometimes suppuration,
or  even a degree of sloughing,  is necessary.  Now
it is extremely desirable in the first instance to know,
how far it will  probably be necessary that the inflam-
mation should extend, that we may be able to  prevent
any higher degree  from  coming on.  This  we can
do in many cases;  and this  circumstance is always
to  be considered, that  the  state  of  health in most
constitutions is such, as to  produce a tendency  to
inflammation  disproportioned  to its  cause.    Could
we examine the  intimate operations of the system
in  the various cases of  inflammation, we should, I
believe, find in most of them, Uat a higher degree
 of this kind  of action existed,  than was  necessary;
 and that  there is  a general propriety in the  practice 
72
of physicians, who  are in the habit of endeavouring
to alleviate inflammation, from whatever cause it  has
proceeded.   So imperfect are we  in our knowledge
of what the system requires  and purposes in  the
great efforts which it sometimes makes,  that it is
commonly, in important  cases,  safest  to take  the
business out of  the hands of nature at the risk of
leaving her intentions unfulfilled, and  a  liability to
the return of the inflammation as soon as the influence
of our remedies has subsided.
   It is  true  however in  some constitutions, and in
some parts, that we find a  deficiency  of power of
action.   An organ will remain a long time in a state
of sub-acute inflammation, which cannot be resolved,
but does not readily suppurate, or if it does, suppu
rates in an irregular and  imperfect manner.  There
are in some individuals peculiar or specific disposi-
tions with regard to inflammation.  It is particularly
exemplified  in  scrofulous  subjects, in those afflicted
with  the  fungus  nematodes  or the fungoid inflam-
mation, and in the  cancerous.   The processes  in all
these cases  are formed  on  the  same general plan
and  carried  on  by  the same powers with ordinary
healthy inflammation.   But the powers  are either
deficient or depraved.  Thus a blow upon the female
breast will  produce a series of  actions, terminating
in scirrhus and  cancer, which appear  to  me to be
unsuccessful efforts at the adhesive and suppurative
stages of inflammation.
   It  has  been often and very justly  observed  by
pathologists that there  is considerable analogy  be-
tween the functions of nutrition and of inflammation. 
73
They are carried on  by the  same vessels supported
by  the  same  materials and the same  powers.   In
those constitutions where nutrition  is most vigorously
performed,  there also inflammation is  established
with more energy and its processes carried through
with more rapidity  and  in greater  perfection.   At
the  commencement  of inflammation, the capillaries
of the part convey more blood than when exercised
for nutrition ;  new vessels are  formed, or blood passes
into an immense number which did not previously
transmit it.   This indicates an increase of vital action
in the part  and an  increased expenditure of vital
power.   To support this action, requires an increased
quantity of blood, and the consequence is an increas-
ed  diameter  and capacity for transmission in  the
arteries  going to the  seat  of disease, and  this same
effect, but more permanent in its nature, is observed
whenever there is an  unnatural growth of  any organ
Qf the body.   T^Jiis I conceive is the first and most
simple  state of the  inflammatory  process,  before
adhesion commences in the cellular and serous mem-
branes,  or suppuration  in the mucous;  it  is  the
state of preparation,  in which the vessels  are rally-
ing their powers and getting ready for  more decisive
operations.  After this has  continued a length of time,
varying according to circumstances, the  vessels take
up a new function,  they  enter upon  the  adhesive
stage, and pour out coagulable  lymph.   This is
either sufficient in  itself for  the  restoration of  the
part, supposing  that  to be the object in  view, and
relieves the vessels from their state of extreme action,
or it paves the  way  for the next  or the suppurative
               10 
71
stage.   In this stage a new function is taken up ;  pus,
a secreted fluid,  is poured out within the  limits of
the adhesive inflammation, an  abscess is formed, the
matter discharged, the cavity filled up by granulations,
and healed.
