36 Berkeley Square
28 Dec 1860
Dear Mr Wells
I am deeply touched
by your considerate kindness
in thinking of writing a little
memorial of my precious
Father – I had in my heart
very much wished it but 
had known of no one to ask
to do it, and therefore had
not mentioned it to anyone
my Aunt Madame de Wahl
(papas twin sister) much wishes
that you would kindly have
20 little copies or so of what
you have already sent me
and what will be written 


printed off for us – if it is 
not giving you inconvenience
It is indeed a happy satisfaction 
to us to know (as we have
often heard) now deeply my 
darling Father was respected
and beloved by all – he was
so good and true a friend
to all
One cannot wish him back
Mr Wells though it seems hard 
at first to part and he left 
behind – the burthen of 



such grief does seem almost
overwhelming it comes with such 
a crushing stunning force that
it seems almost to be overwhelming.
Bless him he is so happy
I cannot write more – dear Mr
Wells thanks are but stupid
little things, but such as they 
are in his name take min
I know you kindness came 
from your true friendship
and love to him – who could 
help loving him that knew
him well.
Yrs sincerely
A Rigby








[Ed:] Rigby.
Presented to the Library of the
Surgeon General’s Office
U.S.A.
Washington
5 August 1886
T. [Sh???] Wells




Chirurgical Lectures
by Mr J: Hunter.




Introduction
In the course of these lectures I shall differ
very much from what is taught in books on
the subject of surgery; the ideas I have to communicate 
are mostly my own & not drawn
from books. I have [reason] to suppose them
true because they are founded on facts.
I shall consider first the animal oeconomy:
I shall chiefly mention the [illegible] of 
the body in a diseased state, with their [recoveries]
& natural functions in health. I 
have it not in view to give a full course
of practical surgery, but mostly to teach 
the principles of the art.
It will be unnecessary to treat of the
operations & of every particular disease
those are taught by anatomists & others: the
principles are most necessary, & these only 
shall be the subject of our present enquiry.
Every art has its principles, from which 
we are enabled to establish old facts,
& account for new ones: the same holds good
in surgery.
Effects are which strike the senses more forcibly,
even while the cause is unknown;
but as those are only consequences, we should
endeavour to discover the cause. In this attempt 


we often fail.
We know the causes of inflammation, suppuration
& mortification, hence we are enabled
to chart their progress.
We find it necessary sometimes to increase
the violence of a disease, before we can affect
a cure, as in indolent inflammation.
Sometimes it is necessary to change one disease
into another, in venereal inflammation by exciting
common inflammation we effect the 
cure.
If the animal were always equal to the
task it was to perform, surgery would be unnecessary,
but the powers of restoration which 
arise out of the animal, being not always
sufficient, it is our business to increase the action
when too weak & moderate it when too 
strong.
It becomes often necessary to introduce chemical
means in the cure of diseases, those
failing, we have recourse to mechanical ones
as the different operations.
As the operations (though the necessity for
them is in truth the defect of surgery) become
sometimes indispensible, it is right to know
how to perform them.
A competent knowledge of the parts of the
body should be strictly attended to; as this 


will lead us to their [illegible], we should know the
different functions & consider the dependance
one action has upon another.
With regard to operations we should know
when they will relieve, & when nothing but an
operation will relieve; we should also know
when the habit will bear an operation, this
indeed, is sometimes almost impossible to 
ascertain.
The facility with which a man thinks gives
him a superiority over others; few have observed
[illegible] with more attention than 
myself; yet even now I think myself scarcely
equal to the task I have undertaken. A 
man will be ignorant of that knowledge
he possesses untill he arranges his ideas.
The principles of disease which are the objects
of surgery, have not been sufficiently 
attended to; these we intend chiefly to consider
We shall begin with physiology, as far as it 
is necessary to understand the principles of disease
Disease may be called a perversion of the 
natural action of the animal oeconomy.
I will first consider those diseases which arise
from accident: secondly, those which are similar
to them; than the union of divided parts by the
first intention; next inflammations which will 
throw light on various subjects, as [illegible], the 




Cure of the hydrocele, indurated tumours, etc. than
the union of the parts not cured by the first intention
as compound fracturs etc.; lastly we shall
treat of some specific diseases, as scrophula
cancer etc.


5.
Rationale of Surgery.
Matters.
1 By matter we mean that substance of which
the globe or earth is composed.
2 By the impressions of matter alone we are
led to the knowledge of our senses & by our senses
only we judge of the existence of matter.
3 But our sensations are excited not by the impressions
of matter itself, but by the impressions 
of the effects of matter; thus when we hear a 
drum beat, our sensation is not excited by the 
drum, but by the vibrations of the air produced 
by the strokes on the instrument
Q So also the properties of matter act upon our
senses; the sensations of sweet & sour are not
matter, but the properties of matter acting upon 
the tongue; touch arises from resistance in matter.
4 Matter is found in one of the following sates, 
solidity, fluidity, or vapor.
5 The general kinds & properties of matter
are few, but different modifications & combination
of those kinds & properties of matter,
produce great varieties in appearance.
6 The following properties are common to 
matter, attraction of cohesion; chemical or 
elective attraction; attraction of gravitation.
Q by attraction of cohesion, bodies of similar s


& globules of [quicksilver] or globules of water 
on cabbage leaves, illustrate this remark
very questionable whether these be [illegible] a 
principle in nature as repulsion The 
cause of fluidity of vapor is certainly not
this principle, but the matter of [illegible]
which simply expands all bodies by enlarging
their [interstices]


Properties tend to come in contact with one another,
& to remain so when this is effected: this
attraction is very slight in fluids; in them, however,
the stronger it is, the more globular or
spherical the particles appear & vice versa X
Elective attraction disposes bodies to join with 
various other substances, forming together one homogeneous 
mass; in this we have an instance in 
the combination of an acid with an alkali;
there are as many different elective attractions 
as there are different methods of mixing matter.
Elective attraction operates only when fluidity 
or vapor are present; the compound may however
become solid afterwards by the attraction of
cohesion; the increased action of cohesion in solid
bodies may be called the attraction of solidity.
X 7. Repulsion is also property of manner, but
it seems doubtful whether it is so universal
a property as that of attraction; nevertheless,
the action of repulsion seems to be in [illegible]
measure the cause of fluidity & vapor.
8. Magnetism seems to belong to attraction 
of gravitation: by the attraction of gravitation,
the different parts of matter are kept together,
so as to form one great whole.
9. Each mass of matter, though ever so minute
has in itself a centre of attraction.
10 Heat alone seems a generally necessary 



agent to fluidity & vapor.
Q Heat seems to destroy attractions: mechanics 
depend upon external [figure] & magnitude 
of bodies, & the properties of gravitation, attraction
etc.
11 The operations arising from changes in matter
are regular & determined according to fixed
& certain laws.
12. We have been considering the properties & 
modifications of common matter, but considerations 
on matter may be carried much higher,
& modifications of or kinds of matter, may be 
found entirely different in every respect from 
common matter. These are the matter of animals
& vegetables.
13. The first principles of animals & vegetables are
perhaps the same; but they have many properties
totally distinct & perfectly different from
one another.
14 It is observed (13) that the properties of animal
& vegetable matter are perfectly distinct, although
their first principles may be similar;
and indeed so perfectly distinct are vegetables 
& animals in many properties, & in the modification 
of matter observed in their production
& formation, that no connection between
them has ever been traced.
15 They differ totally from common matter, in 



X see Keir on the similarity of organic
matter.


That they have each of them a power of acting & 
performing various operations within themselves,
and of producing or generating matter of their own 
genus from themselves.
16 Vegetables & animals partially differ from
each other; both, indeed, have a power of performing
operations within themselves, & of generating
from themselves raw matter, but in other 
respects they partially differ.
X 17 The operations of animals are attended
with waste of their component parts; this waste
is [????ited] by a supply from common matter,
but common matter can not be immediately 
converted into animal substance, nor
can the decay of animal substance be supplied
from common matter, until it has
by certain changes been altered into animal
or vegetable matter. Vegetables can immediately 
convert common matter in to their own
substance, & be supplied from it; but animals
cannot, which proves the animal matter is
still further removed from common matter
than the vegetable.
Q The circumstances of worms etc. which feed 
upon earth, would seem to [illegible] an exception
to this position; it is likely, however, that the 
earth they take in, is only useful, as far as it 
contains animal or vegetable matter. In order 


This would be a fallacious experiment
for Kali will not dissolve vegetable
matter though it will animal, as
is well known by dyers who use
[illegible]


to determine this, we should combine an alkaline
salt with earth, X which will destroy whatever
animal or vegetable matter it contains, then
wash it thoroughly & [by] whether worms will 
live upon it.
18 Animal & vegetable matter may be viewed
in two states, as living or dead. when living, it
has in itself both a power of continuance, and
of generating new animal matter, but when 
dead it loses those powers.
19 Animal & vegetable matter after death is capable
of being acted on by the operations of 
chemistry & by those of spontaneous dissolution;
by which latter it is at length reduced to 
common matter, out of which it is at first, probably,
formed: the presence of life is an antidote
to & assists both one & the other.
20 animal matter submitted to chemical enquiry
& the operations of fire, yields certain
substances peculiar to itself, as the volatile
alkali, empyreumatic oils, calcareous earth
& a [illegible] of water; other substances, as iron etc.
are also found, which are [illegible], & do not
constitute its natural component parts.
22



Fermentation in Animals.
22. Many changes taking place, during life, in 
animal & vegetables, have been attributed to a
certain operation, called fermentation: for it 
is known that fermentation will powerfully 
alter all substances which are subject to its action,
& can change them to new & totally 
different substances. To this the secretions of
animal bodies have been supported to owing:
to this the change of the water in the juices
of the different plants, nourished solely by it,
has been imported; to this digestion etc.
23. But though animal & vegetable bodies are 
the subjects of fermentation; no change wrought
in them during life can possibly arise from
this cause, for the presence of life resists fermentation,
& no body whilst retaining its life can
be acted upon by fermentation; it can only take
place after the destruction of life which is the
preserving principle. We have speak of fermentation
in the same sense that chemists understand
it.
Principles of Life
24. The changes arising in the animal & vegetable
matter during the presence of life, are produced
alone by the peculiar power of the principle
of life; to its operation we refer all the secretions,
all the new productions, the digestion of 




other substances etc.
25. The operations of the principle of life cannot
be referred to one chemical power.
26. Life is totally distinct from any property
of mechanics; we see, indeed, the movement and
construction of the bones are regulated by 
mechanical laws, but the actions of the muscles
which put the bones in motion, are not
owing to any mechanical power of principle
nor by mechanical principles can they possibly
be explained.
27. From an examination & survey of animal 
matter when dead, we join an idea of living 
animal matter; as from life only we gain an
idea of death, so from death only we form
idea of life.
28 The functions of, & changes in an animal
body during life, are all to be referred to 
the operations of the principle of life. The properties
of the principle of life consist in the
preservation of animal matter in the living
state, and in action. Life may exist without 
matter being in a state of action, & the property 
of self preservation may alone be present;
life being, at the same time present in full
force. Thus a new laid egg is truly & really 
alive, though no kind of action is known to 
be possessed by it.
9


Q Experiments to [illegible] 28.
Mr Hunter found that a new laid egg, though
kept by incubation in a heat of 120 degrees,
untill it was hatched in two or three weeks,
when the chicken was excluded, showed not 
the least signs of putrefaction; another egg which
was not hatched, & of course died, became in 
the same circumstances highly putrid.
Experiment 2d A new laid egg was exposed to a
temperature between 17 & 15 degrees of farhanheits
thermometer, in which situation it was 
kept half an hour, its life being then destroyed
by [freezing]; it was thawed by heat, being then
again exposed to 25 [degrees] it frose in half the time
it before required, that is in 15 minutes; while
alive it had the power of resisting cold & consequently
the destruction of the life a considerable
time; but when once killed, it had no longer
 the property of resisting the freesing power of cold
Mr Hunter made a number of other experiments
on animals; he attempted to freese two carps, 
but without success; he found that for a long
time they generated heat & resisted the destruction 
of their life by freezing, at length that
power was exhausted & they died almost [illegible]
They possessed of life enjoys the power of resting
death. Mr Hunter found that living vegetables 



13
would endure cold & resist being frosen, much 
longer than plants whose vegetable life had
been destroyed. Experiments tried on dormice etc.
were found to have the same [illegible].
Experiment 3d A dead egg forse in the degree
of 32 & a living egg gradually sand to 29; it
then continued stationary for some time; it afterwards
rose to 32 & then became frozen; the
same experiment was made on snails, snakes,
eels & other of the colder & imperfect animals,
which proves that the [illegible] egg is as truly alive
as the animals just spoken of though it has only 
the property or resisting death, or self preservation,
& not any kind of action
29 Life does not consist in any modification 
of matter; it either is something [superadated] to 
matter, or else it consists in a peculiar arrangement
of certain fine particles of matter, which 
being thus disposed acquires the properties of life.
Q I enquired of Mr Hunter if this did not make
for the exploded doctrine of [equivocal] generation;
he told me, perhaps it did, & [illegible] to equivocal 
generation, all that we could have
was negative proofs of its not taking place. He did
not deny that equivocal generation happened,
there were neither positive proofs for or against
its taking place.
30 Live has been compared to the spring of [illegible]



as that spring gives motion to all the wheels
so life gives action to the several parts of the
body; but this idea is not just, no one part of the
body is dependant for action on any other part, but
the several parts each possess life & action within
themselves.
31. Life, in the living animal, is as much the property
of every individual part, as gravity is of every 
 part of matter; every one part is as much alive
as the whole.
32. Every action in the animal body is produced
by the living principle; the secondary 
action of parts is as truly produced by it as
the primary.
33. Magnetism will somewhat elucidate what
is said of life being [superadated] to matter, or
arising from a particular arrangement of certain
particles of matter: a bar of iron placed
for a long time in an [illegible] [illegible], will acquire
a magnetic virtue, so perhaps the particles 
of matter arranged & long continued in a certain
position, at length acquire the power of life
Q The doctrine of colors will tend to the same purpose,
we see by different arrangements the same
colors will produce very different shades.
34. Two, three or four, or any number of particles
of matter thus arranged, may form a muscular
fibre, a certain number of these fibres together 



15.
form a muscle.
35. Life does not consist in ay organization
of matter, for matter will remain as organized as
ever after the destruction of its life.
Q Though organization is not necessary to life
it is to action.
36. As far as observation of matter in its inanimate
state, we gain a idea of living matter,
to [illegible] our observations of the functions & actions
of parts in a state of disease, we gain a knowledge 
of or correct our opinions of the natural 
actions & functions of parts in a state of health.
37. Solidity in matter is necessary for its action,
it is the fixed point, from which its actions must
proceed, & on which they must depend; therefore
we find the parts of animals destined for action,
solid: These animal solids are kept together by 
cohesion.
38. The muscular parts of an animal are active
scarcely any part is [illegible] passive; almost all
parts have something of muscle in them, & have
some [stand] or [illegible] of action.
Actions of Animals.
39 The actions of an animal are two fold; the
primary actions are those which every part has
in itself, as nutrition, growth, support, without
regard to any operation, for the benefit of, or
it producing any change in the system in general;
and secondary actions, or those which are performed



by any part with a view to the benefit of, 
or the producing some change in the general system,
as the action of the stomach the brain etc.
The first are the true animal movements, the second
are, what are called operations of the animal
oeconomy: as most secondary actions are completed
for the ends of the first, having necessary relation
to the first, so those secondary actions are in general
permanent & constant. In disease all these
secondary actions may be suspended for a season, the
primary ones are never interrupted for the least 
[portion] of time, so long as the parts live
40 There are, besides the muscular parts (38) 
which are the active powers, other parts which
have a kind of secondary motion, that is, a motion’
communicated to them, elastic parts; but
to the operation of these life is not necessary,
their powers are [illegible] after the death of the [illegible],
to which they were during life.
41. There are other parts also in the animal 
body, that have in themselves no kind of action,
but whose [illegible] is merely passive, which are different
in strength & [density], some for union as 
the cellular substance, some for strength as the
tendons & ligaments
42. It is said (40) that it is not necessary to parts
being possessed of elasticity, that life should be
present; elasticity is indeed a property of many 


17
species of matter besides animal
43. The actions of the living body are simple and
compound. The powers of action distinguish living
animal & vegetable from dead & common matter.
Stomach.
44. The operations of an animal (17) are attended
with a waste of its substance; supply is therefore
necessary to their continuance: This supply 
is performed by means of a bag, which though small 
in comparison to the bulk of the other parts of
some animals, is the most important part of all.
This is the stomach. The stomach is the principal 
distinction between animals & vegetables; all
animals have a stomach, no vegetable is possessed 
of any thing like one. To many animals, the blood,
brain & nervous system & many of the viscera
are wanting, but no animal is without a stomach:
it is the stomach only which is necessary for
the support of a simple animal; & organs of generation 
for the propagation of its species, therefore,
some animals consist of little more than 
stomach & genitals.
45. This stomach may be called the true & primary 
animal: all other parts may be considered
as [illegible] added according to the functions of the
animal, to which some or more are given, to perform
on the stage of live; for one animal that possesses
a heart there are millions that want it.


what is the difference between
vomiting, and puking


46. The stomach by means of its hidden powers,
converts various substances into one kind of
matter, which is taken into & forms part of the animal:
this very curious kind of operation is called
digestion.
47. This viscus, in the most complicate animal,
as in man, is intimately connected with the
general oeconomy; it is as much the seat of
irritability, as the brain is of sensibility; it is
highly affected by many external influences,
which in themselves have nothing to do with 
the operation of digestion, as wounds & it is 
more affected by morbid operations produced
in tendons, ligaments, & other parts of [small]
natural sensibility, than by the same taking
place in muscles. It is chiefly effected by changes
taking place in the internal parts as the brain
is by those in the external parts. It is intimately
connected in the affections of the mind, whether
produced from injuries of the brain or from horrid
stories or sights, to which a vomiting or puking has been 
known to succeed, especially the last.
Vascular System. 
49. In compound animals, or man, the vascular
system, or that by which fluids are carried to & 
taken from different parts of the by, by means 



19
of which growth & nutrition are afforded to parts & 
the whole, becomes an important subject of enquiry.
This is divided into the arteries, the venous 
and the absorbent system.
50. The animal body is considered as an Hydraulic
machine, & by those [illegible] sets of vessels its
course of fluid is conducted.
Q Experiments have [illegible] veins from the
office of absorbing; even in the portion of the 
[penis], the veins do not absorb. I consider the corpora 
cavernosa or veins through which the blood is
constantly flowing from arteries, & that 
there are a number of veins opening into the
corpora cavernosa, & that the blood is flowing
into them; that in exertion there is a spasm upon
the veins, which prevents the blood flowing through
them, hence an accumulation *& distension
of the [penis], which ceases with the spasms. I
found that by tying the veins of a [illegible] [penis]
an erection was produced.
Arteries
51. The arteries carry the blood from the heart
to every part of the body, consequently they convey
the materials, for the growth, nourishment
& support of parts, for the regeneration
of those when lost, & the supply of those when 


[wanted], also for the different secretory organs to separate
[liquors] for any further purposes of the
animal oeconomy, or to eliminate any thing
superfluous or noxious.
Veins
52. The veins return to the heart, the blood 
which remained of what the arteries had carried
from it, after the different purposes (51) 
have been effected. They are also said to carry 
blood from certain parts to the liver, for the
production of bile.
Absorbents.
53. The absorbents take up fluids & also solids
from every part of the body, which they pour
by means of a peculiar duct, into the blood
by this property they become the means of 
supplying the system of circulation with nutritive
particles, also of conveying disease into the
habit. Thus being the instruments both of health
& destruction. By this property of absorbing
solids as well as fluids, they become the modellers of
the shape, form & structure of different 
parts: they prevent parts from growing into
irregular & inconvenient figures; In this light
they may be considered as the builders of the
animal fabric while the arteries are as the 


21.
labourers, bringing & laying before them the
materials for the work, or as the polishers of
the rougher workmanship of the arterial vessels;
by this property they take up & remove
parts, which though useful in one period of
life, become useless in another, as the thymus
gland etc.
Q also the [gubernacular], the membrana [illegible]
etc.; when a limb is removed, we know 
the end of the bone saved [illegible], is a circular
plane with hard edges; if examined at some
length of time after the operation, we find
the end of the stump approaching the [illegible]
of a sphere.
By this property also, when their arteries are
much excited, they take up solid parts, whether
soft or hard, thus producing what has been
called ulceration; this may be called ulcerative
absorbtion
54. The action of this system of vessels (53) being
considered with regard to the ultimate effects 
may be divided into two kinds viz
1st Absorption of extraneous bodies.
2d Absorption of the animal itself.
55 The absorption of extraneous bodies, as
observed (53) introduces both the particles of [illegible]
into the system & the particles of disease.




Final Use of Absorption
56 The absorption of the animal itself, is employed
either for the nutrition of the animal,
either when absorption of extraneous nutrition
cannot take place, or when the mind is unmindful 
of directing nutriment to be taken in,
& yet nourishment is still necessary to the
life of the animal, or when an useless or inconvenient 
part is to be removed.
57. The mind is frequently unmindful of taking
in food in fevers; no desire of it being by [illegible]
perceived; but nourishment being necessary for 
the sustenance of the animal, the fat & other
substances are taken up by the absorbents and
carried into the circulation for the necessary
purposes of affording nutriment to the different
parts of the system. Thus the animal, is for some
time enabled to feed upon itself.
58 Every part of the body may be subjected by 
disease to the second kind (54) of absorption.
Absorption will either take up from parts, portions
of their intersticial substances, as earth 
from [bone] & [illegible] it will take up whole parts
as an entire [illegible].
59. When a stimulus of any kind is about to 
excite the process of absorptions, the circumstances


23.
will take place; a consciousness in the lymphatics
of the propriety or necessity to being absorption:
but when the part to be absorbed is dead,
the state of consciousness is incompatible with
an inanimate state of nature.
60 To the removal of [head] parts by internal
processes this system of absorbents seems alone
to be equal, to chemical process [illegible] perform
it.
Ulcerative Absorption
61. The process of ulceration, or ulcerative
absorption is always the same, different causes
may indeed produce it & different circumstances
may be present with it.
62. The state of consciousness (59) may be induced
by different kinds of stimuli, but the mode of
impression will always be the same.
63. The absorbents have a power of taking up
both solids & fluids.
64. The mode of their actions is not clearly ascertained;
it has been imagined that they are
capillary tubes, but capillary tubes commonly 
absorb fluids, & the absorbents take up solids.
65. The opinion of their absorbing matter in a 
fluid state alone, which would show that the 
solids, if to be absorbed must undergo solution
by means of some fluid which acts upon them


as a solvent, is to be doubted.
66. It is equally & more probable, that the absorbents
have, like entire animals, mouths & 
teeth, that the fever of the mouths & teeth
is different absorbents, essentially differ according
to the parts they are to act upon, so
that perhaps could we obtain an accurate
survey of them, we might be enabled to class
them according to these differences.
67. It is doubtful whether substances mixed 
with the blood are essentially altered or not,
the indestructible parts of vegetables, as the 
coloring part of rhubarb, pass off by urine,
or by some other excretion in their unchanged
state: the [variolus] matter is not altered
by the blood; the venereal matter when 
taken into the habit is certainly much altered,
it is different from what it was before
it was absorbed; this is the only matter that
we know undergoes a change.
68. The power of living animal matter to 
consume itself is equally probable with the
property of living matter to produce part living 
matter from itself.
Brain & Nerves.
69. From a peculiar arrangement of the
particles of animal matter, muscles are produced, 




25.
a different arrangement of those particles
from other organs, so from a particular disposition
of those particles in perfect animals, the brain
& nerves are fashioned; which being acted upon
by various impressions, various sensations arise,
the effects of which are the mind & will
Q The existence of the brain & nervous system, is 
not necessary to simple life, millions of animals
want both, but they are necessary to the performance
of certain functions of life, & without
them, in those classes of animals, to which they 
are given, active life cannot go on. In the perfect
animal as man, there have been instances 
of monsters being born with a head, but not
being able to support the functions of life, necessary
to be performed from the time of birth, they 
die soon after they come into the world, but 
they were truly & virtually alive while in utero.
Senses.
70 The impressions given by external objects are
considered as of five kinds; of these one is touch
or feel, of which every sensible part of the body
is the seat, the other four kinds, severally effect
peculiar organs adopted to them. 
Ideas.
71. The sensation raised by an impression is twofold,
first is effects on a part to which it is applied; 


secondly the change produced in the brain, in 
consequence of that effect; the first is simply passive,
the second state is active, for then motion is produced
in the brain & an idea is formed.
72. According to the kind of change affected in the
brain, the idea will be [agreable] or disagreable.
73 As from habit we gain a power of judging & 
distinguishing what is advantageous & useful, from 
what is inconvenient and pernicious, when an idea
respecting an external object is excited in the mind, 
& that idea is followed by an inclination to possess
or obtain that object, we should be irresistibly inclined
to gratify that inclination when arising,
did not our power of judging of ill consequences 
that might arise from gratifying the inclination in 
question, (acquired as before said from habit, or from
repeated observations) determine as to the contrary,
this weighing an inclination in the mind we
call reason.
Will
74. A determination of the mind whether produced
by inclination or reason, is called the will.
Voluntary Actions
75. In consequence of any changes produced in the 
brain, as concomitant on the action of the will,
an action in any moving part of the body is excited;
this is voluntary motion or action; these 
different parts of the body receiving impressions, 


have a power of acting on, or exciting changes
in the brain, & a change in the brain, however
produced, has a power of producing a change in other
parts of the body.
76. The vital principle, or the principal of simple
life & that principle on which the powers of
sensation depend by this connection (75) act materially 
on each other.
77. It seems as if we had no simple sensations;
but that every sensation of which the mind is sensible
is compounded of two states as (71).
78 The operations of the brain & nervous system 
(64) are not so extensive as some have imagine
they can neither supply a part with nourishment,
nor preserve a part from dissolution.
79 Every living body has an intelligence of its own
feelings, after an impression has been given to it,
previous to & exclusive of an idea existing in the
brain: thus every living part has in itself a 
consciousness of an impression given to it, whether of
pleasure or of pain, & as it were a power of determining
to arteries, independent of the powers of the mind
80 The power of the nerves is purely passive, hance
previous to any action being excited in them, an
impression must necessarily be given to them.
81. The different sensitive organs are appointed to 
received the several kinds of impression, given
to the body & which impressions are of five kinds
yet every nerve is subject to receive the impression 



of touch and pressure.
82. The living principle is [illegible] in all living
animal matter, with the animal matter itself,
& may long exist without sensation. Thus a child
in utero has no sensation till it is born.
83. The nerves are not indebted to the brain
for their existence, there may be nerves, though
there is no brain; but the existence of the brain
is necessary for the function of ideas.
Q Many fishes have abundance of nerves, with
a very small quantity of brain; [illegible], to 
when the brain has been wanting; a cephalus 
[illegible] have still their nerves.
84. Parts intended for strong sensations, have
always a great quantity of nerves distributed 
to them.
85. This principle of sensation regulates all
our external actions, as the principle of life 
does our internal ones.
Q In man & the perfect animals, sensation is
intimately connected with life, if the powers of
sensation are constantly kept exercised, the
sensitive principle becomes fortified, & the principle
of life also suffers with it. sleep, therefore
by giving relief to the sensitive principles 
of life.
86 When an impression is given, it must continue
a certain time in order to produce a sensation, if 


29
it last but a short time, no sensation will be produced;
if an impression continue too long, a distant’
sensation will be yielded; it will then produce only 
a disturbed state of the nerves.
87. Sleep is to the sensitive principle, what [illegible],
or the state of inaction is to the living principle:
as the living principle may exist though no 
action is going on, so the existence of the sensation 
is not incompatible with the absence of sensation
88 Thinking is the effect of certain changes in the
mind, accompanying changes in the brain; though
with respect to ourselves, or a consciousness of 
action or sensations, we are in a state of non existence;
& although we have then no sensation,
yet the effect of sensations are not lost, the
mind will be thinking (which is the effect of
sensation) whilst we are asleep, as in dreams;’
we seem, indeed, then to have sometimes, but
our seeming sensations are fallacious.
89 We often dream when awake, living a
seeming perception of things & objects which do
not exist.
90. Sensation excited in a certain degree is agreable,
in a greater degree painful, & then the natural
sensation will not take place but the
sensation of pain will be produced. Thus an excessively 
glaring light being applied to the retina, 
pain, not vision will be produced.
Q a loud noise produces the same effect on the ear, 


in lieu of distinguishing sounds, the idea of
pain will be exacted; even the tympanum of the
ear has been broken by this violence.
91. An impression different from that which is the
one, for the perception of which, any organ is naturally & particularly 
adapted, may produce in the given
organ the same sensations, as would have taken
place, had the natural impression been given.
Thus a smart blow on the eye, will excite the
same sensations as a flash of light, the same
blow on the ear will produce a sensation of 
sound.
92. Uneasy sensations may in many respects
be similar to a natural appetite; they rather
warn the animal to the avoiding somewhat 
injurious to them, or the removing something
unsalutary.
93. During sleep, whatever actions are derived
from the brain, whether consequent on disease
or health, cease. Thus St Vitus’s Dance does not
affect the patient whilst he slumbers.
94 The living principle in any parts of the body
will continue to exist, after the nerve leading
to any part is divided.
Q Sensation is not necessary to simple life; a 
child in utero has not sensation, & yet it lives.
95. when a part is intended for motion, loses its 
power of motion, it wastes, for being now no 


31.
longer useful to the animal, as a moving part, it 
becomes open to interstitial absorption. The will
can no long influence it.
Q A muscle when its action is suspended, by the
communication with the brain being interrupted,
or by any other means, it wastes. It is a law in 
the animal oeconomy that the size of a muscle
will be in proportion to the frequency of its use:
of this we have variety of instances in the legs
of [chai?man], the arms of watermen & the thickness of
the muscular coat of the [bla??ler], when it has
been long used to frequent contractions, from irritations,
as those from a stone & will be taken 
notice of when we are considering the diseases of the
urinary passages & so also muscles waste, if the
joint they serve is rendered useless, because their
actions can no longer be performed.
96 The more distant any part is from the centre
of its [energy], the less fit it will be for certain arteries,
as instead it will receive less energy; therefore, all
the vital parts are near the heart: all the parts
intended for acute sensations are near the brain.
So mortification from debility, more frequently
attacks the extreme vessels, especially if the patient 
is tall; perhaps one reason may be that the
blood loses somewhat of its nutritive powers
before it arrives at them.
97. In the animal body there are actions which 
proceed from certain fixed principles in the 




animal oeconomy & are regulated by certain
fixed laws: there are only actions which arise
in consequence of the other actions, which we
call sympathy.
98. There is also another kind of action which we
call habit. actions frequently repeated in any 
part, induce a custom of acting in a given manner,
in any certain part; & from this [illegible]
a part to any such action, habit arises.
99. Habit is a kind of force or violence done
or superadated to the first principles: parts from
habit acquire a power of acting in a more
forcible, or in a different manner, from that 
which primarily took place in them.
100. This habit may be called a species of memory:
as memory consists in a repetition of
ideas once taking place in the mind, so habit
consists in a frequent repetition of action
in any moving part of the body.
101. Habit is similar to a body once put in 
motion, which will not cease from motion
unless some new cause for obstructing motion 
arise
102 Habit becomes a course of motion, not only 
in parts accustomed to that motion, but also may 
be a cause of rest at that time in other parts.
like a body once put in motion it does not require
a renewal of the same & equal degree
of force which first gave it motion, but the addition
of a small quantity of [illegible] force is sufficient to 
 


keep up the motion.
103. Habit will even become a cause of action
in the will; it will make those actions of it voluntary,
which were involuntary & also the revers
The strength of habit will be much or little in 
proportion to the violence of the impression which 
gave rise to it.
Q When stimuli are often repeated, they lose the
power of producing sensation; hence the mind
is at last insensible of the change, hence habits
of disease arise (189) & parts got into (& go on
without the mind perceiving it, a diseased
action: hence also parts become insensible even
to noxious stimuli; to the frequent repetition
of which they have been accustomed; hence
whilst in strangers the bit of a bug & mosquito
produce disagreable effects, those who have been 
much subject to the application of their poison,
have their skin at last insensible to it.
As in the body, so it is in the mind, horrid sight
etc. produce in it at first, the greatest changes,
but by frequent repetitions of them, the mind becomes
[recon??ted] to them, & at length scarcely
an idea is excited by their impression (148.
104. As in the memory, it is not necessary, that in 
order to the recollection or renewal of an idea,
the impression which gave rise to it should
be repeated with its full force, so with respect  


to habit in parts, it is not necessary, in 
order to excite them to an equal action, that
the impression or stimulus, should be equally 
violent with what it was, when it first produced
the action in the part. Habit is always
gaining on use & little force is requisite to 
keep it up.
105. As in the mind the remembrance of impressions
which were of little force wears off unless
the impression be repeated, before the effect of the
first impression ceases, & consequently memory of
the impression will not remain: so neither
will the power of habit remain, if second impression
be not repeated before the first ceases.
106. In accustoming parts to habits, or impressions 
two circumstances will arise.
1st If the impressions be slight & after repeated,
or if the force of the impression be each time
gradually augmented, the parts accustomed 
to them, will become by degrees insensible to 
them, so that here the cause may remain, though
the effect diminishes or ceases.
2dly The effect may remain though the cause
ceases; as violent impressions will continue to 
produce their effects, long after they themselves 
have been removed; according to the kinds
of habit complied with, health or sickness will
be induced.
107. All stimuli will not produce the same effect



35.
when applied to different parts, hunger will be a
stimulus to the stomach alone, light to the eyes,
sound to the ears etc.
108. Dispositions of the mind will arise from
ideas produced from certain impressions given
to the brain; a disposition taken place may 
be compared to the state of an elastic body, when
altered from its [pristine] to some other figure;
the disposition of the elastic body to recover its
[pristine] state, is destroyed by its action in recovering
that state: so when disposition has produced
such a state of the will, as to excite the
moving powers to any action, the disposition no 
longer remains; with this difference however,
that the elastic body loses its disposition instantaneously, 
the animal by degrees.
109. When an action is excited by the powers of
the will, in consequence of a particular disposition
in the mind taking place, the brain, or the 
seat of the disposition, which might before be considered
as in an uneasy or stretched state, now returns,
with respect to the consideration of the disposition,
to a state of rest.
110. The blood which is the fluid circulating in the 
arteries & veins, is not a passive inanimate matter
but is [illegible] with a principle of life in itself,
equally with the solid parts.
111. A particular & permanent figure of parts
in a living animal is only necessary to mechanical
action; action is not necessary to the presence 



of simple life. The blood, perhaps, has not
motion in itself, but motion is not necessary to 
animal life.
112. The blood is not only alive itself, but it also
by circulation through every part of the body,
becomes the means of & carries life to other parts;
thus being the living support of every part of the
fabric; even the nerves themselves are supported by 
it, they do not convey life to parts, but only direct
the motions of parts, & without the blood, will
themselves become dead.
Q 110. 111. 112. In inflammation though the blood
coagulates more slowly, yet there is a greater 
disposition in the parts to separate from each
other. The separation will often be so perfect
that if you dip your finger into the fluid at
the top during coagulation, it will not be so colored
at all red. This inflamed blood will sometimes
be full half an hour before it is completely 
coagulated.
113. Whilst the blood is circulating in the vessels 
it is always fluid, but it is not always alive
whilst fluidity remains; if by any means the
life of the blood is suddenly & entirely destroyed,
after its death it will still remain in a fluid
state
Q If the life of the blood be suddenly destroyed
etc.
Cases in support of this
A gentleman died suddenly in a violent fit


37.
of passion; his blood would not coagulate. Two
dears were hunted to death; the blood of neither
would coagulate. The blood of animals killed
by lightning or electricity will not coagulate
sometimes, but this will depend on the manner 
in which the electric matter was applied, of so
as to pervade at once the greatest parts both
of fluids & solids, this effect may be produced
114. Whilst alive it is always fluid, if its life be
not suddenly & entirely taken away, it coagulates
as it dies & the [illegible] component parts recede 
one from the other.
115. Long rest out of the course of circulation & exposure
to the atmospheric air, occasions the coagulation 
of the blood: if unexposed to air, blood will
remain long at rest in the living body without
coagulation.
116. Organization is not necessary to life; an egg
is not organised & yet an egg is alive so blood
is not organised, yet it is possessed of life.
Q. Though the blood, when in its fluid state, has
not sensation, yet when formed into solid it may 
acquire sensation. Before blood is capable of giving
life & support to parts, it must have circulated 
through the lungs, where it undergoes 
some partial change, perhaps it is then first
completely in its second state or vivification.
117. There is a perfect harmony in a state of health
between the fluids & the solids of an animal
body; so also between the blood & its containing 



vessels. There is also a [illegible] between them in disease,
& when the solids are affected, the blood also puts
on a diseased state thus the blood is as capable
of disease as the solid parts are; so also the
blood becoming diseased, the solid parts also suffer.
Q. As the blood acquires an inflammatory disposition
when circulating through inflamed solid,
so it may lose
118. As the blood conveys to parts the means of 
nutrition & growth, so from the blood new solids
are formed, when in consequence of a disease or
violence, there has been a loss of the former ones; 
or when there arises a necessity for their promotion.
119. When there is a disposition to union in parts,
naturally distinct from each other, inflammation
will arise, which inflammation will be in 
proportion to the strength of that disposition. The
blood passing through inflamed parts undergoes a 
change according to circumstances, & from the
change wrought in this, coagulable lymph is
fitted to be formed into solids; by the soldi parts
formed from this lymph, parts violently separated
from each other, are again united & parts before
naturally severed from each other are blended 
together.
120. The living parts of the animal, both the blood
& the solids, being continually [wasting], supply is
necessary; this supply is obtained by means of
the fluid prepared by the stomach (44) but before 


39.
the food taken into the stomach can furnish the
desired supply, it must undergo to processes.
1st Animalization
2d Vivification.
from living matter, only, living parts can be made.
121.f Sensation is not necessary to life, the blood
may therefore be alive, though it wants sensation.
Heat.
122. A certain degree of heat is necessary to the
preservation of animal life, whether existing in 
fluid or solid matter.
123. A certain degree of heat is necessary to animal
life (122) a great degree is necessary to 
animal action; below the former the animal cannot 
retain simple life, below the latter, though
it may retain simple life, it will not retain
the power of action.
124. Almost every order of animals requires a degree 
of heat peculiar to themselves: some animals
will not endure this heat to vary much from
a common standard, as through abolition of the actions 
of life. A bee requires its heat to be kept up,
a wasp will suffer its heat to vary with the heat
of the atmosphere.
125. In the state (121) digestion & generation & other 
faculties will be suspended, & the animal remain
in a torpid inactive state.
126 All animals in themselves have a power of
generating heat, when the arteries of the external [illegible]


are so great, as to endanger the preservation of
life; this power arises wholly from the principles 
of life, for dead animal matter possesses no power
of resisting cold; this generation of heat is truly 
life operating against its destruction.
Q An explanation of the power animals have
of generating heat was attempted.
1st By supposing it to arise from friction; but between
the particles of fluid there can be no friction;
nor between the particles of solids can
Heat be produced by friction, if fluids be [???osed].
Then the wheels of a coach are prevented 
from generating heat by greasing them. 
2d By fermentation (Dr Stevenson), but the  fermentation
of animal substances does not produce heat
3d From inspiring the atmospheric air, this seems to 
be contradicted by the following case.
A man had a contusion of his brain, his respiration 
was exceedingly slow, breathing not above
five times in two minutes; yet he had a general
warmth upon his skin though in February, & the
[clotting] was [illegible] there. The power of generating
heat & cold depends simply in the principles 
of life independent of circulation, the influence 
of the nerves etc. This is finely illustrated in the
care of a gentleman who was seized with an apopleptic
fit; whilst he lay inensible in bed & 
covered with blankets, his whole body would in 
an instant become extremely cold in every part, & 




41.
continue so for some time; & in as short a time became
extremely hot; this was going on for some hours alternately,
yet there was no alteration in the state 
of the pulse, as in the excitability of his sensations
127. The heat of all animals is diminished during
[illegible] & whilst in a state of torpor, but more or less in 
different animals.
128. Variations of heat in the atmosphere will produce
different changes in the heat of different [illegible] animals; 
some animals as man & those which are
constantly in action, have their heat little changed
by this variation.
Q In animals which are in a state of inaction during 
the winter, as sleeping animals, the heat will
vary with the season. The state of the hedge hog
in summer is from 91 to 97; In the winter when
the atmosphere was 44, the heat of the same
animal was 45. The experiment was made on 
its pelvis.
Animals who suffer their heat to be diminished
with that of the atmosphere, suffer it to be as readily
in creased to a certain degree, as that of dead
matter, a living & a dead carp were both placed in a
mixture of snow & water, which was gradually heated,
& both received heat one as fast as the other. 
Q different parts of the same body will have different
degrees of heat, & different powers of generating
it. The projecting parts of the body in man as the
nose & penis will be colder than other parts; the
urethra will be colder than the rectum, & the 


abdominal cavity. the standard of heat in the centre 
of the human body is about 99.
129. animals will suffer their heat to sink below
the freesing point, before they will be frosen Experiment
in eggs.
130. The stronger & more healthy the internal powers
of the animal, the more powerfully will it generate
heat.
131. Cold applied to animals in a certain degree,
proves a sedative to the powers of life, but applied
beyond that degree, it proves a stimulant, and
the faculty of generating heat is excited in an 
extraordinary degree.
132. Excess of heat may prove destractive to animal
life, as well as too great a diminution
of it: the principle of life is, therefore, induced
with the property of generating cold when the external
heat endangers the life of the animal.
Q. Animals have two powers of resisting heat, [illegible]
only one of producing it) they are by the evaporation of
fluids, but as when fluids become condensed
on the surface, instead of being evaporated, they will
not answer that purpose they have, which is of actually
destroying heat. As the extremities, or projecting 
parts are more subjected to be influenced by 
cold, so they more readily allow their heat to be 
;increased, than the central parts. From Dr Fordyces
experiments in a heated room, it appears that 


43.
the human body will for some time bear heat
with impunity, & such heat as is sufficient to boil
eggs, or roast beef stakes; The gentlemen present
in it found that when they moved from one place
to another, in the latter they found the heat also
more intense, than that they had been some time
standing in seemed to be when they left it. So
also in the hot bath, the bathers find the water
immediately in [contrast] to their bodies cool,
& they must either have the water agitated, or
move into another part of the bath, to procure
the first sense of heat.
133. Neither excess of heat, or excess of cold, will destroy
the life of an animal, untill its powers of generating
heat or cold, are exhausted; then the animal 
must of necessity perish.
Q. The operation of generating cold seems to [illegible]
on as animal much more than that of generating
heat. Before an animal perishes in consequence of 
cold, sleep is induced, an irresistible
propensity to which always comes on when the
powers of action for the generation of heat are
exhausted. The case of Dr [Solander] & the people
with him at the Tiera del Fuego is a manifest & 
melancholy illustration of this. After bearing for
a long time an excess of cold, several of the drs 
attendants found this disposition to sleep. In spite 
of his remonstrance, who was aware of the extent
to which it was a precluded they lay down 



& slept, & presently died.  At length Dr Solander fell
& gave way to the same disposition; he had not
been asleep above five minutes, before his feet
became so contracted that his shoes fell of them 
& he lost use of his limbs, he was however 
found, brought away to the fire & relieved.
134 All the perfect animals carry on their actions
in an atmosphere below the torpor [illegible]
of the body, for it seems a natural & healthy 
action for an animal to be constantly exerting
itself moderately in the generation of heat.
135. Different animals as above mentioned, 
either preserve a standard heat, or have their
heat increased or diminished with that of the
atmosphere; yet all animals require a certain 
degree of heat for the standard in which 
their functions are best performed: many 
animals are obliged to the atmosphere for a 
standard heat, whilst man & many of the perfect
animals, have, from their faculty of generating
heat & cold a [illegible] of giving a standard
heat to themselves.
Q The best atmosphere for the human subject
seems to be 63 to 60 Bear & fox 50 Lion
& monkey 70. The animals inhabiting cold
climates have stronger powers of generating
heat than the huma, preserving every part
of their bodies free from injuries in countries where
men are losing their feet, hands, 


from cold. Cold causes the hair of the bear to 
grow much faster & finer, hence they are better 
defended.
136. The effects of a climate will correspond in 
a great measure with the influence of the sun in 
that climate, so that as the climate is exposed in 
a different manner to & is differently [illegible] upon 
by that body it will be hot or cold moist or dry 
or it will be hot & moist, or hot & dry.
Q Between the tropics the heat is greatest: In islands,
the heat or cold is always more moderate
than in continents. Some vegetables have a power 
of living in both extremes of climate. Some 
animals seem also to have this power: perhaps’
animals of passages as birds & fish change their
residence more from want of food, than from the 
inconvenience they feel from a given climate.
Q Some animals which have no power of getting 
their food in the winter, nature has given the
power of remaining during that season in a torpid
state. As the power or generating heat is not equal
to the degree of cold, nature has taken another
method of preserving animals of the very frigid
climates with down, fur etc. which are bad conductors
of heat: so also whatever animals have 
their bodies well covered with hard fat, which is, also,
as oils are, a bad conductor of heat
For most external heat produces diseases of
the liver, spasms, diseases of the bowells, tetanus etc. 


diseases of cold climate are more slow in their action,
& many of them depend on debility as chilblains 
etc. Cold climates also increase diseases, which 
they are not the cause of, as the venereal diseases etc.
137 The effects of heat & cold will be greater according 
to the degree of the surface of the climate a
small surface will be less hot or less cold than 
a larger.
138. The effects of climates will be very great 
in animals bodies; the imperfect animals bear 
changes of climate very badly. Many & many quadrupeds
can accommodate themselves to almost
any climate; yet great changes of climate
prove the causes of disease & distinction, both
to man & those quadrupeds, especially to the former.
139 Besides our being influenced by heat & cold
our bodies are surrounded by, & subjected to the 
influence of the atmosphere, which will always be 
of the same temperature as the climate
we live in
140. This atmosphere having a power of dissolving
a variety of bodies, will be compound of many 
heterogeneous particles.
141. The atmospherical fluids having a [constant]
& powerful influence in the animal body, according
to the nature of the particles of which 
they consist, they will materially effect the health
of animals 
142.