  If this  slight sketch of what takes place in  the
successive stages of  inflammation be  correct,  it is
easy to attribute the whole to a progressive alteration
in the mode  of action of the same vessels  which first
commenced  the process, supported  by an  increased
expenditure of power.  In  the first place, they sim-
ply convey  more blood than  usual, or  blood  when
they previously  transmitted  a colourless  fluid;  in
the second, their action is modified ;  they extravasate
not the whole of the blood, but one of its constituents ;
and in  the  third  they form, from the blood, a new
and  homogeneous  fluid.    What  are the  intimate
actions of the vessels in  granulation, the next  step
towards restoration is yet doubtful. ^A modern patho-
logist*  has  endeavoured to show that granulations
are produced  by  coagulated  pus, which  becomes
vascular by  the  rising of carbonic acid  gas, formed
at the moment of coagulation, through  it, and pro-
ducing tubuli into which the blood rises and from them
forms circulating vessels.   But  so  mechanical  and,
if I may so  speak, unphysiological a mode of account-
ing for a process in the animal  economy ought to
have stronger proofs than can be derived from  mi-
croscopic  observations, before it  can  be  allowed to
pass current as philosophy.
  *Vide the Croonian Lecture in the Phil. Trans, for 1819, by
Sir Everard Home. 
75
   Suppuration  would  seem  then to be  only  the
result of a modified and  in most  cases an increased
action also, of the same vessels which are concerned
in the adhesive  inflammation.  It is  certainly true
in the majority of instances, that the more violent
the first actions  of inflammation, the  more  likely
is suppuration to ensue,  and we generally  form our
judgment of the probability of a resolution or termi-
nation in adhesion, by  the less or greater violence
of the symptoms.  But on the other hand we  fre-.
quently find  the most  violent inflammation existing
without any apparent  tendency to suppuration, and
suppuration  taking place unexpectedly  when  the
mildness of the  symptoms would have led us to pre-
dict resolution.
   Taking it for granted that the  adhesive  and sup-
purative inflammations are only  modified  affections
of  the  same  vessels,  the difference  between  them
would amount to this;  that  in the former they pour
out lymph, a fluid capable of coagulating  spontane-
ously, and with  a tendency to become organized after
coagulation ;  and that in the latter they pour out pus,
a fluid  incapable of   coagulating spontaneously or
of becoming  organized.   This view  of the subject
suggests an explanation of those different phenomena
of these  two stages of  inflammation,  which  might
perhaps appear to indicate  a  greater  difference in
the actions of the vessels than I have attributed to
them.  It is  to be considered, that when the  lymph
is poured out, it immediately coagulates, and becoming
organized excites no  irritation  for  its expulsion;
whilst pus acts as a foreign body, so  soon as it  is 
                        76 t
formed, and  its quantity continuing  to  increase, it
is necessary that room should be made ; this is effect-
ed by  the absorbents and an abscess is thus formed.
The  adhesive and suppurative processes, appear*to
be sometimes  mingled  on the suppurating surface,
and not merely to exist in different parts of the same
organ,  since we observe in the  discharge  of  matter
from abscesses, shreds of lymph which has coagulated,
but could not, from the  stage of the inflammation,
become organized ;  this would  seem to imply  that
although the  formation of pus had  commenced, yet
the change of function  had not extended  to all  the
vessels concerned in the disease, but  that  some con-
tinued  to pour out lymph, whilst those in  their neigh-
bourhood had taken up the suppurative action.   The
rationale of these two  processes of inflammation is
perhaps this; that  being both intended in different
ways  to answer  similar  purposes, one  strengthens
the imperfect or injured organ, by pouring out coag-
ulable  lymph,  as  in the thickening of  many parts
which  do not suppurate; and the other  removes the
spot on which the  imperfection  exists, by means of
an abscess;  for  although I do not mean to imply
the dissolution of the  soft  parts in  the  formation of
pus, yet I believe them to be absorbed, so as to make
way for the abscess, and then  filled up with new mat-
ter by  granulation.
   Suppuration does not require a definite degree of
action,  nor a specific state of the powers of the part,
to carry it on.  It appears to be a relative process,
and  to be the result of a greater or less degree of
inflammation,  according to  circumstances  which we 
77
do not generally understand.  Mr. Hunter observes,
that the inflammation preceding suppuration where
it arises spontaneously, is often more violent than that
which precedes it when arising from an injury, where,
notwithstanding, the quantity of suppuration is equal.
The injuries,  however, to which Mr. Hunter refers
in this remark, were probably those where an exter-
nal opening or a breach of surface was produced, in
which eases suppuration  seems to go on in a manner
similar to that  which  it pursues on  a mucous  mem-
brane.  Another reason  why a spontaneous inflam-
mation  might call  forth  a greater relative quantity
of  inflammation  before  suppuration,  may be, that
where the  former arises, there  is  some  previous
defect in the constitution or part which produces an
imperfect degree of restorative power, and in conse-
quence many  imperfect  and  useless  efforts  when
inflammation occurs.
   Under circumstances apparently similar, there is
a vast difference in the apparent degree of inflamma-
tion necessary for  a  part to suppurate in a  healthy
manner.   We  find in  one  case  every  symptom in
its severest form ;  the heat, tension,  and pain almost
intolerable and  so  violent as even to threaten morti-
fication ; to all  which an abscess affords speedy  and
complete relief.   We find  in another,  when  the
symptoms  have been unusually mild  and  indeed al-
most ambiguous, that suppuration will  have  taken
place before we are aware of it.  There are no cer-
tain rules  by which we can judge of the probability
of suppuration, since it does not  depend on  the  vio-
lence of the inflammation.  Personal experience will 
?8
undoubtedly  do much  to  form a habit of accurate
judgment, and a power of foreseeing the natural event
of a case, yet this  is  a kind of practical tact which
it is as difficult to describe as to acquire.
  It has  occurred  to  me that there was  frequently
more inflammation  than the process of suppuration
required ; that is,  from certain causes  there was a
superfluous exertion on the part of the vessels, which
merely exhausted the  powers of the system, without
contributing  to the process going  forward.    This
opinion has been  suggested by  the  result of a few
cases, in which by  the use of active measures with
the  view of producing resolution,  such as leeches,
blistering, and purging, the  sensible  symptoms  of
inflammation were  very  much  reduced, and  yet an
abscess unexpectedly developed  itself,  full as  early
if not earlier  than  I should have looked for it, had
the part been  suffered to take its  chance with  the
disease.
   Although a violent and rapid inflammation is most
likely  to terminate in  suppuration, yet  this does  not
alone  furnish  us  with  a  general  rule for judging
It must  depend on some relation between the action
of the vessels, the previous cause of the inflammation,
and the  state  of the part,  which we do not entirely
understand.  Our principal object, then, in the treat-
ment of an inflammation  which we wish to have sup-
 purate, should  be to maintain  this relation, so  far as
we do understand it.  It may be sometimes necessary
to do it by increasing, and sometimes  by lessening
the degree of inflammation according to our judgment
of  what the case requires,  and so keeping it at  the 
79
suppurating point.  These remarks are confirmed by
the fact, that some of our best applications for pro-
moting  suppuration seem often  to  act  as powerful
resolvents.  Thus we sometimes apply to an inflamed
part substances, whose  ordinary effect is to promote
resolution, without any such effect, the inflammation
continuing to advance.   If then we  apply poultices
with the view  of  bringing on  suppuration, the part
begins soon to grow better, and finally gets well with-
out forming pus.
   Suppuration being the result of the natural actions
of the vessels,  it is obvious that we can only promote
it by promoting those natural  actions.  There is no
ground for interference, except to enable  the vessels
by our assistance  to act  to the best  possible  advan-
tage, and to do this by removing every impediment
which might prevent it, whether from within, or from
without.  It is an object, when parts suppurate, that
they should do it  in  a healthy manner, so that the
subsequent actions of restoration may have a good
foundation.  It is important that they should do  it
as speedily as is  consistent with their doing it well;
and in general the most  rapid suppurations  are the
most healthy.  It is also of consequence that it should
take place with as little pain, irritation, and  expense
to the consfftution as is possible.
   Suppuration is sometimes  prevented from  taking
place, where a tendency to it has appeared, and it
would be a  desirable  circumstance,  by an apparent
indolence of the part which  has advanced somewhat
in the inflammation, but  shows no disposition to  go
farther, and on the other hand  has  no  tendency  to 
80
go  back.   There are other cases in  which the part
does  not  take  the regular and direct path to sup-
puration.   In  some, this appears to  arise  from the
erisipelatous  inflammation, uniting  with the heal-
thy and causing an irregularity and  imperfection in
its processes.   The presence of a scrofulous diathesis
has also a strong tendency  to produce effects equally
bad.  In these  cases the difficulty proceeds  probably
from a constitutional  cause, and we  perceive  it not
merely  in instances where the inflammation  is spon-
taneous, but in  those the result of blows, wounds, &c.