142. All bodies which the atmospherical fluids take
up & dissolve, are to be considered as in a state of 
[illegible]; to render substances volatile some
degree of heat is acquired; perhaps the lowest degree
is sufficient then to act upon some bodies; according
to the degree of heat, the atmospherical 
fluid or the air will be enabled to take up 
a greater variety & a greater or less quantity of 
bodies.
143. The purity or impurity of the air will depend
upon the quantity & quality of bodies dissolved
in it, & its capacity of dissolving them will 
be according to its heat
144. Cold climates will be for the reasons given 
(139, 140) [illegible] [illegible], found the purest
air & best adapted to maintain health, nevertheless.
145. Heat in warm & dry climates has the property 
of causing bodies taken up by & dissolved 
in the atmospherical fluid to be decomposed,
& thus changing their nature, renders them less
noxious
Q Thus the plague, Int fevers etc. are unknown
within the tropics. another reason why hot
climates are not so subject to putrid & contagious
diseases as might be expected is, as the
termites, as described by Mr [Smeathman], eat up 
& destroy in a curious manner making quantities
of dead animal & vegetable substances;
thus preventing them becoming putrid enough 


to throw off volatile noxious particles; for before 
any animal substance can throw off noxious
vapours to produce contagion, it must be highly 
putrified.
146. Heat & moisture, especially when dead animal
substances are acted upon by the air, produce
the most unwholesome atmosphere.
147. This air will be injurious to the health of 
animals, by effecting them in their distinct manners,
viz.
1st Buy its being simply impure, it lessens the fitness
of them for their several functions.
2d By its containing specific particles of contagion
3d By its containing poisonous vapour
148. Habit, and custom etc. Prisoners have carried
the seeds of the jail fever & communicated it to 
others by their cloaths, though they themselves were
free from it; of this we have had memorable
instances at the oil Bailey & at Oxford assizes.
again persons who have never had the small
pos themselves have [illegible] others labouring under
it with impunity & have on visiting other people,
who have never had the disease, communicated
to them the contagion.
149 All irritating substances will not act in a 
state of vapor, or are not capable of volatilisation.
150. Water is in greater or lesser quantities chemically 
combined with air, when a decomposition


49
of this solution of parts in air, takes place, rain is produced:
previous to this decomposition animals are
sensibly affected, [illegible] & birds vary much so; the
human subject unless unhealthy rarely perceives
much difference.
Q Thus previous to a shower, we see the beasts running
to the covert, the birds flying to the thicket 
People with corns are capable of presaging the decomposition 
of the atmosphere, & also parts labouring
under great debility.
Hence doubtless, people who have had fractures
have the part where the callus was formed, sensibly
affected on changes of weather: is not tis because 
new parts are weaker than original parts? as will
hereafter be shown.
151. The decomposition of substances in the atmosphere
may be succeeded by new compositions from 
which various effects may arise: hence to determine,
a priori, the effects of atmospheric air, is extremely 
difficult.
152. Noxious particles to change by the air of one
climate may be conveyed to another; thus winds 
by bringing noxious particles in their current from 
distant climates, may materially affect & alter
the solubility of any given region.
Q. The [illegible], a wind that blows from the interior
coast of Africa, shows how much winds may 
affect animal bodies, it continues from two or
three to fifteen days, returning three or four times 



a year; it blows moderately; its accompanying fog
& gloom are very considerable; surely this fog & 
gloom cannot be animal [illegible], as we do not find
any thing produced by them: not the least moisture
can be found in this wind, it makes the lips & 
fauces dry & chapped, if it continues three or four
days the cuticle peels off, continuing a few days
longer the perspiration becomes acrid, & in so to 
the taste: it is yet highly conducive to health:
convalescents recover fast, also those labouring
under intermittents, dysenteries etc. are cured;
it checks epidemics; a number of people are inoculated
to the accession of the [illegible], but 
the small pox did not appear, some inoculated
after the wind ceased had it & recovered perfectly,
except one girl who died of a locked
jaw in consequence of a large [illegible] inoculation.
153. Matter will be found either in a state of 
perfection or imperfection, if in a state of perfection,
health is present, if in a state of imperfection, the 
reverse or disease takes place; this maxim is 
universal, it will therefore hold respective animals
as well as inanimate matter.
154. In order to disease being present, three
circumstances must take place
1st Susceptibility of certain impressions 


51.
2d Disposition arising from those impressions.
3d Action in consequence of a disposition.
155. In respect to these requisites the body
bears a perfect analogy to the mind, which must
be susceptible of impressions, must receive impressions,
must have a disposition arising in it, to which 
an action of the proper kind must succeed.
156. Susceptibility of impression is not sufficient alone
to produce disease, but impressions of some
kinds must be received by parts, [endorsed] with 
that susceptibility, which a disposition being produced,
an action naturally succeeds. 
157. Disease being a perversion of the regular laws
of nature, observes less order, therefore, their phenomena
are less easily to be explained, & accounted
for than natural actions.
158. With respect to the changes taking place in 
the body, we know only the cause of them & their
effects; we know not the manner in which those
causes produce these effects.
Q Thus a strain gives occasion to scrofula, a blow
to cancer, moreover, different parts will be more
or less able to resist a diseased action; this in general
will be in proportion to their strength & weakness:
the different parts of the body may have 
their natural actions very dissimilar: yet disease
may produce similar actions in them
as for instance, the lung & the liver have dissimilar 


natural actions in them; yet disease
produces a similarity of action, when they are
affected with scrofula, a disease of which 
they are both susceptible, & which is not a specific
affection.
159. We can judge only from the consequences of 
impressions of the degree of susceptibility of the
mind & body; the causes of action in the body
bear a strict analogy to the causes of action
in the mind.
160 As the human body is compounded of parts 
very essentially different the one from the other,
the diseases of different parts will vary very 
widely: so also the constitutions of different bodies
greatly vary, & of course the susceptibility
of different impressions; in some, the susceptibility
for particular diseased action, is so strong as
only to require the habitual actions to be obstructed
to run into disease
161 Constitutions will be either universally subject
to the same action, as the indolent and
irritable, or constitutions will be subject to 
some specific kind of action, whether local
or general.
162. Constitutions are both generally & locally 
subject to particular actions.
163. Constitutions are subject to particular kinds
both of local & general actions.
164. Constitutions susceptibility may be threefold
1st



[53]
1st Universal tendency for diseased actions of
some kind or other, where, however, the whole
must be in action
2d Universal susceptibility of local action.
3d Universal susceptibility to fall into an 
universal disposition, as though something
was teasing the constitution, as in inflammatory
fever etc.
165 Dispositions are natural, unnatural, or 
diseased; of the natural disposition of the sensitive
or irritable parts, instances are given in 
the secretions of glands.
The natural are divided into three kinds,
1st Disposition to restoration in parts injured
as in fractures etc.
2d Disposition from necessity, as in ulceration.
3d Unnatural dispositions of all kinds
of which great is the variety; the diseased
disposition is that which tends to the destruction
of parts.
166. Every disposition to diseased action, has
a certain time allotted to it, in which that action
will be produced, in some sooner than in 
others.
167. A disposition once formed will go on to 
action & its ultimate action be produced, not 
withstanding some time intervenes unless the
disposition can be destroyed by some change.
Q A girl in the West Indies had a disposition
formed for leprosy; it was some time after she 


came to England that the disease appeared;
[illegible] there was a considerable space between 
the disposition & the action of the disease. In some
specific dispositions years may intervene before
the action commences, as in cancer.
We should not confound dispositions
with actions; dispositions are properly the 
disease, actions the effects of the disease. Diseases 
may exist for a time, though the action 
is superadated as in agues.
168. In diseases, dispositions & their consequent 
actions are of three kinds.
1st Where the disposition has the action frequently 
seperated, without the disposition
itself being destroyed by that action
taking place.
2d Where disposition is destroyed by action,
and the action ceasing, the disease also 
ceases.
3d Where the different action continues to 
go on without removing the disposition
untill the progress of it be destroyed by medicine
Q In the first we have instances in the small
pox, measles, inflammations & fevers, of the 
second in agues, where the disposition to action 
continues, through the action only commences & 
goes off at stated intervals, the disposition in 
the system for action remaining undestroyed
by the action, & until it has lost its power of 



exciting the system to action; the diseased disposition
existing as much between the fits, as
during them, of the third we have instances in 
some specific diseases, as the venereal (gonorrhoea 
excepted) cancer & others, where the disposition,
notwithstanding the action, continues
to exist, because it cannot produce its full
effects; hance it will go on untill it destroys, unless
the disposition be removed by an immediate
increase of action.
169. Two different and opposite actions cannot
go on at the same time, neither in a part, nor in 
the whole: if by means of any disposition, a new
action is produce, the first action ceases.
170. If two dispositions be excited, not to different
& natural actions will be produced at one
time, but a third simple disposition & consequent 
action will be generated, which will be entirely
& altogether distinct from the other two.
Q Of this we have an instance in Dover’s Powder,
which consisting of opium & ipecacuanha, a narcotic
& an emetic, sleep & vomiting should be the 
actions, but as two actions cannot take place 
at one time a disposition to a third action arises,
which produces that third action & is called
sweating.
171. Of susceptibilities for diseases, there will
be great varieties, as above said (  ) for every 


disease there must first be a susceptibility.
172. In diseases either too great or too little a 
degree of actions will take place, & to these
two general kinds of action oof the phenomena
of diseased action my be referred.
Q Too little action in any parts produces weakness in 
it, which although not a disease itself, becomes
the cause of diseases. It causes irritability & thus
gives rise to morbid & irregular affections,
as the locked jaw etc. Mr Hunter says that if the
nerves are weak, the voluntary parts suffer, if
the stomach be weak, the general system suffers.
173. Diseased action will be common or specific.
Specific actions follow certain determined dispositions
arising from peculiar kinds of impressions
Q Inflammation arises from too great a degree.
if a specific action accompanies it, a specific inflammation 
will take place.
174. When part [illegilbe] to a particular sensation,
has that particular sensation, the first [alarm]
or knowledge of disease is given to the 
mind; but the action of disease is often so slow
as not to be sufficient for a long time to produce 
any sensation in a part.
Q By increased actions in parts we become sensible
of their action, which before we were 
insensible of; thus palpitation of the heart makes 


as sensible of the hearts action; of this we have 
not perception in the natural state of the organ.
The whole body being subject to similar actions
with those arising in parts as observed (17) the first
attack of disease is probably intimated to the
mind by the feel of health; previous to the attack
of some diseases it is not unusual for persons
to be sensible of an uncommon degree of
health & spirits. Here the several powers are,
as it were summoned into action to resist or
destroy disease.
175. The whole animal body will be subject
to many actions & degrees of action, similar to 
what arise in parts.
176. Whenever a part heretofore subject to 
the will takes on an involuntary action, the 
disease is called nervous.
177. Whenever the action of a part is superior to 
the strength & power of a part, debility & perhaps
the destruction of the life of the part will ensue
170. a diseased action in one part may first produce
a particular sensation in another part,
then the first knowledge of disease will be conveyed
to the mind by sympathy.
Q. Sympathy will hereafter be more fully explained,
but an example in illustration of the
[illegible] may be given in the pain in the knee being
often the first symptom of the disease in the hip
joints or again in vomiting being sometimes excited





by passing a bougie through the urethra,
though there is no pain in it.
179. Actions are not hereditary, but susceptibility
of impressions, the cause of dispositions, the cause
of action may be hereditary. Thus diseases are 
not hereditary, but a susceptibility of impression
which is to produce a particular disease, it
may be hereditary.
Q. A variety of diseases have been considered as
hereditary, but it is only the susceptibility of any
disease; so that the child shall be more susceptible
of an impression producing that disease than 
other people: this is all that parents can communicate
to their offspring. Mania has been
supposed to be hereditary & in some it seems
to arise spontaneously, without any apparent
exciting cause, as impression; an explanation of
this will be found (  ) where it is said that
in some the susceptibility for a given disease
is so strong that they will run into it, without 
any other exciting cause, than simply some [instructions]
to the natural actions.  The small
pox is equally hereditary with mania or scrofula.
The gout is also considered hereditary, 
but it is in general otherwise & brought on by 
irregularity in living: but it sometimes arises 
in persons under eighteen, then it must be considered
as hereditary in the same manner, that 


[59]
we have considered mania to be hereditary viz
to originate from a strong susceptibility of the given
disease, ready to take it without any visible
cause, & only from some [unseen] one, as the least
obstruction to the natural arteries. The gout is
a disease of the constitution, until it falls upon 
a part, & then the full action being there produced,
the local affection relieves the constitution.
180. When the different specific impressions, naturally 
productive of too distant specific dispositions,
are given to the system, too distinct dispositions
to specific actions may be formed; but 
the action of one will be suspended during the
action of the other; that being finished the suspended
disposition may produce its action.
Q. The small pox & measles cannot [illegible] in
action at the same time, but one disease will
be prevented from action, untill the other has
gone through its natural course.
Case 1st Mr Poole was inoculated for the small 
pox, in a few days the redness around the puncture 
appeared; but he was attacked with the measles,
which suspended, for a considerable time, the eruption
of the small pox, which, however, on the decline
of the measles appeared & went through its usual
course.
Case 2d A lady was inoculated for the small
pox, the measles appeared soon after, & the further 



progress of variolous infection was suspended untill
the measles were over.
Case 3d A boy was inoculated & the same events
took place.
181. Actions must always correspond with disposition;
if the dispositions be simple, so will the 
actions also.
182. Too great or too small a degree of natural
action will cause a disposition to disease.
183. In health there must be both a due degree
of strength as well as susceptibility of action;
moreover the actions must always be in proportion 
to the strength. 
184. The human body is continually undergoing
some changes; it has been considered to be either
in an increasing state, as between birth & 
manhood, when the parts are continually increasing
either in bulk or firmness; to be stationary,
or preserving with little alteration, its 
strength & firmness during a certain period; & or 
lastly to be decreasing, when it loses gradually 
its vigor & firmness. But these three states or 
conditions of the human body, are not explained
by proofs, it is difficult to say where the body, 
in all its parts, is arrived at its perfect state,
& it is difficult to say that the body, as soon
as it has attained to its perfect state, does not
begin immediately to suffer, tough for some time
an insensible, yet a real & gradual decay. 


[61]
185. It is certain, however, that at different periods
of life, the susceptibility of the body for different
dispositions, will be very different; hence different
ages will have diseases in some measure
peculiar to themselves, & these may be divided
into
A. The diseases of youth.
B. The diseases of manhood.
C. The diseases of old age.
186. The diseases of the first & last stages are
many, those of the second are fewer.
Q. The diseases the first stage is particularly 
subject to, are scrophula, consequently diseases 
in the lungs, complaints in the bowels from 
worms etc. hydrocephalus. The young are more
disposed to local & especially universal sympathy.
The middle ages have few specific diseases, if
we except nervous & hypochondriacal disorders,
they are, however, accidentally attached with the 
complaints of youth & age, & this lays a foundation
for disease in a more advanced age.
In the aged we have a variety of disorders;
have the necessary actions are not well performed: 
proper to this stage are cancer, calculi in the
bladder & gall bladder & ducts, ossifications
of arteries etc.
187. The causes producing disposition to diseases
are many & various; when impressions are given 




which are to produce diseased dispositions,
the disposition will vary very much according
not only to the constitution & natural sensibility 
of the body, but according to other circumstances.
188. Whatever can affect or alter the natural
susceptibility of the body will produce variety
of disease, therefore the differences of climates
& seasons, the moon, the atmosphere, will produce
differences of disease, & each absolute
state of climate, atmosphere, moon & the year, 
will have a disease or appearances of disease
peculiar to itself: moreover, affections of the 
mind will produce diseased actions; the weather
the natural powers of action in a part are,
the less able will that part to resist disease,
therefore tendons, bones etc. have less power to 
resist disease than muscles etc.
Climates 
Climates are hot, cold, and temperate; in hot
climates the involuntary actions are carried
on with more violence, whilst the voluntary
actions are more sluggishly performed.
So diseased actions are carried on with more 
rapidity & violence, hence diseases run through
all the stages in their climates, faster than 
in others; when disease kills, absolute
death, that that is putrefaction, quickly succeeds
visible death. Cold climates have not such a variety 



of diseases as hot ones, neither is the progress
of them so rapid. Cold invigorates the voluntary
actions, at the same time it lessens the violence
of the involuntary ones.
In cold climates simple life is not destroyed
untill some time after visible life is departed, for
putrefactions does not so soon follow as in hot
climates.
Temperate climates from the irregularity of
the medium between heat & cold, furnish us
with a greater variety of diseases than either of
the others. Hence scrofula, colds, agues & such
like diseases [observed].
Seasons.
We may consider a change of seasons as a 
change of climate, & as in changes of climate,
dispositions formed in one climate, by removal
into another are retarded from coming into action,
so upon returning to one similar to the first,
they go through their action.
The spring, as it were, ripens diseases & bring
them into action, for a disposition may be formed during
a season, which had not sufficient influence to 
bring it into action, as the winter; but in a season 
more favorable to the forwarding that disposition,
as the spring, that disease has been brought
into action. So also it is in climates.
The moon becomes often the immediate cause of 
diseases, especially those in which the mind is particularly 


concerned, as in madness, which is always
more violent at certain times of the moon; The
full of the moon also affects people whose brains
have been injured by an external violence: this
was instanced in a lamp lighter, who received a 
fracture of the cranium with concussion of the
brain; he was trepanned & recovered, but ever
after found himself much affected at the full of 
the moon. The seasons of the year affect the influence
of the moon on the human body; the lamp
lighter was additionally affected in spring.
A person of very scrofulous habit was very
subject to deafness at the full of the moon, except
in autumn.
Affections of the Mind.
Every action, voluntary or involuntary, may be
affected by changes in the mind; by a peculiar
state of it. [bl??ting] may be produced; other states
of it excite vomiting, sickness, irregularity of 
pulse, diarrhoea, discharge of urine, spasms etc.
The diseases on which the mind has the greatest
influence, are those in which increase or diminution
of action takes place without any alteration
in the structure. Constitutions that are called
irritable, have the active parts more under
the action of the mind, & less under the command
of the will: the state of the mind greatly affects the
involuntary actions that have already taken
place in consequence of disease. Agues have been 


cured by affections of the mind; local affections are
even altered by the same means; tumors have 
been cured by rubbing them with a [head] [illegible]
[illegible].
189. Diseases are 
A. Local.
B. Constitutional
or
C Fixed.
We judge of the presence & nature of diseases by 
their symptoms. a symptom is a sensible effect 
of a peculiar action. Symptoms are either to be 
referred to the mind or to the senses. The former
are only known by the patient, as pain etc. , the
latter a perceptible to the physician, as the 
state of the pulse etc.
When the symptoms are not expressive of the
disease, we call them anomalous; symptoms are
either local or universal.
190. In simply local diseases, a part may suffer,
the general health of the body still remaining unaffected;
in the mind both a part & the constitution
are affected
191. Diseases may be originally local, or originally 
constitutional; or again they may be constitutionally 
universal, or constitutionally local, or
lastly, they may be originally local, & at length
affecting the general system, become constitutional.
192. The originally local (191) & the originally constitutional 


may arise in the same person, at the
same time independent of one another.
193. Dispositions, as above said, must be formed
previous to the existence of disease, so that there
will be disposition to produce originally local
effects, an universal disposition to produce local
effects etc.
194 An originally local disease may take on 
a part of a constitutional one, when the former
has been only commonly diseased action; but a 
local specific disease will not take on a part
of a specific constitutional disease, unless the 
latter has superior powers, in which case the former 
local action will be suspended during the
presence of a new specific action.
195. A constitutional disease may be the cause
of increasing or diminishing a local disease, & a
local disease may be the cause of increasing or 
diminishing constitutional disease.
Q. This should seem to refer only to common 
diseased action; of this we have an instance
in fevers curing or increasing an ulcer, or a 
sore increasing.
196. It frequently happens that a local disease
disappearing, some other will appear. 
197. A diseased action once formed, will go on
increasing untill either it is destroyed by a new
action having induced in a part or constitution, or 
untill the parts to which it is spreading lose
their susceptibility of the disposition to that action, 





or untill it produces an abolition of life.
198. Diseases will be either common or specific.
199. We cannot increase specific diseases unless
we can increase the susceptibility of the
constitution of these diseases; every specific disease
will have two modes of action, the specific & the
common.
200. If the constitution or a part be susceptible of
impression from a peculiar stimulus & a peculiar
disposition is excited, then a specific disease may 
be produced & that specific disease may be either
local or constitutional.
201. When A an impression is given to any 
part susceptible of action, & the action is not produced
in the part, to which the impression was
given, but in some other part; or B when an
action formed in one part produces an action 
in another part, or when an action is formed in one
part & the sensation resulting from that action is 
felt in another part, sympathy takes place.
Q A as in disease of the hip, where it is no uncommon
a thing to have the patient complaining
of his knee.
B. as when a stone in the kidnies produces sickness
& vomiting; as when an impression is given to 
the urethra the testicles become swelled though 
at the time they shall be free from complaint
202. The part (201) receiving the impression, is the [sympathant], 
the part in which the now consequent reaction


or sensation arises, is the sympathiser.
203. A Sympathy is simple or compound.
B Similar or dissimilar.
C Regular or irregular.
D Natural or unnatural.
E Real or delusive.
F Partial or universal.
G Contiguous, continuous, or remote.
H Common or uncommon.
204. The more simple the structure of the being
which is the object of the operation of sympathy, 
the more simple will the sympathy be found, 
even some vegetables are susceptible of it,
the sensitive plant, whose leaves successively
dropping on approach of the hand, arises from 
this simple sympathy between the different
leaves, in successive order sympathising with 
one another
205 In the more compound being, as the perfect
animals, the sympathy may be more [complicated],
for an impression being given to one part, becomes
the cause of action in another part, the
actions in the last part becomes a cause of action
in the third part, & that again in a fourth
part; hence in many animals sympathy may 
become exceedingly complicated.
206 When a part receiving an impression, an
action is formed in it, & a like action is consequently 


[69]
produced in another part, the sympathy is similar
but when the action in the one or sympathiser is
different from the action in the other or sympathant,
the sympathy is dissimilar.
Q. If one part be affected with pain & another
part by sympathy gives the same sensation, then 
the sympathy is similar & vice versa A pain
in the testicles producing by sympathy sickness
in the stomach, the sensation & action in the
latter being different from those of the former; the
sympathy is dissimilar.
207. When an action of a peculiar kind in the
sympathiser has always been observed to producing an impression
& action of a peculiar kind in the sympathant,
such an action in the sympathiser
arising consequent on the impression & action in 
the sympathant is called common sympathy;
as also when a particular part being the sympathant,
another particular part has been observed
to be constantly the sympathiser.
Q. We observe affections of the brain produce
sickness & vomiting, & thus almost invariably;
here we have an example of common or ordinary
sympathy. By attending to this division
of sympathy, we learn a knowledge of the 
symptoms of disease. Some common sympathies,
though but few arise in consequence of disease
only & are therefore unnatural, such is the sympathy 



between the shoulder & the liver between
which in health there seems to be no sympathy.
208. When an action of an unusual kind arises
in a symphathiser, or when the sympathiser is 
a part unused to action consequent on an action 
in a given sympathant, uncommon sympathy
is said to arise.
209. Sympathy is natural, when the sympathant
receiving an impression not productive of disease,
& healthy consequent action is produced
in the sympahtiser; thus the breasts of women
are affected previous to the coming on of 
menstruation.
210. Unnatural or diseased sympathy is when
an impression given to the sympathant produces 
an affection of the sympathiser inconsistent
with its healthy or natural action; so scratching
an issue in the thigh which itched has produced 
a difficulty of breath & pain in the 
breast.
Q The father or the great Lord Chancellor Clarendon
had a stone in his bladder, he was afflicted
with it many years & when it was painful
was always accompanied with a pain in his 
arm.
211. Sympathy is real, when the mind refers the 
affection or sensation produced, to the proper sympathiser,
& delusive when the mind refers the
sensation, action or affection to sympathiser between 


which & the sympathant no possible connexion
can exist. Thus when a man under [illegible]
or delirium, has an impression given to any 
part of his body, & his mind believes the sensation
consequently produced not to exist in 
himself but in some other person, he is under
a delusive sympathy.
Q. A man in a fever & delirium, when he wanted
to go to stool, always signified to the bystanders,
that some other whom he talked of 
or pointed out wanted to ease himself, referring
his sensation to some other individual.
212. Sympathy is partial, where one or more 
parts of the body are sympathisers, some given
part being also the sympathant. It is universal
when an impression being given or an action excited
in any part the whole constitution sympathises
with it; so a wound being made in the
knee, a fever which is the action of the constitution
sympathising with a part, will often arise.
213. Sympathy is continued, when a part receiving
an impression & a consequent action arising
in it, the parts immediately joining & connected
with it, are also thrown into action; thus when
an inflammation arises in a part as the skin,
& spreads wider & wider, the parts of the skin
to which inflammation spreads from the first point
are suffering by continued sympathy.
214. Contiguous sympathy arises, where an impression  


being given to, or an action excited in a part, the
part or parts contiguous to, but not joined & immediately
connected with the sympathant becomes
the sympathiser. Thus an affection of the 
integuments of the abdomen will produce consequent 
affections of the bowells.
215. The sensitive principle, the principle of 
life & the mind mutually sympathise with 
each other, so that affections of the one will
produce affections of the other, or of both the others.
216. Remote sympathy is where the part which 
is the sympathiser is distant from the part which 
is the sympathant, as when a diseased testicle
should produce a sickness at the stomach.
217. Some parts are more particularly disposed
to become sympathisers than others, the stomach 
will sympathise with any part of the 
body.
218. Particular habits are more disposed to universal
sympathy than others; the less determined
is the disposition to partial sympathy, the 
greater will be the disposition to irregularity
and universality of sympathy. Thus infants are
particularly subject to universal sympathy, because
when an impression is given to any part
of their body, their partial sympathies not
being yet settled or determined no particular
part is disposed to become the sympathiser, [illegible]
the constitution takes up the sympathising action 



219. The strength of regular & partial sympathy
will be greater in proportion to the strength of the
power of life & vice versa.
Q I must remark on the text, “that the strength of 
regular & partial sympathy will be in the ratio 
of the powers of life.” I think here we must
make a distinction between a readiness or
susceptibility of sympathy & a strength of sympathising
action; perhaps debilitated & most irritable
persons & those in whom the powers of life
are weakest, are the most ready to fall into sympathy
of every kind; but the strength of the sympathising 
action will in them be but little,
because the sympathiser can have but little
powers of action.
220. The affection of the sympathiser will often 
be more violent than the affection of the sympathant,
but this will depend upon the number 
& the nature of the part & parts taking up the
action of the sympathant, & thus becoming the 
sympathiser.
Q The brain sympathising with some other
part, convulsion, epilepsy, or a sudden abolition
of the visible life may be the event; the action in 
 the sympathiser being here more violent than 
in the sympathant.
221. The vital parts are particularly disposed
to partial sympathy between one another, the 
farther parts which are sympathants are removed
from the heart, the greater will be the 
disposition of the constitution to sympathise 



with them.
Q. Thus in diseases of the extremities, the constitution 
is exceedingly ready to run into hectic fever,
as in [white] swellings of the knees, arms, or
ancles, but the latter part of the text in this paragraph
can only refer to the non vital parts,
for the constitution is always most disposed to 
sympathise when a part necessary to vitality
is affected.
222. Sympathy, being only a secondary action, 
will cease when the first part is destroyed, thus
if a diseased or ulcerated joint be attended with 
hectic fever, quick pulse, restless nights etc., almost
immediately after its removal by amputation 
the pulse grows slow & calm & the patient
recovers his sleep.
Q. Instances of mutual sympathy are but few,
the stomach will indeed sympathise with the
head & the head with the stomach, but the
liver is perhaps never the sympathiser when
the shoulder is affected, though a morbid change
in the liver, produces very commonly an [illegible]
sensation in the shoulder.
223. Sympathy is of many & important [illegible]
in the operations of life; it connects the principles
of different parts, it enables one part
to assist another in the expulsion of offending
matter; it enables one part to assist another
in the performance of its operations,
possibly when one part is affected with pain 
by enabling another to take on pain also, and 


thus differing the sensation it lessens it violence,
as the same quantity of pain being concentrated in
one part, might be insupportable to the animal, but
by its being diffused over other parts, the animal is
enabled to endure it with less injury.
224. Sympathy leads us to the knowledge of the
cause, natura & seat of diseases, by observing in 
what manner one part becomes affected from a 
prior indisposition of some other part; we learn
frequently from the sympathiser, the state, situation,
& manner in which the sympathant is affected.
225. But sympathy often leads us astray, & causes
our judgement to err; when the sympathiser is
only sensibly affected, we too frequently refer the 
disease to it entirely, overlooking or not suspecting 
the sympathant (see the notes) we are, moreover,
often led to imagine, from considering the phenomena 
of sympathy, parts to symphathants, which 
are free from the action in question; so also when 
the mind of the patient has been long habituated
to a particular idea, it frequently, but falsely
refers many sensations to the same cause, that
has given rise to that particular idea, which 
sometimes arise from other causes.
Q. Thus a man having been used to fits of the
gravel, if seized either with a pain in the back 
or loins, from any other cause, refers his pain to 



nephritic affection. (see symptoms).
226. When medicine, or artificial means are employed
for the removal of diseases, & produce either
a partial or universal effect, it is to be considered
as a kind of violence done either to a part or 
to the constitution.
227. Before a medicine can produce any except
mechanical effects upon the constitution, it must
b e reduced to a state of solution.
228. Those in one property only in the juices of an 
animal body which is common also to one
fluid out of the body; & by the solubility of substances
in which fluid we can judge of their solubility
in the animal juices; now all our juices
are more or less of a watery nature, hence substances
soluble in water, will also be soluble
in the animal fluids.
229. But not only the substances (219) are soluble
in the animal juices, almost all substances
are so in a greater or lesser degree, & most of them
are so in the mouth, as we know by then giving 
the impression of taste, previous to their doing 
which they must be in a state of solution, no 
substances having any but a mechanical action 
on a part, which are insoluble in the juices
of that part (228)
230. Many substances are soluble in the stomach,
though insensibility as earths, which are 
neither soluble in water, nor in the saliva & 


consequently are [insipid]
231. For a medicine to produce universal effects, 
it must be dissolved in the blood.
232. The blood is a kind of universal menstruum,
few substances being found incapable of 
solution in it. Its properties of retaining at once
so many substances in a state of solution, may 
arise from its heterogeneous nature, for it is
well known that a fluid, that has dissolved
one substance, though it will perhaps take up no 
more of that substance, yet will even by means
of that substance, be enabled to dissolve a second
substance for which it had otherwise 
been an improper menstruum; this water when
pure, will with difficulty dissolve corrosive
sublimate, but a saturated aqueous solution
of sal ammoniac will enable the water to 
dissolve abundantly more of the sublimate, than
in its elementary state it would have done,
so also water impregnated with fixed air to 
saturation, will still dissolve other substances,
& even such as unmixed it would not have
acted upon.
233. Medicines dissolved in the animal juices have 
a power of inflaming both the nervous & living
principle
234. Medicines perform their operations by their
a. stimulating
b. irritating or 




c sedative powers.
and by the animal body having a susceptibility of
that operation, but never produce any change unless
when they act as caustics by any chemical
operation.
235. The powers q. b. (234) are to be found in the 
same medicine, the quantity in which it is applied
only making the difference.
236. Stimulating medicines only produce natural
action, or in crease one already present, irritating
medicines alter the mode of an action already
present; sedative medicines diminish
action whether natural or unnatural; each
of these may produce both partial & universal
effects.
237. The influence of stimulants will be as the 
power of the stimulant, & the nature & sensibility
of the part taken together; the same will also
be the influence of an irritation.
238. The influence or operation of the same medicine
in different parts, will be extremely different,
so also the action of medicine on a second
part will differ from the action on the same
part, when in a state of disease. 
239. In order to understand aright the influence
of medicine, we must consider parts as capable
of four actions
vis 1st


79
1st The action of health.
2d The action of irritation on health.
3d The action of disease.
4th The action of irritation on disease.
240. Irritation acting upon health produces diseased 
action; irritation acting upon diseases
produces or restores health.
241. As parts are susceptible of a variety of diseased actions,
the removal of one diseased action will 
not always produce a return of health; a disposition 
to some other diseased action may 
have been formed, & wait only for the removal 
of the present diseased action, to go on to its 
proper action; one action can only exist at once
time. (  )
242. The irritation of medicine or disease, may 
although it removes the present disease, even induce
a disposition to some other diseased action,
which as soon as the first action ceases may 
go on to its action.
243l From (241, 242) it is evident, we should be careful 
to discriminate the consequences of disease
from the consequences of cure, we may otherwise 
persist too long in any mode of cure.
244. The powers of the living animal may also
be affected by mechanical means. The operation
of mechanical means may be reduced to 
two species, vis.
a. That of Pressure



b. That of friction.
245. Both a and b (244) produce the same ultimate
effects as medicine.
246. Pressure seems to impede action; it is also
of use as a stimulus; if applied more forcibly
it irritates.
247. Friction does not seem to impede but excite
action, if violently applied, it irritates, if gently,
it stimulates.
Q. Friction can be applied to larger surface
than pressure.
248. Medicinal applications may produce their 
effects, either simply by constant or by exciting sympathy.
249. It is rarely that medicines act simply by 
contact, their influence being carried by sympathy 
generally much further than the parts
to which they are immediately applied.
250. The effects of medicines acting by sympathy 
may be thrown with the same divisions as
the actions of sympathy. (  ) particularly, they 
will act by continued, contiguous, or remote
sympathy.
251. In directing the administration of medicine 
it is necessary to have respect to the strength 
and weakness of the part or constitution, and 
to the great or too little action of the part of 
constitution.
252. As in health the action of a part must be 


always in due proportion to its strength (  ) so in
our endeavours to restore health when impaired
we must always endeavour to proportion the degree 
of action to the degree of strength.
We must never increase action when strength 
is deficient, with endeavouring to increase strength 
likewise.
253. A. Strength of action may both be diminished
or increased. B. Action may be increased & strength
at the same time may be diminished.
In one case A it must be our care to increase
both strength and action.
In the other B we must either reduce the action
to the strength or increase the strength so as to level
it with the action.
254. Weakness and want of action are not the same 
a part may have weakness & yet too great action;
we judge more readily of too great or too little action
than of strength and weakness, because the
former are effects, the latter are often causes.
255. Medicines may act by contact (249) or by sympathy (  )
256. Medicines may also be absorbed (see absorption)
[illegible] and when absorbed will again exert their action
by sympathy or by contact; by contact they 
may affect either the lymphatics of the part, or 
of as much of the lymphatic system as they pass
through; or again when mixed with the blood, may 



by contact affect the constitution in general.
257. There are also applications, which penetrate
beyond the surface to which they are applied, as
heat, cold, electricity.
258. Heat in creases the vital & involuntary actions;
though it is considered as penetrating, it cannot
produce that effect beyond a certain degree, because
the animal is incapable either in a part 
or in the whole or receiving or containing a certain
portion of heat.
259. With respect to cold, also, the same reasoning
will apply; the animal powers whether in a part
or in the whole, will neither receive nor part
with more than certain quantity of heat, that
is without destruction of its principle of life.
260. Electricity indeed, in every capacity of the animal,
is universally penetrating, as no circumstance
or difference in the capacity of the animal
can obstruct its passage.
261. Cold, heat & electricity are capable of powerfully 
exciting action, we must therefore be extremely 
attentive to the circumstances and
degree in which they are applied, lest we sometimes
excite an action superior to the strength. 
262. In the first instance (   ) it produces heat
in which it agrees with the warm bath, with 
this difference that the latter in some measure
gives heat to the animal, the former obliges
the animal to produce its own heat; here the 



[83]
powers of generating heat are increased, the pulse
quickens, the actions of health are, in general, increased;
those effects show the animal is in full 
powers of restoration.
As the causes of these effects are instantaneous,
so the effects will be but temporary, then
the cold applications must at due intervals
be repeated.
264. In the second instance (262) it proves a sedative
& weakens, where the parts to which it is
applied can give no alarm to the constitution,
or the parts or the constitution have their powers
of generating heat diminished; have all the consequent 
actions will be the actions of weakness.
265. Cold may produce various effects, even local.
266. Heat is either absolute or sensible, the latter
we shall here notice.
267. We judge of the degrees of sensible heat by 
our senses or by measurement; this sensible heat
is either native or foreign.
268. Foreign heat in its applications will produce
different effects, as it is applied simple, or
compounded with bodies capable of themselves
of exciting action.
269. Foreign heat is applied with two intentions.
viz.
1st To increase the warmth of the animal
2d To act upon the principle of life.
that has the general property of increasing the 



violence of the involuntary actions.
Q. For the general properties & effects of heat & 
cold in animals see the text & notes on heat, cold,
& climates. 
270. According to the degree in which it is applied
it will be either irritating or sedative.
271. Substances compounded with heat are applied
either in a dry or a humid state.
Heat in dry vapors can be medicated with 
essential oils, spirits etc.; the warm bath is an 
example of humid bodies compounded with heat.
272. The bat is generally used with a degree  
of heat something below that of the animal, or
in a degree above it; the former is called the 
tepid bath, the latter the hot bath.
273. The former seems in general to soothe the 
skin, & by sympathy to effect other parts with 
an agreable sensation; hence it rarely [illegible]
nor does it, in general excite any increased action,
further than simply freeing a part from disease.
274. The hot bath produces more powerful effects;
by exciting an increased action on the surface,
it may produce relief to the internal 
parts if continued for a length of time it produces 
weakness, but not commonly a permanent 
one.
275. It is observed from (  ) that different parts
will be more or less able to resist disease. In the 


[85.]
same manner, in different parts when diseased
there will be more speedy or slow advances towards 
health, & this from the same cause, viz, the 
difference in strength & weakness.
276. Parts in which actions are excited with the 
greatest difficulty, fall into disease more slowly,
& when diseased are more slowly restored to 
health.
Q. Muscles heal or are restored to health more
readily than bones & ligamentous parts; the
cellular substance will take on the healing
group more readily of place between two muscles,
than if placed about tendons, or bone etc. 
taking on, in general, the disposition of parts it 
is subservient to.
277. [illegible] the slowness or readiness with which 
parts diseased recover their health, much will depend
on their situation in the body.
278. The power of healing, or the facility with 
which parts diseased recover their health, will also
be different during different ages, other circumstances
being similar.
279. The power (278) will be greater or more active
during the growth of the subject, than after the 
growth is stopped; during the middle age, or that 
which is called stationary (  ) though this is not 
well ascertained, the power of healing is less active;
but it will be the least active of all, during
the state of decline, when the system seems to 
take on a retrograde motion & nature begins to 


unbuild (  ).
280. It frequently happens that one disease will 
prove the cure of another.
281. One local disease being produced, may remove
a prior local disease; a constitutional disease
arising may prove the cure of a local disease
and a local disease arising may cause a constitutional
one.
282. Constitutional diseases cannot be cured
whilst parts are continually adding to the constitutional
affection.
Q. A scrophulous joint, an ill conditioned [illegible],
an ulcer in the lungs, or any similar cause 
produce a constitution affection, & those existing
in such a state, the constitutional affection 
cannot be removed.
283. When less of substance happens in any 
part & that loss is to be restored, the parts which 
restore the loss, or which regenerate the substance
to fill up the loss in their action for that
purpose, produce the same disposition with which
they were at first formed.
Q Thus the cranium is at first membranous
it afterwards, in due time, becomes bony, or its
bones shoot in membrane; if by fracture 
or other violence a part of it is removed; in 
the restoration, first membrane is formed 
& afterwards bone; so on the cylindrical
bones, as they were at first cartilaginous, 


[87.]
when restoration, in consequence of injury, becomes necessary,
the union is first by cartilage, afterwards by 
bone.
284. The law (283) does not, however, universally 
hold good, as circumstances being present may 
prevent its operation.
Q. If a part of a tendon be destroyed, as by wound 
etc., the injury extending in other parts as skin, [illegible] 
membrane etc. the process of restoration being 
began, the union will not be formed by 
means of a regeneration of tendon.
285. Inflammation is an increased action in a 
part, it is difficult to determine whether it differs
from common action in a part except in degree.
286. Inflammation is the first principle in surgery
it is the cause of may local diseases; it is the
means of preventing the increase of many local diseases,
& it is often a powerful instrument in their
cure; its operations are chiefly performed by the 
small vessels, the larger ones doing little more
than bringing blood to them.
287. It may be divided into
1st The healthy.
2d The unhealthy.
The first, that which is attendant on any healthy 
state of a part or the constitution the other, that
which stands on an unhealthy state of the
part or constitution.


288. It may be divided into
1. Single
2. Compound.
The first, the action of inflammation alone, the second
the action of inflammation with the modes of action.
289. IT may be divided according to the effects, into,
a The adhesive.
b The suppurative.
c The ulcerative.
290. The parts subject to inflammation, are
a The cellular membrane & circumscribed cavities
b All the canals & outlets of the body.
291. The three stages or states of inflammation 
may have a fourth superadated, viz that of a 
specific disposition to scrophula.
292. In the order (a. 290). the adhesive generally 
begins first, the suppurative & ulcerative are its
sequels. In the order (b. 290) the suppurative begins
& the adhesive or ulcerative follows.
293. In the adhesive inflammations, coagulable
lymph is by the increased action of the vessels 
speedily thrown out between the surfaces of the
parts inflamed, & becomes a connecting medium,
glues the surfaces of the cavities to one
another, & thus entirely obliterates them.
Q. By the effusion of coagulable lymph, and its 


[89]
glueing up the cavity, or confining the extent
of the inflammation, is formed, in fact, a cyst to 
contain the purulent matter when formed;
hence we see how matter is confined to one
spot instead of being widely diffused; by it also
is formed a cyst round musket balls, pins,
glass etc.
294. Inflammation is frequently carried on
farther than the adhesive (293.) & then it may
terminate in what is called resolution.
295. The adhesive inflammation often prevents
an increase of local disease, it sets bounds to 
its own progress, & it prevents the diffusion
or extent of the suppurative inflammation when 
it takes place.
296. The coagulable lymph thrown out in inflammation 
(293) always partakes of the nature of the 
solids which separate it.
297. The termination (294) does not always take
place, when it does not happen, if in the violence
of the action, the death of the parts does not ensue,
the suppurative stage takes place.
298. The suppurative stage will arise, when the 
death of a part has actually taken place, but
the surrounding parts have not suffered the same
abolition of their vital principle; here indeed the
dead part may be considered as a foreign substance,
& as a stimulus to inflammation to 



those that surround it.
299. Particular circumstances arising in different 
parts of an animal body, the parts may be disposed
to absorb themselves & so to produce a solution
of continuity; the inflammation attendant on
this action is the ulcerative (289)
200. This is commonly the sequel of the suppurative
stage, & therefore, may, for the most part,
be considered rather as a consequence of that
stage, than as the affection of an original disposition
in a part.
301. This (300) is not, however, always the case, 
it sometimes arising without a part previously 
undergoing suppurative inflammation.
302. The general order in which inflammation 
proceeds in the cellular membrane (296a) is,
1st Adhesive
2d Suppurative
3d Ulcerative.
303. But this order is not always observed,
the suppurative inflammation will sometimes
arise, without the adhesive previously taking 
place; here the disease & the extravasated
fluid will be widely diffused; this is the 
case in all the erysipelatous suppurations.
304. In the canals or outlets of the body (296 390) 
the suppurative generally begins, the ulcerative 



91.
follows, to which the adhesive succeeds.
Q. When inflammation attacks the canals, it rarely
goes beyond the suppurative affection; as those
parts do not readily fall into ulceration, adhesion
will arise still more rarely; the ulcerative
inflammation being in these parts so
uncommon, granulation of course, will as 
as seldom be found to take place.
305. The erysipelatous affection attacking 
the parts, the order, here also is disturbed, the
adhesive or ulcerative arises first & the suppurative 
succeeds.
306. Whatever can increase the violence of the
parts, the action may be called a cause of common
inflammation.
207. A part will take on the affection of the
constitution, that is an universal affection
may become a local one, hence, therefore, a
cause of local inflammation may be traced.
308. The abscesses arising after the termination
of specific febrile constitutional diseases,
as small pox, measles etc. have nothing specific 
in their nature, they only arise in consequence 
of the common disturbance, the constitution 
has suffered from the fever of the disease.
309. Simple inflammatory fever may be 
followed by an abscess on the part (308).



Q. This arises from a particular original disposition
in the part, brought into action by the fever,
or by a part taking up an universal disposition.
310. The remote causes of inflammation are
four, viz
1st From accidental violence.
2d From irritation applied to the part.
3d From a particular disposition in the part
itself
4the From a general state of the constitution
affecting some particular part.
311. Many constitutions have a disposition to 
specific inflammation & will fall into it, when
ever any existing cause shall arise as in scrophula & 
habits subject to erysipelas.
312. Many parts of the body have a greater tendency
to specific diseased action than others, so
any constitutional affection arising, these will
readily take on a specific diseased action.
313. Specific inflammation may be
a Specific & healthy.
or
b. Specific & unhealthy.
314. Different parts more or less readily take
on different inflammations; external parts
are more inclined to the suppurative, internal
parts take it less readily, suffering even the 


[93.]
removal of foreign stimuli a long time, are [illegible]
going into this stage. vital parts do not readily 
admit of the suppurative inflammation, though
they willingly take on the first & most simple inflammation.
315. When a part is inflamed that is not essential
to life, the constitution does not necessarily sympathise
with it, unless from the long continuance 
& violence of the inflammation; for here
the operation of inflammation may be carried
on, without any interrupting the functions of 
the vital parts.
316. But if the constitution of the patient be 
very irritable, & readily take on sympathy, nearly 
the same phenomena will arise as in inflammation
of the vital parts; the pulse will grow, 
small, quick & hard, blood drawn off will
be sizy but loose & the superficies flat; the violence
of pain will however be greater than in 
the inflammation of the vital parts.
Q. There are two powers which can produce a
change in the state of the pulse, that of the
heart, & that of the arteries; the regularity or
irregularity will depend upon the heart, the
hardness, fullness, softness & smallness will 
depend upon the arteries.
317. All parts supplied with their nerves from 
the intercostals & per vagum, when attended 




with inflammation give symptoms of lowness
and depression.
Q. The effects of inflammation on different parts.
Stomach quick, small, hard & sometimes low pulse,
 nausea, dull, heavy pain, depression of mind.
Small Intestines nearly similar.
Large Intestines Pain more acute, general
depression less nausea.
Liver this produces besides its own peculiar
symptoms, effects somewhat similar to 
inflammation of the stomach.
Heart its motions are confused & irregular, 
the pulse quicker & lower than common.
Uterus great oppression, nausea obtuse pain.
Lungs the heart frequently sympathises, preventing
a full diastole; when the muscles
are inflamed the pain is acute, the pulse
full & strong: inflammation of the bones & tendons
produces a dull heavy pain, and the 
stomach generally sympathises.
318. The termination of inflammation may take
place the quicker, the nearer it is to the heart.
319. The pulse growing quick after the commencement
of inflammation, is a proof of the constitution 
becoming affected or sympathising.
320. On the commencement of inflammation,
rigor is frequently felt, this is not simply from the
debility induced in the constitution, but also from 


[93.]
the novelty of the action which it performs, but weakly,
because it is not prepared for nor accustomed
to it.
321. In rigors & syncope the blood is collected about
the internal parts, & the external are left in 
some measure empty.
322. Every new action in the constitution must
tend to induce weakness in it, its effects will, however,
vary in different constitutions, in the strong
it will excite the general powers of action, & a 
hot fit will soon succeed, in the [illegible] the hot fit
will not always be produced, but only a clammy
sweat succeed.
323. Rigors are not attendant on the commencement
of inflammation alone; every new action in 
the constitution may be accompanied by them.
324. Life cannot go always in the same state, 
it must have its stated seasons of rest & action;
hence even in the most combined diseases & when 
the cause is unvaried, there will be intervals of
alleviation & exacerbation; nature observing her
general laws, rests even in disease.
325. Evacuations may be considered as the renewals
of the commencement of diseased action,
& so akin in some measure to rigors.
326. Disease may exist, & yet the constitution be 
insensible to the action, it may want power of
keeping the constitution in arteries beyond a 
certain time; in ague the disease exists as much 




between as during the paroxysms.
327. From (  ) it is evident that a change arising
in the constitution, a change in the blood, as partaking
of & possessing the living principle, may take
place also.
328. The appearance of the blood, will not be always
the same under given symptoms of 
constitutional affections, such as the state of the
pulse etc.
329. Inflammation begins at a point at first; all
the local symptoms being confined within a small
compass; afterwards it spreads according to the
state of the surrounding parts, which may be 
either local or constitutional; as the surrounding
parts are more or less in health they will be 
more or less disposed to continued sympathy; at
length the inflammation & redness will be lost
gradually in the surrounding parts.
330. Inflammation is attended with a [swelling]
of the part, the more healthy, the more the swelling
will be increased at a point.
331. The swelling of a part arises from the vessels
of the part being more distended with fluid than
natural, from the extravasation of coagulable 
lymph, & of some serum, which is known from the 
oedema of the surrounding parts; the less extensive 
the oedema is, & the firmer the margin of the inflammation
is, the more of the healthy inflammation 


97
will be present, for have more coagulable lymph
& less serum is thrown out.
332. The color of the inflamed parts (329) will also be
altered; the reason it approaches to a pale scarlet
redness, the more healthy the inflammation will
be; the less healthy the inflammation is, the color
will be less of the scarlet & more or of the darker
red inclining to purple, & sometimes to a bluish
hue.
333. The changes of color (332) will arise
a From vessels which naturally contained
only lymph or serum, carrying red blood
b. From their containing more blood than
circulated through the part in the natural
state, according to the law of the animal harmony,
that the more a part has to do, the 
more blood will be given to it; the color
is that of arterial blood.
c From new vessels being formed in that
part by coagulable lymph becoming organised.
334. When inflammation attacks parts near the 
surface of the body, the heat of the parts will 
be considerably increased. 
335. But the heat of the inflamed part will not be
increased beyond the standard heat of the animal,
though compared with the heat of other parts of the
surface, it will be greatly increased.
336. An increase of a heat in a part does not always 



arise from an increase of its power of action, it may 
arise from increased action though attended with 
weakness.
337. Coldness in a part is, however, generally arising 
from weakness & want of power of action; but a part
may have its degree of heat lessened by its sympathising 
with the affections of other parts, as the stomach,
changes in the mind, etc.
Q. Mr Hunter threw tart emet: gr iv into the veins
of a bitch, it soon vomited [her], she became convulsed
& died, she was astonishingly cold during vomiting;
& upon opening her immediately after her death
the heart & lungs were found remarkably cold.
338. The source of heat is probably in the stomach,
from whence by means of the circulation it may 
be conveyed to every part of the body.
Q. The stomach sympathising with any part of 
the constitution, is probably the cause of rigor:
rigors are not only produce by constitutional 
affections but even by local ones, as the pricking 
of a finger; also by affections of the mind, as fear,
horrid sights etc. The absorption of any contagious
or putrid matters into the system is attended with 
rigor. Rigors probably do the same thing in the
constitution as vomiting, rousing the constitution 
to greater action; the heat of the blood cannot
be altered by the sympathetic fever, a constitutional
affection can only produce a change in it.
339. Inflammation is commonly attended with a 



[99.]
painful sensation, communicated from the afflicted
part to the mind; in the adhesive state it is rather
of a dull heavy kind; when proceeding to suppuration,
it becomes more acute, when suppuration
has taken place it abates, when ulceration 
begins, it again increases, but in the latter state 
it rather gives the idea of soreness.
340. Every time the arteries dilate, there is an increase 
of pain; hence the sense of throbbing, the 
cause of the pain is the distinction of nervous and 
sensitive parts.
341. The disposition of inflammation will sometimes
cease, even before adhesions are formed, and 
this after a part has begun to swell, this is called
resolution.
342. As the increase of the pain was a proof of the
progress of inflammation; so its diminution is to 
be attributed to the cessation of the inflammatory 
state; when the uneasy state is removed, the
disturbing cause is taken away and the parts
return to their ordinary state & action.
343. The constitution will not only be differently 
affected by the different situations & functions of 
parts inflamed, & greater or lesser extent of the
inflammation, but it will also be differently affected
by the different stages of the inflammation 
present; thus the suppurative inflammation will 
affect it much more than the adhesive or ulcerative,
by whose action in general, the constitution
is but little disturbed.



Page 101 is placed after 
94



344 The vital parts subject to inflammation may 
be divided into
a Those, which readily take on sympathy, and
b  Those, which do not.
of the latter the lungs, of the former the stomach are
instances.
The pulse will, in general, be harder though smaller
under the affection of the former than the 
latter.
345 Whatever can obstruct the natural circulation
through the minute vessels, will produce 
inflammation, its causes, therefore, may be very 
different & various.
346. When a part perceives an alteration in its 
structure, or a change in or obstruction to its
natural function, the stimulus of imperfection
arises.
347. The stimulus of imperfection excites in parts
new dispositions, whose consequent actions are
either processes of restoration or destruction,
according to the strength of the parts and
their facility in the art of healing (252).
348. Irritation of whatever fluid being applied
may produce inflammation peculiar to the 
constitution or condition of parts. (311, 314).
Q. Thus if small pos matter be applied, if the
constitution have a peculiar susceptibility
of a putrid disposition, the disease will partake
of the constitutional disposition, as in the [illegible]




103
becomes vascular & nervous, & thus readily reunites
the sides of the wound; this process is accomplished
with more ease in the first class 
by injuries than in the second, because the blood
by coming in contact with the atmospheric air, the
sooner loses its living principle.
Q. When wounds are inflicted, it is evident from’
the text, that where the first mode of union is to 
be affected, the surgeon should bring the lips of it 
in close contact, and retain the blood in the wound,
then defend the part from the action of the air; no
foreign matter should be introduced, hence the 
suture must in general be objected to
Union will not only take place between divided
parts of the same body, but also between 
parts of different bodies still retaining their living
principle when brough in contact with each 
other. Thus Mr Hunter introduced the testicle of 
a living cock into the abdomen of a hen, the
testicle became united to the liver of the
latter, & sometime after when the hen was killed
Mr Hunter injected the testicle from the body of 
the animal.
Again he fixed a tooth recently extracted on 
the comb of a cock, & on injecting the animal, 
the membrane lining the tooth was also injected.
Upon this mode of union depends the cure
of the hare lip; from this arises the natural cohesion 
of fingers one to the other, when the [cuticle]
has been destroyed by burns etc., from 



[104.]
out small pox. To venereal matter shall in one person
produce a chancre surrounded with common
inflammation, in a poison of a different constitution 
it will be accompanied with an erysipelatous
inflammation, which may spread to a wide extent.
349. The disposition for restoration of parts injured is
the most simple (165) that from necessity is the more
complicated of any.
350. The stimulus of imperfection may arise in parts
from different causes, as obstruction to their natural
actions, or from an alteration in their structure by 
external violence; the latter becomes chiefly the 
object of surgery, though the former may also fall 
within its province.
351. The effects of external violence will be different
according as that violence is applied to sound
parts or to parts diseased.
352. Mechanical injuries on sound parts may be
divided into two heads.
1st Those which do not communicate externally.
2d Those which do.
Q. To the first may be referred bruises, strains, simple 
fractures etc.
To the second, wounds of all kinds, opening externally.
353. The first division may by circumstances be
changed into the second, & the second may be
brought back to the first.
35. The effects of the first division on the circulation,
will be different according to the state of 



the constitution, and the nature of the parts injured;
if the power of healing in a part be strong, the part
injured not vital, & the constitution not highly disposed
to sympathy, no material change will
take place in the constitution, & the process of 
restoration will go on with only local effects.
355. The second division is much more complex
and its varieties will be numerous depending upon’
the nature & situation of the parts injured, the 
kind of violence inflicted & the degree of that violence.
356. Its effects on the constitution will be determined
by the same laws as those regulating the
effects of the first class.
357. When vascular parts naturally in contact
with each other, are separated by violence, an effusion
of their contained blood follows the injury.
358. The union of parts violently separated from
each other is accompanied either by 
a The extravasated blood being the bond of union.
b The adhesive inflammation or 
c Granulation.
259. It has been already observed, that the blood
is a living fluid; when extravasated it does not
immediately lose its living principle. In the
separation of parts by violence when the blood
is effused, the first mode of reunion is affected
by the red particles & serum being absorbed;
and the coagulable lymph being left, the lymph 


thus arises the union of chin to the breast,
when ulceration has preceded etc.
360. But a variety of circumstances may present
this mode of union taking place; the second
process, or that by adhesive inflammation is next
excited. Coagulable lymph being still the necessary
medium of reunion is supplied from 
the vessels of the sides of the wound, by the first
or adhesive inflammation arising, this becomes
organized & again fills up the breach.
361. But many circumstances impede this process
also, such as the death of the solid parts 
receiving the injury, hence their becoming foreign 
bodies; the too great violence of the 
inflammation (360) producing suppuration, the
interposition of foreign bodies etc., & have the process
of restoration cannot be accomplished 
without the third made (  ) granulation.
362. When an internal cavity is exposed, the 
whole of the cavity would run into inflammation,
unless some part of its surface
be in contact with some other living part;
that simple contact will set bounds to the 
spreading of the inflammation.
Q. Hence when a cavity & exposed & don not 
unite by the first or second mode of union, the 
whole cavity still will often escape running
into the suppuration process, the contact of
the edges, or the part near the edges of the wound



[103.]
with some of the containing parts [illegible] bounds
to the process of the new action.
Q The parts taking on sympathy, may, however, 
produce an exception to the [illegible] in the text.
363. The adhesive inflammation is sometimes 
imperfect, not answering the final intention, & 
this is when the violence giving rise to it, has excited
too rapid an action to admit of the adhesive
process taking its full effect, this, however, 
seems rather to belong to the erysipelatous inflammation.
Q. This is illustrated by dissections of woman dying
with the puerperal fever, when inflammation 
had produced some adhesion between the peritoneum
& some of the continual viscera, while
the suppuration had generally diffused itself
over the parts of the abdominal cavity.
364. The cure of inflammation(  ) is by resolution;
but before we attempt the cure of inflammation
artificially, we must enquire into the constitution
of the patient, as whether he is disposed
to irritability or indolence his former habit, torpor
of the mind etc. and also the situation & other 
circumstances of the affected part.
365. The time for attempting the cure of inflammation 
by resolution, is before the suppurative
process has taken place.
366. We must consider whether the inflammation 
be of the true healthy kind, or whether it 



has the erysipelatous disposition, or any other
specific disease mixed with it. We must also consider
whether there be any increase of life, or only 
an increased disposition to make the use of life, a 
distinction any necessary to observe.
367. We have noticed (332) that a change of color
in parts is produced by inflammation; when 
the inflammation is seated in parts near the 
skin, & its action is violent, vesications will arise,
the cuticle being separated from the cutis; then 
arises from the action producing death of the
connecting medium between the cuticle & cutis.
368. The coagulable lymph (319) fulfills not only 
the intentions (293, 359, 360) but also when the third 
mode of union, or as it takes place, becomes the 
basis of the future granulation.
369. In the case, if the inflammation be of the true
healthy kind, we have only to remove whatever 
causes keep it up.
370. An increased disposition to make use of life
(366) or too great violence of circulation, is to be 
[illegible] by weakening with evacuations, and
the exciting of nausea, & by soothing or anodyne 
remedies.
371. When there is both an increase of life and 
powers, & an increase of action, weakening the system
becomes necessary.
372. The system is weakened by bleeding; if only 
increased action is present, without increased powers,
bleeding is only to be had recourse to from 



107.
particular indications, viz.
a. when it is desired to lessen the present action
in order to give the disposition time to 
wear out itself without destroying parts by 
its violent action.
b. when the part affected is a vital one.
c when it is near a vital one.
373. Unless the powers of action are great, or the
exigency of present circumstances requires that
blood should be drawn from the system, topical
blood letting is to be prefer’d, & that from
& as near to the inflamed part as possible.
Q. Topical bleedings, however desireable, cannot 
always be had recourse to, for instance in increased 
action of the vessels of any of the internal 
organs.
374. When the action only, not the powers are
increased, it is to be desired that the constitution
should perceive the loss of blood as little 
as possible Topical bleedings give less alarm to 
the constitution than bleeding from the system.
375. Topical bleeding should be particularly 
insisted on when there is a disposition in the habit
to form but little blood, & the part inflamed is
distant from the source of circulation.
376. In our choice of bleeding, we are in a great 
measure to be regulated by the pulse, but as the
pulse is differently affected by the inflammation of
other parts, we cannot be absolutely determined for 
or against bleeding by any one general state of 


the pulse, for the most part, however, it is to be considered 
that a quick & hard pulse generally indicates
bleeding.
377. Another general indication of blood letting is the
state of the blood, but this can only be an after proof.
378. If the state of the blood be sizy, & the coagulum 
flat & its texture loose, bleeding is contraindicated,
or at least to be sparingly employed.
379. Another general indication of bleeding, in urine,
high in color & small in quantity.
380. A comprehensive view of all the symptoms
of health and weakness, present violence of action,
the nature & the situation of the parts affected, can 
only enable as to decide on the rectitude of using
or omitting bleeding.
381. Purging weakens universally; it is to be had 
recourse to with the same caution as bleeding;
and in irritable habits still greater caution is 
necessary.
Q. In weakened habits a single stool frequently
produces fainting, may it has even caused an 
abolition of the powers of life.
382. Sudorifics may be proper, when the constitution
sympathises much; because they do not so 
considerably diminish strength.
383. Nauseating medicines lessen universally 
the powers of life, vomiting ones rouse the posers,
for vomiting seems an action intended to relieve
weakness.
384. Soothing remedies. opium is the principal. 


109.
opium will only lessen actions not alter them.
As the disease sometimes consists almost entirely
in increased irritability, by lessening the latter it may 
diminish the disease.
385. We also endeavor to promote the intention
(374) by topical applications; of those preparations 
of lead appear to lessen the power, as well as lessen
action; they are not, therefore, universally to be had
recourse to. [?66)].
386. Cold powerfully weakens action, from its use
therefore, great effects may be expected; the degree 
& length of applications of cold is [illegible], to be
considered. (262).
387. The effects of topical remedies will be either
a. Immediate.
b By repulsion.
c By revulsion & derivation.
d By sympathy.
388.  The first order (a) seems to require no explanation.
applications acting by repulsion only produce
their effect upon a part, when the inflammation
has arisen from a part’s taking on the 
disease of the constitution, & the disease from a constitutional
one has become a local one, as the 
gout.
389. Revulsion and derivations are not well
defined, the distinction between them is perhaps
ideal; by them we must understand a cessation
of action in one part produced by an increase of
action in another part; this does not depend upon 



the humours, but upon a change in the place of 
action, or irritation.
Q. Upon this principle we use blisters to remove
deep seated pains; upon the same we apply sinapisms
to the feet when the brain is affected, vomits
when the testicle is inflamed.
390. Repulsion is the cure of the part, be the consequences
of the cure what they may.
391. Sympathy. The cure of a part by local sympathy
is when the same effects arise in the part diseased 
from an application used to some other part,
as if the application was made to the diseased
part itself.
Q. Hence it is that mercurial ointment applied
to the skin covering a node, will cause the node
to disappear, in the same manner as though the 
mercury had been applied to the node itself, with 
out the medicine of the integuments.
392. A cure of local inflammation by derivation 
or sympathy will often take place, when sedative
applications have proved ineffectual.
Q. Vomits curing inflammation of the testicle, after
sedatives etc. had been used in vain; cavities 
behind the ears curing opthalmia which had resisted 
all applications to the eyes, elucidate the 
truth of the text.
The cure of the tooth ach by burning the ear, is to 
be refer’d either to derivation or sympathy.
Derivation seems to be the reverse of sympathy.
we cannot, however, always distinguish one effect 
from the other. The cure shall often be effected by 


111.
sympathy; thus blistering one part will remove a
part existing in another part, though the action excited
by the blister may be of a different kind.
393. Topical applications may be divided into
a Fomentations.
b Steams.
c Lotions.
d Poultices.
394. The order a and b are of shorter duration
in their actions, but may afford relief during the 
application; the order c are more lasting in their
actions & are only substitutes for the order d 
which or all applications produce the most permanent
effects.
395. Poultices will be either
a Simply warm and moist.
or
b Medicated.
396. The effects of a poultice will be immediate
on the parts to which it is applied, but by sympathy
they will be extended farther.
397. Medicated poultices will be formed according
to circumstances, with lead, opium, mercury etc.
398. When inflammation however excited, exceeds
the adhesive state, & gets beyond the point 
of resolution, suppuration is produced.
Q. Among the causes of the effect are sounds not
uniting by either of the first modes of union, & 
the third or granulation becoming necessary
for their cure; violence having produced the death 



of parts, to the removal of which suppuration becomes
necessary, or violence having exposed internal
surfaces.
399. The cause of a parts running into suppuration
is its perceiving the stimulus of imperfections, & 
being thence necessitated to begin a new & animal
process.
400. Communication with the amospheric air, is not
necessary to suppuration.
Q. The application of air to internal surfaces, as the
cavities of the thorax, abdomen & joints, has been considered
as the cause of suppuration, but this is evidently
not the case, for suppuration would take 
place even in the [illegible]. In emphysema where
air is diffused all over the body we have no such
effects untill an opening is made; but in case 
of suppuration from an opening, the stimulus
of imperfection takes place, the cavity being an
improper one; to prevent this imperfection as
much as possible, we observe in the wound of
the abdomen of a fowl, that adhesion takes
place between some of the intestines & the edges
of the sound; if this does not happen, general
suppuration succeeds; another proof that air
is internal cavities is not the cause of suppuration 
is that in some animals the air has
a free communication from their lungs into
the cells of their bones, and into the abdominal
cavity, without producing suppuration,
as is the case in many birds.



113.
401. Great violence of action is not necessary 
to suppuration, it is rather productive of gangrene;
suppuration is sometimes produced in 
a part without any visible violence of action
in the part which takes it on.
402. Although it sometimes arises without any 
visible violence of action in a part, yet in healthy
constitutions it is generally found that the inflammation
is considerable.
403. The action producing it is most violent, when 
it arises spontaneously.
404. Suppuration takes place more readily 
in internal canals, than in internal cavities.
Q. This we readily account for, knowing that
suppuration is the first ordinary process is inflamed
canals, whereas adhesive inflammation
is the prior action in the cavities.
405. It is not necessary to forward suppuration
even in inflammation arising from the constitution;
the constitutional disposition seeming to 
have produced its full action in the inflammation,
or inflammation is to be considered as
the disease taken on by the part from the constitution 
& so curing the latter, & suppuration is only 
the sequel of the disease.
406. The adhesive inflammation going on to 
the suppurative, in the latter stage the general 
symptoms increase, the pain becomes more acute,
the sensation arising from it is as much as possible 


that of simple pain; the redness is more intense,
new vessels being formed & old ones being more
dilated; hence a more violent throbbing from an 
increased dilatation of the arteries; the swelling
of the parts increases from a still greater effusion
of coagulable lymph & serum; the surrounding
parts become oedematous.
407. One, two or more parts lose the power of resolution
& take on a similar state to cavities exposed.
(   ) a cavity is formed in which [illegible] is secreted,
at first mixed with coagulable lymph.
408. A return of adhesive inflammation checks 
the progress of suppuration.
409. When the progress of suppuration is not stopped,
the matter will be carried onwards to the skin,
the parts between the cavity & the surface of the
body are gradually absorbed, the cavity becomes 
daily enlarged, the skin becomes thinner & thinner,
at length ulceration from the pressure takes
place, and the abscess bursting, a natural exit is 
given to the contained matter.
410. When the suppurative inflammation is
going on, rigors frequently occur, a common attendant
on new action in the constitution.
411. When the progress of suppuration cannot be
stopped, the matter is to be carried on towards
the skin, hence the [??lity] of stimulating plasters
etc., poultices can do little untill the inflammation 



has invaded the skin, they then keep the
surface moist & soft.
412 Suppuration sometimes goes on without previous
inflammation; here parts suddenly fall into
it, without allowing the previous action of the
adhesive inflammation, as in the erysipelatous
suppuration, or it goes on slowly & without pain,
as in some scrophulous cases.
413. When a healthy abscess is opened the parts
readily take on a disposition to heal, but in
the collection of matter (412) when the abscess is opened
& the cavity becomes exposed, a general inflammation
takes place & a perfect suppuration
is formed; but the constitution is generally 
much affected by this process, for here the inflammation
is to arise in a part already in the habit
of disease.
414. The matter contained in the abscess formed without
inflammation, will be different from that
in the common inflammatory abscess, in the former
it will be a curd like substance, mixed
with a thin purulent fluid.
415. The fluid produced by the healthy suppuration
is called Pus, which is quickly and readily 
formed on the surface of [illegible]
Q. Observations on pus from 415 to 423.
Pus cannot be formed from the melting
down or [waste] of the solids, otherwise how
could the human penis furnish in the virulent 


gonorrhoea, pus many times exceeding in
quantity the substance of that organ; some have
denied the discharge from the urethra & contain
other canals to be purulent, & affirmed that it
was only mucous; but it has every characteristic
of pus. No injury arises from the absorption
of pus into the circulation, otherwise how must 
those fare who have large sores, as patients
undergoing amputation, when the health is often
undisturbed through the whole of their cure.
Pus may become offensive by living mixed with 
other fluids as putrified blood etc., hence its 
[fetor], when its discharge attends a diseased bone.
Pus is a bland, unirritating fluid, we see it
make its way in psoas & [slip] cases from the loins
& slip low down into the thigh, without producing
the least sense of pain, unless [illegible] from 
its weight & distension of parts amongst which 
it is seated
Pus cannot change animal solids into its own
nature by any fermenting process. Chemistry cannot
imitate the process of nature in forming pus in the
animal body, any more than any of the other
secretions; nor can chemistry decide on the nature
of pus; the conclusions drawn from the precipitations 
of it by vitriolic acid etc. are irrational
& unsatisfactory; the precipitate from any 
other animal substance, so dissolved, will give
equally the same appearances.


117.
416. To the fomentation a particular organization 
of parts seems necessary, though we do not exactly
know in what the nature of that organisation consists,
any more than we do that which is necessary 
for the different secretions.
417. Pus is to be considered as a secretion, as the 
parts secreting it to be glandular; it does not arise
from a destruction or dissolution of the solids
by fermentation etc., the solid parts may 
die, slough and be found in it, nor is it a mere
straining of matter from the blood.
418. Pus is a fluid which in its perfect state 
has certain peculiar qualities, as color & consistence,
it is somewhat sweet & mawkish to the
taste. It consists of a number of large whitish
globules, swimming in a fluid resembling serum
of which globules it will have a greater or lesser
proportion according to the health of the body
that produced it; like serum the fluid is coagulable
by heat.
419. It is perfectly mild & inoffensive in its natural
state, incapable of irritating the most [sensible]
sore.
420. Pus when absorbed into the habit & mixed with 
the blood is productive of no ill effects, unless it
421. Pus is less disposed to putrify than other
animal fluids; when in certain situations & 
in contact with air it readily takes on putrefaction


& becomes offensive, but this is probably 
from other substances as blood etc. mixed with it.
422. When an abscess is first opened, portions of
coagulable lymph mixed with pus are commonly
found; these are parts of that lymph which had
been employed in making the cyst to contain
the matter, becoming loosened from the internal
surface of the abscess, & being blended with pus.
423. Chemical experiments cannot explain
the nature or manner of the formation of pus. (see 
last note)
424. The formation of pus is to be considered 
though a new, yet as a process of health, parts
taking on a diseased action, the secretion of pus
is interrupted, & it is longer generated pure
& possessed of its peculiar properties.
425. Pus, like all other fluids, thrown off from solid
parts, always partakes of the nature & properties 
of the parts from which it was secreted, & 
accordingly will have occasionally, the specific
properties of the lues, the cancer, the small 
pox etc.
426. The final use of pus, or intention of nature in 
producing it is not known.
Q. Pus may be of use to sores to keep them moist
etc., but this does not explain why it is formed
in internal cavities; it may also be of use as
a vehicle in the removal of extraneous substances, 


119.
this, however, can only be a secondary intention,
with its final use we are still unacquainted.
427. Ulcerative inflammation is that action into
which a part falls from a disposition to absorb
itself, even to the solution of continuity.
428. The cause of this ulcerative absorption will
be an inability of parts to support themselves under 
present circumstances; these circumstances will be
a Irritation.
b Weakness.
429. These circumstances give rise to 
a A consciousness in the parts of the necessity
to be absorbed.
b A consciousness in the absorbents of the 
necessity of commencing the absorbing 
process.
430. Irritation will begin by 
a Pressure (246). b. Contact with dead or foreign matter.
431. Weakness or a want of power in parts to carry 
on their natural functions, may be a cause of
the ulcerative absorption.
432. Pressure considered as irritating is of two kinds,
a Pressure from the surface inwards. 
b Pressure from within outwards.
433. Parts strongly resist the action of the pressure
a but readily yield to the action of the pressure b (432).



434. From the above, then, we infer that when 
the irritation of pressure a (433) is applied to produce
ulcerative absorption, it must be very violent
in proportion to the strength of the parts,
for it is not sufficient to destroy the power of resistance
in the parts pressed, it only produces a
thickening of them.
435. Nature resisting the entrance of foreign matters
into the body, thickens & thins, as it were [illegible]
them the parts to give them a greater power of resistance
to the admission of what would prove 
injurious to them.
436. In pressure from within outwards (b 433) the 
internal parts as cellular membrane etc. fall
more readily in the ulcerative absorption
from the skin; in irritation from external pressure
and from contact with foreign matter, the 
skin falls more readily into it than the other substances.
Q. When a collection of pus makes its way to the
skin, we find the cellular substance, adipose membrane
& a [muscles] ulcerated to a considerable extent,
while the skin ulcerates only so as to form a
hole for the exit of the matter.
437. When the pressure is from within outwards, all 
the sides are equally in contact & compressed by 
the body making the pressure, yet that side will 
accept of ulceration which is nearest the surface 
of the body.



121.
Q. If inflammation attack the internal part of an
intestine adhesions are produced between it & the peritoneum,
& if the inflammatory action goes on, an
abscess is formed in the middle of the adhesion, after 
which the matter contained acts as an extraneous
body. Ulceration takes place on the side next the
skin, between which & the matter, even in the most
corpulent persons, the muscles, [fatty] membrane, & 
cellular substance will be dissected by the pressure
of that matter & that matter eliminated before; so 
[illegible] their anterior substance, as the intestine, will 
fall into ulceration. Le Dran gives several cases o f
the kind but does not explain them.
438. When bodies making pressure from within, outwards 
are to be carried to the surface in the natural 
process, the adhesive inflammation of the 
neighbouring parts precedes the ulceration of the skin; for
nature finding exposure must take place by the
former process, provides against that inconvenience,
and renders its extent as small as possible.
439. When absorption is to take place of the parts
between a surface lodged within and the external
surface, in order to the removal of the substance
there is always a mixture of the ulcerative and
interstitial absorption. 
Q. When living tumors are brought to the skin,
in their progress the interstitial absorption only 
[illegibe] on, untill there arises a necessity for the
ulceration in the skin; many other substances are 


also brought to the skin, without producing the ulcerative
absorption.
440. Ulcerative absorption goes on either with or without
suppuration.
Q. Suppuration very commonly & in some parts always
attends on the ulcerative absorption; of this we
have abundant instances in the muscles, cellular
substance & skin; we have also instances of its proceeding
without producing pus, in bones, when sustaining
the pressure of aneurism etc., in the absorption 
if the alveolar processes after removing a tooth,
& in the removal of callus after fractures. In 
Lord [Ansins] voyage, we find that several of his 
crew, who had been severely afflicted with the
scurvy, which occasioned the spontaneous dissolution
of the cicatrices & even of the callus formed
after fractures.
441. Bones as well as soft parts become open to the 
ulcerative absorption from pressure & irritation,
but the cuticle is incapable of irritation & the 
ulcerative absorption.
442. An exception to (437) will arise when the irritation
from pressure is violent, & the adhesive inflammation
has not truly taken place in the parts behind,
within, or on one side of the irritating substance.
Q. Hence it is that matter sometimes bursts into the
air cells of the lungs, when a suppuratory inflammation 
of the pleura & lungs has happened, instead
of making its way through the intercostal muscles 


123.
to the skin: for the same reason, sometimes
in abscesses of the liver, pus makes its way internally,
bursting into the intestinal tube, or the abdominal
cavity.
443. The difficulty with which the cuticle (441) is
removed for the expulsion of matter, is the cause
of pain in suppurations, where the cuticle is very
thick, as in the [whit???], abscess in the sole of the
foot etc.
444. The ulcerative absorption but little effects 
the constitution, although the constitution has powerful
effects on the ulcerative absorption.
Q. A change in the constitution will often occasion 
a sore to spread more or one night time, than
we can procure a fortnight.
445. As ulceration consists in the division of 
parts naturally united, or in a particular mode
of [solution] of continuity, so its cure is affected
by a reunion of them, either by adhesion (358) 
or by granulation, the third mode of union 
(350). When the first & second modes of union will
not take place in parts violently separated, the
thin mode is pursued in the process of restoration,
[thus] is by means of granulation.
446. Granulations are formed by coagulable 
lymph effused from the surface of the ulcer, becoming
vascular. Vessels from the original parts
pass to the bones, & also to the surface of the granulations, 
& would almost [seem] to terminate them.
447. Granulations are always of the same nature 


as the parts they arise from.
448. Granulations will be healthy or unhealthy
the more convex they are seen, & the smaller their
points, & the more florid red color they are of, the
more healthy: the flatter their surface, the 
[illegible], or the more they approach to a livid hue,
the less will they be found healthy, & the more
slowly will they admit of the parts being heated.
Q. By attending to the appearance of a sore, we
may judge whether it is healing or disposed to 
ulcerate; further, if the latter, the edge will be 
irregular, inverted or hanging over the ulcerated 
surface, the discharges in general thin, the
surface in the whole or in many parts concave;
whereas when there is a disposition to healing
they are convex, the margin purple, covered with a 
whitish transparent membrane.
449. By the appearances of granulations we
may judge in some measure of the state of the constitution.
Q. In the irritable constitution, mostly, the granulations
will be loose & flabby.
450. When granulations are healthy they have
a strong disposition to unite with one another.
Q. Mr Hunter saw two granulations, one from 
the scalp & the other from the dura mater, arising
after trepanning, united so firmly that they 
could not be separated without an hemorrhage.
451. Granulations are, in general the consequences


125.
of suppuration, but granulation may 
sometimes take place without suppuration preceding.
Q. A man aged 50 broke his thigh bone, & the attempt
at reunion both by the first & second intention
failed, for the fracture, which was simple,
did not unite after being bound up for a considerable 
time, at length the man died. Upon examination
it was found that granulations between
the ends of the fractured bones, though 
without suppuration, had taken place. Scratches
& slight wounds in the skin, though they unite by 
the first intention, do not always require suppuration,
they heal frequently under a scab. 
452. To perfect the cure of an ulcer it is necessary
that the granulations receive a covering,
or that the process of cicatrisation takes place.
453. Cicatrisation is performed partly by the 
elongation of the original skin & partly by the formations
of a new skin.
454. The original skin is necessitated to elongate 
or stretch itself by the contraction of the 
granulations.
455. Cicatrisation is always in view, when 
granulations are formed: when the granulations
have been carried to a certain degree
the contraction of the granulation begins 
at every point; as the contracting process goes on
the skin on all sides is drawn nearer to the centre
of the sore.
456. When contraction of the granulations 



has been carried so far as circumstances will 
admit of, & the consequent elongation of the skin
has been carried to its greatest point, from the
margin of its original skin, the new skin shoots.
Q. The contraction of granulations, perhaps,
goes on in some degree untill the cure is compleated,
but after a certain time, 
they do not contract sufficiently to oblige
the skin to stretch itself & hence there must
be a necessity for the formation of new teguments.
When the original is unfit or cannot give
the disposition for the new one to form, then there 
is sometimes a disposition in the centre of the sore 
to produce it, hence it is why we sometimes see
sores begin to cicatrise in the middle.
457. The contractions of the granulations, or their
effect in elongating the original skin is impeded 
by its being situated on hard parts, as
bone & where the sore is circular instead of 
having considerable length in proportion to its
breadth.
Q. We see that if the wound or ulcer takes place
on soft parts, as the buttocks etc. & when the skin
is loose, the quantity of new skin formed in the 
healing is very little, but in ulcers on hard parts, 
as on the head, the skin is enabled to stretch 
but little, hence in wounds of the scalp, the new
formed skin is nearly of equal extent to that
of the lost substance. 


127.
458. The formation of new skin is a process nature
forms with difficulty, & with more difficulty in the
lower extremities than in the upper parts of the body.
Q. Hence it is evident that surgeons cannot be 
too cautious in saving skin, when it becomes 
necessary to remove parts, as in amputations of  
the leg etc., & especially where the wound is to be
inflicted in bone, the natural covering of which is 
little besides the skin, as in the tibia etc.
459. The new skin is a very different substance
to the old; whether it consists of the granulations
altered in their structure, or is a new and 
distinct substance from them is not to be 
ascertained. It is less moveable than the original
skin, appears to be upon the stretch, as if
a small piece of skin was stretched & [illegible] into 
a [larger] [hole], so that the sides of the old skin seem [illegible]; 
it is, however, gradually subjected to 
mechanical motions & becomes more loose and
flexible. The young cutis when formed first, is
very full of vessels, but these are either afterwards
taken away or changed into absorbents, untill
at length the part becomes quite white.
Q. From part of this aphorism it must be evident 
of how much utility motion & friction must be
to a part stiffened from having undergone granulation
& cicatrisation: mercurial [illegible]
& electricity both conduce to this end & seem to be
very properly indicated.



460. Whenever a new cutis is formed, a cuticle
is formed also; the cutis forming it more readily 
than the granulations form the cutis. Every point
of cutis is forming cuticle.
461. The rote [mucosum] is always late in forming
cicatrices between the cuticle & cutis, sometimes it
is never formed at all.
Q. As in the negroes, who when they are burned or blistered,
the cicatrix formed after healing wants the
black tint.
“But even in negroes the rote mucosum is formed,
as I have found on examining the cicatrix
of a negro adult, from which by maceration, I 
[illegible] off the cuticle & found the rote mucosum
perfect.”
462 The cicatrisation is sometimes laterally affected
during the going on of the process of restoration
above described, by certain actions.
463 The most ordinary actions are.
a Hectic.
b The action of dissolution.
c Spasms.
464. Hectic is a remote constitutional sympathetic
affection, taking place in a constitution weakened 
by a long continued local disease, which 
it can neither get rid of, nor cure.
465. It will be caused either by an affection of
vital or of nonvital parts.
466. It is produced earlier by the affections of vital 


129
than of nonvital parts.
467. In the nonvital it most frequently arises from
affections of those parts which have a backwardness
to and a small power of healing. (275/276/277).
468. The more extensive the seat of diseased action
in parts of equal powers of healing the earlier
will the hectic be induced in the constitution
Q. (467 & 468) Thus we see affections of the ligamentous
parts more readily being on hectic, than 
those of the muscular parts; disease of the joints
very often produces this constitutional sympathy,
& the larger the joint the earlier this effect
will take place. an affection of the knee or elbow
brings on hectic operation than a disease
of the wrist or ancle. Again the backwardness 
of parts to heal depends much on their
situation in the body. (277).
In the lower extremities the power of healing
will be less than in the upper, & never a disease 
in the knee or hip produce hectic [illegible]
than a disease of the elbow or shoulder
joint.
Hectic will arise from affections of parts
whose natural powers are not weak, as in large
abscesses if the muscular parts; but it still depends
upon the same principle, a disease 
which the constitution can neither conquer
nor get rid of . (464).
469. Hectic does not arise from the absorption 
of purulent matter into the system.



Q. It will arise in affections of the vital parts,
& joints even before suppuration has taken
place; did it arise from the absorption of pus,
it should take place in one large ulcer as
well as another, for it does not appear that
there is a greater disposition for absorption’
in one ulcerated surface than in another, it
should arise from venereal buboes where the
matter is often poisonous.
In large abscesses the hectic disposition comes
on after opening & when the matter has been
discharged.
If the constitution can heal up these abscesses 
no hectic arises; large suppurations have taken
place & the matter been absorbed again 
without opening, yet without the rise of hectic.
We readily conceive why it should take place 
sooner in vital than in nonvital parts, because 
the former gives the alarm sooner to the constitution
(22). Hectic commonly arises from,
lumbar or psoas abscesses, scrophulous joints,
white swellings etc.
470. Hectic then depends upon a part being irritated
beyond its power for restoration, & beyond
the power of the constitution to overcome the 
disease.
Q. Whatever then will long & obstinately tease
the constitution may become the cause of hectic.
471. It is however sometimes doubtful whether
the hectic is not an original disease of the 



131
constitution, we see it arises when there is a sore
in a part which has no impediment to healing,
& here in general the hectic must be cured
before the sore will heal.
472. Hectic is a kind of slow diminution of animal
life, even to gradual dissolution; its
symptoms are in general, slow fever, with great
debility & languor, want of appetite, paleness
of the skin, sweats easily provoked, & indeed
arising spontaneously, frequently sickness & vomitings,
an habitual purging, clear urine etc.
473. The administration of internal medicines 
can only be useful in order to the cure of the hectic,
by somewhat strengthening the constitution 
& enabling it to support its struggle longer
than it would do unaided.
474. Its cure can only be effected by the removal
of the local disease, either by taking away
the part of by inducing in it a disposition to 
heal.
475. The constitutions most disposed to hectic
are the weak & irritable.
476. The action of dissolution is different from 
common hectic. The constitution seems to 
have every thing in its power; having gone
through & supported the processes of inflammation
& suppuration, its powers will suddenly 
sink & the destruction of animal life
be readily accomplished. 


477. The symptoms are an universal affection
of the stomach, shiverings, nausea & frequent
vomitings, small quiet pulse, haemorrhage from
the surface of the ulcer, excessive spontaneous
sweatings, soon succeeded by death.
478. The habits most disposed to it are the robust
& full.
479. For the cure nothing seems to effectual.
480. Muscles lose their power of action not only 
when the nerves leading to them, or which 
are their immediate instruments of motion, are
compressed or destroyed, but also when there 
is no longer a necessity for their propriety in 
acting (53). & here they become through naturally 
voluntary, inobedient to the will.
481. They also become open to interstitial
absorption & waste in size & firmness.
Q. If a limb have its bone or bones fractured,
the muscles will no longer act in obedience
to the will; the same is the case when 
a joint is rendered useless; if the patella
be fractured, the patient cannot voluntarily
act with the rectus muscle.
It is extremely curious to observe that 
voluntary muscles, when the final use of their
being no longer exists, become so longer the
instruments of the will, & that they then waste
in bulk, strength & firmness & become soft & 
flabby.
End of first part.