A wound, which is doing  well  and rapidly healing
with  healthy  granulations  and pus,  may  suddenly
change  its whole  character and   appearance;  the
granulations be absorbed or grow pale,  the  pus alter
its qualities, &c.   Now this, I conceive, must  for the
most part arise from  a cause which affects  the gen-
eral powers of the  constitution, and not this particular
part,  and  the other irregularities  before  ailuded to,
are probably produced  in the same way.  The stom-
ach, or rather the  digestive system in general, is the
most  likely to  lie at  the root of any such imperfec-
tion.  It is more  closely connected  in its  functions
and sympathies with the  extreme nutritive  vessels
than any other.  It would seem as if the stomach  had
the controul and direction of their functions by means
of its vital influence and support; as  if it not merely
supported  their actions with the necessary supply of
materials, but  as if it held  the reins  by which their
motions were  governed, and  impressed  upon them
every change by  which it was itself affected.  The
stomach cannot be deranged  but every organ  in the 
81
body  feels the want of that countenance and  support
it was wont to receive.  The skin is affected by chills
or by sweats, the  muscles are relaxed  and  languid,
the head dizzy and pained, or the respiration shorter
and  unequal; all  these, which  sometimes occur, are
to be attributed to the sympathy of the extreme ves-
sels with the stomach.  This leads us to look to that
organ for  the cause of  those  irregularities of the
same vessels, which have been alluded to, as taking
place in inflammation ; and we find in fact, that there
is in these cases a derangement of the digestive sys-
tem, either from  oppression, exhaustion, or debility,
and  that  a removal of this derangement restores the
right method of action.
   It is not my intention to enter into a detailed con-
sideration of the method of treatment in these cases ;
our object  ought  to be to enable the part to pursue
the  natural  bent  of its own actions;  and  to do  this
it requires a supply of the same powers and materials
necessary  to  health.   It is  therefore  important to
restore them both.    To  do  this  we must  put the
digestive system into good order and the part inflam-
ed will then  act  to  advantage.   It is obvious, that
in this way an attention to the state of the digestive
organs  may  be the  most  efficacious  means  in  our
power to  promote suppuration, as well as to bring
about resolution ; for where  this  termination is de-
sirable and indeed almost  necessary to the part, the
derangement  of the digestive  system may  be the
cause which  prevents its occurrence,  and therefore
the  removal of this  derangement  will be the  most
effectual measure  by which to promote it.
              11 
82
  Suppuration, as I  have before suggested, is some-
times prevented from  taking place by an excess of
inflammatory action; or  rather perhaps  by a strong
disposition  in  the part  to  continue  that stage of
inflammation, that kind of action of the vessels, which
precedes suppuration,  and  to change  from it slowly
and  reluctantly.   This may  be either «a local effect
merely, or it  may proceed  from  an  excessive con-
stitutional sympathy, which reacts on the local disease
and aggravates its violence, but directs its exertions
towards a wrong object.   We are to  be directed in
this  case, when we would wish to  bring  about sup-
puration,  by the circumstances we observe.  We are
to attempt  the  alleviation of the  inflammation, but
not its  removal.   We must reduce it down to the
suppurating  point, but not  below it,  by  the consti-
tutional remedies  of bleeding, purging, diaphoresis,
and the production of  nausea, as we find them neces-
sary, and by the local  applications of leeches, poulti-
ces, fomentations,  &c.
  There is  probably no organ, whose inflammation,
when once fixed, goes  on with so much  certainty to
suppuration, as  the  female  breast.  It is rare, when
any  considerable  portion of it has become affected,
for resolution to be procured; and it  often happens,
when we  have been  flattered by an apparent success
in our  endeavours to effect  it, that a sudden change
takes place, and the part goes on inevitably  to form
an abscess.   Yet  it  is extremely  desirable in these
cases,  on every  account, to cut short the inflamma-
tion ; and if this cannot be done, at least  to have the
suppuration take  place  with as little suffering and 
                        83
expense to the general health as is possible.   It is too
common, however, for a female breast to be exceed-
ingly painful  for some  length of time before an ab-
scess is formed, and  to go on  with the  formation of
matter in a very slow and tedious manner.   This in
part no doubt is to be attributed to the peculiar struc-
ture of the organ, its functions and  relations ;  to  the
same causes indeed from which it derives its great sus-
ceptibility to the cancerous inflammation ; but, in part
also, it may be ascribed to something in the processes
of the inflammmation itself, which render  it slow in
passing   from  one stage  to another, although  the
vessels themselves seem  to act with a good  deal of
power.   I state this  opinion with  diffidence, because
I feel how liable I am, from  the  narrow range of my
experience, to have  formed  a partial  view of this
subject.   It  has appeared to  me, however, in a  few
cases, that  suppuration was  hastened and  facilitated
by the applications on which I depended for resolving
the  inflammation.
   A female, about seven or eight weeks after  deliv-
ery, was attacked with  inflammation  of the right
breast, causing a good deal of pain.  She permitted
it  to  pass  several days without assistance; leeches
were  then  applied,  purges  administered, and  discu-
tient applications made  to  the  part.   The affection
of  the  breast abated, the  part became softer,  the
tension  and pain  left it, and  the swelling subsided.
 She had then an  affection within the abdomen, pro-
 ducing pain, soreness, a sense of fulness and tightness,
 accompanied by a constant and distressing nausea, and
 total loss of  appetite; her pulse at one hundred and 
84
twenty.   These  symptoms  lasted with considerable
severity  for eight or ten days, and were removed by
emetics,  purging  and blistering.  Immediately upon
their  removal,  or rather as soon as they were alle-
viated, the breast became again affected, not however
as it had been at first, but simply with a degree of
soreness  and  fulness; this continued, a little increas-
ing, till it suddenly pointed and discharged a large
quantity  of matter exactly  eighteen days from  the
first  attack ;  half of which time there had  been no
mark of inflammation, and during the remainder only
an inconvenient soreness without acute  pain.  In a
week more the abscess had  entirely closed  and  the
breast remained well.
  The same  patient two years afterwards was con-
fined with her second child.  Within a  few days after
delivery  she  was attacked with inflammation in the
same breast and the same part of it.   It was bathed
with a mixture consisting of Tinct. Mel. Ves. and
Tinct. Saponis, in the proportion of one part of  the
former to two of the latter, till some slight vesications
were produced; the inflammation seemed to abate, the
part softened and  became quiet.  After a short time
the difficulty returned and  was again  removed;  till
finally, at  least six weeks after the  first  attack, the
inflammation again  made  its appearance.   It was
thought in vain to oppose its progress,  poultices were
applied,  a small abscess  formed and discharged,  and
this without any  very  severe or long continued pain.
   Another subject, about five weeks after delivery,
was  much exposed to  cold  and moisture and was in
 consequence  seized with  an  inflammation of  her right 
85
breast.   She took an emetic and  purgatives, a mix-
ture of equal parts  of  Tinct. Mel. Ves. and Tinct.
Soponis was applied to  the part, which lessened the
pain and seemed to put back the inflammation, but
did not carry it away.   Upon a fresh  exposure, in-
flammation came  on afresh.   A blister was  applied
over the whole hardened part of the breast.  It gave
immediate relief to the pain,  and restored the  flow
of the milk, but  the drawing of  the  breast by th&
child gave exquisite suffering,  and consequently it
was not completely evacuated.  It continued however
growing softer, though I had no suspicion that matter
was forming.  A few  nights after the blister was
drawn, the milk  produced  violent sickness, vomiting
and diarrhea in the infant, and in an elder child who
had nursed  it, and no more attempts  were made  to
draw the breast.   It now became more painful, and
more tense,  and for a day and a half  produced con-
siderable suffering, when it most unexpectedly point-
ed, broke, discharged  a large  quantity  of  matter,
and healed in a few days without the slightest  diffi-
culty.
   Now so far as my observation  has extended, inflam-
ed breasts do not commonly go through the process
of suppuration so easily or  so speedily as happened
in the above cases.   It  is true that one or two instan-
ces do not afford sufficient  ground  for the establish-
ment of a general rule of practice ; but they do afford
a sufficient motive for  farther investigation.   It ap-
pears to me in these cases, as if the applications made
to  the system and  to  the parts removed  all the in-
flammatory action, except so much as was absolutely 
86
necessary to suppuration, and  as if this process was
performed more speedily, because every useless  and
superfluous  effort  of the  vessels was checked;  and
for the same  reason, the  pain, instead of being ex-
crutiating, was  comparatively so  trifling  in  these
cases, as  scarcely  to disturb  the  repose  of a  single
night.
   I would add to these remarks the relation of anoth-
er case, which has some connexion with this subject.