133.
Rationale of Surgery.
Part second.
Illustrating of the doctrines contained
in part first.
482. In the circumscribed cavities, when taking
on inflammation, the adhesive, it is observed (  )
is the first to take place; if the progress of the
complaint be not checked or put a stop to
by the adhesions, the suppurative or ulcerative
stages are the necessary sequels.
483. In cavities containing vital parts, the ulcerative 
stage is seldom produced, for before the 
complaint proceeds thus far, it generally kills.
To produce adhesions between contained & containing
parts, it is not necessary that the surfaces
of both should be inflamed.
484. According to the degree and extent of the
adhesions, the suppuration in a circumscribed cavity
will be greater or less: if suppuration comes
on in a cavity where no adhesions have previously 
taken place, the whole surface of the cavity
will become the seat of the suppuration.
485. The contents of an inflamed cavity will not 
always partake of the inflammation of the containing
parts, for the lungs or the intestines may 
remain uninflamed though a pleuritis or a 
peritonitis may be present.




486. The preceding doctrines will be illustrated 
by observations on the inflammation of 
the following cavities.
1st The thoracic cavity or inflammation of the 
Pleura.
2d Inflammation of the Pericardium.
3d of the peritoneum as
containing the abdominal viscera.
4th of the bladder.
5th of the joints & sacculi mucosi
6th of the eye.
7th of veins.
8th of the encephalon.
9th of the tunica vaginalis.
also by injuries & diseases of bones, by 
wounds in soft parts, & lastly by common & 
specific diseases of the constitution & parts.
487. The pleura is more subject to inflammation 
than any other membrane lining a 
cavity in the body, not from its particular
nature, but from particular circumstances,
as being much exposed to the action of cold etc.
488. The pleura becoming inflamed, adhesions 
are formed between that membrane & 
the lungs, sometimes with but little if any pain;
sometimes in parts only; there adhesions frequently 
terminates the complaint.


[133.]
489. But it frequently happens that the inflammatory
action goes on to suppuration;
if the whole cavity becomes the seat of it, then
the true empyema takes place; if the suppuration
is by means of the adhesions confined to 
certain parts, then the spurious empyema, or 
cullation of matter not communicating with 
the general cavity of the thorax, is produced.
490. The empyema will be preceded by violent
pains in the thorax, difficult respiration, 
quick pulse, rigors etc.
391. The empyema when present will have
symptoms peculiar to itself, together with
the common symptoms, & symptoms from
sympathy of a fluid contained in the cavity 
of the thorax.
492. The common symptoms of fluid extravasated
in the chest are difficult & frequency 
of respiration.
Breathing easiest in some particular situation.
If the fluid be in one lateral cavity
only, the patient lies chiefly & most easily on
the affected side, if in both cavities, then he will 
only lie on his back, & that not horizontally,
the head & chest will be elevated, otherwise
he feels a sense of impending suffocation: there
is a sense of weight in the diaphragm: there
are patients who perceive the fluctuation 



between them. Frequently anasarca & sometimes
ascites is present.
493. The peculiar symptoms of the true empyema,
are a great difficulty & uneasiness in expanding
the chest, great lowness & depression of spirits,
frequent sense of seemingly impending dissolution
of the heart etc. (494 omitted)
495. Water may be extravasted in the cavity
of the chest, and the disease then becomes a
dropsy of the thorax; to the common symptoms
(492) and the sympathetic (494) may be added the
circumstance that the fluid is suddenly collected.
496. Air may be extravasated in the cavity
of the thorax, by a wound in the lungs from the 
end of a fractured rib; here the pleura being
also wounded, the air will escape into the cellular
membrane & produce a partial or a 
general emphysema.
Q. Emphysema will often remain a considerable
time internal parts do not fall so readily 
into the adhesive inflammation as the more eternal
parts, hence the wound continues open
so long & admits of the egress of the air.
I believe the presence of pus or water in the
thoracic cavity, will be alone accompanied with 
the anasarcous symptoms; blood or air not producing
these appearances.
497. Blood may be extravasated into the cavity 


[137]
of the thorax, & will occasion the common, & 
probably several of the other symptoms.
498. For the discharge of extravasated fluid from 
the thoracic cavity, the operation for the empyema,
or the paracentesis of the chest becomes necessary.
499. This should be performed as rarely as possible
because (its sequel) as being an exposure of
rendering the thoracic cavity imperfect, is an 
universal suppuration generally ending in 
death.
Q. When pus is present in the cavity of the thorax
no objection to the operation can arise, for the 
part is already in a state of suppuration.
500. When emphysema (496) in consequence of wounded
lungs, arises & extends to a considerable
[illegible] the cellular membrane may be
scarified to discharge the offending air.
501. The scarification should be made at
some distance from the seat of the fracture of the
rib.
502. The lungs on the opposite side, if only one side
is wounded, should not have their action confined,
nor should the escape of the air from the cavity of 
the thorax into the cellular substance be impeded.
Q. If you make the incision open or near to the
fractured rib, with respect to the bone, you 
place it in the state of compound fracture, and
may induce all its ill consequences, besides 


rendering the chest an exposed cavity; the sequels
of a compound fracture will be hereafter shown.
503. In the case before as, tight bandage applied
on the thorax & compressing the parts which received
the injury is improper.
Q. This must be obvious from considering the 
text (502). The scarifications (501) need not be 
more than half an inch long, but sufficiently 
deep to make exposure of the cavities of the
cellular substance; when much blood is extravasated 
(497) the paracentesis of the thorax must 
be generally necessary, from the great danger
of suffocation that must attend its continuance
in the cavity.
Mr Hunter has sometimes seen patients
recover from injuries of the thorax, even when 
suppuration has taken place, as after gunshot
wounds; he finds it difficult to account 
for the means of the recovery, but thinks
it must be a kind of resolution; for the lungs
in the exposure of the cavity of the chest are
generally collapsed, so that adhesions between
this membrane & the lungs in those cases cannot
be effected.
504. It will be difficult to distinguish the inflammation
of the suppuration of the pericardium
from that of the pleura or thoracic lateral
cavities; the heart sympathising with affections
of the latter, & the latter with those of the pericardium.


139
505. If adhesion takes place between the heart
& pericardium, the patient generally recovers.
if the inflammation goes on to suppuration, the 
patient is always destroyed.
506. The adhesion of the pericardium to the 
heart, is attended with palpitation of the heart,
irregularity of the pulse, frequent, difficult, and
oppressive breathing, pain in the sternum, frequent
syncope, debility.
Q. To such symptoms the name of angina
pectoris has been given.
507. The peritoneum is the largest investing 
membrane in the body; it is subject both to 
spontaneous inflammation & to inflammation 
from external injuries.
Q. By spontaneous inflammation is signified
an inflammation arising without any visible
cause.
508. The peritoneum taking an inflammation 
runs through its arteries sooner than any 
membrane or cavity in the body.
509. The inflammation may be either common
or erysipelatous (307) at the onset it
is difficult to determine its nature.
510. Whether it is of the common or the erysipelatous
kind, it will at first be accompanied 
with a violence of action if the constitution, which 
is powerfully roused, but if of the erysipelatous 


kind, the strength of the patient will soon
sink
511. The peculiar symptoms will be a pain 
in the abdomen, not of the cholicky or spasmodic
kind, with a sense of soreness of the abdominal
region, greatly increased by pressure
or by stretching the peritoneum.
512. The intestines will also, from sympathy,
take on an unnatural action, costiveness
in some cases, in some cases a diarrhoea
will be induced.
513. The inflammation if it does not go off by 
revolution, or unless adhesions taking place
prove the case, will produce suppuration.
514. The suppuration will be
a Partial, of adhesions taking place limit
the extent of it.
b Universal, if the adhesive inflammation
be insufficient either in the time
of its direction or degree, to produce
adhesives of the membrane to the contained
parts.
515. If this suppuration be universal, it always
destroys the patient, the prevention of this state
is therefore to be diligently attempted. 
516. Bleeding seems the only means we have
of preventing suppuration, & therefore should
be had recourse to; it should seem to be improper
in the erysipelatous species, but even those 



141
we know of no other means of warding off
suppuration.
517. When universal suppuration of the cavity
happens, trial must be made of opening the
cavity with a trochar, evacuating the fluid
as much as can be, & working the part well
by injecting warm water.
518. When the suppuration is partial (a [?13], 482, 362) 
the matter frequently points outwardly, 
like any other abscess; either ulceration
takes place & it bursts or it is opened & the 
patient does well; here is a striking proof of the
utility of the adhesive inflammation.
519. The lying in or puerperal fever is a sympathy 
of the constitution, with an inflammation 
of the peritoneum.
520. The causes of the puerperal inflammation 
of the peritoneum, arise, as well as of every other 
inflammation of this part, from a stimulus of impression 
which in this case is given by the uterus.
Q. The uterus is dissection is generally found [illegible]
& free from inflammation; the disease does not
arise than from an inflammation of the uterus.
But the uterus [illegible] of some change affected
in its nature, will give the same stimulus
to the peritoneal cavity as would arise were 
the uterus removed & thus the abdomen be made
an imperfect cavity: parts may retain their life 


& yet give a stimulus productive of death
to other parts.
“This seems to be the action of the sympathiser,
because more violent than that of the sympathant.”
The disposition of women dying of this disease,
proves, in general, the fatal affection to be a 
suppuration of the peritoneal cavity.
521. Some times after  lying in, the adhesive inflammation
will prevent the suppuration
from extending itself far & an abscess will from 
at the lower part of the belly & do well.
Q. Here Mr Hunter supposes the broad & round
ligaments of the uterus most affected.
522. The peritoneal suppuration will sometime
succeed to tapping, or the common operation
of the paracentesis of the abdomen.
Q. This most commonly takes place with patients 
with [illegible] viscera & peritoneum, & in when 
the disease has been of long standing; rarely 
the first time of tapping, but not uncommonly
the third or forth. Mr Hunter has seen in the 
second day after tapping the inflammation 
spread over the whole cavity of the abdomen
yet proceed no further, in which case it does
not kill; hence we should be cautious in our 
prognosis of the event of tapping.
ON dissecting patients who have died after 


143.
tapping, the same morbid appearances have
occurred to the examiner, as in women dying of 
puerperal fever, & the symptoms have been the same 
during their illness. Mr Hunter mentioned the cases
of two men who died after tapping & the appearances
on examination after death.
523. From what has been said it must appear
that whatever can produce in the peritoneal
cavity the stimulus of imperfection, whether the
death of one of its contained parts, external violence
or penetrating wounds not healing by the
first intention, or by adhesion formed near 
the opening, between the membrane & some viscus,
may occasion the peritoneal suppuration.
524. The operation for the bubonocele & femoral
hernia, the caesarean operation, may all be productive
of the peritoneal suppuration; because 
they all occasion an exposure of the cavity, to 
which suppuration must succeed, if the exposure
continues long enough for the cavity to 
take the alarm.
Q. The suppuration of the peritoneum after the
operation of the bubonocele & femoral hernia
do not happen, because the sides of the sac are 
brought together & closed before the alarm is given
to the cavity. In the umbilical hernia after
the operation, the external parts do not adhere,
but the union mut be formed by suppuration 
& granulation.



Here the membrane should be made the basis
of the granulation, that uniting with the external
parts, it may prevent the general inflammation 
of the abdominal cavity.
325l After the caesarean operation & other cases of 
wounds into the abdomen, care should be taken 
to bring the lips of the wounds in contact, but
not to press ligatures, if suture be used, so 
deep as to penetrate the peritoneum.
Q. A.B. a crooked woman was with child 
& went her full time; her pelvis was so narrow
& deformed that she could not have been delivered
even with [crotchets]. Mr Hunter delivered
her of a living healthy child by the caesarean
section, immediately on its contents being
removed, the uterus contracted strongly, the 
lips of the wound were brought together by the
uninterrupted suture. The women died soon
after; on dissection the small intestines were
found adhering about the wound, the uterus was 
very much contracted, there was a quantity of
extravasated blood likewise in the abdomen; 
it should soon prove this latter circumstance
that in similar cases the wound should not 
be closed untill the bleeding ceases.
526. The internal coat of the bladder is liable
to suppuration on exposure, though not
very susceptible of it.
Q Of this we have abundant evidence in observing 


145.
what happens during the cure of patients who 
have undergone lithotomy.
527. The doctrines (482-483) are further illustrated
by the common consequences of the exposure of
cavities of joints by penetrating wounds, which 
 if they heal not by the first mode of union, a 
general suppuration takes place, for here,
there being no contained solids, as in the abdominal
& thoracic cavities, whose adhesions forming
might prevent the general action of suppuration,
an universal suppuration of the cavity 
must be the event
Q. Joints as consisting of ligamentous & membranous
parts, have their processes carried on slowly.
We see the worst consequences follow the suppuration
of the joints: the loss of limb & even the 
life of the patient is no unusual sequel; if a 
cure be effected it is by granulation, & the granulation
afterwards for the most part becomes
bony, & thus the joint is rendered motionless.
529.  Granulations forming, though they affect
a cure, alter the structure of the parts, hence
its utility as a joint is lost, motion is destroyed,
& an anchylosis takes place.
530. Hence it is evident that surgeons when they 
intentionally cut into a joint for the purpose 
of removing any extraneous body, as a loos
e bone or cartilage, or for evacuating a fluuid 



as in dropsy of a joint, should always be extremely
attentive to procuring union by the first mode & 
of avoiding every circumstance, that can tend
to interrupt it.
Q. Therefore, sutures, penetrating into the cavity of
a joint should be avoided.
531. The [saculi] [macosi] are similar in their nature
& [the] to joints, & contain a fluid to facilitate
motion, the consequences of injuries done to them, will
be similar to those inflicted on the cavities of 
joints.
532. They are subject to dropsy, & when affected
with it are to be cured by obliterating their
cavity, this is generally followed by a weakness
& stiffness of the parts to which they belong, but
this is soon relieved by giving them motion.
Q. 531, 532. The saculi mucosi are found between 
bone & tendon, between cartilage & tendon, between
bone & skin, between ligament & skin; so
between the patella & the skin, the olecranon & 
the skin, the annular ligaments of the finger & 
the skin etc. etc. (532) obliterating their cavity etc. This
is done by opening them, preventing the lips of the 
wound uniting by the first intention, & so making
suppuration & granulation necessary; on the
same principle is the dropsy of these parts as that
of the tunica vaginalis, or hydrocele, which 
will hereafter be explained.


147.
533. The chambers of the eye are subject to the
suppurative inflammation, which may have its
seat in one chamber, as the interior, only.
534. The causes of this may be whatever you can give
the stimulus of imperfection to the cavity, whether
spontaneous inflammation not terminating by 
resolution, or a wound not healing by the first
mode of union, hence it may follow the extraction
of the cataract etc.
535. By inflammation of the chambers of the eye,
the iris may be made to adhere to the crystalline
lens.
536. The formation of the pus in the anterior chamber
of the eye will obstruct the passage of the rays of light,
similar to an opacity of the cornea.
537. It will produce an appearance of an opaque 
cornea, which indeed may be complicated, or it may 
be single, no opacity of the cornea being present.
528. When single it may be distinguished from an 
opacity of the cornea, by the pus forming in the 
anterior chamber a section of a circle, a strait
line forming its superior side; as the accumulation 
of the pus increases, it figure approaches
nearer & nearer to a perfect circle, till
at length it entirely covers the pupil: however,
when fully confirmed it is not easy to 
be ascertained, whether it is complicated with an 
opacity of the cornea or not.


539. In general if the disease be of long standing
the cornea is opaque.
540. The removal of the pus is obtained
a By absorption into the system.
b By ulceration of the cornea evacuating it.
c By an artificial opening.
541. a is the most desirable mode of cure, as if the
cornea be not opaque, vision is readily restored.
b is the worst mode of all, being invariably
followed by blindness, from the cavity becoming
obliterated, as in other abscesses, from the injury it
may do to the crystalline lens, & from the [sprinkling]
or washing of the eye therefore,
c is to be preferred, though even from this
mode, small hopes of restoring vision can be entertained.
Q. A gentleman had an inflammation of the [illegible],
but the cornea remained transparent, he had
darting pains in the back part of his head, with 
lassitude etc. a white speck appeared on the
cornea, which being a collection of pus, gradually 
increased; at length the suppuration filled the whole
anterior chamber, & the matter was let out by 
an incision, similar to that for the cataract: 
on the 5th day the eye appeared flat, the iris and
pupil could hardly be seen; 6th day the cornea
was rendered full by a thinner & more transparent
fluid; 8th day matter was visible at the 



149
bottom of the cornea; in the end his eye was lost, as
to its vision & diminished in size.
542. The veins are not to be considered as canals, but
as cavities, & like other cavities the internal coat
is liable to the adhesive as well as the suppurative
& ulcerative inflammations.
543. The causes of the inflammation of veins, will
be the same as those of the inflammation of other
cavities, whatever can produce the stimulus of 
imperfection in them will bring on inflammation.
Q. The internal coat of a vein may inflame from’
the puncture made in bleeding, should it not
heat by the first intention. 
Therefore, in bleeding, the surgeon should always
be careful that his lancet is very sharp & that
after stopping the blood he well closes the orifice.
When the [arm] bleeds a second time after venaesection
from the same orifice, a sore arm is no unusual 
consequence; this arises from the orifice
not healing a second time, without inflammation.
Linen or lint is a better application after
bleeding than sticking plaster, for obvious reasons.
There are more sore arms after bleeding,
[where] sticking plaster than where ling has been used. Sore arms
after bleeding have been attributed commonly to 
the wound of a nerve, but Mr Hunger thinks they 
more commonly arise from an inflammation 
attacking the internal coat of the vein. If [illegible]
horses are bled, the farrier is not careful 



to produce union between the edges of the wound,
a suppuration not unfrequently attacks the internal
surface of the skin, & if it extends, as it sometimes
does, to the heart of the animal, it dies.
Adhesion suppuration and ulceration may all 
be going on in a vein at the same time, as Mr 
Hunter found in examining the body of a man in 
St George’s Hospital, who died after bleeding. We
sometimes observe a chain of abscesses in the 
course of the veins after bleeding, fin the [illegal]
when suppuration takes place, a compress on the
vein above the seat of the suppuration is useful both to 
produce contact between the sides of the vessel
and obliteration of its cavity, & to prevent the
blood conveying the pus onward towards the 
heart.
544. If the adhesive inflammation take place 
in any part of a vein, its cavity is obliterated
and a cure is [performed].
545. Suppuration arising, if by means of adhesions
taking place above the point suppurating,
a simple abscess will be formed, & no ill consequences
arise, but 546)
546. The inflammation & consequent suppuration 
may extend, in default of the adhesive inflammation
setting bounds to it, through the 
whole course even to the right auricle of the
heart or pus may be formed & carried with the 
blood to the heart, either of which circumstance 


151.
taking place, kills the patient.
547. The internal coat of the arteries is not liable
to suppuration, they will however take on the 
adhesive inflammation.
Q. This we see by observing the effects of a ligature
put round an artery. Mr Hunter has never 
seen an artery suppurate except once, & that 
was the immediate consequence of a mortification.
548. Brain. We should be extremely cautious
how at any time we open or wound the dura
mater, as the exposure of the [Pia] mater & brain is
in general productive of fatal consequences; the
brain will inflame, swell & protrude, through
the opening of the dura mater, as the cutis throws 
out a fungus through the opening of the cuticle,
in the whitloe: suppuration will take place, but the 
patient will be destroyed before a cure 
can be effected.
549. Hydrocele. The tunica vaginalis is a circumscribed 
cavity; when exposed, the same local
circumstances, as in the exposure of other circumscribed
cavities, take place.
Q. This being the case, it is to be observed that when 
the cure is attempted by seton, the water being
suddenly evacuated, the tunic collapses; now though
the seton as a foreign body may excite inflammation,
yet the tunic, at the time of producing
the inflammation, being in contact with the 


testicle, it is not certain that the inflammation 
will extend over the whole cavity, but it must,
in general, have its progress bounded by the
contact of the membranes (362).
550. It is unnecessary that we should carry this
idea in our minds, when we prepare for the
radical cure of the hydrocele, or proper dropsy
of the tunica vaginalis.
551. The hydrocele is of two kinds.
1st Where the fluid is collected between the
vaginal coat & the testicle.
2d Where the fluid is contained in an hydatid 
adhering to the tunica vaginalis
552. We know little of the cause of the first kind
of hydrocele, & of the cause of the second we are
totally ignorant.
Q. Mr Hunter, in his lectures, took notice of the
anasarcous hydrocele, but as that is a mere 
symptom of anasarca, & has nothing to do with 
the doctrines we are now illustrating it becomes
[illegible] an object of our present attention.
A diseased testicle is frequently the course
of the first kind of hydrocele, we shall have 
occasion to speak of the diseased testis hereafter.
553. The radical cure of the hydrocele is to be
obtained by no other means than the obliteration 
of the cavity which is the seat of it; thin obliteration



153.
is accomplished by 
a Inflammation, by which the surface of
the tunica vaginalis & testicle must be 
united, so that the cavity between these 
shall no longer exist: or
b a total removal of the membrane,
forming the cavity, that is the tunica vaginalis.
554. The first purpose is fulfilled by one of three
operations.
a Caustic
b Seton & [Fant.]
c Incision.
Q. whichever mode of operation is chosen, suppuration 
is to be exported, since we cannot promise 
a certain cure by adhesion only: no one
can have a great superiority in point of 
utility over the other: different men will have
different opinions in making their choice.
555. The second (b 554) by the excision or [departing]
out of the whole of the tunica vaginalis, except
where it adheres at the back part of the testicle.
Q. This must be a certain mode of cure, for it is 
not only removing the disease, but taking away
the very seat of it; the severity of the operation,
however, together with its being followed by 
more violent inflammation & greater danger 


has brought it generally into disease.
556. No certain cure can be performed unless
the whole cavity be obliterated, if any part of the
tunica vaginalis should not adhere to the 
testicle, the disease may return for.
557. In this as in all other circumscribed cavities,
the adhesive inflammation may take place
only in a few points, & thus the perfection of the
cavity may still be preserved; & consequently
the stimulus of in perfection will not be given
to the internal surface of the cavity.
Q. Mr Hunter experienced the truth of these 
remarks in a patient upon whom he performed 
the operation for the radical case
by seton: soon as he evacuated the water, the 
tunica collapsed, the inflammation excited by 
the exposure was not general, consequently the
cavity was not obliterated. Within two years
the disease returned. Stimulating injection
have been practised to being on the adhesive
inflammation & thus obtain a cure,
but here we shall be too frequently foiled 
and in this mode we can depend but little.
358. The adhesive inflammation will namely
affect the cure; in general an unusual 
suppuration must take place, before the 
purpose of the surgeon can be accomplished. 
559. Tapping for the hydrocele, the wound 



155.
not healing by the first intention may also
accomplish the desired effect: the same
circumstances here take place as in the
peritoneal cavity, after tapping for the ascites;
or accident, or a bruise producing a rupture
of the vaginal coat & a diffusion of the contents
through the cellular substance of the 
adjacent parts, if followed by inflammation 
of the tunic may also effect a cure.
Q. It has been usual to divide the cure with
the palliative & the radical, of the former, unless
when it accidentally becomes the cause 
of the latter we have very little to say, since
it teaches nothing respecting the exposure and
inflammation of cavities; it is needful only 
to observe that the palliative cure consists
in puncturing the tumor with a lancet or
small trochar, & this evacuating the fluid,
but it is rarely that this mode does not require
repetition throughout the life of the 
patient.
The palliative cure should not be attempted
unless the patient can lie by for some time,
became sometimes inflammation succeeds
& the radical cure with all the circumstances
takes place, when the palliative only was
intended.
560. It is to be remembered that the operation
for the hydrocele is not necessary for the preservation 


of the life of the patient, or the support
of his health, but only for the removal 
of an inconvenience; therefore the danger of 
the operation is to be balanced against the 
extrication of the patient from present [trouble].
561. If a radical cure for the hydrocele 
be [illegible] upon, we are then in our choice of
the mode of performing the operation to consider.
1st The comparative danger of the different methods.
2d The comparative certainty of success of
the different methods.
3d The state of the testicle.
562. The greatest comparative degree of danger
attends the operation by excision (  ) which is
therefore, perhaps, never to be advised; this
danger will arise from the sympathy of
other parts & of the constitution with the testicle
in this mode of operating, is rudely handled
and so entirely & suddenly exposed.
563. The mode by excision is most certain 
in its success; next to that the mode by incision, 
& the [illegible] & the seton are less sure 
in their efforts.
Q. Inflammation arising in consequence of any 
operation, it is [no] animal consequence for a 
considerable quantity of coagulable lymph 
to be thrown out, surround & give the appearance 


[157]
of enlargement to the testicle: this
effusion of coagulable lymph, forms also the
sloughs that are thrown off in the process,
when suppuration takes place, & which were 
by the author of a [illegible] publication considered
as sloughings of the vaginal coat, to which he 
imputed the cure by caustic, but the vaginal
coat rarely sloughs, the sloughs discharged
being generally false membranes made from 
coagulable lymph, now & then, however, 
when the tunica vaginalis is in a diseased state,
a partial sloughing of it may take place. 
The circumstances which may give the appearance
of an enlarged & diseased testicle deserve
particularly to be attended to, as otherwise a
surgeon may be induced to remove it as schirrous
and incurable; the testicle requiring no such 
operation
Case A man laboured under a hydrocele,
the tumor inflamed suppurated & at last ulcerated;’
the  surgeon enlarged the opening, and
finding the testicles apparently enlarged, our
supposing it schirrous, was about to remove it
Mr Hunter was desired to attend the operation;
he found the suppuration of the tunica vaginalis
too general for the complaint, in his
opinion, to be cancerous. The history of the case
confirmed this opinion: the patient being extremely
timid, there was no difficulty in getting 



the operation put by: it was referred, & he recovered 
from his ailment by very simple means.
Further respecting the state of the testicle, it
becomes necessary, particularly to attend to 
it, that if the disease requires, it may be extirpated,
without the necessity of a second operation.
Care should be taken to distinguish a swelled 
testicle from a dropsy of the tunica vaginalis,
if the tumor consists of the latter, it will
be mostly [pyriform], if the former, it will be 
[flatted]: this attention to the appearance, added 
to the assistance of the [illegible], will mostly
preserve the surgeon from error.
again, in the hydrocele, the stimulation of
the testis should be ascertained, that we
may not, if we have occasion to tap, the tumour,
be in danger of wounding it.
Mr Hunter by accident wounded a testicle
four times, & yet no ill consequences supervened,
which is somewhat singular, as so much
mischief frequently follows the slightest [illegible]
of this gland.
A pulpy testicle will be very apt to be 
mistaken for a hydrocele.
again, respecting the state of the testicle, we 
should take care to distinguish a scrophulous
testicle from a cancerous one. Mr
Hunter never saw a cancer of the testis follow
the radical cure of the hydrocele.
The best means of ascertaining the situation 



159.
of the testicle and whether this gland
forms the tumor, is the sensation the patients
experience in squeezing the tumor; if it be
a diseased [illegible], the pain is the same in every
part, if only a hydrocele, pain is felt is
pressing that part alone in which the testis 
is situated.
564. All the modes of operating give us an 
oportunity of examining into the state of the 
testis, that by caustic alone excepted; the mode
by incision gives the best oportunity.
565. The mode by incision, being the most simple 
of all, more certain, yet not more dangerous 
than either caustic or seton & more safe
& easy than that by excision, is probably to 
be with [illegible] preferred; it is performed by 
making an incision three inches in length, or 
throughout the length of the tumor, into the cavity
containing the water, which being evacuated,
poultice or crumb of bread is to be introduced
every where between the two tunics & kept in
by means of lint stuffed into the mouth of the
wound: rags wetted in brandy or spirit of wine 
should be kept on the scrotum & often renewed 
to prevent the too sudden coming on of inflammation,
& the scrotum should be suspended in
a bag truss.
566. The advantages of knowing whether a testis 


is diseased or not, is that if found so in a considerable
degree, it may be removed without the
patient undergoing a second operation.
567. We cannot perhaps a priori determine
whether the disease be a hydrocele of the tunica
vaginalis, or the water be contained in an 
hydatid; nor is the knowledge of consequence
in the cure, as in birth the same mode of treatment
is to be observed, but the consequences of
an opening with the tunica vaginalis will
be different from those of wounding an hydatid.
568. In the former (567) the sympathetic affection 
usually following an exposure & inflammation 
of the testicle will come on such as rigors, nausea,
vomiting, dull pain in the back & loins
great sense of lassitude, swelling of the testicle.
these will in general come on in twenty four
hours after the operation: but when an hydatid
is opened, as the body of the testicle is not exposed,
these will [not] arise, but only the common circumstances
of inflammation, as heart, soreness of the 
scrotum etc. 
Q. In cases where the hydrocele has been tapped,
we should be led to suspect that the cicatrix
left at the puncture would be the proper part
to perform an operation again, either for
the palliative or for the radical cure, but
this is not always the case, for the testis sometimes 


161
adheres to the cicatrix, & if this rule be observed, 
would be wounded; in consequence, after the symptoms,
following the operation for the radical 
cure, [illegible], an enlargement of the parts always remains,
which is not an enlargement of the testis,
but only a thickening of the tunica vaginalis,
this gradually subsides, & the parts return almost
to their natural sise, which diminution
may be forwarded by rubbing in mercurial
ointment.
[Haematocele] is an extravasation of blood
into the tunica vaginalis, it is not of much consequence 
to distinguish from the hydrocele, as
the same treatment is advisable, but it must be carefully 
distinguished from an enlarged testicle;
sometimes the contents are only extravasated 
blood coagulated, sometimes coagulated blood & 
serum, & sometimes the coagulum be found to have 
become vascular.
569. The treatment of both (560) will be the same 
as in inflammation in general, but the scrotum
must be necessarily, suspended.
Q. Further remarks on the cure of hydrocele,
by seton or [font] & by caustic.
If the seton be used care should be taken that
the strain of silk or thread be large enough, to 
fill up the wound made by the lancet or seton
needle, & thus by plugging it up prevent the escape
of the water, untill a general inflammation 


has taken place, for the water keeping the tunic
every where distended, partial adhesion will be 
prevented, & the influence of the operation become
general (566, 567) The seton should be passed in
the perpendicular axis of the tumor: the place of
choice for the [Font], should be neither at the upper
or lower part of the tumor, but about midway:
the water should not be [supposed] to escape before
the [Font] is introduced, for the same reason as
the confinement of that fluid is recommended
where the seton is used. Sponge [Font] is preferable.
Caustic There is an uncertainty how deep the
caustic will act, should it not penetrate so as
to include the tunica vaginalis in the [illegible],
we shall be under the necessity of making
a puncture through that membrane, & 
we shall gain no advantage from the use of 
the caustic.
When the [illegible] is sufficiently deep, the inflammation 
of the cavity takes place before the water
is discharged, which have also prevents partial
adhesions & an imperfect cure but the 
uncertainty of the action of the caustic is an
objection to its use.
It may happen that the testicle may 
lie upon the fore part of the tunic, & its situation



163
not be known, or not attended to by 
the operator; if in performing the radical cure
by incision, he finds he is cutting on the body of
the testicle, he should carry his knife more to
the lower & outer part of the tumor in finishing
his incision, for fear of cutting the spermatic artery,
an accident that has happened.
570. Fractures. The bones as well as the soft
parts are subject to every stage of inflammation, 
either arising spontaneously, or being induced
by external violence, & when their continuity is
[divided] they are reunited by processes similar
to those which we observe take place in the soft
parts.
571. Bones are liable to solution of continuity
from external violence, solution of continuity
in bone is called fracture.
572. Fractures in bones are either
a Simple.
b Compound.
c Compound simple.
d Simple compound.
By a simple fracture is meant a solution of
continuity in a bone, without a wound communicating
externally.
573. By a compound fracture is meant a solution
of continuity in a bone, with a wound communicating




externally, which does not heal with 
out suppuration & granulation.
574. By a compound simple fracture is to be 
understood a fracture which has a wound
communicating externally, but which wound 
heals either by the first or second mode of union 
& without suppuration.
575. The simple compound fracture takes place
when originally there was no wound communicating
externally, but where in consequence 
of some parts losing their living principle from 
any cause, ulceration of the integuments is rendered
necessary, the circumstances of a compound
fracture are induced.
576. Previous to our [entering] upon diseases, or
the mode of restoration in bones, it is necessary 
to consider the five following aphorisms. 
577. Bones consist of an inanimate earthy matter 
attached to a living organised substance.
578. Bones may either be in a dead or a diseased
state; between the death & disease of a bone
it becomes necessary carefully to distinguish.
Q. It has been usual to distinguish all unnatural
states of the bones by the name of a caries.
Caries was divided into moist & dry,
moist seemed to imply a diseased state of the 
bone, dry, the bone becoming dead. By converting
the moist into the dry state, the cure was 


165.
frequently accomplished, why this happened from 
(506, 597, 632).
The term caries signified a rottenness in the 
bone, it is evident this was improperly applied
to bones becoming dead, because a dead bone 
is generally thrown off without the least appearance
of rottenness; indeed it is much more firm 
and solid then the margin of separation in 
the living bone, which had thrown it off.
579. Bones fall more slowly into disease than soft
parts, & when they become diseased are proportionably
slower in the art of restoration, for all processes
go on more slowly & difficultly in bones
than in soft parts.
580. It will be necessary also to consider the doctrines 
advanced in (352, 358, 359, 361, 362, 482.)
581. Also that bones receive their nutrition
& means of support chiefly from the periosteum,
or membrane covering the bones (382) different
bones varying much in their structure, their
diseases, will vary, as well as the readiness
with which they go through the process of restoration.
582. When a solution of continuity happens in
a bone from external violence, productive 
of simple fracture (572) the care may be affected
by the first mode of union, without either
inflammation or suppuration. In simple fractures,



though accident produces a rupture of several
blood vessels, and an immediate effusion of
blood into the cavity made by the division 
of the bone; if the oeconomy of the parts be not
very much disturbed by this violence, the blood 
retaining the living principle, the red part & 
serum are soon absorbed & the coagulable
lymph alone remaining becomes vascular;
the cure is accomplished with little pain & without
disturbance of the general system.
583. If so much injury be done to the parts,
that a considerable & unusual action is 
necessarily excited int hem, the first & most
simple made of union will not take place, but
the ossific inflammation or that which is 
perfectly similar to the adhesive inflammation
in soft parts arises, coagulable lymph is
poured out into the cavity, from similar in 
its nature to any circumscribed cavity which 
is to form the callus, this becomes vascular, 
at length cartilaginous & lastly [ossific] matter
as in the first formation is deposited, & thus 
the cure is accomplished. Here pain, tumefaction
of the circumjacent parts & the common symptoms 
of the adhesive inflammation takes place.
584. In the compound fractures (   ) the cavity 
made by the division of the ends of the bone
becomes exposed, from the fracture being complicated 


167
with a communicating wound: the blood
effused does not as in (582) retain its living
principle the stimulus of imperfection obliges
the cavity to set up a new proof, suppurate
on takes place, & the only means of reunion
left are those of granulation.
585. As in wounds made into circumscribed
cavities; if the lips of the wound come into contact 
& unite either by the first or second mode
of union, before the stimulus of imperfection gives
the alarm to the cavity, a suppuration of the
whole cavity does not necessarily take place; so 
in the compound simple fracture, if the external
wound be thus made to unite before the blood
effused into the cavity has lost its living principle,
& the stimulus of imperfection has given
rise to a new process, the case may be accomplished
with the same case, as in the simple
fracture.
586. But it may occur that either a splinter of 
bone being detached & dying, or the extravasated
blood losing its living principle, or from a misplaced
end of the bone producing ulceration 
of the integuments, or an irrecoverable injury
being done to the parts covering the bone, that
ulceration was to the exposure of the cavity in
produced, in this case, which we term a simple 
compound fracture, the same circumstances  


will take place as in the compound fracture.
587. When a part of bone becomes dead, exfoliation
or the throwing off the dead part from the living
must take place. In what the proofs of exfoliation 
exists we will hereafter show.
588. When a surface of a bone is exposed, it is
very common for a portion of it to become
dead, & a necessity for the process of exfoliation to
take place. For the bone receiving its nutrition 
from the surrounding periosteum, that being
destroyed, or becoming dead, a part of the bone
must lose its means of support.
Q. It can rarely happen that any longer portion
of the periosteum shall be destroyed or become
dead without a consequent death of a 
portion of subjacent bone, if only a small extent
of periosteum be destroyed exfoliation of the
bone does not always follow, because its
life will still be supported by means of its
vessels anastamosing with those which pass from 
the periosteum nearest to the exposed part.
589. The union of broken bones in more slowly 
accomplished than that of the soft parts; became 
in the former two processes are to be accomplished;
viz the formation of soft parts & then the
formation of bone.
590. The ossific inflammation arises, when there 
is an increased disposition in a part to form bone.




169
591. It consists in the vessels of the bone & the
parts covering the bone, taking on the same action 
as the vessels of the soft parts do in the adhesive inflammation.
592. The consequence will be similar, for it will
produce tumefaction & enlargement of the bone;
if extending from one bone to another, between which 
& the other there is a natural motion, it will produce
anchylosis, like as adhesive inflammation 
produces immobility in the soft parts to which 
it extends; it will be followed occasionally by 
suppuration & ulceration.
Q. Of this we have instances in anchylosis of the 
vertebrae of the spine, especially in horses; between
two or more of the vertebra of these animals it
is common to have an anchylosis formed.
593. The causes also of the ossific inflammation 
will be similar to those of the adhesive, external
violence, as exposure or pressure, a necessity for action
in the vessels of the bone or its membranes [illegible]
may give rise to it.
Q. Pressure will not uncommonly occasion ulceration
& absorption of bone, but it may also excite
the ossific inflammation and a thickening of the
bone.
504. The final intentions for which the ossific inflammation 
may be employed are first, to produce 
restoration of parts & reunion in a diseased 
bone, & secondly to strengthen weak parts.
595. The seat of disease in bone can only be in 


its living parts.
596. The more spongy & soft the bon is, or the
more living matter it contains, the more liable
it is to disease, the harder the bone, the less ready
it is to fall into disease, but a death of
some of its parts is more easily induced.
597. When a bone becomes diseased, it is over
business to endeavor to get the better of the 
disease, but when a bone becomes dead, nothing
can be done but to produce exfoliation.
598. The treatment of diseased bone is rendered 
difficult by the impossibility in general
of discovering the extent of the disease.
599. The inflammation & suppuration may 
have their seat either in the surface of the
bone, or within the substance of the bone,
or in the medullary substance.
600. Hard bones becoming diseased are more
difficult of cure than soft ones, & when cured
are more liable to fall again into a diseased
state.
601. Bone is liable both to ulceration & interstitial 
absorption.
602. When a portion of bone becomes dead, the 
process of exfoliation is performed by the dead
bone giving a stimulus to the living bone in 
contact with it, & to which it adheres by the 
attraction of cohesion the living parts immediately 
in contact with the dead bone are absorbed, 


171.
& a cavity between the dead & living
surface is found, the former being now a more
extraneous body, in according to a law in the
animal oecomony (  ) carried from within 
outwards & at length thrown off from the 
body surface; ulceration of the integuments having 
made way for its exit, the cavity is filled up 
with granulations which became new bone.
Q. The first appearance of separation, in order
for exfoliation is a sponginess in the living
bone now becoming more vascular, then a groove
is formed in the direction of the fibres that 
surround the dead bone: the living bone becomes
more softened & more porous: part of the
dead bone seems sometimes absorbed, for it has the
appearance of having undergone ulceration; it is
certain the absorbents have the power of taking
up dead bone; the absorption beings at the circumference
& is continued to the centre. In the
skull they become first membranous, nature
observing the same order in the repair of bones
as in their first formation: a pulsation in the 
granulation often attends the exfoliation of
bone: granulations will sometimes arise, 
short over the surface of the bone to the exfoliated,
& prevent its being thrown off so soon as it 
would otherwise be, in this case it excites new
inflammation & ulceration.
603. Granulations will arise from the surface 



of bone without suppuration having preceded, 
but this is only where that surface has not been
exposed by a penetrating wound.
Q. The granulations forming bone irregularly 
become often a considerable obstacle to the cicatrisation
of the ulcer after the process of ossification 
etc. is finished. 
604. A thickening of the periosteum & integuments
has often been mistaken for an enlargement 
of the bone.
605. A bone may be enlarged without any 
alterations in its original structure, by bony 
matter being formed on its natural surface, then 
laying in of new bone will arise from the ossific
inflammation taking place on the periosteum
or on the surface of the bone; we call this adventitious 
bone.
606. Os, a bone may be increased by the ossific
inflammation taking place in its substance, which 
causes an alteration in its structure, and enlargement 
of its dimensions.
607. A bone may be increased in size at the
same time that those is an absorption going 
on in its substance, for the ossific inflammation 
may be laying in new bone on its surface,
at the same time that absorption is 
removing portions of its internal surface; then 
a bone may at the same time be increasing in 


173.
its dimensions & losing in its quantity.
608. Suppuration may take place either in the
surface, or in the substance of a bone.
609. Matter when formed may be confined, if
in the substance of the bone, by the natural bone
remaining unulcerated through its substance, & those
by preventing the exit, or if on the surface of the
bone, by the ossific inflammation forming a cave round 
it of new or adventitious bone, but in the latter
case, the progress of the suppuration must be rapid,
otherwise there will not be time for the bony
case to be contracted, & the matter will make
its way to the skin as in a common deep seated abscess.
610. Matter may also be confined on the surface 
of a bone, for a considerable time, simply by the
thickening of the periosteum, just as it is confined
by a fascia in a whitloe.
611. The periosteum or the cellular substance connected
with it may take on the ossific inflammation.
612. Suppuration taking place in the substance of
a bone, & the ossific inflammation being also taken 
by the surface of the bone & the parts covering 
it, the matter will produce a disposition to the 
ulcerative absorption, which will be continually
removing large portions of the internal surface 
of the bone; the ossific inflammation at the 
same time depositing new bone on the outside; 


thus the bone may be enlarged to any size, and
these two processes absorption within & ossific deposition 
without going on together, the dimensions 
of the bone shall be wonderfully increased, at
the same time that, perhaps, the original bone
shall be entirely removed & even some of the internal
parts of the new bone shall be taken 
away, & at last instead of a solid bone, only a 
large bony case shall remain, from which at
length the matter shall be evacuated. Ulceration
from within may however go on even after
the matter has made its escape.
613. Ulceration is the sequal of suppuration, it
removes the effects of the ossific inflammation; 
when ulceration has gone through the surface of
a bone it affects, first the periosteum, next the
muscles, & lastly the cellular substance & skin.
614. Bones, when the first & second mode of union 
fail, are, as heretofore observed, cured by the formation
of granulations & those taking on 
the ossific disposition.
615. But it sometimes happens that the ossific 
disposition shall not be taken on by the granulations
between the ends of the bone so that 
there shall be no union by the bone; the restorative 
process going no farther than the production
of granulation, or the change of them
into cartilage.
616


175
616. It sometimes happens that no union at all
takes place between the separated ends of the 
bone, even after a simple fracture, in this case
a new joint is formed, the ends of the bones becomes
covered with cartilage, & as in all other
cavities, a power of secreting synovia is given
to it, & it is in every respect similar to any other
joint, except the want of the proper moving powers,
that is corresponding muscles, there not being
generated, the new joint becomes extremely 
inconvenient.
617. Ossific inflammation may terminate in a 
suppuration, or the bone may remain swollen
but indolent.
618. Exfoliation of bone is of three kinds – viz.
a External
b Internal
c Mixed exfoliations.
619. The process of simply external exfoliations
has been already explained (602). It happens also
that an internal part of a bone shall become
dead; becoming dead, it gives a stimulus to 
the surrounding living parts; as an extraneous 
body it must be thrown off, for all parts, as has 
been shown (  ) admit readily of the passage of
foreign substances from within outwards; hence
from its stimulus its ulcerative absorption 
is finally produced in the surrounding parts 


& a passage is given at last to the dead bone
in consequence of the stimulus, granulations arise
also & fill up the cavity occasioned by the 
separation of a part of the bone, & these granulations
becoming bony, the cure is accomplished.
620. The mixed is when the external exfoliation
becomes an internal one, which is accomplished
as follows.
At the same time that the process of absorption
goes on for removing the dead bone from
its contact with the living part, the parts in the
neighbourhood take on the ossific inflammation 
on which in the end forms a bony case round 
the dead piece of bone & prevents its exit.
Q. Here nature seems to be counteracting her
over ends, but the final intention of this bony case 
seems to be a hasty attempt to [illegible] the weakness
in the limb that might spring from the extent
of death in the bone.
621. Bones often become painful before a swelling
of them is perceived.
622. The matter discharged from diseased bone, or 
where the process of exfoliation is going on, is seldom 
laudable. Pus, & is extremely disposed to 
putrify, tinging the probe of various colors.
Q. This happens
1st Because it is the matter of diseased parts.
2d Because the continual irritation of 


177.
the bone, like other irritations, occasions a 
flow of this matter.
3d Because there is commonly some blood
mixed with it, which soon becomes putrid.
623. When the skin is affected, that is, when the 
inflammation of the bone is communicated to 
the skin, suppuration commonly takes place.
624. The periosteum becoming inflamed, and 
its internal surface taking on suppuration,
a disease, or death of the more external parts of
the bone may be induced.
625. The hard bones, having fewest living parts, & 
of course, fewest vessels, have their life soonest destroyed
by any destructive cause whatever; it is
scarcely possible to lay them bare to any considerable
extent without death & exfoliation being 
the consequence.
626. Where the ossific inflammation, or other inflammation
of a bone requires the assistance of art, [&]
is to be treated by [illegible] remedies &
by insisting upon rest being given to the part affected
& if in the lower extremities that the patient
lie in an horizontal position.
When the swelling of the bone becomes indolent,
the parts are to be roused into action, & if
possible intersticial absorption excited, by the administration
of mercury both internally & externally. 
The [mezereau] root has been much recommended 


as a specific in the enlargement
of bones.
Q. The quantity of mercury to be used may be somewhat
less than that fitted for curing the lues.
627. If the seat of suppuration be the surface of the
bone, or the internal surface of the periosteum,
the matter should be evacuated as early as
possible, & this by simple incision through all the
teguments down to the bone, but without removing
them & more especially if the cranium
be the object of our consideration.
Q. The integuments need not be removed because 
of exfoliation is to take place, it will 
prevent granulation & the healing of the disease 
which will not close while there is a bone
to be thrown off (see doctrine of gun shot
wounds).
628. Sometimes in this superficial suppuration
bones are so much diseased that they have
not a disposition for restoration, & the bone
will not exfoliate unless the actual [cautery] be used.
629. In case of suppuration in the substance or
in the medullary substance of the bone, (which 
is the worst case by far) the matter is to be evacuated
by the actual or the potential [cautery]
or by the trepan.
630. Bones which have undergone external ulceration 


179.
often fall into an indolent state, in which case
stimulating dressings are to be used.
631. When the actual cautery is applied are most
use [an] iron of a thickness sufficient to give a 
degree of heat in proportion to the depth of
the bone. The time of continuing its application
must also be in proportion to the same
circumstance. 
632. Cauteries may also produce a case of diseased
bones by inducing a death of the diseased 
parts, & so rendering the process of exfoliation necessary,
but in order to have this effect, their 
action must produce the death of the whole diseased
part.
633. The actual cautery not only induces the 
death of the diseased part, but an inflammation 
in the sound parts, & this hastens the separate
or of the part to be exfoliated. The potential
cautery rarely does more than producing 
the death of the diseased bone.
634. A natural or spontaneous exfoliation
is however much more to be desired than an
exfoliation produced by art, because of the
uncertainty of our endeavours to extend our operation
to be the whole of the diseased bone.
635. In specific diseases producing a disease
in bone & consequent exfoliation; the exfoliation 


goes on more readily & kindly from the 
venereal disease, than from scrophula & others.
In scrophula the extent of the disease is more
considerable whereas the venereal disease is
more partial & confined to a narrower limit.
636. When after a solution of continuity in a 
bone, the case proceeds no farther than the soft 
union, the rest of the limb should be disposed 
if possible to excite a further disposition to the
art of restoration in the parts.
637. When the fracture with the circumstances
(626) is in the lower extremity care must be 
taken by means of splints & [ironwart], that the
whole weight of the body does not [illegible] open 
the fractured bone.
Q. Mr Hunter has seen patients with fractured
legs in which from union would not take
place, untill they were set upon their legs,
the fractured bones being well supported & 
defended by splints etc. 
638. When a new joint is formed (616) these 
[precautions] are also to be attended to.
639. But, it may sometimes be desireable to 
attempt the destruction of the new formed
joint & procure from union between the ends 
of the formerly divided bone: in this case we 


181.
are to consider the doctrine of inflammations 
of cavities & particularly that of the cavities
of the joints (258 etc.)
640. The mode of accomplishing this purpose 
will consist in procuring in the new articular 
cavity the stimulus of imperfection by making
an opening into the joint & introducing some
foreign body to prevent the healing of the wound 
by the first or second mode of union & excite
universal suppurative inflammation which 
being followed by granulations & these granulations
becoming long, the ends of the bone
will be immoveably united.
Q. It must be evident that the less time has
elapsed since the formation of the new joint,
the more readily its destruction will be accomplished.
641. Diseases of bone may have powerful influence
on the constitution; we may readily [conceive]
the effects of a constant & long continued
pain, want of rest etc., which are their attendants.
We also know they will bring on hectic, & this is 
accounted for by considering what is advanced
 on hectic (479 etc.)
642 When ulceration has removed so large a portion
of the bone, that the remainder, on account
of its weakness shall be unable to support its
necessary actions; or where disease extends through 


a greater part of the substance of a bone that art 
can restore to health, or procure a separation 
from the sound parts, or where there is an inability 
in the constitution to support the disease,
or the processes necessary to healing
Amputation becomes indispensible.
643. In simple fractures, if the patient be healthy,
the union of the bones will be in general 
accomplished in three weeks; but something
[illegible] in the upper than in the lower extremities.
644. Rest. Retention of the bones in their natural
position, [illegible] on from pain & the prevention
of inflammation, are the general indications
in all fractures of the extremities. Whatever
position of limb best fulfills these indications 
is the position to be recommended.
645. To prevent the displacement of the ends 
of the bone, we use splints & bandages.
646. Of the different species of fractures enumerated
(572) the compound in the most dangerous,
& frequently attended with troublesome, if not fatal
symptoms, or fever, symptoms of dissolution,
gangrene etc.
647. We can rarely keep the bones perfectly 
at rest in bad compound fractures, hence constant
irritation, pain etc. 
648. The same indications are to be fulfilled in the 


183.
compound as in the simple fracture (582) We 
should move the limb as rarely as possible. Poultices,
though they should otherwise seem desireable
applications in compound fractures, become
injurious by their admitting of motion in the ends
of the fractured bone.
649. The simple compound fracture is attended
with less danger than the compound, although
the former also may produce troublesome and
dangerous symptoms
650. The treatment of the constitution when 
affected by the consequences of compound fractures,
will be the best understood by recurring to 
(462 & 479).
651. From what has been said it must be evident
that when a fracture of a bone is complicated
with a communicating wound of the
parts that cover it, as muscles, cellular substances
& skin, it must be always the duty of the surgeon 
to endeavor to render the case a compound 
of simple fracture; to which end he will 
be careful to remove extraneous bodies which 
may hereafter produce the stimulus of imperfection;
to place & retain the bones in
their natural position, & prevent their irritating 
the soft parts, to being the soft parts into 
contact one with another, in short to observe the 


rules laid down in cases of wounds into cavities,
& the doctrine (682).
652 In bones, as in soft parts, the observation, that 
all new formed are weaker than original
parts, holds good.
653. In bones as well as soft parts, the process of 
restoration goes on more readily in the upper 
than in the lower extremities. Compound fractures,
therefore considered as injuries done but 
to the bones & soft parts are more dangerous in 
the leg & thigh than in the arm or fore arm.
654. Fractures of bones which communicate 
with cavities of joints whether simple or compound,
require peculiar attention & peculiar
treatment as
1st The fracture of the patella
2d of the olecranon
3d of either ancle.
655. Also when a fracture happens near a 
joint, the bone may be so splintered as to communicate
with it.
656. In case it be a fracture attended with a 
wound of the joint communicating externally 
the wound must be healed, if possible without suppuration,
which arising will occupy the whole
cavity of the joint & too often produce a necessity 
for amputations.
657 If a simple fracture communicate with a 


185.
joints cavity, the bond of union will escape into 
the cavity & form a case similar to a compound fracture.
658. The fracture of the bone will be here [illegible]
by the third mode of union or granulation (the 
first & second being lost by the escape of the bond 
of union into the cavity of the joint.) except that
here there will be granulation without suppuration 
preceding (683). In case of fracture communicating
with a joint it is [apt] in the case to 
produce a stiffness or loss of motion in the joint
from the blood escaping into the cavity & becoming
organized; in this case as soon as the fractured
bones are united by callus, it is necessary 
to give passive motions to the joint, often
repeating these, & when the callus is confirmed
the patient should diligently exercise
the part affected by constant motion of the 
proper muscles.
659. When the patella is fractured the union 
of the fractured parts will be either by bone or 
by ligament.
660. If the fractured parts remain in contact, or
very near to each other, the union may take 
place by bone, as in the fractures of other bones,
but if the fractured portions are at a distance
from each other union by the formation of ligament
will be the mode adapted. 


661. For, the patella being employed in the 
formation of a joint, a union by lengthening
the bone two or three inches must have been 
extremely inconvenient to the patient, & incompatible
with the future motions of the knee.
662 The patella being the point to which the 
principal extensor muscle of the leg is inserted
when fractured transversely, the muscle being 
now no longer confined, contracts itself, & draws
the superior portion of the fractured bone to a 
considerable distance from the [inferior].
663. When the union is formed by ligament as 
is always the case when the fractured bones remain
it a considerable distance [asunder], the patella
is very much lengthened & the two points
of attachment of the rectus muscle being therefore
brought much nearer together, the muscle 
must be considerably shortened.
664. As the original length of the muscle is
diminished, its power of contraction must be 
diminished in proportion; for the two ends of the
muscle have in consequence of the action approximated
themselves nearly or entirely as 
much to each other, as they were accustomed
to do in voluntary motion: hence it is evident
the powers of extending the limb must
remain lost unless the muscle requires a new 


187.
action, thus accommodating itself to the present
circumstance
665 The muscle, however, will acquire new
actions in time, & moreover, will in time, be enabled
to shorten itself, so that by its contraction 
the power of extending the limb shall return 
to the patient.
666. This power will be the sooner restored, if
the surgeon & the patient join in their endeavours 
to induce in the muscle a habit of acting.
667. This is to be done first by giving passive
motion to the limb, & then by the patient exerting
himself attentively in exercising the influence of 
the will upon the part.
668. For the muscle being originally under this influence
of the will, if the powers of volition be resolutely 
& industriously exerted, will in time recover 
its pristine action, & voluntary motion of 
it will be restored.
Q. Lady B—broke both the patella; they were
reunited by ligament & she lost entirely the
power of extending her legs, consequently was
unable to walk; she had been in this state 
two years. Mr H- then saw her He sat her up 
on a table, with her legs hanging inflected
over the ends of it, he desired her to think attentively
if extending her leg, & try by the powers 
of the will to raise it forward; at first her 


mind had not the least influence on the leg, but
by repeatedly determining the influence of the will
to the muscles, & repeating this endeavor for two
or three days, she gained a trifling power of extending 
her legs; by persisting in the same means she
increased that power so as to be able to extend
them completely; she was then directed to raise
her leg with a small weight affixed to her toe;
this weight was gradually increased: at length
she was set upon her feet & obliged by an attempt
to walk to exact greater force; by daily 
exercising the muscles in this manner, & gradually 
increasing their labor, she was at last
restored to the use of her legs, which were before
considered as irretrievably lost.
669. If the union be formed by bone, by the irregular
formation of callus, a long bony ridge may
be raised on the internal suface of the patella,
which may be impede the portion motions of the
joint.
670. It must be evident that the knee should
be kept straight, & that in order to the retention 
of the bones in their approximate state; we must
apply a bandage rolling the thigh from above
downwards to prevent the involuntary contraction 
of the rectus [famosis]; also that [illegible]
should be insisted on: the surgeon should repeat this 


189
motion of the limb once in two or three days, afterwards
more frequently untill at length the proper 
time comes for the patient to exert self motion
(see lady B-‘s case (667.)
671. The union of the bone will be much sooner
accomplished by bringing the separated pieces of bone
near together & keeping them in that situation
for by this means of the muscle will not lose its
original length & of course its power of contraction;
consequently less difficulty will afterwards 
arise to the patient of extending the limb, & the 
evils of irregularity of callus & stiffness of the
joint may be prevented by the attention of the 
surgeon.
672. When the cure has been attempted, as soon as
reunion has begun to take place, a slight degree
of passive motion should be given to the limb, & 
as soon as union is perfected, voluntary or self motion 
should be insisted on
673. The olecranon is to be considered as a fixed
patella, & the same principles, allowing for that
difference, will apply to a fracture of it.
Q. The triceps extensor [cubiti] being fixed to the olecranon, 
when a fracture of that process happens
the superior portion of the bone will be drawn 
upwards by the involuntary contraction of the 


muscle. In the cure the superior portion is to be
brought downwards, the arm for sometime kept 
extended, untill reunion begins to take place, & 
the action of the triceps is to be checked by bandages:
when union is partly formed, as after a
fortnight it mostly will be, the passive motion
is given to prevent stiffness of the joint, & lastly 
when the union is completed a voluntary motion 
as in the case of the patella.
It is remarkable that is general in luxuriant 
collus of a bone is on the outside, if its internal
surface be exposed to the action of moving 
parts; thus a ridge from a collus in a fractured
rib is never on the inside of the rib.
After muscles have acquired a new action, the 
next stop is to give them strength, which must be
done by frequent exercise: it is to be observed that 
the greatest possible contraction of a muscle is somewhat
more than the motion of a joint which it 
serves, admits of; hence when the patella or olecranon 
is fractured, the extensor muscles will be 
shortened more than in voluntary action.
674. When the ancle bones are fractured they are
only to be considered as bones making joints, & not
as liable to be influenced by the action of the
muscles, none of which are inserted into them; they 
are therefore to be returned if any displacement
has happened, to their natural situation & retained 


191.
In it by bandages etc. & when union has begun to 
take place between the divided portions of bone,
passive motion should be given to the joint.
675. Cartilage is an animal substance intermediate
between the hard & soft parts, approaching
very much in its nature & properties to [horn] it
has very few vessels, is insensible, has very little
power of absorption, is not liable to exfoliate, even
when exposed & even scraped, never goes into the suppurative 
inflammation, nor even becomes the basis
of granulations.
676. Cartilages may be divided into two kinds 
a The permanent.
b The changeable.
677 The order a are such a remain unaltered
during life; such are those of the nose & ear.
678. The order b are two fold.
1st Those which at a certain time become bone
for which before they served as a substitute, such 
are the epiphyses of bones, which in the infant are
cartilaginous, in the adult are bony.
2d Those whose change into bone takes place
at an uncertain period of life, & sometimes are 
never changed into bone, as the cartilages of ribs 
& the ends of cylindrical bones.
679. When cartilages are exposed they do not exfoliate
like bones, nor do granulations arise from 
them, but granulations arising from the circumjacent 


soft parts on all sides shoot out & [illegible]
over them, thus closely covering them without
adhesion.
Q. Mr Hunter has once seen cartilage die, become
black & be thrown off with a portion of the bone 
lying under it; this is also the case in white swellings,
the cartilaginous ends of the bones being 
[illegible], the bones are removed together with 
the cartilage.
Mr Broomfield amputated the arm of a young
woman at the shoulder joint; she recovered; 
several years after she came into St George’s
Hospital, where she died: in dissecting the shoulder
in which the operation had been [illegible]
it appeared that the granulations & soft parts 
were not the least adherent to the subjacent
cartilage which they covered loosely like a 
purse. The same thing happens when fingers
are amputated at joints. Mr Hunter has seen the
cartilage of the larynx & ribs exfoliate, but
they have been previously ossified, & become 
a bony spongy substance.
680. When the permanent cartilages are divided 
the reunion is formed by cartilage, but when the 
changeable cartilages undergo a solution of continuity,
they are consolidated by a bony union.
681 when the changeable cartilages inflame
they take on the ossific disposition; when they fall 


193.
into disease, they also become bony.
682. Cartilages seldom admit of the ulcerative [illegible];
they are, however, liable to undergo contiguous
absorption, from the lymphatics of the surrounding 
parts.
683. Joints If we judge of them by the laws of 
mechanics, they are in general very ill formed;
but this [illegible] from mechanical principles
fits than for a variety of actions, which had the
rules of mechanics been strictly adhered to 
would have required a greater number of additional 
joints.
684. In considering the structure & properties of 
joints, we are also to take into account, the ligaments
& muscles.
685. The ligaments in general same as pivots.
686. The ligaments of some joints regulate the 
motion of the joint, but these are only such as are 
moved in one direction only, as the two upper
joints of each finger; others only serve to sustain
& to support.
687. The powers that give force & firmness & direct
the actions of the joints are the muscles; the muscles 
support the joints in the motions they have to 
perform.
Q. The lower jaw seems an exception to this; the
depressions are always attempting to dislocate 
the jaw, but the elevators pressing it firm in 
its socket; opening the mouth does not give 



firmness to the joints: we see in immediate [illegible]
the jaw will be sometimes dislocated; the 
elevators have either for a time losing the power
of action, or being overcome by the power of the
depressions: the latter are not inserted near the
centre of motion.
688. From knowing that the strength & weakness
of a joint depends in a great measure on the muscles,
we are enabled to account for several circumstances
otherwise inexplicable.
689.Joints are capable of motion either passive
or active; by the former we mean motion given 
to a joint by external force, by the latter that 
motion derived solely from its proper muscles.
Q. 688, 689. These aphorisms require considerable
attention, it is observed (48) that the voluntary motions
may occasionally act of themselves & independent 
of the will, & this may be either from 
disease as from spasms, or from a kind of consciousness
in themselves of the necessity of acting.
When a man is descending from an eminence
as when he is coming down stairs, the muscles are
all prepared to receive the joints of the knee 
& ancle, so as to prevent their giving way, and
of course, being strained, or any jarring between 
the bones that compose those & this without any 
direction from the will, but seemingly from a 
kind of attention in the [illegible] to the security of 


195.
the joints but if a man in walking along a plane
suddenly steps down a descent, which he is not aware
of, the muscles being unprepared for the exertion
& off their guard, do not give firmness to
the joint, & in this sudden action a jarring &
strain of the parts composing the joints take place,
hence why strains so often accompany falls.
When a man falls from an eminence, it being
uncertain what part shall be immediately receive
the shock, no particular set of muscles can prepare
themselves to support a joint against injury.
We gain most information on this subject by 
considering the cooperation of muscles; this will
enable us to learn why a man shall jump
from a considerable eminence to the ground without
injury & yet from a slight fall shall [???lently] 
strain the parts subservient to some of
the joints of his body; if we but eagerly clench
our fist, we find not only the muscles of the hand 
in action, but a degree of rigidity pervades 
the whole body, the general system of the muscles
cooperating so as to give additional strength
to the primary ones, or those immediately concerned
in the action of the hand; this is a familiar
instance of the cooperation of muscles; so when a 
man is about to jump from an eminence, not 
only the muscles of the legs prepare themselves 


to give firmness to the joint & vomit violence,
but all the muscles of the body exert themselves 
likewise to give general firmness & by their
general cooperation to assist the muscles of the 
legs in over coming the violence of the jar. If one
suddenly raise an animal as a cat, upward,
the body being elevated its muscles are relaxed,
but the moment we let the body sink towards 
the earth, the whole muscular system becomes
in action, & a degree of rigidity is sensible
throughout its body: the same holds good with 
a child, if in playing with an infant, though ever 
so young, we toss its body towards the heavens,
its muscles while it is going upwards remain lax
& at rest, but as it descends towards the earth
they all become rigid & firm, prepared, as we
may say, to resist the shock of violence.
If a man intentionally jumps from a considerable
eminence to the ground, as from an
house top, his knees or ancle joints are injured,
because the power of the muscles, though
prepared to resist violence & give firmness to the
joints in less than the face with which he 
comes to the ground, & the greater force overcomes
the lesser.
If a man jump out of a carriage in quick 
motion, he generally injures his knee or ancle
joints, for the same cause, for although he does 


197.
not in this case jump from any great height,
yet the projectile force of the carriage, out of
which he is thrown as a stone from a sling, added
to the weight of his own body, combine to 
give a greater shock than the vomiting power 
of the muscles can support: In those cases, the degree 
of violence forcing the joint to [illegible] motion,
& that packages in an unnatural direction,
in superior to the power of the muscles to give firmness
& resistance to the joint.
690. Strains always arise from a weakness of the 
muscles in question, or to an inattention in them 
to the [illegible]they have to execute, being then 
taken by surprise.
691. If the force of passive motion given to a joint
be greater than the power in the muscles to give
firmness to that joint then a strain or some
other injury in the joint will ensue (687, 689.)
692. The muscles themselves as well as the 
joint suffer from strains, & this from the same
causes, being obliged to act unprepared, or being
obliged to excite a force superior to [illegible] powers.
693. Dislocations arise from the same causes 
as strains, & it is not impossible but fractures
of bones may also be produced by them.
694. Crookedness of the spine may also originate 
in a deficiency of muscular powers,
the muscles of the bark not being able to contain 




the trunk in its erect posture
695. The same cause likewise, probably, gives
occasion to knocked knees, we rarely see very 
muscular people fall into this state.
696. The power of the muscles in preserving joints
being overcome by the violence of external force applied,
the joint gives way to this violence as
far as its ligaments will allow; these are stretched
to that side to which the joint bends,
& those ligaments are not unusually torn.
697. The joint being their injured the following
circumstances may arise
1st Tumefaction of the joint & this almost instantaneously.
2d Ecchymosis.
3d Heavy dull pain in the part (  )
4th Sickness (   )
698. The tumefaction arises from an increased secretion 
of the synovia, added to the other common
causes of tumefaction from external injuries.
699. The parts which are the seat of pain, though
in their natural state insensible, now
acquire great sensibility; this sensibility leads 
to a natural cure by incapacitating the patient 
for motion, & so necessitating him to remain in 
a state of rest.
700. In the treatment of strains & injuries of 
the ligamentous parts of joints, the indications 


199
are
1st Rest
2d Topical bleeding, as by leeches.
3d The application of cold water, vinegar,
spirit of wine etc. or fermentations.
701. But the powers of restoration here being
weak, the cure will in general be tedious & too 
often imperfect, the joint sometimes never recovering
its original health.
Q. When joints after an injury recover their health
it is probably the ligaments were injured & not
the cartilages.
702. The common causes of strains (690) will be also 
the causes of dislocations.
Q. If dislocations be not easily reduced, the parts
receiving the dislocated bone adapt themselves
to it.
703. When a bone is dislocated, its end is thrown
beyond the articular surface of the bones, with 
which it was naturally conjoined.
Q. In speaking of dislocations we say the bone 
farthest from the trunk is dislocated; thus when
there is a dislocation at the elbow joint, we say 
the ulna is dislocated not the humans.
704. The bone being thus displaced, the action of the
muscles inserted into it draws it upwards, so that
the limb, if one of the extremities be concerned, appears 


generally shorter than its fellow, & if
suffered to remain long so, the reduction is frequently 
impossible.
705. In attempting the reduction of a dislocated
bone, the indications are
1st To make the naturally most immoveable
part a fixed point.
2d To overcome the action of the muscles which 
draw up the dislocated bone, & resist its recovering
its natural situation.
3d Then by making lateral pressure to force
the head of the dislocated bone into its
proper place.
Q. Here then a retrograde motion is to be observed, 
& the [illegible] actions in the dislocation is the 
first to be overcome; the last actions is that of
the muscles drawing up the dislocated bone, & 
their force being overcome by distension in a 
proper direction, & by it the head of the bone
being brought to the edge of its receiving [articular]
surface, is then by lateral the pressure to 
be forced into its place. The humerus is the bone
that is most frequently displaced, & its reduction
is rendered difficult among other courses by 
the scapula being a moveable bone; it is of
the least consequence sometimes to make the scapula
steadily fixed; a great variety of [illegible]
& a great degree of mobility are incompatible 




201.
with great strength; this is a course why dislocations
of the humerus so frequently occur; how far the 
ligaments are lacerated in dislocations is not yet
ascertained.
706. If a dislocated bone remain in its unnatural
state a considerable time, & in contact with 
a bony surface, by degrees it forms to itself a 
new socket; the bone against which it [illegible]
undergoes absorption & the adhesive inflammation
arising in the parts around, a new joint is formed;
there may be called [illegible] joints.
Q. This happens most commonly in irreducible 
dislocations of the thigh bone; for its head comes
in contact with the os ileum: this may also take
place in certain dislocations of the humanus,
where its hand happens to be placed against 
the scapula; those necessitous joints are vary similar
to fractures not uniting (616)
707. Joints are more subject to fall into diseased
habits than any of the other circumstances to
cavities & this from the nature of the materials of
which they are composed: some joints are more
frequently the subjects of disease then others 
here being more exposed to injury, as the knee.
708. Joints are subject to adhesive, [suppurative]
& ulcerative inflammations & to specific
diseases as scrophula
Q. When a joint inflames it swells & becomes
extremely painful; inflammation of a joint 


always requires great attention; inflammation
arising spontaneously is in general more
dangerous than inflammation produced by 
external injuries.
709. Scrophula may be brought into action
in joints having a disposition to it, by any external
violence
710. The adhesive inflammation is not carried
to the same extent in cavities of joints as in
other circumscribed cavities, because adhesions
being produced would render a joint useless,
but the inflammation runs into suppuration, or 
the inflammation becomes of the scrophulous
kind.
711. Inflammation of joints whether arising spontaneously, 
or from violence, require, rest topical
bleeding, sometimes bleeding & general antiphlogistic 
treatment, but as soon as the disease
becomes stationary, it is to be considered
as falling into scrophulous state, & the treatment
of scrophula must be had recourse to.
712. If a joint takes on suppuration every point 
of its cavity falls into it, abscesses in the joints
should always be prevented if possible, as they 
are productive of the greatest evils.
713. The suppuration here rarely goes on kindly,
it is a mixture of the adhesive & suppurative inflammations;
the parts want power to carry on 
readily any process; even the ulceration goes on 


203.
very slowly & a considerable time is taken up in 
bringing the matter to the skin
714. The ends of the bone have forming a joint, become
ulcerated, indeed the bones seem to accept 
of the ulcerative absorption more readily than 
the other parts employed in forming the joint.
715. From the backwardness or inability of the parts
to commence the process of restoration, & the constitution
being long [illegible] with an incurable
local disease, hectic (  ) is produced & the
patient is destroyed, unless saved by amputation
which is general it is best to perform early.
716. Diseases of the joints more readily produce
hectic than diseases of the bones in which
the joints are not affected: should circumstances
more kindly arise & the suppuration & ulceration
go on quickly, it may happen than 
granulations may arise & a case be obtained
without the loss of the limb, & only with abolition
of the motion of the joint.
717. When motion is lost in a joint, anchylosis
is said to have taken place
718. Anchylosis is produced by two causes. 
1st By an immobility of the bones, produced by 
a change in the soft parts, forming or surrounding 
the parts.
2d By an immediate union between the bones
themselves.



719 Anchyloses are of five kinds.
1st Lateral anchylosis.
Q. As between two ribs; this is seldom inconvenient,
but may if it take place between the radius
& the ulna, hindering the pronation or supination
of the hand: it happens when two bones are
within the reach of ossific inflammation arising
in either of them.
2d Surrounding parts becoming bone
3d The capsular ligaments of joints taking
on the ossific inflammation & becoming 
bony.
4th Granulations arising from the soft parts 
in a joint & afterwards becoming bones.
5th The ends of bone forming a joint becoming
ulcerated, & granulations taking 
place, those granulations uniting becoming
bony, & in fact forming the two bones 
into one.
Q. Have circumstances are similar to a fractured
bone being united by granulations, as in 
compound fracture.
720. When in consequence of preceding inflammation
or any other cause, a stiffness & partial loss 
of motion in a joint take place, the joint preserving 
its original structure, or at least with little
variation, we can restore its use by giving it a
passive motion, frequently repeating it, as is advised
after fractures of bones [communicating]
with joints (658).



205.
721. The powers of flexion are more easily restored
to a limb than the powers of extension.
722. when joints communicate or are in contact
with each other as those of the tarsus & carpus,
suppuration beginning in one joint will generally
extend itself throughout the whole & all
of them will equally fall into disease.
723. A loose cartilaginous or bony substance is
sometimes found in the cavity of the knee joint,
this may be formed in the following manner,
some blood being extravasated with the cavity of
a joint may become organized, & at length cartilaginous 
or bony; not being an original formed
part, it may in the motions of the knee be broken
off from the part in which it has been formed
& thus become loose in the cavity of the joint.
Gun Shot Wounds.
724. Gunshot wounds are to be considered in 
general as  wounds accompanied with contusion,
they are followed by the same effects, and require
the same mode of treatment.
725. These wounds being made by a projectile 
body [driven] with violence against the parts, the
extent & degree of the injury will be in proportion 
to the magnitude of the projectile body
& the velocity with which it is driven against 
the part
726. The danger of gunshot wounds is to be estimated 
according to the nature of the part or 


parts injured & the deeper & extent of the part injured
727. Many circumstances will depend upon the 
degree of velocity with which the projectile 
body is driven against a part, as 
1st The greater the velocity of the projectile 
body as a ball, the more like wound will
be made in a straight line.
2d The greater the velocity of the ball, the 
more the wound will approach to the 
nature of an incised wound.
3d The greater the velocity of the ball, the 
greater will be the danger of hemorrhage 
4th The velocity of the ball will decrease in 
inverse proportion to the obstruction given
to it.
728. Gun shot wounds, as all other contused
wounds, are attended in general with less hemorrhage
than wounds from incision & gun 
shot wounds in general are slow in taking on 
inflammation.
729. Those wounds being attended with a destruction 
of the life of several parts cannot heal by the
first or second intention; the dead parts must
slough & be thrown off, so that the process of separation
is necessary.
730. The slough will be where the ball 
enters than where it goes out.
731. We divide gun shot wounds into simple & compound.




207.
732. By simple we mean where the ball passes in 
to or through soft parts only as muscles & integuments,
& which are not attended with the effects
enumerated in the following aphorism.
733. The compound we divide into
1st Those in which a bone is fractured.
2d Those attended with the division of some
large artery.
3d Those penetrating some cavity.
734. The penetrating wounds (733. 3d) are either
a Simple penetrating or 
b Those also wounding some contained viscus.
735. When a ball passes through a part, the most
depending [orifice] will heal sooner than the superior 
one.
736. The healing of gunshot wounds is always 
more slowly performed than the healing if incised
wounds.
737. The degree of mischief done by gun shot
wounds is not always to be ascertained early, because
parts may suffer violence without any 
proof, the kind of injury not appearing untill
some time after the accident for 
738. The artery may be so injured that a portion of
it shall become dead; yet the separation of the
dead portion shall not take place at the time 
of the [accident] but some time afterwards, so that 


though some hemorrhage happens when 
the injury is received, yet a violent one may 
come on when the dead portion of the artery 
sloughs away, or
739. A ball penetrating the abdominal cavity,
may bruise even to death a portion of some
gut, yet the canal shall for the present [illegible]
nor the exit of foeces through its [sides]
take place, untill the separation of the dead
from the living part is affected. 
740. Dilatation of gunshot wounds is not
in general necessary, & therefore not to be practiced;
however the same indications which require
the dilatations of other contused wounds,
may also direct us to enlarge there.
741. Dilatation of the wound, or even a removal
of a portion of the soft parts may be necessary 
when a ball or other foreign substance presses 
upon any vital part, a large artery, or a nerve,
likewise in case a large artery is wounded and 
can be taken up; also when a part is displaced & 
can be restored by dilating in all these cases 
it is right to enlarge the wound.
Q. As when a ball, bone or extravasated fluid
prefer upon the brain, we may remove a portion
of the scalp to prepare for the trephine; 
or when the intestines came through the 
wound & cannot be returned without dilating it.


209.
742. When a ball is lodged in a part where its
continuance may be the cause of danger, if we
can extract it, it is right to make a dilatation.
743. It is wrong to dilate merely because a ball
is lodged in a flashy part, or with a view to extract 
a ball, where the circumstances similar
to those (741, 742) do not indicate the dilatation
of the wound.
Q. Balls we know often remain in parts for 
years without producing any inconvenience 
and sometimes they are never found; with 
regard then simply to the ball being lodged 
in the body, the surgeon need to be under but 
little concern, he has only to take into consideration 
the other circumstances present, as 
the seat of the ball, the nature of the part injured 
etc.
744. In simple gunshot wounds, no advantage
is gained by their dilatation, for the wound
made by the knife of the surgeon will heal
much sooner than the wound made by the
ball, so that dilating will not alter the nature
of the wound, or hasten the cure.
745. Moreover, if an extraneous body as a ball
splinter of a bone etc. is to be thrown off, the
wound though dilated on treated in any other
manner, will not heal untill the foreign
matter is thrown off; so that all attempts towards


a cure must be fruitless untill that
event takes place; the wound will heal so
as to leave a small hole only upon which 
will remain unhealed untill all the extraneous
matters which are to be thrown off, [illegible]
come away.
Q. Four Frenchmen were badly wounded by 
gun shots at Bel Isle, two were shot through the 
chest, one through the elbow & one through the 
deltoid muscle, scapula etc.; all the patients
did well without dilatation of their wounds.
If the surgeon makes a dilatation the consequence
is that the [cure] will remain unaccomplished
equally as long as if nothing had
been done: the superficial parts will heal to 
a very small hole & the deep seated [illegible]
remain open, so that a fistula will remain 
incurable untill all the dead or foreign’
matter is come away, as exfoliation of bone 
etc. Again in gunshot wounds, where the ball
cannot be followed, as where it has entered
the bones of the face, dilatation must be evidently 
useless. A reason given for Dr [Cetation] 
has been the preventing or taking off inflammation 
and tension, but has not the incision 
made in dilating a tendency rather to 
induce those affections?
746. In examining gunshot wounds, the probe 


211.
should never be used where the finger can be
admitted, & the forceps etc. is never to be introduced
but when the ball etc. is withing our reach.
747. If a ball pass some way under the skin, & 
again passes out at a considerable distance, on
opening should be made midway between the 
two orifices to prevent the formation of an abscess.
748. If a ball pass through & through immediately 
under the skin, the orifices not being far 
asunder, it might be right to open the sinuous
wound it has made through its whole length,
 for the skin does not so readily unite with the 
parts underneath, as muscular parts do with 
each other.
749. If a ball be lodged under the skin & can
be felt & the integuments are bruised & [illegible]
to slough away, it may be right to incise the
skin & extract it, for the mischief will not be increased
by taking it out & it will be giving satisfaction 
to the patients mind.
750. If the skin appear quite sound & free from 
inflammation or disposition to slough, the 
immediate extraction of the ball is by no 
means necessary.
751. The course of the ball will [become] extremely
irregular; it will vary from the perpendicular
or horizontal direction to oblique 
or tortuous, & sometimes its course will make 



a considerable section of a circle.
Q. Balls that do not go through & through are
generally spent balls, unless it happens
that a ball strikes against a bone a ball
shall sometimes enter the breast obliquely,
& afterwards go almost round the whole body,
& be directed by a rib untill it pierces the
skin & makes its way outwards; the course
of some balls is really surprising. Mt Hunter 
has seen a ball enter in one side of the
skin bone, go across it & raise up the skin
from the periosteum, & make its exit on the 
opposite side, without doing any injury 
to the bone; now had the ball struck the
part with great force, it must have gone
directly across the bone & carried away a
portion of it. A soldier had a ball enter the
biceps muscle of the arm & pass out under the 
scapula, close to the spine.
752. A red line appearing on the skin, will 
in general mark the course of the ball.
Q. It is difficult to say on what this red line
depends, it seems to be neither the effect of 
inflammation nor of extravasation.
752. It is unnecessary to dilate a wound penetrating
a cavity, as the abdomen or thorax, as 
less some other object requires the attention  


213.
of the surgeon, than the singular penetration 
of the cavity.
754. Compound gunshot wounds in which 
an artery is divided or a bone fractured, as
there is nothing specific in their nature, so the
general principles of surgery will apply to
their treatment.
755. Penetrating wounds (733 – 3d) are divided into
a Simply penetrating wounds.
b Wounds penetrating some contained
viscus.
The containing cavities will be the abdomen
the thorax & the cranium. 
756. Wounds simply penetrating the abdomen
will in general do well, provide the first
or second mode of union takes place, so as to 
exclude the stimulus of imperfection from giving
a general alarm to the whole cavity.
757. Compound penetrating wounds of the abdomen
will again divide themselves into to kinds.
1st Those which penetrate some containing
viscus, as the stomach, small intestines,
large intestines, bladder etc.
2d Those which penetrate some non containing
viscus, as the liver, spleen etc. 
758. The compound penetrating wounds (757 ]?])
will have different symptoms according to 
the part receiving the injury
759. The symptoms of wounded viscera will 
be either 



1st Immediate or
2d Secondary
By the first is meant peculiar symptom arising
immediately from the injury done to the
viscus.
By the second those which arise from the consequences 
of that injury, & not from the injury 
itself.
760. The immediate symptoms of wounded
stomach will be sickness, vomiting, great
depression of mind etc.
Wounded intestines bloody stools.
liver pain in the right 
or left shoulder, according as the right or left ‘
lobe of the liver is wounded, discharge of
pure blood by stool kidneys or bladder,
bloody urine; & have the ball if it remain unextracted 
may become a nucleus for a [fi?ture]
stone. Wound of the spleen will give not
particular symptoms, it is in general followed 
by a profuse extravasation of blood into
the cavity of the abdomen.
In general wounds of the liver & spleen
will have none but immediate symptoms.
Q A young gentleman received two or three
shots in his abdomen, one of which went 
through his body, entering before & coming
out near the spine; his stools were natural
[illegible] which Mr Hunter pronounced his bowells
unhurt, his urine was bloody, which 


215
showed his kidneys or bladder to be wounded,
he recovered.
761. It will, however, be very different in wounds 
containing viscera, or those which naturally contain
quantities of foreign or secreted matter, as the
stomach, the intestinal canal being wounded, a
considerable time may be elapsed before the
separation of a slough gives an oportunity for
the foeces to escape, these getting into the common 
cavity of the abdomen at what distance
of time [illegible] from the injury, will become the 
cause of general inflammation of the whole 
cavity with all the consequences, as suppuration,
gangrene & death: a wound of the gall bladder,
[ductus] [choledicus], pancreaticus or urinary
bladder, if communicating with the common 
cavity of the abdomen may produce the
same effects, though probably more [stocky] see (  )
762. In general wounds of the containing viscera
will destroy the patient, but it sometimes 
happens that previous to the appearance 
of any secondary symptoms, adhesions shall
take place between the wound in the intestines
& the wound in the peritoneum, and
common integuments, so that when the slough
comes away the foeces etc. will escape [illegible]
into the cavity of the abdomen, but through
the [???icial] canal  formed by the adhesive 



inflammation, & which as an artificial anus or
urethra, will give an exit to the substances to 
be evacuated; when this circumstance takes place,
no other ill symptoms forbidding as, we may [illegible]
a favorable prognostic.
Q. A gentleman in a duel had a ball passed 
through his belly; he had no particular ill 
symptoms for thirteen days, on the 14th foeces
came through the wound, nothing further indicating 
mischief Mr Hunter pronounced him 
out of danger, forming his prognosis on the
principles laid down in the text.
763. The time which may elapse before the 
secondary symptoms appear, may be ten, twelve
or fourteen days (762).
764. The artificial canal (762) will sometimes
close & heal up.
765. Wounds simply penetrating the cavity of 
the thorax, will be only so for dangerous, as
they may produce exposure of the thoracic cavity,
if the first or second mode of union take place 
before the alarm is given to the cavity, no 
mischief arises.
766. Wounds of the lungs are not always fatal;
those made by a shot are less frequently 
destructive than those made by a sharp
instrument, as a sword or bayonet for 


217.
767. One great cause of the mortality of wounds 
in the lungs, being excessive hemorrhage into the 
cavity of the thorax; the hemorrhage following
a gun shot wound, will be much less than
that produced by a cutting instrument.
768. Symptoms of a wounded lung, will be bleeding
from the larynx, cough, pain in the side,
fainting, difficulty of breathing, diminution
of motion in the muscles of the thorax, because
the muscles of one side cannot act without those
of the other side acting likewise.
769. The wound being in a vital part, the
pulse will grow hard.
770. The patient will not be in a horizontal 
position, but in desirous of sitting erect,
that his diaphragm may be as fully expanded
as possible.
771. A profuse extravasation of blood in the
thoracic cavity may be judged of, from the [illegible]
weight complained of by the patient, from 
the lowness & faintness which must attend
a sudden & copious evacuation from the legs,
& the common symptoms of a sudden accumulation 
of fluid in the thorax. (  ).
792. A gunshot wound penetrating the lungs,
the wounded lung commonly collapses & therefore
an adhesion of the wounded part to the pleura 



cannot take place.
773. Gun shot wounds not healing without suppuration,
room will be left for the matter 
which may be collected in the chest, to drain 
off, but this will be attended with the [illegible]
of making the thorax are exposed & imperfect
cavity. if the quality of blood extravasated 
be small, it may be absorbed, but of these 
[illegible] symptoms of a large quantity being collected
in that cavity, the operation for the empyema 
should be performed as early as possible, because
if the blood coagulate it will adhere
to the sides of the cavity, & not be got out without 
the greatest difficulty, or in some cases it
may suffice or be best to enlarge the original
wound.
Q. Penetrating wounds of the cavity of the head
will be considered among the diseases of the encephalon 
(785).
774. Gunshot wounds may so far injure a part,
that the process of restoration cannot take
place in it, & therefore the wound is rendered 
incurable: in this case the removal of the
part becomes necessary; & when a part, as an 
upper or lower limb, has been so injured that 
its removal is necessary, we must determine
in what cases amputation should be immediately 
performed or in what it may be deferred 
to some [future] period.



* Sir James Poulhenry Bullard late keeper of Boston
May 19 1815


219.
775. Should a part, as in upper or lower extremity,
be so nearly separated from the body, as
only to hang by a small portion of soft parts,
it may be immediately removed.
776. should a hemorrhage from some vessel
which cannot be retained, endanger the 
life of the patient, amputation of the limb 
should be immediately performed.
777. But in most other cases it is adviseable 
to defer the amputation untill the inflammation 
is gone off.
778. If a cavity be wounded & any of the contained 
viscera protruded, they should be immediately
replaced.
779. Bleeding is not indiscriminately to be 
had recourse to in gunshot wounds.
780. We are always to be directed in our opinion
respecting this evacuation, by the nature
& situation of the part injured, & its powers of
action, & the general strength of the patient
in proportion to the general action of the 
vessels.
781. Excessive bleedings having been employed,
patients have sunk suddenly.*
782. The use of the bark becomes highly proper 
after inflammation has subsided, and 
even during the presence of inflammation 
if attended with weakness of the system, it 


is, however, necessary sometimes to accompany
its use with small bleedings.
783. After the sloughs occasioned by gunshot
wounds, have been thrown off, though the
ball or other extraneous matter remain 
in the body, the ulcer will granulate & continue
to heal, so long as the extraneous matter
remains quiet & does not stimulate.
784. When an extraneous body remains
unremoved, the ulcer may become fistulous,
or a fistula may even be formed when the 
foreign body has been extracted in which 
case it is to be treated as another fistula.
785. [Fonts] are, however, always improper.
786. Diseases of the brain are of two kinds.
a When the imagination is affected from 
various causes as from mania etc.
b From mechanical injuries.
787. Mechanical injuries may be either.
1st Concussion.
2d Compression.
3d Wound or loss of substance
4th Wound compression
788. The three first may exist separately, or
any two or all three together, their symptoms 
will be nearly similar; those are a cessation 
of sensation & voluntary actions, the muscles 



221.
of the mouth & throat becoming flaccid, froth
being discharged from the mouth, with the appearance
of fullness of the vessels; the symptoms 
of the fourth will be restlessness, & insensibility.
789. Vomiting accompanies all these affections
of the brain & arises from sympathy.
790. Vomiting, however, never takes place during
the time of perfect insensibility.
791. Injures done to the brain diminish sensibility:
injuries of other parts increase it to a certain 
degree.
792. Concussion may depend upon a displacement
of parts of the brain; the degree of concussion 
will be in proportion to the violence with which
the blow is given, whether the head falls against 
any hard body, or any hard body is driven
against the head
793. Compression may follow accidental violence
immediately, or arise some time after.
794. Compressions may be owing to any of the
following causes viz
1st To a depression of the skull from fracture. 
2d To pressure of some part of the cranium
from the thickening of a diseased bone.
3d To water in the ventricles.
4th To distension of the blood vessels.