A female aged  about fifty, of somewhat  intempe-
rate  habits, applied  to me on account of an affection
of her arm.   She  had struck it some weeks before
by a fall which had torn off a  piece of  skin  and
bruised the surrounding parts.   In  this  spot  there
was  a  small, irritable,  and  painful ulcer; the  rest
of the  arm from just above the  elbow to  the ends of
the fingers was  in a state of inflammation.   It  was
much swelled, was cedematous and sore to the touch,
but not very painful except in the ulcer.   The fingers
were useless and destitute  of any feeling  but that of
soreness.  By the  application of blisters to the  sound
parts and of poultices, fomentations &c.  to the seat of
disease, and of such  internal remedies as  the consti-
tution seemed to require, the inflammation, pain,  &c.
abated;  there seemed to be no tendency to suppura-
tion, and  yet almost before I was aware of it, an ab-
scess formed upon the  side of  the arm  opposite to
the injury, and discharged a large quantity of matter.
She  soon after complained of soreness and  swelling
in the arm-pit;  on examination a collection of matter
was found and another in the lower part of the right
breast; these were opened and slowly got well. Anoth- 
87
er then formed just above  the clavicle; another on
the upper part of the arm,  and another on the lower
part just above  the elbow.   All of these and  espe-
cially  the three last, began with a soft red  swelling,
evidently  containing matter  from  the first, with no
sensation  but that of tenderness  and soreness, and
appeared  to be the  consequence of  the suppurative
inflammation simply, with  no  more of the  adhesive
than was necessary to form  a proper cavity for con-
taining the pus.
   Hence  I would  draw the conclusion, that the sup-
purative  inflammation  simply  is  not  necessarily
attended  with much  pain;   that  the  sensation it
produces is dull and rather that  of  soreness.   This
is certainly  the case when it takes place on the mu-
cous membranes, and we have no reason to conclude
it to be different elsewhere ;  for as soon as an abscess
in the cellular membrane is opened, it becomes com-
paratively  easy,  and the  pain which  accompanies
its formation proceeds  from the  coexistence  of the
adhesive  stage of inflammation with  the suppurative
and the consequent  tension and  pressure  of  parts.
Does  not  this afford us some ground  for doubting
the  universal truth of the principle stated by Mr.
Hunter and  other writers, that it is best to suffer an
abscess to open itself?   "Suppuration," says Mr.
Hunter, " takes  place on exposed  surfaces,  with  a
much  less degree of inflammation and  in much less
time, than on those  which are not exposed."   Now
when  an  abscess  is  opened, it is in fact converted
into an exposed  surface and  suppuration  continues
to go on with  as much rapidity and  with greater 
88
comfort to the  part.   Every surgeon does in fact
disregard this principle, for the most part, in practice,
and opens  collections of pus whenev er he can get at
them, for his own reputation as well as for the ease of
the patient.
   Supposing a part to be healthy and the constitution
in good order, it seems doubtful when the suppurative
inflammation is  taking place, whether  we  can do
better than to leave nature to effect the object she
has in  view by  her own means.   But in the majority
of cases, these circumstances do not both exist; the in-
flammation labours under some degree of disadvan-
tage, and it becomes our duty to afford such assistance
as lies  in our power to promote suppuration.  It has
been doubted by some writers on  surgery, and among
others by Mr. Hunter, whether the local  applications
usually  made are of any service in bringing  forward
suppuration.  It was his opinion, that poultices and
fomentations  were only of use when the inflammation
approached the  surface, and  acted by rendering the
skin more easy and comfortable under the operation
of the disease.
   These applications however, in all their numberless
varieties, have always been held in  common opinion
even among  surgeons, to be  peculiarly adapted to
the promotion of suppuration; and it would be dif-
ficult to persuade people in general,  that an inflam-
mation  could suppurate favourably   without them;
that their effects have  been prodigiously  overrated
I am not inclined to deny.   The vulgar are always
disposed to attribute that  which  takes place while
a remedy is operating, to the effect of the remedy. 
89
We cannot doubt, that in the majority of rapid, acute
inflammations terminating  in  abscess, poultices do
little more than render the part easy, by keeping the
skin warm,  moist, and relaxed.    But it certainly
would  appear, that where  there is any thing like ir-
regularity or inequality of  the inflammation, where it
is deficient from  want  of power, or excessive from
too great irritability, that  these  applications are of
considerable service in bringing about suppuration to
the best  possible advantage.