5th To inflammation.
6th To the formation of pus.
7th To extravasation of blood.
8th To a tumor in the substance of the brain 
itself.
The causes of wounds, or less of substance in 
the brain must be sufficiently obvious.
795. Concussion will be either
a Simple
b Compounded immediately, or
c Compounded simply.
796. Simple concussion is where there is no 
fracture, compression or extravasation; we
must endeavor to distinguish between concussion
& the effects of intoxication. The effects
of simple concussion will soon be carried off
by plentiful bleeding etc. but if it be complicated
with compression, the effects will not
be diminished by time, but rather increased,
compression may instantaneously follow concussion,
in which case it is said to be compounded 
immediately, or compression may 
arise when the effects of concussion would
be naturally going off, in which case it is said 
to be compounded secondarily.
797. Fractures of the skull may always be considered
as compound fractures, they are either
made so intentionally by the surgeon, or are 



223.
found by him in that state.
798. Fractures of the skull are of three kinds, viz.
1st fracture of the outer plate.
2d Fissure.
3d Bone broken in several places.
there may be complicated with each other.
799 The first & second (790) may be the remote cause
of compression (793) & the third may in itself become
the immediate cause of pressure on the
brain.
800. Bleeding from the nostrils or ears, is a common 
though an equivocal symptom of a fracture 
of the cranium.
801. The concussion will in general be less
where the bone is much shattered than when
otherwise, for the force being spent upon the skull,
less shock is given to the brain.
802. Gun shot wounds of the head, & those made by 
other bodies moving with great velocity, do not
produce for the most part great concussion.
803. Fissures of the skull will run in many different
directions along the cranium, across it, & even 
across the sutures
804. when there are fracture & depression of both
tables, if the fracture detach an entire piece of
bone from an undepressed cranium, & that whole 


piece be driven downward, than the fracture of
the internal table will always be larger than 
that of the external.
806. If the fractured bone be depressed on one edge
only, & through both tables, the union table will still
go shelving off beyond the outer.
807. Hence will appear the difficulty of elevating 
depressed pieces of bone, so as to make the separate
portions fit themselves to the undepressed cranium 
perfectly smooth; hence also the [illegible] when a
portion of bone is to be removed, to make the margin
of the depressed piece a part of it.
808. The indication in all fractures of the skull,
is to prevent or remove pressure on a vital part,
that is, the encephalon, therefore it is necessary 
whenever there is a fracture with depression,
when a piece is detached & driven in, to remove
it entirely, or if one edge only is depressed,
to take care to elevate it properly: the operation
employed for the purpose of elevating or
removing depressed bone, or for making an opening
for any necessary purpose into the cranium,
is called trepanning, & the instrument and by 
surgeons for that end is called the trephine.
809. when a fracture is discovered, it should 
in general be traced as far as possible throughout
its extent, & therefore we are sometimes obliged
to remove the scalp freely.


225.
810. Fracture of the skull are so often complicated
with the immediate or secondary symptoms of injured 
brain, that few cases will offer in which 
the trephine will not be necessary.
811. It is never necessary to apply the trephine
either in fissure or fracture of the outer table,
only unless those are also symptoms of an injured 
brain, & those not of simple concussion alone.
812. in all cases of compression, either immediate
or secondary, of concussion complicated with compression,
& in all wounds of the brain it is necessary 
to apply the trephine.
813 It may be sometimes impossible to ascertain
to exact situations of the compressing matter,
yet have, as the patient must undoubtedly die
if not relieved, it is justifiable to operate at 
random
814. The situation of extravasated fluid will
sometimes be opposite to the part where the blow
was received.
Q. The situation of the extravasated fluid will 
be very different in different cases, & hence the
great uncertainty of our relieving the patient
who labors under depression from some 
cause independent of depressed bone, it may be
between the dura mater & the skull, between’
the dura & the pia mater, between the pia
mater & the brain, or it may be in the ventricles 



& even in the substance of the brain itself.
815. The dura mater should never be divided,
unless from the greatest & most evident necessity,
as when matter or blood is visibly lodged beneath
it, for penetrating wounds of the dura mater, which
expose & render imperfect a cavity containing
the brain, will in general be mortal.
Q. Mr Hunter computes that not more than one in 
twenty persons in health, would recover from a
penetrating wound of the dura mater.
816. The trephine must be applied, once, twice,
or as many times as the extent of the injury 
shall require.
817. The trephine may be applied in any part
of the [arch] of the cranium, where an accident
may render it necessary or eligible; if the 
fracture be circular, it will be right to repeat
the application of the trephine, untill it is surrounded
with the perforations.
818. As life consists in the properties of preservation
& action, so death is the loss of both.
819. The immediate cause of death in a part and 
appear in most cases to arise from a total loss 
of circulation, but this must be the effect of 
some remote cause.
Q. In health we know the strength is always 
greater than the action.
320. Mortification in a part differs must from 


227.
common universal death; in the latter case
the vessels can be injected, & the structure of
the parts examined; but this is not the case with 
the former, its vessels cannot be injected, its structure 
is changed, is destroyed.
821. The immediate cause of mortification will be
whatever can excite the action of a part so as to 
render than superior to its strength, or reduce
the strength of a part so as to be unequal to its 
actions.
822. Debility can be only the predisposing cause
of mortification, it cannot immediately produce 
it, if a part be ever so weak, while its actions
do not exceed its strength, it will retain life.
823. From (813) it is evident that a part may 
fall into mortification either with or without
previous inflammation, in the former case
the inflammation is the immediate cause of death.
824. Heat should always be in proportion to 
the living principle, otherwise it produces a necessity 
of exertion, which the strength of the part 
is not equal to; the exciting of heat than in 
a part whose posers are very weak may induce 
mortification. 
Q. The greater the distance from the heart, the 
more liable are parts toa mortification.
825. When parts are extremely weakened as to 
their principle of life, by cold, as when people 


are frost bitten, the application of heat must 
be gradual & slow, otherwise it will necessarily 
induce mortification (  ) as the principle
of life increases the heat may be increased.
826. From (819). we are enabled to discover why 
scarifications in the legs of anasarcous persons,
or wounds made in their extremities, either by 
act or accident, & why blisters applied to parsons
in whose systems there is great debility 
& a disposition to putrefaction should be followed
by mortification.
827. Also why persons who have suffered severe 
famine, & long exposure to intense cold, are in extreme
old age, or have the circulation obstructed
in a part, or those of tall stature, are subject
to mortification, especially of the feet & toes.
828. In the cure of mortification, or restoring parts
falling with mortification, it must be evident
that as the cause is a diminution of powers 
in proportion to the actions of a part, whether
common or increased, so the cure must consist
in lessening the actions & is increasing the powers
of the part.
829. Whatever the stimulates a part to action 
without increasing its strength & powers must be 
contraindicated.
856. Hence also it is evident why bark should
have so much power in checking some inflammations, 


229
& that opium may prove a very useful
remedy.
Q. The temperature of the atmosphere in which 
patients to be cured of mortifications are best placed,
should be neither very not nor very cold, that the
natural actions may neither be impeded, nor 
hurried on too fast.
831. The causes (819) will be either.
a Mechanical, as a blow or
b Chemical, as a caustic.
832 The less vascular a part is the more readily 
its life is destroyed. 
833. Also, the weaker the powers of life, in a part 
are, the more easily will they be acted upon by 
caustics.
834. No substance can act chemically but in 
solution; in order for the caustic to act chemically
it must be moistened, this is affected by the serum
produced from the vesication which arises from 
the irritation caused by the application of the 
caustic substance, which serum moistens the
substance, & thus after the life of the part is unable
to act for its preservation, operates chemically 
on the skin etc.
835 The action of a caustic when applied to a 
part, produces an abolition of its life, & then the
caustic acts chemically open its substance, coagulating


its mucilaginous parts & changing its
texture.
836. Mortification or the death of a part is often
induced with a view to destroy a diseased, or even a 
sound part, in order to enable as to make application 
to some diseased part otherwise out of 
our reach, or to give an exit to some foreign 
substance, retained under the skin, as pus etc.
837. The effects (83[?] etc.) will be produced by a variety
of substances artificially & intentionally 
applied; of these the principal are 
Caustic alkalis 
Concentrated acids and
Metallic salts.
838. Of the metallic salts, arsenic is the most powerful,
whose action is different in some measure
from that of the other caustics, as it produces mortification
simply by its exciting violent actions
in parts which they cannot support, & not
by any chemical process.
839 The application of those substances to 
[sentient] parts is attended with violent pain,
that is to be diminished
1st By the administration of opium by the stomach.
2d By mixing opium with the substance to 
be applied
3d By applying plaisters of opium to the part 



231.
for some hours previous to the application of
the caustic.
840. The natural sequel of a mortification is 
the sloughing of the mortified part, or the process
by which it is thrown off from the living parts.
841. To this process the suppurative inflammation 
of the living parts immediately in contact
with the dead & the ulcerative absorption of
these is necessary (449).
842. As in the exfoliation of bones, so in the sloughing 
of the soft parts, the absorption begins at the 
external edges of the dead parts, the dead part 
becomes dark coloured & dry: the ulcerative absorptions 
beginning at the edges & going through
the whole surface of contact between the living
& head parts, the slough is obstinately thrown off like 
any other extraneous body.
843. As the weaker the part is the more easily 
it is acted on by caustic, so the greater the strength
of a part, the more readily the slough will go
on.
844 New formed being weaker than original
parts, it is evident they will suffer their life 
to be much sooner destroyed by caustics.’
845. From (844) we are able to learn, why in 
new formed parts, mortifications is so easily induced
as in cicatrices etc.
846. Also why caustics so easily destroy the fungous



excrescences of ulcers etc.
Q. We know with some certainty how far the parts
of the body, the brain excepted, & with what comparative 
facility they go through the process of sloughing,
the nearer the heart, [illegible] paribus, the more
readily the process of separation will go on;
the common integuments & muscles will throw 
off a dead part sooner than a tendon, ligament
or bone; as to the brain it has not been ascertained
whether it will slough or not, for before
the separation of the dead part can take place,
the patient generally dies.
847. In a mortification no incision or wound is
ever to be made, into living parts at least, untill
the process of separation is begun; a portion of the
parts quite dead may, however, be removed 
at pleasure.
Q. Thus if a limb be mortified through its substance,
we may cut off a portion of the dead
parts to lessen the stench from so large a mass
of putrid matter, & render the patients situation
more comfortable, but we must not proceed to 
amputation in the living parts, untill a compleat
separation has taken place
848. Haemorrhages may arise either from a wound 
made in an artery by external force, or by such 
a state of weakness being produced by disease in 


233.
the coats of the arteries themselves as to render
them incapable of withstanding the impetus of the
blood.
849 When an artery in health is divided, there 
is a natural power of contractility in its coats, 
that disposes its orifice to close & prevent the
further escape of the blood.
856. This contractile power is stranger in increase
proportion to the largeness of the artery, in the larger
vessels it is not equal to the business of restraining
the haemorrhage, & therefore renders the assistance
of art necessary. 
851. Another natural cause of the restraining
an haemorrhage and which we call the accidental,
is the plugging up the mouth of the vessel 
with coagulable lymph.
852. Art is employed in restraining haemorrhages
in three ways.
1st By increasing the contractile power of the
arteries.
2d By increasing the coagulation, & thus plugging
up the mouth of the vessel
3d By compression of the sides of the artery together, 
near its mouth, & thus rendering it
impervious to the blood.
853. The first intention we fulfill by the use of
stimulants, & of those the most powerful is the oil
of turpentine. 


854. The second intention by such remedies as
will forward the natural & produce an artificial
coagulation of the animal juices.
855. This coagulation will be forwarded by the
retardment of the bloods motion.
Q. It is evident the artificial retardment of 
the motion of the blood commonly takes place
when the bleeding is from an extremity. We have
sufficient testimony of the use of the retardment
of the blood’s motion in the stopping of
haemorrhage, when we see people faint who 
have suffered great loss of blood, & that on 
the syncope taking place the haemorrhage commonly 
ceases.
856. The substances forwarding the formation
of the [illegible], are spongy bodies, as lint,
fur, agaric, flour, cobwebs etc.
857. The means productive of an artificial coagulation 
of the animal juices, are the application 
of matters which act chemically upon 
them, such will be the actual cautery, concentrated
acids, boiling water etc.
Q. If the actual cautery be used, it should be
very thick & heated nearly to a red heat.
858. The mechanical means of stopping haemorrhage
is by compression, this is made by 
inclosing the vessel near its orifice in a ligature 



239.
applied by the use either of the tenaculum
or the needle.
859. The tenaculum should only be used when 
when we have sound & [illegible] arteries, and 
those situated not in the centre of a muscle,
but loose in the interstices of muscles and in 
the cellular membrane.
860. The use of the needle is to be preferred where
there is reason to suspect the artery is not quite
sound, or when it is situated in the middle 
of a muscle
861. When the needle is used, a considerable portion 
of the circumjacent parts, as muscular flesh,
cellular substance, nerves etc. is commonly 
included together with the artery in the 
ligature, which gives an additional support to
the artery when weak or suspected to be unsound.
862. The degree of tightness to which the ligature
is to be drawn will be in properties
to the size of the artery & the quantity of surrounding 
parts inclosed in the ligature.
863. The ligature should be made thicker than 
is commonly done, that a larger extent of the 
surface of the artery may be compressed.
864. An accidental method of stopping haemorrhage
is tearing the vessel asunder, for in 
a contused wound the bleeding of a vessel is 


less than an incised one.
Q. of this the miller’s case whose arm was torn
off by the wheel of a mill at the articulation
with the scapula is an ample testimony.
(See [Charlton’s] anatomy).
So also the case of a person sometime ago in 
Middlesex Hospital.
The farmers are sensible of this, for they [divide]
the [tarsis] of their calves & [illegible] by tearing
it in two.
865. The disagreable & sometimes fatal symptoms
following the use of the needle where it is necessary
to compress the sides of an artery together,
do not arise from irritation produced 
by a nerve being inclosed in a ligature, but
from some peculiarity in the constitution.
Q. of this Mr Hunter is satisfied, having several
times tied the nerves with the artery & no ill
consequence supervened.
866. It sometimes happens that after tying an artery
consequent on an accident or operation,
that the artery shall bleed apart at some distant
time, as one, two, or three days, or even 
when granulation is going on; this mostly 
happens in the large vessels.
Q. In St George’s Hospital a boy’s thigh was amputated
for a disease of the knee joint, by 
repeated bleedings from the stamp, which always 



241.
stopped spontaneously, the patient was so much 
reduced that at last he sank; upon examining
the limb after death, the artery appeared sound 
untill an inch within its termination in 
the stump, where it was black & had lost its elasticity.
The bleeding anew happens more frequently 
in the radial or ulnar arteries than in any 
other.
867. When it arises within two or three days, it
commonly is owing to some circumstances attending
the operation, as tying the ligature too 
loosely or too tightly.
868. when this is not the case, & when bleeding 
happens after granulation has taken place,
it may be attributed to a diseased state of the 
artery.
869. The artery should be laid bare, if diseased,
untill the sound part comes in view, & there a 
ligature should be passed.
870. In some patients after granulation has taken
place after a wound, or when a considerable
surface is stripped of its integuments, [illegible] an
amputation of a thigh, there will be a proper bleeding
from every point of the exposed surface.
871. This will occur in patients who are extremely 
debilitated, & whose vessels, even the smallest
[illegible] the power of contracting.
872. The term spurious aneurism has been improperly 


applied to an extravasation of blood
in the cellular substance, which blood has escaped
through the puncture of the coats of an artery.
873. This may be either recent, or not recent; in 
both there will in general be a necessity for
performing the operation of the aneurism.
874. In this case as there is a lateral wound in 
the artery, the [illegible] of the blood will continue to 
go on, because the artery cannot contract itself
longitudinally, & was it to contract [circularly],
there would be no obliteration.
875. Therefore there will be no natural case 
for the accident, it must either kill or the operations
be performed.’
876. In the non recent spurious aneurism the
wound in the skin is healed, the cellular substance
has thickened & with some coagulum
of blood formed a cyst, into which blood from 
the inclosed wound is continually effused; this 
must ultimately burst & destroy the patient, unless
the operation for the aneurism be peculiarly 
performed.
Q. The thickening of the cellular substance round 
the artery, & its being lined with tough coagulum,
will make this complaint [illegible] the real
aneurism, but in the latter the coats of the artery
are always forming the cyst, in the former 
the coats of the artery are never dilated.


243.
877. To this state the recent spurious aneurism
must always proceed, unless it either destroys the
patient, or the operation be speedily performed.
878. The arteries are subject to two diseases, [illegible] 
& weakness; the latter will be the [predisponent]
cause of dilatation of the coats of an
artery, to which alone the name of aneurism 
should be given.
879. The immediate cause of aneurism as the destruction of equilibrium
between the force of the bloods motion & the power
of resistance in the artery.
880. Accident, as some violent exertion of muscular
power, may give rise to it, but it more commonly 
depends entirely upon some diseased state of
the coats of the artery.
881; This more probable because it is not unusual
to find several aneurisms in the same
person, from which it should appear that the
disease is a weakness or disposition to dilatation
in the arterial system.
882. Moreover the common seat of the aneurism 
is in the large arteries, whose coats are less muscular
than those of the smaller.
883. An aneurism we believe never takes place
from a rupture or wound of some of the coats of 
an artery, & a dilatation of the rest.
Q. This has been supposed to happen & has been 



called the mixed aneurism, but from the experiments
similar to the following the convulsion
is to be made.
Mr Hunter laid bare the carotid artery of
a dog, & afterwards thinned it with his knife 
even to transparency; as dilatation of the vessel
ensued; three weeks afterwards the animal was
killed & the artery on which the experiment
was made was not found in the least dilated,
but thickened by the adhesive inflammation 
& the adhesion of the adjacent cellular substance
884. The dilatation of the artery will always be 
to that side one which there is the least resistance
from the surrounding parts if there be no 
resistance on either side, it will be in that direction
in which the blood is most forcibly thrown,
if these circumstances be equal on all sides
it is then uncertain in what direction the dilatation 
will be made.
Q. In the arch of the aorta if an aneurism take
place, the dilatation will be upwards.
In the carotid artery outwards.
In the abdomen forwards.
In the axilla downwards.
In the ham backwards
In the groin forwards.
In the leg uncertain.
 


243.
hence absorption of bones often arises from its making
pressure against them.
The artery will continue to swell in that
direction in which it first begins to tumefy, & the
lower part will be dilated more than the upper.
885. The natural tendency of the disease is to destroy
life; this is affected either by the tumor bursting
& the patient dying of the haemorrhage, or by its enlargement
so as to press upon some parts essential
to life & hinder their functions.
Q. It may suffocate by pressing upon the traches, if 
the carotid or the aorta be the seat of the disease,
to pressure on the returning vessels may occasion
dropsy etc. If the aorta in the abdomen be the diseased 
part, it may burst inwardly, or if it produce
absorption of the bones of the spine, it may swell
outwardly & the skin inflaming & sloughing & the
coats of the artery undergoing the same change, the
coagulum gives way & a fatal haemorrhage [illegible]
886. When the operation for the aneurism is proper,
it should always be performed as early as
possible; this rule will also extend to specific aneurism.
887. The operation is proper.
1st When the dilated artery can be included
between the ligatures.
2d When there is a probability that the part to 


whose support the artery in question was subservient
before, will be still nourished & supplied with 
blood.
3d When it has done no mischief to surrounding
parts as bones etc.
4th Where it is distinct & circumscribed, not
connected with the parts which may be incurable
when exposed, as bones etc.
5th When there is a distinct pulsation in 
the tumor.
6th When it is probable that there is no other
aneurism between it & the heart.
Q. By the first rule all the aneurisms of internal
parts will of course be excluded from the 
operations.
As to rule 2d The only arteries admitting
of a question will be the femoral & the [illegible];
but [illegible] here only is to be doubted of
yet by no means improbable, the other arteries
are either out of the way of operation, or have
free anastomoses.
In the aneurism of the [illegible] anterior and 
posterior fibral arteries, the operation cannot
take place from the difficulty of taking up 
those vessels, therefore recourse must be had to 
amputation, & also when a diseased state of the 
bones etc. in any part is induced by the pressure
of the tumor. 


247.
On the whole this aphorism will allow of the operation 
of rule 3 4 5 pointed out in the following
arteries.
In the carotid, above the sternum.
In any of the branches of the external carotid.
In the subclavian, when it has passed the 
muscles & in any of its branches.
In the crural after it has given off the [illegible]
In the popliteal.
Directions for the operation.
5th When the tourniquet can be applied between 
the aneurism & the heart, after putting it on, make
a longitudinal incision in the course of the artery,
through the integuments etc. to a greater extent than 
that of the tumor: then cut into the aneurism
& scoop out the coagulated blood, as well as evacuate
that which is fluid: the inferior orifice 
will most readily be discovered, as it will throw 
out a little blood of a venous color: (27) to discover 
the superior the tourniquet should be 
slackened. Tye the artery at least an inch above
the superior orifice; the same caution is not necessary
respecting the inferior. When the tourniquet 
cannot be applied, the ligature must be passed 
both above & below the tumor, before the incision
is made into it; it is then to be laid open throughout 
its extent.
The sac deed not be cut out, but left to 



slough away: the dark color of the blood issuing
from the inferior orifice is caused by the blood 
taking a slow & retrograde motion, which is
explained by the next diagram.
For blood by having a slow motion or by stagnating
will even in the arteries acquire a 
dark hue: the older the aneurism the more
will the coagulum approach to a frown 
color, & the more recent, the nearer will it be
to the natural color of arterial blood.
When an aneurism forms the cellular substance
thickens round it, but being elastic readily
yields to distension.
Aneurismal Cases.
A young man had a pain in the calf of his
leg for two years, at length he received a blow 
on the [illegible], after which a pulsation & swelling 
soon appeared. The operations was performed,
every thing went on well to the fifth day,
when the artery burst, either from the upper
ligature being applied too tight, or too 
low; before the tourniquet could be applied
he lost so much blood as occasioned his death.
Upon dissection the artery was found perfectly 
sound above the part where the ligature
was made.




249.
2.
An aneurism of the crural artery in the middle
of the thigh extended five or six inches in length 
the tumor being oblong; the operation was performed
& the patient recovered in a short time.
3.
Mr Martin had an aneurism in the popliteal
artery; the operation was performed & he recovered
the use of his limb so perfectly as to be able to 
dance etc.
Remarks on the propriety of operating for
the aneurism of the popliteal artery in the preference
to amputation.
Whatever objections are made to the operation,
the same must hold good also against the 
amputation of the limb.
That one, so much insisted on, of the disease
being most commonly a disease of the arterial
system & not of the part in question only, if
true militates equally against amputation as
against the operation.
If there be not only an aneurism in the
[illegible], but another higher up as in the artery, or
in the aorta it is evident that amputation of
the limb does not give the patient a better
chance for his life than tying the artery, but it
perhaps most commonly happens that whatever
may be the general disposition of the arterial system, 


yet the arterial dilatation shall only take
place in one part; now if tying and removing the
diseased part can be accomplished, the patient 
still retaining the use of his limb, it is certain 
that the operation must be highly preferable
to amputation; so the latter though it may pressure
the patients life, yet leaves him imperfect & mutilated.
888. In our treatment of fresh wounds it is necessary 
to consider.
1st The nature of the part wounded. 
2d The management of an haemorrhage should
one arise.
3d When the first or second mode of union is
to be desired, or whether suppuration be indicated.
889. If the divided parts are to be joined by 
the first mode of union, the indication will be to 
bring them into contact & retain them [illegible] This will 
be fulfilled by means of bandage & in some cases
by sutures.
890. But when a part is to inflame & suppurate,
it is better to defer the application of bandage
untill after inflammation has subsided.
Q. In treating the gunshot wounds it is observed
that contused & lacerated wounds will not heal
without suppuration. In wounds penetrating cavities,
if the wound be made to heal without inflammation 


251.
& suppuration, it is then similar
to any other simple wound; but of the suppurative
inflammation be to take place, it will
be requisite to advent to the doctrine of exposure
of cavities & of penetrating gunshot wounds,
it must be evident also that if extraneous bodies
be introduced into the cavity either by accident
or design & not removed the suppurative inflammation
will be necessary.
891l Wherever a wound is to go through the adhesive
or the suppurative inflammation it is generally 
improper to use applications which will 
adhere to the wounded surface, become dry & 
which cannot be removed at the pleasure of the
surgeon, hence the use of dry lint is extremely improper.
But if the substance to be applied be soft 
& moist, have no continuity of parts & can with
care be removed on any occasion it can do no
harm.
Q. A poultice answers this description, & the best
manner of making it, is to pour boiling water into
linseed meal, & add as much oil or hogs lard as
will kept it from drying, but poultices cannot
universally be [illegible] recourse to, & in lieu of 
we use lint dipped in olive oil.
892. When a wound has suppurated & granulations
are arising, if they do not readily contract, so 
as by their contraction to forward the formation  


of a cicatrix, it will be proper to employ the pressure 
of a bandage.
893. Abscesses will be either sound or unsound.
By the former we understand abscesses arising
in healthy constitutions, or from some specific
disease.
894. The nature & treatment of sound abscesses will
be readily understood from considering the [illegible]
of the adhesive and suppurative inflammation.
895. The evacuation of the matter contained in 
an abscess as either obtained by the abscess bursting
of itself, or by an artificial opening: abscesses
may be suffered to burst, unless some particular
circumstances require an artificial opening.
896. The circumstances most generally requiring
an artificial opening, is the danger arriving from 
the long retention of the matter.
897. All abscesses of the abdomen, thorax, brain,
eye & joints should be opened artificially, and early
898. When an abscess is opened artificially, it is
necessary in general that the opening be large, 
to prevent the future inconvenience of a fistula 
899. When an incision is made into an abscess, the
wound should be so dressed as to prevent the
reunion of the incised parts by the first or second
mode of union.




253.
900. There are two methods of opening an abscess.
a By caustic.
b By Incision.
Where no particular circumstances, as the [illegible] of 
the abscess, forbid, the choice may be left to the patient.
901. another circumstance indicating the artificial
opening of an abscess will be its being of such a magnitude
that the natural opening will not be
sufficient for the discharge of the matter.
902. In determining the size of one opening, it is 
necessary to have a regard to the present distension
& future contraction of the integuments.
Q. This note is added to explain, it not being clear
whether Mr Hunter’s idea be properly conveyed.
If the magnitude of the abscess have produced
only simple distension without considerable absorption,
(ulcerative or intersticial) on the parts on which 
it is seated, it is not necessary to make a very 
large opening, because when the distending fluid
is removed, the parts will immediately contract
themselves & recovering their original situation,
the cavity will become obliterated; but if the cavity
has been made by the ulceration & absorption
of the parts in which the matter is lodged, & 
not by simple distension of the surrounding
parts, then it will be necessary to make a large
& free opening to prevent the inconvenience of 


a succeeding fistula;  because here the parts cannot
contract themselves to obliteration of the
cavity, but the cure must be accomplished by 
granulation (see fistula).
903. The living principle well always be uneasy 
under extensive exposure, & will therefore be powerfully 
excited to action; hence large openings in abscesses
where the contraction of the parts is not sufficient
for the obliteration of the cavity, & consequently
for the cure, are always useful, because
they are the means of exciting the process of restoration.
904. Abscesses may be free from any specific disease,
may arise in a healthy constitution, and
yet certain circumstances may retard their
hauling.
905. There may be
1st Peculiarities of situation.
2d The stimulus of some deep seated, foreign
body, as a ball, splinter of bone etc.
The first causes of backwardness to heal we cannot
alter.
The second causes we must wait for the removal
of, before we can hope for the healing of 
the slough.
906. when sores of any kind have a disposition
to healing, the surgeon has little to do, except 
to prevent any obstacles arising, that may hinder
the process of restoration.
907. If dry ling be used to healing sores, it should 


255.
be applied, so as not to extend quite to their
margins; if ointments be used, they should be free 
from stimulus.
908. Among the obstacles to the healing of a sore
will be 
Intemperance.
Neglect of [rest] and
The granulations rising too high above
The surface of the sound skin.
909 The [later] obstacle is to be removed by pressure,
as that of a bandage, & by touching the granulation 
with some metallic salt, as vitriol of [copper], 
lunar caustic etc.
910. New formed parts being weaker than original
parts, are less able to support the fatigues of the
[offices] of life, than the latter; hence when a slight 
stimulus is applied they readily inflame, & if that 
inflammation be not removed, the suppurative
& [illegible] stages come on rapidly, or mortification
speedily takes place.
911. The absorption of new formed parts may 
be either 
a Ulcerative or 
b Intersticial.
912. The tendons of muscles are sometimes raptured,
& the accident arises from causes similar
to those of the broken patella. The muscle being
in violent action at the same instant of time


that there is an unconquerable resistance 
made by the point to which the tendon is attacked.
Q. This will be both illustrated by considering the
rupture of the [tondo] achillis; it is generally affected
when the muscles of the leg become tired & unfit for
voluntary motion, as after long continued dancing;
& therefore the muscle will act involuntarily;
hence the cramp etc., by this acting very violently & 
involuntarily, the tendon is ruptured. In doing this
the patient feels little or no pain in the part, but
seems to receive a blow on the gastronomius 
muscle, & hears a noise as of some elastic body
snapping in two: inflammation etc. may succeed,
the muscles may be squeezed out & the ends of the
tendon approximated together, & as much as can be 
retained [illegible] when these symptoms are removed no
inconvenience arises from suffering the patient to 
walk, if he himself have courage enough to do so,
for there is no danger of the will throwing the
muscles into action, & thereby producing a further 
separation of the ends of the tendons; for the will 
cannot now act upon the muscle, but an involuntary 
action of the muscle may take place,
especially during sleep; & this is to be guarded
against by placing a tight bandage round
the calf of the leg, & making the patient wear 


257.
a high heeled slipper or sandal.
The bandage & sandal are now particularly 
necessary by night & whilst the patient sleeps;
during the day time their use may commonly 
be dispensed with; from the back of the sandal
a piece of leather is to be carried & fixed to 
the bandage, or a leather strap placed tightened
the calf of the leg; where the rupture happens no 
bandage should be applied.
The patient will find little amendment during
the first two months, but will after that period, generally 
recover the use of his limb: keep the 
foot nearly at a right angle with the leg the heel
a little raised, when the patient walks he should
turn his toe outwards, & not attempt to bend 
his knee.
The ancle & foot will commonly swell considerably.
about three weeks from the accident,
the roller & slipper may be left off: it may be 
[illegible] when the patient may attempt to use his
muscles; we answer, whenever he feels a consciousness
of a power to use them.
Mr Hunter broke his own [tondo] achillis in 
[illegible]; he is not clear whether cramp of the
muscles precedes the snapping of the tendon, but 
it certainly immediately followed it.



913. In order to the cure of this accident, the indications
will be 
1st To place the divided ends of the tendons
as nearly as possible to their natural [illegible]
2d To take off, or prevent inflammation.
3d To prevent the involuntary action of 
the muscle.
914. It is unnecessary to forbid voluntary action 
of the muscle, because in the present state, it will 
be no longer subservient to the will.
915. Should the divided ends of the tendon not be 
brought into contact, but remain at some distance
asunder the union will be accomplished 
by new formed substance, & therefore the tendon
be something lengthened; the muscle will
be however thereby shortened & its power of contraction 
lessened: no inconvenience will ultimately 
take place, for the muscle, as in the 
case of fractures of the patella, & olecranon,
will acquire new powers of contracting adapted
to its necessities.
916. In wounds connected with joints it is necessary 
to pay great attention to the motion 
during the cure, if there has been loss of substance,
without great care on the part of the 


259.
surgeon, rigidity & less of motion will be the 
event.
Q. The motions of the shoulder joint are restored with
most difficulty, after any wound or considerable
injury of that joint, because to some of them the
gravity of the arm is an obstacle; [illegible] it possible
to heal a wound of the shoulder joint with the
arm elevated, then the motion would be 
as easily restored as those of other joints.
917. After the inflammation has entirely subsided, & 
the cure is somewhat advanced, the joint should
be gradually moved by the surgeon from time to 
time, that the irritating matter may be elongated,
in a manner similar to elongation of coagulable
lymph in adhesions between the lungs
& the pleura.
End of the second part.


Rationale of Surgery
Part third.
We now come to treat of those affections of
the body which are the objects of surgery, that may 
more properly be called diseases, that is, those affections 
in which parts have no disposition for
restoration, but only a disposition to destruction,
& which disposition will continue to exist
untill either it [illegible] worn itself out, or has destroyed
the patient, or is cured by art, in short those
affections for which there is no natural cure.
Inflammations whether arising spontaneously 
or from external violence, suppuration etc. and [illegible]
[illegible] (unless so much mischief be done either
to a vital part, or to the constitution, that the
functions of the body cannot go on) become
themselves the causes of restoration. These we 
have already enquired into, so far as concerns 
the principle on which their different phenomena
depend, and have also considered the particular 
attentions by which we shall facilitate
the natural process of healing, in which in fact
little is to be done except removing impediments 
to the natural cure: but in diseases the present 


261.
Disposition is to be removed, & a new one induced
in its stead.
It has been shown that as irritation in health
produces disease (  ) so irritation or disease is to 
bring back health. The aphorism in general holds 
good, though in some cases of diseased irritability
or objection may be made to it.
After some previous general remarks on indolence,
we come to particular diseases originating from
that cause, tumors are those spoken of, but those
only which originate from indolence are those
meant to be explained: the definition given of 
them will indeed apply to swellings from other
causes than indolence, as inflammation etc., but the
subsequent remarks will show that when speaking
of tumors in that place, it was only intended to 
treat of indolent swellings.
918. Diseases or unsound disposition will be properly 
divided into the irritable & the indolent,
or those in which there is a disposition to too great
or too little an action.
919. Either of these dispositions will be a hindrance 
to the restitution of health, & must be changed before
health can be restored.
920. It is easier in general to increase the disposition 



of a part to action, than to abate it.
921. In the indolent diseased disposition, there is
neither sufficient power, nor sufficient excitement 
to action. In the irritable there is too great excitement,
without corresponding powers.
922. Again in diseased irritability parts are impatient
under any removal from a state of perfection,
yet have no disposition to set about the process of
restoration. This disposition may be either simple 
or connected with some specific disease, as syphilis,
cancer etc.
923. When simple we must have respect to the
principle laid down (  ) but when complicated with 
some specific disease, both the specific & the irritable
disposition acquire attention.
924 Diseased irritability may be local, or it may 
be a state of the constitution at large.
925. It appears in general to be passive, requiring 
the application of some stimulus to bring it into
action.
926l An increased degree of sensibility will in general 
accompany diseased irritability, the living 
& sensible principle commonly sympathizing.
927. Inflammation with diseased irritability
should not be hurried on to suppuration, n or, on 
the contrary should those means be used which 
lessen their powers; the indication being simply to 


263.
before violence of action, not to diminish powers.
Opium may be properly used in solution, or mixed
with emollient poultices; or preparations of lead
[illegible] (  ).
928. The diseased irritability of the constitution 
is lessened by the use of bark & those [illegible] which 
increase the strength. 
929. When a suppuration has taken place in parts
under this state, if an opening is to be made to 
discharge the matter, a caustic is to be applied 
in preference to the knife, for incision has not [illegible]
in general such favorable consequences as the
other method.
Q Caustics are not followed by so speedy or extensive
an inflammation as the knife, an [illegible]
wound in such circumstances has frequently for 
its sequel an erysipelatous inflammation.
930. Ulcers have sometimes a diseased irritability,
& when this is the case, the dressings in general
should be of the mildest kind.
931. We cannot a priori always determine what 
application will assuage the pain & other symptoms,
we must therefore change our dressings untill
we meet with one fulfilling that intention.
Q. Some ulcers which have shown every sign of the greatest 
irritability, as pain etc. will have then symptoms
unrelieved & often increased by [mild] dressings,
but will grow easy under the use of the most 


powerful stimulants, as the ol: terebinth: but we
would first try poultices with opium etc.
932. The unsound disposition with indolence, or 
the diseased indolent, may be either the affection of
the constitution or of a part. the constitution will 
rarely be indolent in a great degree.
Q. We meet with few constitutions which will 
not readily take an inflammation, a stimulus
being applied to any part of the body in which 
there is no particular local affection; how far
constitutional indolence may prevail we have
a proof in scrophula.
933. Specific diseases may give rise to, or accompany 
indolence in parts, as the syphilis, the scrophula
& sometimes the gout.
934. The common effect of indolence in parts, is
a thickening of them, the process of restoration
in parts in a state of indolence is extremely 
slow.
935. As the extent & spreading of disease in diseased
irritable parts in great & rapid, so the disease 
of parts in a state of indolence is in general
any circumscribed & rarely spreads to any considerable
extent.
936. The thickening or swelling of parts morbidly 
indolent is of two kinds, namely,
1st Interstitial
2d Superadated.


265.
and indolent swellings commonly go on to a
considerable degree, before any knowledge of them 
is communicated to the mind; but when [illegible] far
advanced, some dull heavy pain, with sickness
will be produced, but this probably arises from 
the distension of the surrounding parts.
937. The causes of indolent disposition arising
in parts are 
1st The long continued action of cold.
2d Violent actions terminating in weakness.
3d Prepare from mechanical cause.
Indolence may be also spontaneous, arising without 
any visible or known cause. 
938. The first species (936). or interstitial the [illegible]
is that in which no new or distinct parts 
are formed, but there is simply a swelling or 
enlargement of the original parts, as a corn, varices 
of veins etc.
939. The second (936) or diseased indolence with 
parts superadated, is that in which new parts
are actually formed, distinct from the old.
940. The intention of cure will be to increase 
both actions & powers. In the intersticial thickening, 
as the swelling generally consists in the 
deposition of coagulable lymph in the cellular
sub stance etc., we endeavor to procure a reabsorption 
of it, & to this end we employ those 
means which increase the action of the absorbents,
as mercury, pressure applied so as to stimulate 



late, fumigations etc., cure is, however, necessary 
not to excite the parts to greater action than
they can support, least mortification ensue.
941. When these thickenings cannot be removed
by absorption (940) stimulating applications may 
produce a cure, by exciting the suppurative inflammation 
in them; however their suppuration is
with difficulty brought about, the & when it has
taken place & ulceration followed it, the cure
is not easily obtained.
942. Abscesses have been divided into sound & 
unsound, of sound abscesses on account has already
been given, of those which were unsound & in which 
there is a disposition of indolence, it will be 
better to [speak], when their common course & 
consequences scrophula & fistula come under 
consideration.
943. Ulcers or sores may have an indolent disposition
& thence a backwardness to heal, when 
simple indolence is the [course] we have recourse
to those means which will excite the 
parts to action, as turpentine balsams etc.
944. Corns are an instance of intolerance from pressure,
the article thickens from the stimulus
of necessity, & as it increases in thickness, presses
on the skin & produces uneasiness & pain.
Q. The cure of corn consists in obtaining a separation
from the article, either by leaving off the 


267
pressure, soaking the part often in warm water, & 
keeping it always moist & defended by some proper
plaister, or by removing it at once; when a corn
has become of long standing, it is often difficult to remove 
by excision, as a wound of the part underneath 
is often followed inflammation and 
even gangrene: but we may attempt it by removing
the pressure, soaking the part long in warm
water & then applying a blister to obtain the separation 
of the article from the cutis.
945. Various veins are also an indolent thickening
from pressure: if the disease be not too extensive,
or the operation too hazardous, they may be 
dissected out & the inconvenience thus removed.
946. Chilblains may be given as an instance of indolent
thickening from cold, though they have in 
them, especially at first somewhat of an increased
irritability. The constitution most disposed to 
this kind of indolent thickening, are the delicate & 
such as [have] but small power of generating
heat.
947. Schirrus of a gland may be offered as an 
example of violent action terminating in weakness,
& acting on the cause of an indolent thickening.
948. Of the spontaneous indolence (  ) proofs may 
be given in the swelling of the legs so common 
in Barbadoes, & sometimes seen in this country;
& in the swelling of the lymphatic glands. 
949 Some indolent swellings may require extirpation, 


as an increasing their action in order to suppuration, 
they may be made to turn out cancerous.
956. Lymphatic glands may slowly, gradually & 
indolently tumefy ‘till they become of a size which 
may render extirpation necessary, from [illegible] making
pressure on some important part & disturbing it
oeconomy, or from their occasioning deformity.
Q. Of this kind are the swellings of the inguinal
glands, which have been so often mistaken form
venereal, & for which people have been ever 
salivated. Sometimes these enlarged glands are
so situated that extirpation is difficult & to be
undertaken with the greatest caution; this will 
be spoken to when we come to tumor & scrophula,
to which two articles they belong.
951. Wherever a cure can be obtained, the indication
will be the same, either to increase the action
of the absorbents, or to remove the part entirely.
951. In all indolent the [illegible] we should endeavor 
to ascertain whether they arise from the 
constitution, or whether they are purely local (see 
constitutions local & original local)
953. Indolent swellings of parts will be either
circumscribed or diffused, by the former we understand
a tumor (954) the latter we mean when 
we spent of thickenings of parts.
Q. When we speak of indolent swellings being
diffused, we only speak as comparing them to tumors
for indolent thickening compared to swellings of 


269.
parts from the same causes are generally circumscribed.
954. By the term tumor we mean a circumscribed
substance produced by disease & differing
in the nature & consistence from the surrounding 
parts.
955. Tumors may be divided into
a The solid.
b The encysted.
956. The solid (955-a) may be subdivided into
three, namely
1. The interstitial
2 The superadated or new formed substances.
3 The mixed.
957. The first or interstitial (956) belongs to scrophula.
The second or superadated are entirely new formed
substances, they take their rise from some fixed
point from which they grow, as from a root, which 
will be of different sizes, they are perfectly circumscribed,
are generally more detached from 
a lymphatic gland & they [have] no coat.
The third or mixed consists of those tumors 
called wens and schirri in which there is a 
mixture both of enlarged original & of new
formed parts.
958. These differ very much in their appearance
& consistence, being only fatty tumors, some time
almost cartilaginous, when cut through, they 
somewhat resemble a divided lemon.
959. The second & third species will rarely if 


ever admit of any other treatment in order to a 
cure than extirpation.
960. Previous to the extirpation of any tumor it is
necessary that we enquire
1st What part it adheres to or is connected
with, & its situation.
2d The manner in which it ought to be extirpated.
3d Whether it is necessary to remove any of 
the surrounding parts with it
961. The second species may be of different degrees 
of hardness, may grow from a bone & be bony
or from a tendon & be of a ligamentous firmness.
962. They may also be adherent to the skin, to a 
muscle etc. & they may be either superficial or 
deep seated.
963. The third may be loose under the others, or they 
may adhere to the skin; they may be situated
superficially or deep, upon a muscle, a bone, a 
large blood vessel etc.
964. If the surrounding parts be not diseased,
they may be suffered to remain; they must be removed
as far as the disease extends, for it 
must be a rule to remove the whole of the disease.
965. If the tumor be loose & does not adhere
to the skin, a longitudinal or crucial incision,
according as it is large or small, deep seated or
superficial, may be sufficient, & then the tumor 


[271]
may be raised from its bed & removed.
966. But if it be adherent to the skin, then a portion 
of the integuments must also be removed, at least
as large as the extent of the adhesion.
967. If it spring from a root originating from a 
bone, it is to be removed by the [saw], pincers, or 
chisel, in this case it may also be necessary to 
cauterize that part of the bone from whence 
it sprang.
Q. A young lady had a tumor situated on her
lower jaw; it became hard & almost bony: Mr 
Hunter pared it away even to the surface of the
jaw bone but it arose again; when it had been
pared off a second time & the maxilla cauterized,
the patient got well: the tumor consisted
of a thin plate of bone, forming a shell, which 
contained a cartilaginous substance.
A young woman had a cartilaginous excrescence 
growing from the upper jaw after the extraction 
of tooth; it was removed but grew again 
after being a second time extirpated, the patient
get well, these seem to occur most frequently 
in the jaw bone or on the tibia.
In the third or mixed, calcareous earth is sometimes
deposited, they not unusually fall into a kind
of suppuration, without the surrounding parts being
affected; in removing these great caution 
is sometimes required; Mr Hunter has dissected 


them of the temporal & carotid arteries & once
laid the trachea itself bare.
968. If it be situated on any large vessel & great
care will be required in the dissection of it from 
its seat (see note 967).
969. If it be only a fatty tumor, not adhering & of a 
small size, a simple incision down to it will be 
found sufficiently & then the surgeon may squeeze
it from its bed with his fingers.
970. When the third or mixed very much enlarges, they
are not unfrequently productive of pain; however 
it is not acute, it is of a dull heavy kind, and 
it depends upon pressure upon parts more sensible.
The stomach sympathises with the affection, and
sickness is not an unusual circumstance.
971. As in the pain, so likewise is the inflammation,
when it arises, that of the surrounding parts;
these, however, are seldom much thickened.
972. As to endeavouring to induce the supportive
inflammation in these tumors, the [illegible]
given (   ) will here be applicable.
973. The encysted tumors are substances contained 
in a coat, which is either natural or 
acquired.
974. The natural are the hydrocele, dropsy 
of the ovaria peridarcium [sacculi] mucosi
etc. in all which the contents are inclosed in 
a natural bag
975. The contents of encysted tumors, whose [tunica]



273.
are acquired, will be various in their consistence 
& nature; hydatids form a considerable
class of these tumors.
976. Hydatids are collections of watery fluid
inclosed in an adventitious bag, we do not know
the cause, nature or manner of their formation.
977. Every part of the body where there is cellular
substance becomes the seat of hydatids
but more commonly the plexus choroides of the
brain, the tunica vaginalis of the testicles,
forming a spurious kind of hydrocele.
970. They are different [illegible] as they enlarge their
coats thicken & become stronger; their coats are
but little vascular; sometimes one large hydatid 
will contain several smaller ones one 
within another; they are often found in the 
uterus, the kidneys, the liver, the thyroid gland,
the lymph etc. but how formed is unknown.
Q. Hydatids. It is difficult to explain the
manner in which they are formed, or to determine
which are formed first, the exterior or the interior
ones: are they not animals of the polypi
kind?
Remarks on particular hydatids.
Hydatids are sometimes formed in the brain 
& [illegible] in the plexus choroides; these occasion
no symptoms peculiar to themselves, & from 
their situation can admit of no cure.
Uterus and ovaria. The fluid contained within 


The hydatids found in these places is sometimes of a 
gelatinous nature; they are more detached at
first than afterwards; sometimes they increase
to an enormous size, occupying the greatest part
of the abdominal cavity, & then they are called
incysted dropsy. It is to be distinguished from 
ascites by the manner of the attack; the patient
first feels a weight & swelling on one side, which 
as it grows larger rolls about untill at length
increasing gradually in size, it becomes fixed, and
than the abdomen swells regularly and gradually,
the health of the patient is often but little affected 
by it, tapping is the palliative cure & should
be done with a large trochar, least the fluid
be gelatinous: when large they will adhere to 
the parietes of the abdomen, & then the operation
is safer than at any other time: they are
often made up of a number of cells, so that
sometimes only a small quantity of fluid is
discharged by one tapping: as this disease will
certainly kill in the end, if it can be ascertained 
early, it would perhaps be right to make
an incision through the whole length of the
tumor & extirpate it entirely. Electricity has
seemed of late to have been of very great
service to one patient afflicted with this disease.
Hydatids of the kidneys. Here they are generally 
situated between the external & the internal 


275.
[lamilla] of the proper tunic of the viscus,
& are out of the reach of relief.
In the liver. They are most commonly found in
the substance; sometimes they are discharged externally
the bags making their way through the peritoneum
adhering to them, inflammation & suppuration
coming as, the integument ulcerate & the
hydatids are discharged. Mr Hunter on opening
a woman found a great number of them inclosed
in one common bag.
In the lungs. Sometimes they make their way
into the traches & are coughed up.
In the thyroid gland they may become troublesome 
by impeding deglutition.
They are found in the cellular substance in 
different parts of the body, especially in the neck
& about the lips of women.
979. As to the cure of encysted tumors we can do 
little, unless one can either procure a discharge of
the contents & an obliteration of the cavity of the
cyst, or an entire removal of the whole 
980. Tumors may appear in parts where they 
were not formed, but into which they have made
their way from some deeper part, this circumstance 
the surgeon should consider when he is about
to extirpate a tumor.
981. If the surgeon be not attentive to this circumstance 
he may be deceived & operate ineffectually,
only removing a superficial appearance of disease, 


& neglecting the keep seated cause of it, & 
when probably some other tumor arising has driven
the first into its present situation.
982. Some ingested tumors are found to contain
a quantity of hair; the internal surface of these
has taken on the nature & disposition of the cutis
& cuticle, & thus given room for the growth of 
hair.
Q. In this manner we suppose hair is formed, which 
is found in tumors of the ovaria: Mr Hunter once
found an incysted tumor in a sheep which contained
a ball of wool; now it is probable this 
was thrown off from the interior surface of that
tumor on which it had formerly grown.
983. The carbuncle [illegible] its ultimate effects 
might have been classed with mortifications, as 
it produces a considerable sloughing of soft parts,
but some characteristic appearances attend
it, which would [illegible] it to be a distinct disease 
& of a specific nature.
984. The predisposing causes we cannot easily 
ascertain. It cannot be supposed to be owing to
weakness, as in general it arises not far from 
the source of the circulation, & it does not commonly 
arise in weak parts, or in weak habits;
its seat is commonly the posterior part of the 
body, as the [illegible] part of the neck, the back etc.
985. It begins with a considerable inflammation 


277.
of the skin, approaching nearer to the erysipelatous
than to any other; the skin is somewhat
tumid but not prominent, the part has a doughy
feel. For a short time a pimple arises, the inflammation
spreads rapidly & widely & the 
cellular membrane to a considerable extent
mortifies, the skin & muscles still retaining their
life.
986. The skin above has pimples, which now ulcerate,
forming large holes, through which the sloughs 
of the cellular membrane are thrown off, & as
they come away, leave large chasms which are 
loosely covered with the skin, which is flaccid & 
hanging inwards; sometimes the matter discharges 
itself through an infinite number of small holes.
987. The disease though it has its progress chiefly 
in the cellular membrane, seems to begin in 
the skin, & the matter generated seems to be of 
a specific nature, which contrary to the course 
of all other matter, tends inwards, & [burrows] in 
the cellular membrane, which wants power to 
resist its spreading from a want of the adhesive
inflammation.
988. Should not free openings be made in the infancy 
of the disease, to give free exit to the matter
& to prevent its spreading & diffusing itself 
through the cellular membrane?
989. The loose skin remaining after the coming away 



of the sloughs of cellular substance, should not be
removed, as it will commonly in the end unite with 
the subjacent parts & thus greatly forward the 
cure, which if things go on well from this time 
proceeds as in sound ulcers.
990. Boils seem to be a species of carbuncles, but
more of the adhesive inflammation arising in the
circumjacent parts, they do not spread; the cure
of boils vulgarly so called is in a slough
or mortified part thrown off.
991. The [illegible] & free livers are most subject to 
carbuncles, the young to boils. 
992. Though the cellular membrane sloughs, yet
suppuration freely goes on, in which matter is
either furnished from living cells, which are
endeavouring to throw off the dead parts, or 
from cells which are also about to die.
993. Carbuncles are sometimes local & sometimes 
they seem connected with a diseased state
of the system.
994. Bleeding is rarely proper, though it may 
sometimes be indicated at the beginning, if there 
appear symptoms of an inflammatory diathesis.
995. A diseased state of the system, as scurvy, may 
occasion both intersticial & ulceration absorption 
of new formed substances, which we have shown 
are weaker than the original; hence in violent 
scurvy, cicatrices have been known hastily to 
ulcerate & even calluses which formerly reunited 



279
broken bones become absorbed, 7 the ends
of the bones loosened.
Q (see Lord Anson’s voyage) here the constitution not 
having the power of supporting the new parts, or
even the original reclaims, as it were, the former
and causes than to be absorbed.
996. Tetanus or locked jaw is a disease which 
consists in an involuntary contraction of voluntary
muscles; sometimes it becomes an unnatural
contraction of involuntary muscles, & then 
perhaps it becomes fatal.
Q. Unnatural contraction of muscles is a genus
of diseases that has many orders; to it belong 
tetanus, cramp, wry neck, St Vitus’s dance, subsultus
tendinum, one of the kinds of quincy
ague: it bears some analogy to epilepsy and
catalepsy; though these are properly affections of
the brain; it is not peculiar to the human species,
horses, monkeys, stags etc. are subject to tetanus.
997. When it affects the muscles of the lower jaw,
it is called locked jaw; when it extends to the 
anterior muscles of the body it is called [empros]
[protonos], when the posterior opisthotonos.
998. The predisponent causes will be whatever 
can render the habit weak & irritable.
999 Amongst these climate is a very powerful 
one: in hot climates it is extremely common, being 
produced by the slightest occasional causes,
and even sometimes arising spontaneously.




1000 in temperate climates it is more rarely 
found, in very cold climates it is unknown.
Q. In this it is similar to other spasmodic complaints,
which are very common in warm climates, 
but rarely felt in cold ones.
1001. Other predisponent causes may be fever,
large suppurations, wounds of tendons & ligamentous
parts.
Q. These act upon the principle of producing weakness
& an irritable state of the nervous system.
Locked jaw has been attributed to the wound
of a nerve or a tendon; with respect to the former
the opinion appears quite erroneous, with 
respect to the latter, as wounds of the tendons
do not heal readily, they induce an irritable
& weak state of the system & this being present,
irritations which do not become sensible give 
rise to it upon that principle it is that it
has been known to follow large wounds which 
have considerable suppurations & which induce
a weak & irritable state of the habit. It does
not arise here from inflammation, for it does 
not take place until after inflammation has
gone off. Mr Hunter is satisfied from his experiments 
that wounds of nerves, or the [including] a nerve
is a ligature made upon an artery, have no 
particular tendency to bring on locked
jaw, which he has frequently found to take
place, where it was evident no nerve was wounded 



281.
1002 The most trifling external injury may 
be the occasional cause of this disease, even a 
scratch or puncture, where neither nerve nor tendon
are found to have suffered.
1003. It appears to be a disease of the nervous 
system & not of the principle of life, every circumstance
appertaining to the latter commonly 
remains natural & unaltered sometime after the 
attack of the disease.
1004. The muscles of the lower jaw seem more
disposed to take on this affection, than any other 
muscles; here the disease commonly begins and 
soon spreads itself to other muscles at length 
spasm being extended to those muscles whose action 
is involuntary & necessary to life & then the 
patient is destroyed.
1005 It begins with a small degree of stiffness in 
the muscles raising the lower jaw, the patient finding 
a difficulty to open his mouth; at length
the jaw becomes less & less capable of being depressed;
the muscles of the eye lids are next affected,
& the upper eye lid falls more & more, so
that the patient looks like a person going to sleep; 
sometimes soreness of the mouth & throat precedes, 
but this is only accidental; then the muscles of the 
head become effected; at first the head is held 
immediately erect by the spasm, then it is drawn
backwards; the muscles of the spine become next
affected, & the body of the patient is bend backward 


for those of the abdomen, the bowels are drawn 
inwards, the patient complains of a pain in the 
lower part of the sternum, perhaps from the diaphragm
being affected; a difficulty of respiration 
from the spasm extending to the diaphragm, intercostal
muscles etc., in which [illegible] [illegible]
pain like cramp is felt. Universal convulsive
motions of the body sometimes attend, like the
subsultus tendinum. In other respects health 
seems to remain & the functions of the body
go in; the spasms of the involuntary muscles, however,
increasing in violence, & perhaps the heart 
also becoming similarly affected the patient is
cut off sometimes stupor precedes his death.
Q. Stupor. This shows that the brain must be 
somehow affected; as it is neither muscular, nor
connected with the muscles, it is difficult to say how
this affection of it is produced; is it from any compression 
on the brain induced by the spasm in 
the muscles of the neck making pressure on the
jugular veins, or is it from sympathy?
1006 Should the patient live untill the habit
becomes accustomed to the disease, it then wears 
itself out & at length the patient gest well; in 
general, however, it kills before the system
can be habituated to its action.
1007. The disease does not always increase gradually
& regularly as described (1005) but sometimes it 


283
will extend itself suddenly from the jaw over the
whole body, so as to excite unnatural contraction 
in the muscles in general. When the spasm confines
itself to the jaw the disease may be called
mild & then it does not prove fatal.
1008. The disease kills at different periods of time;
but if the patient live through the second or third
week from the commencement of the complaint, the
constitution becomes so much habituated to it,
that it loses its power of destroying life, then wears 
itself out.
1009. The disease continues sometimes even ten 
weeks, a great part of the time remaining stationary,
& at last the patient gradually loses the 
psasmodic affection & his muscles are resolved
to a natural state.
1010. All ages are subject to it, of constitutions the
delicate & relaxed are most liable to its attack
1011. When it kills the muscles remain contracted 
until the contraction is removed by force, but 
when art has relaxed them they do not contract 
again; no preternatural appearance presents itself
upon dissection in any part of the body, in general 
the disease kills suddenly.
1012. From considering what has been said we are
perhaps able to discover
Why the patient remains under the disease 
a long time without his general health 
being affected 



Why the disease kills; & only it may kill at different
periods & why it commonly cuts off the patient
suddenly.
1013 No internal remedy has yet been his discovered
that will cure or relieve this disease.
Q. (1013, 1014) Bark, opium, blisters, camphor, bleeding,
warm bathing & a variety of other methods have
been tried; whenever Mr Hunter has seen the patient 
recover, the disease has seemed to have
gone its course & to have worm out itself, without
his having had any reason to attribute anything
to the power of medicine: he recommends 
the sugar of lead to be tried upon the principle
of the known tendency of lead to produce relaxation 
of [muscles] & mobility in them to contract
externally; as a substitute for a change of climate 
he recommends that the patient should
be put into a cold bath or an ice house, he 
never saw a patient die after the third week.
1014. External applications have also been
found ineffectual; as climate is one great predisposing 
cause to the disease, a change from the 
present to a colder might be tried. Electricity 
has once been found serviceable 
1015. As the indication of cure must be to relax 
the present contraction of the muscles, & to take
off the disposition in other muscles to unnatural
contraction, the internal use of lead might 


285
probably deserve a trial, as lead by inducing 
paralysis may cause one disease by producing 
another.
1016. If the locked jaw have followed a wound
in any part of the body, the removal of the 
part is not found to remove or lessen the disease,
unless the tetanus arises during the state of 
inflammation of the wound. For when the inflammation 
& irritation of the wound. For when the inflammation 
& irritation of the part which received 
the injury are gone off, it must be evidently useless
to remove it, in case a locked jaw should have
come on; became whatever irritation was here 
before applied to the part, is now taken away,
& that is no longer the diseased part, nor can it
now tend to cause or keep up the spasm, its
action on the system has been already produced
& terminated.
Cases of Locked Jaw.
1. A locked jaw & convulsions of the muscles
of the arm from a compound fracture of the radius;
heat & perturbation of mind increased the 
symptoms; he was always observed to be worse
after drinking any thing warm, or after warm 
external applications, opium & bleeding were 
tried; he died on the sixth day.
2. A soldier received a wound in his leg
when it was nearly well, a locked jaw came on 


musk & opium were tried for three weeks, the
patient finding no change would not take any 
more; he continued in the same [illegible] for more
than seven weeks & then began to mend, which 
he continued to do insensibly untill he recovered
his health. He took bark & port wine
during the whole of his illness; his wound healed 
long before the complaint left him.
3. A soldier with a locked jaw after using
musk, opium & even the cold bath & finding no 
relief, left off all his medicines; he took none 
for eight days & then began gradually to mend.
4. A young man had his thigh amputated, had
violent pain in it & frequent spasmodic affections
of the muscles of it. 13th day the locked jaw
came on, 15th became locked all over, 16th he tried
opium, [illegible] then & sweating were employed, the muscles
continued rigid after death, but when relaxed
by force, did not contract again.
5. A sailor had a tetanus affecting the jaw 
& muscles of the spine came on after having received
a wound in his wrist; during his illness
he had ischemia & costiveness, both of which were 
relieved by glyster; opium camphor, bark
steel, port wine, cold bathing were all tried,
he lived some days, had pain of his heart 
& great oppression about that organ having
come on he died suddenly
6. A man had a locked jaw, & was uncertain 


287
whether this disposition to it was induced by 
wound of the tongue, he died the ninth day
the second day of his illness the spasm extended 
to the muscles of the neck & spine; the fourth his
skin became exquisitely sore to the touch, his
eye lids did not open properly, he had universal 
spasm & a degree of stupor; the eighth his breathing
was difficult, & he had a pain in the lower 
part of the sternum; on the ninth he died suddenly.
7. Locked jaw came on after trepanning; opium 
was freely given; as visible good effect followed 
it, but after a fortnight the patient mended 
gradually and got well.
Q. Locked jaw arose spontaneously after a
nervous fever; the patient took nothing but port 
wine & recovered.
9. Locked jaw arose in a child of two years 
old, after a scratch of a finger by a saw, it died
the tenth day.
10. Locked jaw arose spontaneously after dysentery.
Upon the whole from what has been said we
must be justified in acceding to the conclusion given 
in (1013-1006.)
1017. Scrophula, is a disease which may be considered
as constitutionally local (  ) it is not hereditary;
as in other diseases so in this a susceptibility
of the disposition for a diseased action, in all that can 


be inherited (  ).
1018. It is a specific disease every process of which
is marked with indolence & soreness of action, whether 
it produces tumefaction, suppuration or ulceration,
all of which when the disease is true scrophula
go on with little or no pain.
1019. When it produces swelling of a part, the tumefaction 
increases slowly; there is hardness with 
little pain or soreness; all the appearances of common
inflammation are wanting: should not 
resolution of the tumor take place, a kind of 
suppuration is produced.
1020. When the tumor becomes soft & suppurates,
which it does very slowly & without pain, the 
matter very gradually makes its way to the 
external parts.
1021. The ulceration of the integuments in order for 
the evacuation of the matter is equally slow & 
tedious; the matter does not make a point, as in 
healthy abscesses, but it stretches the skin equally
to some extent & renders it as far as it 
distends it, shining & of a purplish hue; in this
state the disease will frequently remain stationary
for months. When the skin can no longer
resist the pressure of the matter it [illegible], and a 
fluid like mixture of curds, & whey is evacuated;
there is rarely any common pus when the 
scrophula has gone on [illegible] & are mixed with 
the common inflammation.
1022. When the abscess has emptied itself, it has not 


289
readily fill up, or suffer its cavity to be obliterated,
but will often remain a fistula, the small hole
through which the matter bursts remaining open.
1023. When scrophula, ulcers granulate, the granulations
are large, soft & pointed, appearing like 
a transparent glossy substance; their sensibility is
little, the margin of the sore is loose, flattened & 
turned inwards, the skin round about it has a 
purplish hue, the granulations went the 
power of contracting (  ) so that the ulcer will continue
stationary, or at most the sore will be 
slowly diminished.
1024. The process of cicatrization is equally difficult
& tedious, & when formed has not a healthy 
appearance.
1025. The disease seems to have a sedative e3ffect
upon the system, diminishing all the action of 
the parts which in invades.
1026. It has a power of producing in the parts, surrounding
the part originally diseased a similar
state, but it does not produce continued sympathy in 
any great extent.
1027. The predisposing cause is a delicate & irritable
constitution with weak powers of action; the parts
most disposed to take on scrophulous action are 
the lymphatic glands, especially those which 
are most exposed to the influence of the atmosphere, 
as the glands of the neck & lungs, the
[???enteric] glands, joints, particularly those o f
the foot & hand, ligaments, the soft ends of bones 


in all which parts, the strength & powers of restoration
are but small.
1028. Persons between the age of 15 & 40 of a fair
complexion & light [illegible], who do not appear to have
the usual quantity of red blood in their vessels, & 
those who live in climates which are very changeable
and irregular, are most liable to this disease.
Q. It is not peculiar to the human species, several
quadrupeds, as monkeys, some birds as turkies
are subject to the action of scrophula.
1029. Though it produces continued sympathy 
to a small distance, it has no power of affecting 
the absorbents, nor is the disease capable of
being communicated by these, it cannot like
the small pox be communicated by inoculation.
1030. The skin is rarely if ever or originally & 
primarily affected by this disease, it may, however, 
fall into it by continued sympathy.
1031. The exciting causes will be externally violence, 
especially if not very great, sudden application 
of, a sudden exposure to cold, the 
[illegible] of mercury. The slightest of degree of external 
violence in habits predisposed to it (1026-27). 
will cause the part to take on a scrophulous action
1032. The susceptibility of scrophula in some
constitutions is so great that every complaint 
which deranges the habit for a time, as fever
syphilis, small pox etc. will give occasion to a 


291.
scrophulous disposition & action.
1033. The appearances of scrophula will vary according 
as different parts are affected, however it
will always be found with one of the following
circumstances.
2. A circumscribed tumor.
2 A tumefaction more diffused.
3 A suppuration with or without tumefaction
1034. The circumscribed tumors are chiefly 
lymphatic glands, although they are sometimes
found in the brain, breast, uterus & testicle.
1035. When the disease attacks a part which may 
suffer without much disturbance of the general 
health, we are often unacquainted with the nature
of the disease, untill a swelling in consequence
of suppuration appears either in the part originally 
diseased, or in some other part to which 
the matter has made its way, the suppuration going on 
without inflammation & perhaps without pain.
1035. When the disease affects the knee, the
pain is more considerable than when other parts 
are attacked, & here somewhat of the true
inflammation is mixed with it.
1037. Whenever the lower extremity is the seat
of the disease, the limb appears longer than the 
other, this is from the patients particularly 
favoring that side & leaning on the other.
1038. Children are often [illegible] for months, and
at length a swelling has appeared in the foot; 


when scrophulous abscesses appear about the
fingers, hand or foot, the swelling sometimes 
does not subside even after the matter has been 
discharged.
1039. Lumbar abscesses sometimes appear without
any previous pain; sometimes patients remember 
to have had pain in the loins in general; however,
if they have pain, it is felt beyond the seat
of the disease, as in the thigh, the knee or foot,
the matter very frequently here presents itself
in the thigh though formed in the loins.
1040. Patients under thirty are most subject to 
this complaint; it is produced by the common exciting
causes of scrophula; it is to be distinguished 
from a disease of the hip by attending
to the motion of the foot.
1041. Abscess in the joint of the thigh is of the 
scrophulous kind; there is commonly a thickening 
of the soft parts forming & surrounding the
joint; the patient has a sense of weakness in 
the limb, which wastes & has its motions contracted.
1042. White swelling is a form that may be 
applied to every scrophulous swelling of a 
joint; before the skin becomes inflamed it is 
generally attended with an increase of synovia;
sometimes it is truly scropohulous, & sometimes 
has a mixture of the common inflammation.
Q. A fever has sometimes cured scrophula


203.
and hence we might be led to think that stimulating
remedies are indicated, but the analogy
will not hold good, for the disease is a specific 
one & will go on untill it has worn itself 
out, untill it has destroyed life, or is cured by 
some specific.
Should lumbar & hip abscesses be opened?
They are in themselves [a] curable, possibly a chance
for life may be given to the patient by opening
them early, that is as soon as we are satisfied
absorption of the matter cannot be brought 
about. In some scrophulous abscesses we can 
obtain a real absorption of the fluid, it is always 
to be denied, as the healing of them after ulceration 
has taken place is accomplished with difficulty.
1043. The common pulmonary consumption is
commonly a scrophulous affection of the lungs.
1044. The young, the fair & the delicate are the
most subject to it, & the common exciting cause
is cold, it commences with tubercles in the lungs,
swelling of the glands of the neck often appear
in the beginning; the disease increases slowly, the 
tubercles suppurate & ulceration being formed 
the patient becomes hectic & is at length destroyed.
1045. The pulmonary consumption is however
seldom a purely scrophulous affection, it too 
generally somewhat of the common inflammation  
mixed with it, as we know from the pain in the 
chest, the quick hard pulse etc.
1046. An Haemorrhage from the lungs is [illegible]
commonly the forerunner of a pulmonary 


consumption, but how for this has to do with scrophula 
are cannot determine.
1047. The testicle is also the seat of scrophula 
as in its actions upon other parts, so here also [illegible]
attack is scarcely known, & its progress slow.
1048. It rarely occurs before the age of sixteen,
or in old age.
1049. The breasts of women also fall into this
disease in which they will gradually, slowly
& with little pain swell to an enormous size.
1050. The scrophulous testis (1047-1048) are to be
distinguished from cancers of these parts by the
want of swelling in the spermatic chord, and 
axillary glands, also by the absence of local
sympathy, at least untill the skin is beginning
to be affected by the suppuration. (  ).
1051. The indications of cure in scropohula 
with respect to the constitution are 
A. 1st To give strength to the system.
2d To counteract the effects of climate.
3d The use of some specific
with respect to a part
B. 1st To produce resolution of the tumor, or 
absorption of matter if it have [suppurated]
2d To extirpate the disease if practicable 
1052. The indication (A-1.) we endeavor to fulfill
by means of bark & other tonic remedies.
The indication of (A-2) by changing the situation
of the patient; or if that cannot be done 


295.
by rendering the system less susceptible of the
influence of the climate in which the patient
lives.
The indication (A-3) by the administration 
& application of such remedies as experience 
has proved.
1053. If climate cannot be changed, which is to 
be desired, and which should always be altered to 
[illegible] warmer & more regular, than we may lessen
the susceptibility of the body by tonic medicines.
Cold bathing & the use of such cloathing as will
maintain on the surface of the body an uniform 
& equable heat, such as flannel which 
conducts heat from the body slowly. 
1054. Experience seems to have proved the powers 
of sea bathing as the most powerful specific
In every scrophulous complain, whether hip
cases, white swellings, consumption etc., & some specific
powers are likewise to be attributed to [fossile]
alkali, hemlock etc.
1055. Sea bathing is to be used with that degree
of heat which is found most agreeable to the
system & followed by the greatest increase of
vigor & spirits.
Q. We consider sea bathing as a specific in scrophula,
but we are also to consider under which
circumstances it will act most powerfully, for 
instance whether sea bathing & a cold bath,
sea bathing & a tepid bath, sea bathing & a 
warm bath will best agree with the patient, 



for we are not only to consider what will cure
the specific disease, but also what will least agree
with the patients constitution: some persons
cannot bear cold bathing, but will find
themselves must repeated by the tepid baths;
again others require the affect of the warm 
both to render salt water agreeable to their
constitutions. Again the season of the year is to 
be considered, for more additional  heat will
be required to be given to the water in the
winter than in the summer if the cold bath
cannot be endured. In the warm or tepid
bath, the patient should remain ten or fifteen, 
minutes, with the precaution of [terpenning] the 
heat to the agreeable degree. Sea bathing 
may be employed in all cases of scropohula
even pulmonary consumption; to prove that
the bath agrees with a patient he should feel
a glow & his spirits be enlivened by its use,
of these appearances be wanting after a second
or a third trial, & the patient feels himself
dully & enervated, some other degree of heat 
should be tried. In bathing, the sores of the scrophulous 
parts should be always uncovered.
1056. The means recommended (1052-1053, 1054, 1055) 
are most to be insisted on where there is
the greatest predisposition to the disease, & 
the patient most exposed to the action of exciting
causes; hence children & young persons
stand most in need of them, than those advanced
in life, also in irregular climates, & 


297.
in winter, more than in regular climates and
in summer. It is a bad practice with parents & 
nurses to carry young children about in the 
cold, with the extremities naked & exposed to the 
atmosphere; they bear cold ill & suffer from it 
more than those advanced in life.
1057. We are not to expect a speedy cure from 
any remedies [illegible] in the treatment of scrophula,
length of time being always required
to give them efficacy from three months
to two years.
1058. Moderate exercise is to be recommended & perhaps
a vegetable diet may be employed with advantage.
1059. Mercury is in general improper in scrophulous
complaints; bleeding is often necessary in 
scrophulous consumptions to diminish the quantity 
of blood to be circulated through the pulmonary 
artery, & proportion it to the quantity of unobstructed
lungs.
1060. As to the topical treatment, where the disease 
admits of it & it can be removed with propriety
all at once, extirpation is the best method.
1061. In the resolution of tumors & the healing
of scrophulous sores few topical applications 
except sea water & the juice of hemlock are of
any advantage.
1062. Stimulating applications are generally 
injurious, violence increases the action of the
parts, & at the same time does not cure but add to 


the disease.
1063. When there is suppuration, the abscess should
not be opened with a knife in general they 
should be left to break of themselves.
1064. Variations in age will often tend to the 
spontaneous cure of the disease, & this is most
observable in females.
1065. In scrophulous bones, exfoliation is tedious
& obtained with difficulty: in these as in 
soft parts every process of exfoliation goes on
not without difficulty.
1066. In scrophulous swellings sometimes only 
a white curdy or caseous matter is found; indeed
the parts being altered in their structure 
& incapable of carrying on their functions, lose
their life, but do not putrefy, nor is there a disposition
of the parts immediately in contact, to 
throw them off, themselves also being affected
by continued sympathy.
1067. Rickets may be deprived 
1st A want of disposition in the vessels of the
bones to form calcareous earth arising from 
weakness of a peculiar kind, or 
2d Too great & hasty an absorption of earth 
from the bone in proportion to the quantity
formed by the vessels.
1068. It is a disease of the constitution & originates
in a weakness of a peculiar kind; for 
weakness in general does not produce [ricketty]
complaints, although rickets are always attended 


299
with weakness. the first cause (1067-1) operates in 
the production of rickets in children; the 2d (1067-2) 
produces the disease in adults.
1069. The rickets in children are known by the 
bones becoming enlarged, by their bending beneath
the incumbent weight of the body & yielding to the
ordinary action of the muscles, so as to be thereby 
distorted.
1070. A certain size of the bones & a certain proportion 
of the earth should be present together, as the 
size of the bones is determined in adults, it is
impossible the increase of the bones in size beyond
their proportion of earth can constitute the disease  
in the full grown subject.
1071. But in children this is the case; it is a known
fact that during the time of growth the enlargement
of the bones is the greatest whilst the quantity of 
earth formed in them is the least, for the formation 
of earth checks the growth of bones.
1072. The animal matter of the bones is also altered,
for it is found to be different from the 
animal matter of bones simply deprived of their
earth.
1073. The rickets cannot produce an increased 
growth of bones in the adult, but in other respects, 
as softness of the bones & their inability to 
support weight & muscular action; though the
causes of rickets in the infant & adult may 
be different, the effects will ultimately be the same
1074. The general consequences of rickets in 
parts supporting weight,  are, that the joints are 



obliged to form more acute angles.
1075. From what has been observed, we are enabled 
to understand why the bones of the inferior
extremities are more frequently [bent] than
those of the superior; & also why those of the superior
themselves are sometimes bent, & why the knees are knocked.
1076. Why the disease affecting the spine shall 
produce difficulty of breathing & other complaints
of the viscera & why the pelvis should be 
[illegible] distorted by it, & labors difficult.
1077. The bending of the bones & their throwing
an increase of weight upon the joints gives rise
to the stimulus of necessity, which excites a disposition
in some parts to take an ossific inflammation
& to generate new bone, hence irregular
[illegible], anchyloses of the joints etc.
Q. If the bones of the cranium have been 
affected, an irregular ossification may arise
in them inside next the brain, & by its pressure
induce morbid affections of that viscus.
On the concave side of [illegible] bones, nature
will sometimes from an additional quantity
of bone, in order to strengthen the original one.
of the softness of ricketty bones a case occurred 
at lime house, where the bones were as
soft as tendons.
It is unnecessary to add that Mr Hunter
considers the [illegible] opium as a species of
rickets, & think it is here described as rickets
in adults.


301.
1078. From what has been said we also understand
why bones bend in particular & different 
directions.
10789 For the disease no certain remedy has
yet been found.
1080. The disease is either a species of or allied to 
scrophula, & sea bathing seems to be what approaches
newest to a specific for it, as well as for scrophula.
1081. The general indications of cure are to give strength
to the system; hence the cold bath, exercise, bark, & 
other tonics may be advantageously employed
1082. Exostosis has probably somewhat in its nature
similar to rickets, it is a growing out of a bone from 
a bone.
1083. It appears to be of two kinds.
1 Constitutional.
2 Local.
In the first a similar disposition shows itself in 
almost every bone, in the latter perhaps only in a 
single bone.
1084. It has generally its seat near the heads of 
bones, & therefore seems much connected with soft 
parts.
1085. The tumor sometimes arises all at once 
out of the substance of the bone, sometimes very gradually.
1086 When near the joints it sometimes produces
lameness, altering the direction of the muscles and 
tendons.


1087. It is peculiar to youth & rarely appears in 
the more advanced stage of life.
1088 Though we know the absorbents have a power
of removing superfluous substances, even bony ones,
yet we know not of any medicine whose powers
will either produce a removal of those
tumors, or a prevention of them.
1089. When the removal of the tumors by mechanical
means is feasible & convenient, it should 
be done by the pincers, chisel or saw.
1090. Fistula are of two kinds.
1st A passage for the discharge of the pus etc. from 
a diseased part.
2d An artificial canal in lieu of some natural 
one, the natural one being obstructed.
1091. It is the consequence of some parts being 
afflicted with disease, which they are not able 
to get the better of, although the fistula itself 
is seated in a sound part.
1092. The disease part to which the fistula 
leads, is always large & more extensive than the
fistula itself.
1093. As the fistula commonly opens in the skin,
and as the diseased parts are more deeply seated,
the lips of the skin will be more tucked inwards,
(though sometimes the lips of the orifice 
are turned outwards so as to resemble a prolapsis 
ani) & the orifice will be nearly filled 


303.
up with loose fungous granulations, which if
destroyed readily shoot up again.
1094. Whatever is the disease in the part to which 
the fistula leads, untill the obstruction to its
restoration be removed, or its disposition, if specific
or unsound, be changed, no cure  will be obtained.
1095. If the seat of the disease extend to or occupy 
a vital part, it will tease the patient and the 
constitution, untill hectic is induced & death succeeds.
1096. The indication of cure is the first species of 
fistula (1909) will be 
1st The removal of whatever obstructs the healing
of the parts, and
2d The inducing a new disposition in the diseased 
part.
1097. The first indication of cure will consist in 
the removal of all foreign or stimulating bodies, 
as splinters of bone etc., under the limitations 
heretofore given in cases of gunshot wounds & 
diseases of bones.
1099. The second indication (1096) will be fulfilled
by laying open the fistula or cavity through its
whole extent & even carrying incision into the 
sound parts, that the mouth of the cavity may be as 
large a layer than the surface of its bottom, and 
that the whole being exposed, a necessity for some
new process in consequence of the irritation of exposure
may arise.


1100 If the parts in question have any powers of
restoration, the consequence of (1099) this treatment 
will be the excitement of inflammation, suppuration 
& ultimately granulation, which will 
at length  fill up the unnatural cavity & cure it.
1101. In the second species of fistula, the indication 
of cure will consisting (1090) 
1st In opening again the natural canal, or
2d In making some new one, which will answer 
the purposes of the original one.
1102. In its first species there is a greater disposition
to heal in the parts through which the
fistula passes, than in the deeper seated parts, hence 
the disproportion in size (1091-1092-1099)
1103. We cannot simply from the appearance 
of a fistulous orifice determine its extent, we
must therefore examine its depth, the seat and
extent of the disease, by some convenient instrument,
as a probe etc.
1104. Sometimes one diseased cavity will have
several openings leading into it; it is generally 
necessary to lay the whole into one cavity, & 
to induce a healing disposition at the bottom of
that cavity.
1105. When fistula of parts they lead to are 
laid open, the external parts should be kept from
healing, untill the deep seated ones have acquired
a disposition for restoration, & the ulcer can
be healed from the bottom. 


305.
1106. These observations may be better understood
by considering
1st Fistula in ano.
2d Fistula in perineo.
3d Fistula leading to joints 
4th Fistula of the lungs, liver etc.
5th Fistula [E???hymalis].
6th Fistula of the parotid duct.
7th Fistula of cowper’s glands in females.
1107l Fistula in ano is the consequence of inflammation 
beginning two, three or more inches
higher up in the cellular substance on the outsides
of the rectum, which going on to suppuration
the matter descending commonly makes
a point externally near the anus, & bursts, but 
sometimes the rectum becomes so diseased that
it will also give way & a breach be made
in it opposite to where the inflammation began
1108. The cure (1099) will consist in laying open
the whole cavity, making its external mouth
equal to or larger than the surface of any 
side of the cavity & preventing the too early 
reunion of the lips of the wound (1105.)
Q A person had a fistula in ano, for which he 
was thrice cut, but the part still remained
fistulous; upon a more accurate examination,
it was found that the sinus extended two inches
above the anus, & then penetrated above
the orifice; it continued its course along the side 


of the gut for another inch, the incision was then 
carried up to the end & the man got well.
1109. Fistula in perineo may have for its cause
stricture in the urethra, disease in the prostate 
gland, or more becomes part of the urethra, the
external orifice cannot heal as long as the disease
remains uncured.
Q. A fistula in perineo will not get well
through a wound in the same part in lithotomy 
readily heals, in the latter the internal parts 
have not lost their disposition to healing, hence
there is no obstacle to the case.
1110 In fistula in perineo there will often be
several sinuses whose mouths open externally 
communicating with the fixed point of the disease; 
there it is right to treat if we can according 
to the rules given above but before a 
cure can be accomplished, the diseased disposition
in the parts must be changed, for instance
strictures in the urethra must be
cured if they give rise to the fistula.
1111. Fistula communicating with joints will
not heal, because they communicate with 
parts whose powers of restoration are weak, & 
making free openings only increases the disposition
to disease, & the violence of the hectic,
neither can we cure fistula of the lungs or
liver, because we cannot lay open the cavity.


307.
1112. IN cases, therefore, where we cannot have
recourse to the treatment recommended (1099 [illegible])
we can only endeavor to give power to the constitution 
by tonic & strengthening medicines, that
if possible a natural cure, (though little to be expected)
may be obtained.
Q. We take no notice of amputation for fistula
in joints, as it has nothing to do with the doctrines 
now before us.
1113. Fistula lachrymalis is sometimes an original 
local disease, sometimes a constitutional 
local, as arising from syphilis, scropohula etc. 
1114. From whatever cause the ductus ad nasum 
may become obstructed, whether from inflammation 
or a disposition to contract similar to 
that which arises in other membranous canals,
as the urethra etc. forming strictures in it,
the passage of the lachrymal fluid is impeded
distension gives a stimulus to the lachrymal
sac, which stimulus is also increased by 
the salt in the tears, hence inflammation and
suppuration are produced, & the matter [bursts]
through the skin near the eye.
1115 Through this [raw] & unnatural opening
the purulent matter mixed with the tears continue
to flow, untill the surgeon either dilates
the natural canal, or makes a new one, so 
that the tears may again have a passage into’
the nostril, & then the fistula will heal.
1116 If the obstruction in the natural passage be 


very great dilatation of it will rarely cure,
because we cannot in general destroy the disposition
in the canal to form strictures, and
those recurring, the disease will also return, so 
that most commonly a new & artificial canal
into the nostrils must be formed.
1117. Fistula of the parotid gland. The duct
from the parotid gland, passing over the [illegible]
& [buccinator] muscles, consequently lying
very superficially is extremely liable to be
divided, & the saliva will flow outward
from the end next the gland; or suppuration
from any cause whatever arising in the duct, 
and bursting externally, a similar circumstance
will take place. 
1119 The cure is performed by passing a needle
armed with a round ligature of thread, from 
without through the duct into the mouth, & 
let the thread remain there untill the wound
made by the needle has lost a disposition to 
heal, the external wound we should suffer 
& encourage to close.
1120. The ducts leading from cowper’s glands
to the inner surface of the vagina in women,
are sometimes obstructed & a sore will be formed,
containing a slimy matter, which will 
cause a distension or enlargement of one 
of the labia to a prodigious size & produce
the resemblance of a hernia.
1121. An incision should be made into the tumor 



& the matter discharged, after which the incision
should be suffered to heal.
1122 Then a second crucial incision should 
be made into the sore, near the natural
opening of the duct, & this should be kept open
untill it has lost its disposition for 
healing, & the mucus is discharged by it, as it
formerly was by the natural passage
1123. Unsound abscesses are to be considered as twofold,
namely
1. Those forming in a part.
2. Abscesses of a part.
1124.In the first we have a collection of matter
formed in the part where they appear, & 
in the second the matter is formed in some
other part more or less distant, & from thence
makes it way to the part where it appears.
1125. Of the first we have instances in many 
scrophulous suppurations, in abscesses in 
the joints etc.
1126.Of the second we have instances in the
psoas muscle & hip joint, which after present 
their matter in the thigh or groin
1127. Whether the latter burst or be opened 
the doctrine of fistula will apply to them,
nor will opening unsound abscesses of a part
be of utility unless we can also induce in it
a disposition to heal, or we have some foreign 
body to remove, as splinter of bone etc.
1128. Unsound abscesses are generally caused by 


some specific disposition as scrophula, lues
venerea etc., or from a disposition to indolence
either acquired or natural, that is either
in parts which have natural powers of
healing, but fall into a state of diseased 
indolence, or in parts which have natural 
but small powers of healing, as in joints,
ligamentous parts etc.
1129. New formed parts as cicatrices & calluses
are sometimes suddenly falling into
the suppurative & ulcerative absorption, & 
the progress of the absorption will be uncommonly
rapid, as this arises from an unsound 
disposition in the constitution; that disposition
is to be removed or altered.
1130 We come now to poisons, especially 
the animal & principally the morbid.
1131. But we can give no unexceptionable 
definition of poisons.
1132. The definition, however, which we
can give & which is most free from exception
is
A matter which produces a peculiar
mode of irritation & affects the vital principle
in a peculiar manner, when even 
used in the smallest possible quantity; & 
this without any relation to any known
chemical or mechanical powers, or by any 
common irritation.
Q. By this definition, glass, metallic salts, 
even [illegible] & a variety of vegetable substances 


as hemlock, opium etc. are excluded 
from the class of poisons, also honey, particular 
kinds of fish etc. for three reasons.
1st Because those are no poisonous in 
the smallest possible quantity.
2d Because their action is not universal.
3d Because their irritation is not specific  
but common. 
1133. We know no substance in the mineral 
kingdom answering to this description, nor is
there much poison of this nature in the vegetable,
but the animal kingdom possesses it in 
great abundance.
1134. No secreted fluids are poisonous to the 
part secreting them, but they will act as 
poisons on any other part of the animal
they belong to.
1135. Poisons answering our definition (1134)
of four kinds
1st Those which act locally as the story of
a wasp, cancer, [illegible] etc.
2d Those which have their effect on the
constitution as jail fever, hooping cough etc.
3d Those whose influence is upon the whole
nervous system, as the poison of the mad 
dog, of Indian poisoned arrows etc.
4th Those whose powers are mixed, as the 
poison of the small pox, lues venerea etc. 
acting both locally & on the constitution.