   It is  true, the immediate operation of  these rem-
edies is  confined to the skin.  Yet  there  is perhaps
no system,  except the  digestive,  through which  so
powerful  an effect can  be produced on the constitu-
tion, or on a diseased part, as the cutaneous.  I  con-
ceive, in  this case,  that the influence is something
more than physical;  the application of warmth and
moisture affects the vital state  of the skin, with which
the inflamed part sympathizes.  There seems  to  be
a peculiar power in  the application of warmth and
moisture  combined,  to promote a full, free, and  at
the  same time, easy and  natural  circulation in  the
capillaries of a part.  They appear to be peculiarly
adapted to  correct an irritable state to  which the ex-:
treme  vessels are sometimes liable, in which, if we
may so speak, they act at random, act  without effect-
ing the object for which they act.   Take for example
an irritable ulcer, which has ceased to discharge pus
and pours  out instead, a thin, acrid, serous fluid;
which  has become painful, has an unhealthy, ragged
aspect, in which there is manifestly a deterioration in
the action of the extreme vessels forming  its surface.
              12 
90
Apply a poultice to this ulcer for a few days, and in
most cases, how completely will  it alter the character
of the sore.  The discharge  is again converted  into
pus, the edges  become even and  healthy, and  fresh
granulations cover the surface.
  We certainly cannot expect so much where the appli-
cation is not made to the part itself which is  affected.
Yet we  know that any state of action, produced in the
skin,  has  a commanding  influence over that of the
parts underneath.  This  is  particularly  remarkable
in the case of  blisters, of fomentations applied over
the cavities,  &c.  We can conceive  that  a state of
action in  the vessels of a deep seated part,  which is
suppurating, might exist,  similar to that of the vessels
of an  open suppurating sore  just alluded to, and  that
the deep  seated  part  might be remedied, though
perhaps less speedily and less perfectly, by the same
means which were successful upon the surface.
  Suppuration  may  be  prevented  from coming on
in a favourable manner, by  a state of irritability in
the vessels of the part, or by one  of torpor, sluggish-
ness  and  indisposition to action.   These  states,  I
conceive,  arise  in general from constitutional causes ;
but while the constitution in this manner  affects the
actions  of the part, the latter in its turn by a  reflected
operation  on the system, increases its  derangement.
In  these  cases, our  treatment is to be directed  both
to the general  and local  affection.  We are  to regu-
late the system, in different  ways, according  to the
manner in which  it  is affected.   The  stomach  is to
be  put in good order, the bowels cleansed, the state
of the  liver amended if  necessary, and then  stimu- 
91
lants, tonics, &c. administered according to the ex-
igencies of the case.  Of  the local  treatment, it must
be confessed, there is little to be said.  We probably
effect much less than we  are apt to imagine and our
chief reliance should  be  upon the efforts of nature,
with  such assistance and guidance as we are able to
afford.
   Nothing  is more important, in  treating disorders
where the constitution is at all implicated and where
our  treatment is  to operate  principally through the
constitution, than  to  keep in view this principle ;—
that  although  life is  the result of an assemblage of
functions carried on by a variety of  organs, it is still
only one in itself.   All these functions work together
in different ways  for one end, that end  is the good of
the  system as  a whole.  However varied their indi-
vidual  objects, they  are linked  together  by  such
indissoluble  ties of mutual dependence, that no one
can  be affected without  a  proportionate  effect  upon
every other.  Life, like gravity in the physical world,
seems to be dependant on every  part of tue system
in proportion to the importance  of the part.   Throw
but a stone, as philosophers have observed, and every
planet, sun and star, to the extremity of the universe,
feels the alteration which this  motion  has made in
the relations of the different masses of  matter in  ex-
istence.  So in the physiological system, any  change
in any organ affects the relations of the whole system,
just  in proportion to the extent of the change and
the  importance of the organ.   Now this being  true,
we  ought undoubtedly to  give this  principle  great
weight in the application of our remedies, especially 
92
those whose  influence is upon the system at large,
and we  ought always to  investigate, before the rem-
edy is applied, the state  of the constitution and what
the  relations  of  the  different organs and functions
have before been.
   Many practitioners have been apt  to direct their
exclusive  attention  to the phenomena of disease  as
affecting some particular function, or class of func-
tions, and  consequently  to direct their remedies  in
the  same way.   Thus  there are some  who would
cure every thing by the lancet, because they believe
that the essence of disease is in the circulating sys-
tem ; others  who would  do it by emetics and cathar-
tics, because  they conceive the stomach  and  bowels
to be at  the root of all disorder ;  others who rely  on
opium and narcotics,  because  they think  the nervous
system principally implicated  ; and others on stimu-
lants and tonics, from  the opinion that every disease
consists  in debility.  All must  be partly  wrong and
partly right,  for the causes and phenomena of disease
exist by turns, or even at the same time,  in each sys-
tem and influence every  function.
   The  treatment of constitutional  disorder,  in this
point of  view,  and likewise  the treatment  of local
disorder as affecting the  constitution, becomes exceed-
ingly delicate. We have to determine, at first setting
out, the actual state of the system, its relation to the
local disorder, and  then  to keep constantly  in  view
the  changes  in  these  respects  which our  remedies
or the progress of the disorder occasions.   We ought
to keep our  eye fixed upon  this, as the  pole-star of
our practice.  It is  only in this way that we can 
                           93

   know, what  we have done, what we are to do, and
   what are  the  resources  of nature  on  which we can
   depend.
     In general the character of any  considerable local
   inflammation affords  an index  to  the state  of the
   constitution.   It is an exhibition,  a sample  of the
   disposition and the powers of action of the system at
   large.  Where there  is  vigorous, regular, and rapid
   inflammation,  it is  a  good  test of firm health, and
   every deviation from this kind of action is a mark of
   some deviation from firm health.  Where the indica-
•  tion is  merely  to reduce  excessive  healthy action, our
   power is almost  certain, and we can promise ourselves
   success, since  we do  it  by  the  direct abstraction of
   strength.  But every deviation  is more  or  less com-
   plicated ;  we  cannot  be so certain what our objects
   ought to be, and have not so certain means  of effect-
   ing them.  We cannot  directly give strength ; the
   most we  can  do, is to  call  forth  and regulate the
   expenditure of those  powers the system  already pos-
   sesses, and  to do this in such a way, as not only to
   produce a temporary capacity for exertion,  but  indi-
   rectly  an accumulation of power.   It is only in this
   way that we  can look  upon tonic and  stimulating
   remedies as giving stength.  By their use we prima-
   rily  excite action, and of course expend the  powers
   of life.   If we  can so regulate  this  action  as  by
   its means to have the natural functions properly per-
   formed, we accumulate as much or  more power than
   is expended.    But if this is  not done, tonics  and
   stimulants,  whatever be their immediate  effect, act
   only as causes ultimately debilitating; and a powerful 
                         94
evacuant will  often  be the means of increasing the
strength, when such remedies entirely fail, by removing
those causes which  oppressed the natural perform-
ance of the functions.
  Where the deviation consists  in  irritability—by
which I mean  a tendency  to action, without a corres-
ponding power of supporting it, the consequence  of
which is, that  the action is imperfect, as in the case
of an irritable ulcer before mentioned—we must either
increase the strength so as to be  on a level with the
action, or else reduce the action  so as not  to exceed
the power of supporting it.   The  last is unquestion-
ably most within  the  power  of  medicine,  although
the former,  in chronic diseases where there  is suffi-
cient time, may  be frequently brought about by the
gradual operation of diet and exercise.   Where action
is exhausting  the strength, without  answering any
good purpose, we virtually restore it by any means
which  will lessen  this action.  These means, so far
as medicine is  concerned, principally consist in putting
the skin, stomach, and bowels  into a natural state and
in quieting the  morbid actions by the use  of opium
or applications to the diseased  part.   The  character
of an  irritable, ill-conditioned ulcer,  will sometimes,
where the  stomach  is previously  put in  order,  be
speedily amended by a few grains of opium, or the
exhibition of bark.                  X
  It is difficult to write upon  this subject with accu-
racy and clearness, and more difficult to practise than
to write.   The ideas of physicians  differ so  much
with regard to it, that it is difficult for them mutually
to comprehend their different views.   It appears  to 
                       95

me particularly important in the treatment of internal
suppurative or ulcerative  diseases, to have  in mind
the considerations which have been suggested, and if
we are ever to attain any controul over that  hitherto
untameable malady, phthisis pulmonalis, I conceive it
will  be brought  about by a careful  investigation of
the subjects of which I have now briefly spoken. 
 
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