Q. In the animal kingdom, some animals as the 
bug & mosquito & probably the poison
the part at the same time they get their food
from it, the bug, for instance, poisons the part & 
produces an extravasation of its juices, which 
it feeds upon. the [leech] after making a wound
poison the vessels of the part wounded, so as
almost to destroy their power of contracting,
hence the haemorrhage which often continues
so long after a [leech] has been sucking, which never 
follows other similar wounds. 
1136 We intend to consider animal poisons only,
and these are of the kinds, namely, 
1. Natural.
2 Morbid
1137. They naturally are such as belong originally 
& naturally to the animal possessing them 
& not depending upon any preternatural affection
or alteration in the structure of any 
body or its parts.
1138. The natural has no power of propagating
its effects beyond the individual its powers are 
exerted in poisoning.
1139. The morbid, on the contrary, depends on a 
preternatural action, or change of structure in 
the body communicating 
1140. But the morbid, in general, may be communicated
by the body poisoned to other bodies,
& therefore may be propagated to many 
individuals, became the individual poisoned 



313.
receives the same power of poisoning others,
as the animal possessed by which he was poisoned.
1141l Some of the natural act locally only, as the 
wasp, others both locally & constitutionally as
the viper, rattlesnake etc.
1142. Those acting on the constitution generally
first produce local effects, before they are
absorbed & affect the system.
1143. Pain in the past receiving the poison,
red streaks & swellings of the lymphatic glands,
in the course of absorption are sometimes preludes
to rigors, convulsions, general livid
extravasations, swelling of the whole body & 
death.
1144. Inflammation is produced in the part of 
the adhesive kind (for the parts well) which 
rarely terminates in suppuration, though 
sometimes pus is formed.
1145. The pus is of the common kind, when it
does form & it contains no poison, whereas
when suppuration takes place in the morbid
poisons, the pus itself is poisonous.
1146. All the natural poisons must come in 
contact with the part to poison it, some require
to be inserted by a wound in order that their 
influence may be exerted.
1147. Morbid poisons, probably, all arose at first
from a diseased state of the body or of parts.
1148. Many are obliged to the power of contamination


for their continuance, & that power
being destroyed, they would cease to be known.
1149 In what they differ from the natural has 
been already shown, they are, like the natural 
communicated by contact & some of them
is a state of vapor.
1150. Those which arise spontaneously, seen
to be confined to the species of animals, in which 
they arise, as a cancer, syphilis etc. which are
peculiar to the human species, & cannot be
communicated to any other animal.
1151. Morbid poisons applied to animal bodies
have specific distances of time between 
the time of applying the poison & the time
of its producing irritation.
Q. Mr Hunter suspects the venereal poison 
militates a little against the general definition of 
poisons, in that he imagines its 
action depends in some measure on the 
quantity applied.
Small pox by inoculation, between the time 
of its application & the time of its visible irritation 
requires two or three days.
Natural small pox twenty three days; measles
nine days; cancer some months, [illegible] not
ascertained.
1152. The actual poisons do not in general
produce extensive local sympathy.
1153. Morbid poison being applied to a part, that 
part becomes infected & diseased, without a power 



315
of contaminating other parts by means of the
absorbents, as in the [illegible] or
1154. Morbid poisons being applied to a part, that
part becomes diseased, & has a power of communicating
the disease to other parts by means of
the absorbents, but not to the constitution as the
cancer or 
1155. When a part has the power of contaminating
the system, as the small pox.
1156. Of the action of some poisons, as small pox, 
measles, etc., the constitution is sensible only once
in the course of life; of others it may have the
action repeated.
1157. Cancer is a disease produced by a morbid 
poison arising spontaneously in a part, without 
being able to account for the manner
in which it is generated.
1150. It is a local disease, which may produce 
a consequent similar local disease in another
part, but has never the power of affecting the
constitution.
1159. Some parts are more liable to the affection 
produced from different poisons than others; so 
the secretory glands are most commonly the 
seat of cancer, the breast & uterus in women,
the lips, external nose, pancreas, pylorus and
testicles are commonly seized with this disease 
1160. It is a poison of whose action the human 
species are alone susceptible; experiments 
have shown us that it cannot be communicated
to other species of animals.
1161. We find in parts affected with cancer on 



indurated knotty feel, with a kind of suppuration 
in the centre, or an ulceration of the external
surface attended with pain.
1162 Previous to a disposition to ulceration
being formed, the pain is dull & heavy, but this
disposition being produced, the pain becomes violent,
giving a shooting burning sensation.
1163. The part affected has its functions destroyed;
if a secretory organ, it loses entirely the power of
secretion.
1164. In its suppurating process, the cancer becomes 
adherent to the surrounding parts, the skin becomes
disclosed, smooth & shining & matter is formed, sometimes
without much previous inflammation.
1165. When the cancer is cut into, previous to 
ulceration having taken place, there is sometimes 
found the appearance of a cyst, which contains
an ill conditioned serum, blood, curdy matter etc.
but seldom or never matter resembling good pus.
1166 The process of cancer in all its states and
stages is generally slow.
1167. When ulcerative absorption has taken place,
the integuments round the ulcer are tight and
rigid, the skin is tucked in at the edges, and
wrinkled into folds, an ill conditioned matter
is discharged.
1168. The lymphatic glands in the neighbourhood 
became indurated & enlarged, sometimes soon, sometimes
even before the ulceration has taken place,
and little lumps are sometimes formed in the circumjacent
skin.
1169. It has a power of poisoning other parts, and of 


317.
producing in them a similar disease, but it has
no power of contaminating the constitution.
Q. We may infer that cancerous virus has no power
of affecting the blood, or producing similar diseases
in any part by means of the blood.
One reason why cancerous matter should not
be able to act upon the system when absorbed,
may be, that it is so slow in producing its action,
that time cannot be sufficient for that purpose 
after its being absorbed, before it is thrown out
of the body.
1170. A cancer of one part may produce sympathetic
swellings of other parts, but not true cancer,
unless of parts which are in the course of absorption.
1171. Constitutional effects as hectic fever etc. may 
arise in consequence of a patients labouring and as 
a cancer, from the irritation the disease produces;
but the affection of the constitution will
be only that common to simple irritation, nor
will there be any thing specific or peculiar in 
the manner in which cancerous irritation acts 
upon the system.
1172. The time of life seems to be the powerful
predisponent cause of cancer, the age which most
strongly predisposes is from 40 to 60; it sometimes
however, appears earlier, though rarely.
1173. The exciting cause
1184 The parts most susceptible of the cancerous 
disposition, seem to be those proper to the 
sexes.
1175. Women are more susceptible of the cancerous
disposition than men, probably became they have 
more parts peculiar to the sex.


1176. Is there not another cause in the parts peculiar
to the sex in women, at the given time of life undergoing
a change which renders them unfit for 
preservation?
1177. We know of no medicine which will cure 
a cancer
1178. Arsenic is probably a specific for the cancerous
disposition, but its powers are too weak to 
produce a cure, nor will the system allow of its
being introduced in sufficient quantity.
1179. Yet a cancer, if left to itself always kills, either
by its constant irritation it exhausts the principle 
of life or by producing continued or contiguous
sympathy, & thereby inducing a similar incased
affection in some part necessary to life.
1180. Therefore extirpation of the diseased part is 
always to be desired, & if practicable, is always to 
be performed before a consequent cancerous
affection has taken place in any other part.
1181. We are always to consider not only the
original or first formed cancer, but also [every]
part, which may have been poisoned by matter
absorbed from it, & which we call the consequent
cancerous affection.
1182. Nor can we be always certain that a consequent 
cancer is not formed, because ulceration
& the formation of cancerous matter has not taken
place for
1183. Coagulable lymph, which had been extravasated 


319
in the thickening & induration, if absorbed
will equally contaminate and poison the parts
it is applied to, for whatever the fluid separated
in a part may be, it will always possess the specific
properties of the part, from which it is secreted.
1184. The consequent affection begins either in the
lymphatic glands, or the lymphatics themselves,
but a cancer once formed, whether original or 
consequent, there is no part contiguous to which
it may not extend its action even to bone.
1183. Hence cancers should always be extirpated
as early as possible, the earlier they are removed
the fairer prospect there is for the patients future 
health.
1186. Previous to extirpation it is always necessary 
to observe
a. The common rules laid down touching the 
extirpation of tumors.
b Whether any consequent be found & where 
c Though no consequent cancer be visible 
whether there be just reason to believe
a disposition for one in any where formed.
1187. In extirpation it must be an [????able] rule
to take away the whole of the disease.
1189. If the whole of the disease cannot be removed 
extirpation is not to be attempted.
1190. If the tumor adhere to the skin, it should
always be a rule to remove more skin than 
the diseased part is adhering to, that if possible or 


may be sore not only of taking away any part in 
which it is probable from its contequity, that a 
disposition for a consequent cancer may be formed
1191. The consequent, if left, will be equally injurious,
& equally fatal with the original cancer,
& though the original be taken away, will itself 
contaminate other parts, in the same manner etc.
the same degree as the original, & is equally incurable
by any powers of medicine.
1193. Notwithstanding all our care, the disease will 
sometimes appear again, even after we have removed
all evidently diseased parts & those also which
we were justified in suspecting.
194. For the slowness with which the cancerous
[illegible] sometimes acts may be a cause of deceiving 
[illegible]; a disposition to a consequent disease may 
be formed in some part, which we can by no 
signs whatever ascertain the existence of
195. Nevertheless when the operation is admissible,
we ought always to endeavor at the extirpation 
of a cancer.
1196. Cancer must be distinguished from scrophula,
& from indolent thickness of all kinds, which 
may be done not only from its appearance, pain 
etc. but also from its acting as a poison on the
neighbouring parts, which scrophula & simply
indolent thickenings never do.
1197. It should always be distinguished from the 
fungated sore, which though it is not a poison, 



321.
as it has already been considered as cancerous,
may not improperly be noticed in this
place.
1198. The fungated sore is a specific disease,
entirely local & has no power of contaminating 
or poisoning parts, beyond the extent of continued 
sympathy, & even this not widely diffused.
1199. It has its seat in every part of the body
without exception.
1200. It begins in a circumscribed tumor, partly solid
or incysted, is not for a time very painful, 
it gradually & not very hastily enlarges the 
skin, becomes discolored, & at length bursts and
ulcerates.
1201. A loose spongy fungus of the color of dark
[illegible] is then thrown out, which rises & enlarges
faster than escharotics can take it down, it 
bleeds easily from the surface of the fungus, & 
the pain is acute.
1202. It resembles cancer in being absolutely in 
curable by medicine & if left to itself is destruction,
1203. But it differs from cancer in not being poisonous,
& in never producing either in the lymphatics 
or lymphatic glands a similar affection,
1204. The disease kills without seeming to have 
done so much mischief as might be supposed
admissible without destruction of life
1205. Nothing can be done to relieve the patient 
but extirpation in which we should be extremely 


careful to remove every [atom] of disease,
otherwise the parts will again take on
the same affection.
1206. Many diseased appearances on the face
which have been considered as cancerous, are
only fungated sores.’
1207. In the extirpation of cancer two methods have
been employed, namely
1st The knife or excision.
2d The use of such means as produce the 
death of the whole of the diseased parts,
& the subsequent separation of them
from the sound parts.
1208. Diseased as well as newformed parts have
much less power of preserving life & resisting
death, than sound parts, hence we can conceive
how the application of arsenic to cancers shall 
sometimes produce the destruction of the whole
of the parts, labouring under cancer, without
depriving the circumjacent parts of life.
1209. Chemical applications, as the different 
caustics (  ) have also been employed, but the
powers of arsenic are the greatest, the caustics
making less distinction in their action between
its sound & unsound parts, the latter acting 
chemically, arsenic by its irritation, & exciting
an action under which the diseased parts have
not strength to subsist.
1210. If we employ the knife, we should always 




323.
cut into sound parts, in general we can employ
excision more universally than the other means.
1211. If we should in the course of the cure of the
ulcer, after the operation, observe any lumps arise,
or any consequent cancer appear, it is right
to remove them as soon as discovered.
1212. If a cancerous disposition remain after the 
operation, the wound either will not heal, or 
the cicatrix will soon ulcerate absorb, or the 
consequent disease will make its appearance.
1213. It is necessary to take notice of some cancerous
affections of particular parts. 
1214. Cancer of the breast mostly begins in a small
schirrous lump, which is in general circumscribed;
at other times it begins with a discharge of 
blood, or a kind of matter from the nipple, sometimes
the skin becomes diseased very early, being
thickened & discolored etc.
1215. The natural function of the breast is destroyed
it loses the power of secreting milk, is painful etc.
1216. It should be amputated before there is any 
adhesion of the breast to the pectoral muscle
or ribs, & before the glands in the axilla become
affected, or at least before these circumstances 
take place in any great degree
1217. We must be cautious in examining the axillary
glands, sometimes when enlarged, they may 
seem moveable, but when we come to operate
we find them a chain of little diseased glands, 


extending beyond the reach of the knife & rendering
our endeavours fruitless.
1218. If the cancer of the breast be suffered to 
become irremediable, the ulceration increases, with 
a stiffness & tightness of the surrounding parts,
the breathing becomes affected & is difficult & 
laborious.
1219. The axillary glands being universally & 
greatly enlarged, the [return] of the lymph from
the arm is obstructed, hence an oedema of the
whole arm, sometimes hard, sometimes soft,
takes place.
1220. In some patients the integuments on that 
side of the body, will become oedematous, & 
even a paralytic affection of that side of the
body on which the disease is situated, may 
ensue
1221. Consequent cancers will be formed & at 
length the patient being worn out for want 
of sleep, with pain & hectic from the constant
irritation, untill at length she sinks & an end 
is put to her sufferings.
1222. In this as in all other cancerous affections, 
the liberal & unlimited use of opium is to be 
permitted. 
1223.l If cancer be seated in the testicle, it should
be removed before the spermatic chord is thickened,
or at least [illegible] so much of it is apparently
undiseaased without the abdominal ring
as to have room for the performance of 



325.
contraction, & then are we justified in operating
though the success is uncertain.
1224. In the cancer of the testis the poison is
more excruciating than in the breast; with regard 
to the extirpation & the administration of
opium, the rules given will apply.
1225. In the cancer of the testis, the consequent
cancer will be in the spermatic chord, the absorbents
of the testicle pursuing its course.
1226. If the scrotum be the seat of caner, the 
consequent disease will be in the inguinal
glands.
1227. In the lips, the disease begins with a thickening,
it is to be removed by the operation of the
hare lip, in other respects the preceding general
rules must be observed.
1228. It is not necessary to dwell on the particular
cancers of other parts, as the eye, the nose,
the uterus etc. extirpation when practicable
should be early employed, when impracticable 
means of alleviating pain can only be had 
recourse to.
1230. The itch is a specific disease produced by 
a morbid poison, which being applied to the skin
occasions an ulceration in it.
1231. The itch is contagious the person infected
with it, being always able to communicate it to 
others in the same manner as he received it.
1232. Contact of parts is necessary to its being communicated: 




in a state of vapor; it has no power
of contagion, & its powers of infecting are very 
weak & easily guarded against.
1233. [Animal???] may exist in the matter, but
not necessarily or universally.
1234. Continued sympathy produced by it, is very
little & contiguous sympathy hardly ever takes
place, from its action it has no power of poisoning
the system, nor have the absorbents ever
been seen to be affected by it.
1235. Its most ordinary seat is where the cuticle
is thin, its first appearance is a small vesicle, 
containing a little fluid, to this succeeds an ulcer
discharging pus, which in the recent state is
very minute, but when of some standing considerably 
increases in breadth, so as to be sometimes 
as large as a sixpence.
1236. The little ulcers made by the itch never
heal spontaneously, & when healed by art, they 
do not again break out, nor so other ulcerations 
arise in the surrounding skin.
1237. Its power of irritating is not very considerable,
the surface of the body must be heated
to be sensible of its irritation; the sensation of 
occasions in itching & not pain.
1238. Different remedies are found to be specifics 
for the itch, sulphur, hellebore, mercury
externally used are known to cure it, but
sulphur ointment seems to be the most powerful 





327.
remedy.
1239. A mercurial girdle has been known
to cure the diseases, even when mercurial ointment
applied to the skin has failed; brimstone
taken internally will sometimes produce 
a cure. 


The Venereal Disease.
1240. The venereal disease is one of the morbid
animal poisons, & like other morbid animal
poisons may be communicated by the persons
infected to others.
1244. It is always communicated in the form of 
or united with purulent matter, which shows 
that it originally arises from inflammation.
1242. When communicated to a part, it produces
in general inflammation, but its progress is
attended with symptoms peculiar to itself & 
distinct from those of other animal poisons.
1243. The presence of inflammation is not, however, 
necessary to its existence, an infected poison
may communicate it to others after all 
inflammation has left him, as in the case of a 
venereal gleet.
Q. Man who have a gleet after all inflammation 
is gone off, may infect women & women
men.
1244 To produce infection the venereal matter
must be communicated in a fluid state or in 
a state rendered immediately fluid by the
juices of the receiving part; in the form of a vapor
it cannot infect, nor can it be communicated 
without the presence of purulent
matter. (1242)


329.
1245. The poison first arose probably in the genital
parts in the intercourse between the sexes, 
this intercourse is not however necessary, it may 
be communicated from other parts besides the 
genitals, & even when applied by other substances 
than living bodies.’
Q. A gentleman by passing a bougie that had
been formerly used by him, when he had a 
clap, caught a gonorrhoea.
1246. Actual contact with the part is however, always
necessary.
1247. Venereal matter applied to sound parts 
has generally the effect of producing inflammation, 
which is always of a specific kind.
Q. Mr Hunter has sometimes known gonorrhoea 
arise without any preceding inflammation, 
& confessed himself very much puzzled concerning
the nature of such a case, if it were venereal,
it should seem this aphorism will not
universally hold good.
1248. From what has been said it is evident
those parts which are not naturally or accidentally 
secreting surfaces, cannot communicate
the venereal disease. 
1249. It may affect the body either locally 
or universally, & therefore may be divided into 
too genera, namely 
1st Genus original or immediately local.
2d Genus constitutional.


1250. The first genus has two species, seemingly different,
yet their ultimate effect is the same.
1st Without ulceration or a breast in the
solids, called a clap or gonorrhoea.
2d With a breast in the solids, or solution
of continuity, called a chancre.
1251. The bubo, or local consequent, may follow
either the first or the second species of the first
genus, & when suppurating differs in nothing 
from the chancre, except the size.
1252. When the infecting matter is applied to a 
secreting surface, the first species will be produced;
when to a [????erating] surface, as the 
skin covered with the cuticle, the second species
will arise; from either of these a gland in the
line of absorption being affected, the bubo or
weal consequent will be brought on.
1253. All secreting surfaces in the human body
having nearly the same mode of action, will 
take up the infection from simple contact,
& may any, or either of these, be the seat of the 
disease of the first species.
1254. The second species may be induced 
a By a wound.
b By application of the matter to the cuticle.
c By application of the matter to a sore.


331.
1255. Secreting surfaces being natural as that of
the urethra, nostrils etc. or accidental as an ulcer,
whenever the venereal matter is applied to 
them, increase their secretion to work away the 
offending matter.
1256. But the further consequence of the application 
of venereal matter to the natural and 
accidental secreting surfaces will be different, 
of the former it will in general only change
the nature of the secreting fluid, from the latter
it will first increase the quantity of secretion,
& then producing for a time, a gonorrhoea of
the sore, it will change the nature of the sore 
from a common one to a venereal one & then 
the disposition to ulcerate will increase & the 
[illegible] be in every respect converted into a chancre,
or the second species
1257. Whenever a part becomes infected with the
venereal virus, it takes on a new action, if it
be a secreting or fine cuticular surface, as
above described, the nature of the secretion 
will be changed, if a non secreting surface, the
ulcerative absorption of the part will take
place & the pus will be secreted.
1258. Some secreting surfaces seem more susceptible
of the venereal irritation than others 
the urethra seems evidently distinguished
to take it on.
1259. Absorption of extraneous matter always
goes on more readily from an ulcer than from 


a fresh wound or from a canal, it must be evident 
that the local consequent much more readily
& frequently arise from the first than from 
the second species
1260 The venereal poison will be always the 
same in point of strength or acrimony, it may 
indeed at one time be dilated through a larger 
quantity of fluids than at another, but it will 
produce the effects of a poison in the smallest 
possible quantity.
1261. Yet it produces different efforts in different 
subjects, in some it will cause the most violent,
[illegible] others the slightest affections, it is therefore 
evident the susceptibilities of different persons
of its irritation, must be very different.
1262. This (1261) will not be easily explained, for 
the susceptibility of venereal irritation will not
be in proportion to the susceptibility of other irritations
Q. A gentleman had chancres many times,
they always healed very readily, but the slightest
scratch from any accident he received
was very difficult to heal; so that some are 
very susceptible of this specific or venereal irritation,
though highly so of any other irritation.
1263. The local consequent will differ nothing 
either in its nature or its ultimate effects
from the original local, having the same 
power of poisoning other parts, or the constitution 
& the matter secreted in it being equally 
infections, as that of the first or second species 


333.
of the first genus.
1264. A natural secreting surface cannot be 
affected with the poison, longer than a certain 
time, for had it a power of keeping up a specific
action in the part longer than a certain 
time, the duration of the disease would be and 
less; for part matter being continually secreting
would be the cause of a still further secretion 
of similar matter & so on ad infinitum, for it
would still continue its secreting action.
Q. Parts lose their sensibility of the stimuli applied
to them in the urethra, the nature of the 
solids is not changed but only the mode of secretion;
no in process of time the membranes becomes
habituated to the presence of the venereal 
matter & is other no longer sensible of its stimulus,
which can now no more produce the specific 
disease, & therefore the disease decays, and a 
natural cure takes place (see Note 1265)
1265. We are induced to believe this to be the 
case, from knowing
1st That all gonorrhoea are cured without 
any specific remedies.
2d That a secreting surface will retain venereal 
matter after inflammation is gone off, 
& also a power of poisoning other parts, for a considerable
length of time, without being [sensible]
of the presence of venereal matter, a [illegible]
any morbid affection from its remaining in contact
with it.


3d That the application of part venereal 
matter may be said to the secretory surface in 
question, without increasing the present disease
or even retarding the cure.
Q. When we consider the different methods
different people have of curing the gonorrhoea,
& that all are successful, many of which cannot
have any specific action upon the part, we
may readily suppose in general the complaint 
goes off itself.
Cases.
1 A married man during several years had
known no other woman but his wife, he at 
length lay with a woman of the town & caught
a severe class; the woman who gave it him 
was not sensible herself of any ailment, she 
continued her connection with him for many 
months without perceiving any change. She 
then formed a new connection & gave a gonorrhoea
to her second lover; she had no marks
however of the disease herself; he continued
his intercourse with her from some time, but not 
withstanding [got] [cured] the while, at length the
first lover returned, had connection with 
her but once & she clapped him again
2d A gentleman kept a mistress, who becoming
clapped left him, she was taken into the [illegible],
where she was apparently cured; she 


335.
continued in the hospital near two years, seemingly 
will & when discharged was picked up
again immediately as her dismission by the gentleman
who had formerly kept her, to 
when she nevertheless gave a severe gonorrhoea;
he continued however to cohabit
with her & got quite well without interrupting
his connection, which at last he broke off. 
a married gentleman in the city took her
into keeping, & was immediately clapped by 
her; he was likewise cured though he continued
the intercourse with her during the cure;
his mistress however left him & returned to her 
former lover when she clapped the second
time.
These histories abundantly serve to prove
what has been advanced, many more of the 
some kind might be adduced; moreover if the
venereal matter of a gonorrhoea or a chancre 
be applied to a bubo, or that of a bubo to a 
chancre, it will not in the least increase the 
disease or retard the cure.
If a man continue to be intimate with a 
woman who has clapped him, & if he be cured & 
she not, still he will not receive a fresh infection,
provided he continues to cohabit with her,
but if he absent himself from her for some time,
that is, untill his genital parts have recovered
themselves, & as it were lost the recollection 
of the venereal stimulus, he will then get 


a fresh gonorrhoea.
This we see depends upon the force of habit,
for being long accustomed to the stimulus of venereal
virus, the parts lose their sensibility of it
& cannot be irritated by it; thus in general
if a man got several successive claps, the 
first till be the severest, & they will become
slighter & slighter every time: was a man once
clapped to continue during his cure & ever so 
long afterwards his intercourse with venereal 
woman, it is extremely probable he would find
it impossible to contract a part venereal gonorrhoea 
(see habit [illegible] etc.)
1266 But this natural decay of the specific
morbid action & spontaneous cure will only arise
in natural secreting surfaces; whenever a chancre 
or venereal ulcer has formed, no natural or spontaneous
cure is ever affected, but the disease 
continues increasing in violence, untill it is 
cured by art.
1267. The matter of a gonorrhoea & chancre is
exactly similar & equally capable of poisoning
other parts
A gonorrhoea will produce in the same
person a chancre, or a chancre in gonorrhoea
& both or either of them may produce a constitutional 
disease in general when the chancre
appears, the gonorrhoea goes off & frequently 
the gonorrhoea appearing the chancre 
will go off


337.
It should therefore appear that one irritation
cures the other, the two parts sympathizing 
with each other.
1260. It is extremely difficult to decide when 
the power of contamination is entirely lost,
persons sometimes retain a power of communicating
the disease, after not only inflammation
 but even the discharge has seemingly disappeared.
1269. If the venereal poison be applied to a fresh
wound or by means of any wound, suppuration
must in general take place first before it
can produce any effects upon the body.
1270. The discharge from a gonorrhoea is purulent,
but is very rarely attended with any 
ulceration of the urethra.
Q. Were the pus discharged from ulcers in the
urethra, the gonorrhoea would not be cured
without mercury, which we know is by no 
means the case.
1271. The local consequent or bubo sometimes
neither suppurates nor goes off by resolution,
but becomes indolent & will frequently remain
in that state, notwithstanding the [illegible]
of the most powerful remedies. 
1272. Not only different persons will be affected 
by the venereal virus in different degrees of violence 
(1261) but the same remark will hold good
in respect to the different parts of the same
patients body.


Q. We have seen a chancre readily cure in a 
person, & he afterwards contracted a gonorrhoea
which was very severe & very difficult to remove.
1273. The second genus or constitutional (   )
takes place when the venereal virus is absorbed 
& carried into the circulation
1274. It may be communicated to the constitution
by means either of gonorrhoea or chancre,
sometimes though rarely from venereal matter
being applied to the surface of the body, without 
ulceration having previously taken place, & 
sometimes from application of it to an ulcer, without
producing any change, but these two latter
modes of infection are very infrequent.
1275. It may also be introduced into the system
by poisoning a wound, but there it must first 
produce inflammation, in the same manner as
inoculated small pox [must] produce inflammation 
& suppuration in the place of the incision
before the constitution becomes infected.
1276. The venereal virus will not act as a poison
applied to some parts of the body, it will
have no effect upon the stomach, as has been
proved by experiment
Q. A boy of eight years of age, swallowed some
milk & water in which some chancres had been
[illegible], with impunity a lady also drank by 
mistake a bason of milk & water, in which a gentleman
had worked his chancres, it was near 


359.
eight hours after before she took an emetic,
yet no bad consequences ensued.
1277. The venereal virus cannot be taken in 
by the breath, sweat, saliva, milk, or any other
natural secretion of a person laboring under the 
disease in its worst state.
1278. When the venereal virus is absorbed into 
the circulation, it produces no change in the
blood, but has a power of producing local
effects in different parts of the body, as blotches,
ulcers, nodes etc. but it is certain the venereal 
matter undergoes some change, as the [ulcers] etc. so 
produced, that is from the constitution have 
no poisonous quality; the matter from a venereal’
constitutional ulcer will not communicate
venereal infection, nor will it differ in its powers 
from the matter of common ulcers.
1279. The blood, although the matter has been absorbed
into the circulation, will not communicate
the disease to a second person, nor are any of the
secretions of a patient labouring under the second 
genus, any ways infections.
1280. The venereal virus then can never be 
communicated unless from a part that labours
under the first genus, or has an original local
complaint.
1284. It must be from [illegible] evident that the opinion 
that an infected child, unless it has its [illegible]
or sign originally infected, cannot communicate 
the disease to its nurse, nor can the milk 



of an infected nurse communicate the disease 
to the child.
Q. A nurse breast inflamed & supported, after
suckling a child who had lately died, a physician
gave it as his opinion that the lues was
universal & that she had been giving such to 
a [illegible] child: but the event of the cure contradicted
him; mercury did not mend the state of 
the sore, indeed new sores broke out upon her breast 
while she was taking it, at length she left off
the mercury, & recovered by goo diet & country 
air.
1282. We almost believe that a child in utero
is never poxed, it may receive the infection, in 
its passage through the vagina & & thus it may 
be locally & in the end universally affected.
Q. It has been supposed that if a pregnant woman
be poxed, the infant in utero must partake 
if the disease, if ever this be the case, it 
can only happen from the original matter,
from a sore being conveyed unaltered to the
child, which is what we can hardly conceive
to happen.
1283. Many anomalous morbid appearances resemble
the venereal disease, from which it is
by no means easy to distinguish it by the eye.
1284. The only unequivocal criteria for distinguishing 
the one from the other, are, 


341.
1st No venereal eruption blotch, ulcer, or 
other affection, gonorrhoea excepted, whether originally 
local or constitutional, ever disappears 
or is cured without the operation of mercury,
its specific remedy.
2d No eruption, blotch, or other affection that
is truly venereal will appear while the constitution
is under the influence of mercury.
1285. The same person may have an original local
& constitutional disease at the same time. Of
the first genus the person may have both the first
& second species at once, & the first species or gonorrhoea
may be cured, the chancre or second 
species remaining notwithstanding & vice versa.
1286. So either or both species of the first genus 
may exist together with the second or constitutional,
& either or both gonorrhoea or chancre 
may be cured without the removal of the constitutional
disease
1287. But the chancre will not remain uncured
when the second genus is cured, although the
gonorrhoea will yet continue to exist.
1288. The constitutional as above acted, almost 
always arises from some species of the first genus,
but the chancre or gonorrhoea does not at all 
become altered, or have its action awakened
by fixing the constitution (1285).
1289. The specific local diseases have all their
specific distance for action, which they do not exceed; 


so also the venereal disease has its specific distance
for local action; this is however not always 
of the same extent, being sometimes affecting
a small space, sometimes a larger one, it is, however,
always circumscribed, but when it spreads
more widely than common, it has always a 
mixture of the erysipelatous.
1290. The venereal disease is peculiar to the human 
species, other animals not being susceptible
of its irritation.
Q. Mr Hunter has proved this by a number of experiments
on the dog, the [illegible], the bitch & by soaking 
[illegible] in venereal matter from gonorrhoea and 
chancres & introducing it into the vagina etc.
1291. Does the venereal disease produce its
effects by fermentation, or by producing a peculiar
action in the solids? The quartan is not easily
determined.
1292. A man who has got a pox, may [illegible]
get a chancre or gonorrhoea without increasing
the pox; it is evident then that when the 
habit is once infected with the venereal poison, it
cannot receive any addition from the absorption 
of fresh venereal matter. 



343.
Q. A gentleman had blotches in his face which 
resembled venereal ones, & had been [illegible] so 
by many medical men; he had also blotches 
in his legs & thighs; they continued for six months,
several of them having got well during that
time & others broken out notwithstanding the
use of mercury; he at length consulted Mr Hunter
who is judging of them according to his idea advanced
in the text, spared him they were not venereal
& advised him to leave off medicines, to 
live well, though [???perately], & bathe in the sea
if he chose; in a few weeks he lost his complaints.
A nobleman labouring under some complaints
which appeared to venereal, & which those also
attended spared him were so consulted Mr 
Hunter; he was with much difficulty persuaded
to leave off medicines & take a sea voyage, to 
change the air; he followed this advice & was 
cured.
When any diseases affect the genital parts,
they are generally considered as venereal, but
gonorrhoea, sores on the glans penis, buboes may 
[illegible] without any venereal infection, moreover
there may be a variety of the morbid appearances 
that take place in the constitutional disease 
or second genus, which are common also to other 
diseases; swellings of the bones, blotches & 
may be produced by other diseases; we are not 
therefore, hastily, to determine whether a disease 


be venereal or not, but together with observing 
appearances, inform ourselves also of the history 
of the complaint previously.
1294. When the venereal virus has been absorbed
into the system, it has in itself no particular tendency
to produce affections of one part more 
than another, but from some peculiarities in 
different parts of the body themselves, some parts
will be more susceptible of the venereal irritation
than others, & of course take on the venereal 
action soonest.
1295. One cause which disposes parts to take on 
venereal action readily is exposure to cold, therefore
it makes it appearance in the more external
parts of the body first; this reasoning is strengthened
by observing
1296. That the disease is found to prove much 
more speedy as well as much more violent in 
its action is cold than in warm climates, in 
the latter it rarely arises to any great violence.’
1297. The parts first in order of susceptibility are
a The skin.
b The inside of the mouth & throat, and
c The tonsils.
1298. The parts second in order of susceptibility are 
a The periosteum.
b The fasciae.
c The bones.


345.
1299. The bones seem the more susceptible of it 
the harder they are, & the nearer the surface of
the body, consequently the more exposed to the
action of cold.
Q. Then the tibia being of all bones, most exposed
to the action of cold, is of all others most frequently
affected; it may be objected that the tibia is 
naturally colder than many parts, which take
on the disease before it; but we know whatever 
dispositions are formed in bones, they came into
action much more slowly than the soft parts.
1300. Many of the internal parts are not liable, 
(as far as experiment has proved,) to the venereal 
disease, as the brain, the stomach, the liver etc.
Q. They are either not susceptible of the venereal irritation,
or else they never come into the venereal action,
before the disease is totally cured.
1301. The lungs are sometimes the seat of the venereal 
disease, although they are late in coming into’
action, perhaps their susceptibility of this irritation
depends upon their being in some measure an external 
part. 
1302. The venereal matter when taken into the constitution,
does not long continue in the circulation 
but produces its action on the part susceptible
of the disease, & is then thrown off by some of 
the secretions, as any other extraneous matter.
1303. It does not long continue circulating in the 


system, we know this because the parts first in 
order may be cured, & the parts second in order still 
remain uncured; yet the first parts will not again 
take on the diseased action; now were the venereal
matter still circulating in the blood, there
would be no reason why the parts first in order,
should not again fall into disease.
Q. Thus if a man with venereal blotches, and 
also diseased bones, be put under a course of mercury,
the disease of the skin may be cured, that 
of the bones remaining notwithstanding. The diseased 
action of the bones may continue to go 
on if he leaves off mercury but the disease will 
not appear again upon the skin.
1304. Dispositions once formed will go on to action,
though some time may elapse before that action
appears; (see 167). Parts having received the venereal
taint, will if left to themselves always
go on to diseased action, although the distance
of time may be considerable.
1305. Hence we may understand how many parts 
of the different orders may be contaminated at 
the same time, but their diseased appearance
may take place at different times
1306. Those parts which most readily fall into the 
specific action, are the first in going through a 
cure
Q. When a part has received a strong disposition
for action, a cure sometimes cannot be affected
untill that disposition has actually gone 


347.
into action.
A man might suppose that those parts which 
are most susceptible of the venereal irritation
would in the advanced stage of the disease suffer 
this most violently, but this is not the case, a part 
having gone fully into action, loses the susceptibility
of the irritation which it has at first.
1307. As a further proof that the venereal matter 
becomes altered when taken into the constitution,
we may observe that a venereal constitution 
we may observe that a venereal constitutional 
ulcer, on the application of venereal matter 
from originally & locally diseased parts, which 
[illegible] a gonorrhoea & so take on the action of 
an original sore, now the matter of [illegible] constitutional
sore will not irritate another constitutional
sore.
1308. If the matter of a gonorrhoea be applied to 
a chancre, it will produce no effect & vice 
versa.
Again the matter of one originally local sore
or chancre, will not irritate another chancre.
1309. A part which has lately been under the 
irritation of venereal matter, will not readily 
take on the same diseased affection again
Q. A man also has a gleet, though he has connection
with a venereal woman, will not catch a 
fresh gonorrhoea.
1310. The seat of the first species of the first genus 
in man is the urethra, the surface of the glans 


penis, the internal surface of the [praepatium]
1311. Its attack on the praepuce & glans penis is
generally at the root of the latter, & the beginning
of the propentium; have the cuticle is extremely
thin, & the cutis is easily affected.
1312. It then produces itching, soreness & tenderness,
with a discharge of the matter.
1313. When this part takes on the disease the
symptoms begin very early; forty eight [illegible]
have been the whole of the time elapsed between
the infection & the appearance of them.
1314. When the urethra is the seat of the clap, 
the inflammation has generally its place with 
in an inch or inch & half of the external opening.
1315. It mostly begins with a sense of itching
at the end of the orifice & sometimes over the 
whole glans, the lips of the orifice will be unusually 
full, & turned somewhat outwards,
the penis is general seems something enlarged;
pain, heat & uneasiness in passing the urine,
sometimes is preceded by & sometimes following
the appearance of a running from the urethra,
the canal of the urethra feels inflamed 
the patient [illegible] his urine with [illegible]; from the 
sense of the something, & than the urine comes off
in small divided streams.
1316 The glands of the urethra become inflamed 


[349]
and swollen, they become hard & may be [fixed]
on the under side of the urethra.
1317. According to the [illegible] & the degree of inflammation,
the discharge becomes of different 
colors & different in [consistances], the venereal
[illegible] is, however, always the same.
1318. The matter or received upon a cloth will
be found to give spots of various hues, in the
centre of the spot the color will be darker [illegible]
in the circumferences.
Q. Perhaps the changes of color in the discharge
will depend upon a small quantity of blood
being extravasated & mixed with it.
1319. The matter will have a small peculiar to 
itself, which will be foetid & diseased to putrefaction.
1320. The symptoms & progress of the complaint 
will differ very much according to the susceptibility
of the parts, & the degree & extent of inflammation.
1321. The more violent the inflammation etc. the 
more commonly it will produce [great] extravasation
of the coagulable lymph, occasioning
[chorde], soreness of the whole length of the urethra,
even to the anus, producing a sensation 
like that of chorde, inflammation & hardness 
of the glans penis, haemorrhage from the urethra 
& various sympathies.
1322. The running comes from the urethra and
its glands & in general not high up, it does not
come from the bulbous portion of the urethra 



otherwise it would be thrown by [illegible], & not
run off in the manner it is known to do.
1323. On the examination of patients after death,
who at the time of their dissolution [illegible]
under this complaint, the ducts leading from 
the glands have been found filled with matter.
1324. The inflammation penetrating very deep, 
compress glands may inflame, suppurate & produce
an abscess, which is frequently the cause
of fistula in perinaeo.
1325 The cause of the gonorrhoea of the urethra,
must be a translation of the matter from 
the external part to the [main] surface of that 
membrane, though it is difficult to account for
the manner in which it is done.
1326l It certainly can never be introduced durante 
coitu, but the external part must always
receive the venereal infection.
Q. We know it may be communicated this way.
An officer who had no intercourse with the 
female sex for a considerable length of time when 
in Germany, want to a necessary, the tube of which
according to the custom of the country went [illegible]
downwards, when he arose from his 
seat he found something sticking to his penis,
when taking it off he found it was a plaister 
from a sore, which some other person using the 
necessary, had left behind him, in a few days
after a gonorrhoea appeared.



351.
1327. Chordi is of two kinds.
1st The inflammatory.
2d The simply spasmodic.
1328. The first is owing to an extravasation of 
coagulable lymph in the reticular substance
& the corpus spongiosum, generally in the 
lower part of the penis, this is much more obstinate
& remains much longer than the spasmodic,
which is without extravasation, & comes
and goes at uncertain periods of time.
1329. The haemorrhage arises from some rupture 
of vessels in the urethra, either by a spasm or giving
way to the increased violence of the circulation.
The haemorrhage is sometimes considerable,
& for the present not unfrequently relieves the 
violence of the inflammation & its consequences.
1330. The parts which sympathise with the urethra 
will be 
a The fistula.
b The Bladder.
c The muscles of the urethra & penis.
d The glands of the groin 
e The whole pelvis.
f The loins.
g The stomach
h The whole constitution.
1331. Sometimes there will be an erysipelatous
eruption of the neighbouring parts.
1332 At different periods of the gonorrhoea the 


testicle will sometimes become swollen, this is
never to be accounted a venereal but purely 
a sympathetic affection of the parts sympathizing 
with the urethra.
1333. A swelling of the testicle may arise from any 
cause irritating the urethra, even the passing a
bougie has brought it on.
1334. It sometimes appears during the more inflammatory
stage of the gonorrhoea, but more frequently
when the inflammation has abated, & it is sometimes 
attended with an increased, sometimes a 
stopping of the running.
1336. The complaint beings with a pudgy & softened 
[illegible] of the testicle, a slight enlargement of it, & 
a sense of increased painfulness on the touch 
or pressure, its tumefaction then increases & it
grows hard especially the epididymis.
1336. Sympathy produces pain in the original
seat of the testicle, the loins, nausea & sickness,
even vomiting, loss of appetite, uneasiness
in the bowels etc.
1337. The swelling of the testicle is not peculiar
to the gonorrhoea, it is often produced by gout,
cancer, & scrophula, although more slowly
in the latter.
1338. When the bladder sympathises, stranguary 



[353]
mercury, which shows, then, they are not venereal.
Q. When the inguinal glands swell it is to be 
doubted whether they are always inflammatory & 
not sometimes purely spasmodic.
The swelling of the testicle will sometimes arise
suddenly in a few minutes, & go off as readily, requiring 
often less time to subside in by a great deal
than the common swelling of the testicle after the 
radical cure for the hydrocele. The swelling will 
sometimes change sides, being similar to the gouty 
sympathy of the testis.
1340. The muscles of the penis will often sympathize, 
& often undergo spasms, producing sudden & involuntary 
erections of the organ.
1341. Of the loins, pelvis & kidneys sympathizing 
with the urethra it is unnecessary to speak, farther
than noticing the [illegible], that pain of those parts 
attends gonorrhoea.
1342. When the whole constitution sympathizes,
there will be slight rigors, heat, & other mild symptoms 
of general irritation.
1343 The distance between the time of infection
& the appearance of the symptoms, so far as can
be ascertained is all the intermediate time, between
ten hours & six weeks, most commonly 
however within twelve days.
q. In one person 10 hours.
another 12 hours
many 36 hours
Do 2 days.


In may six days
In a great number twelve days.
In many four weeks.
In some six weeks.
1344. The gonorrhoea is not peculiar to the venereal
disease, a discharge from the urethra, with
heat etc. has been known to accompany gouty & 
rheumatic affections of the body.
1345. It has moreover been known to sympathise 
with cutting the tooth.
Q. In a boy the gonorrhoea returned twice while
he was cutting his teeth. 
1346 The urethra of a patient who has once
had the disease is ever after extremely liable to 
it.
1347. We should endeavor to distinguish a gleet 
from a venereal gonorrhoea, in the gleet the 
glans penis does not change later, nor does it
sweet a kind of pus, as it does in the venereal
gonorrhoea.
1348. It often goes off spontaneously, & then it makes 
a somewhat puzzling case, it has no specific
remedy.
1349. A constitutional disease in the second genus,
is as we have above observed sometimes though
not very often known to arise from the first species 
of the first genus; whenever there is a kind
of hard chord arises leading from the penis to 
the glands in the groin, absorption of the virus is
always to be suspected, & the constitutional genus 


355.
feardd.
1350. This circumstance most usually occurs in
the gonorrhoea of the glans & praepuce. The second
genus has also followed an internal gonorrhoea,
in which there was a rupture of a vessel & 
an haemorrhage from the urethra, consequently 
in internal wound, but it is very rarely the
virus is communicated to the system by means 
of a wound.
1351. The seat of the first species of the first genus
in women is the vagina, nymphae, clitoris, and 
urethra.
1352. It is not so complicated in women as in 
men, its symptoms are much milder, & it is still
with more difficulty ascertained.
1353. Appearances will in general give but 
little information, nor will its symptoms enable
us to decide.
1354. We can only judge the woman has the disease,
if she have the common symptoms following 
has connection with an infected man, or
if she while labouring under these symptoms 
give the disease to some sound person.
Q. The vagina is not a part sensible to common 
irritation; hence matter may remain inoffensive.
1355. We cannot however always determine 
that a woman has a gonorrhoea became she
communicate infection to a man, as her genital
parts may have a power of receiving and 
communicating the infection, without having ever 
felt any complaint herself, or may retain 


the power of poisoning after the gonorrhoea
has been cured.
1356. From this it must be evident that a woman
does not always know whether she has or has 
not the disease.
Q. A woman had a bubo formed in her groin,
without knowing in the least of any preceding 
affection.
1357. The common symptoms of gonorrhoea in 
women are pretty similar to those in man, as 
smarting in making water, a running from the 
vagina, a disagreeable sensation of the external 
parts as the clitoris & nymphae, a fullness of 
the labia, pain in walking, & the complaints
rarely having exacerbations, except at the time
of making water.
1358. Sometimes the discharge will run down
from the vagina to the anus, & produce [exalcerations]
of the perineum.
1359. When the disease goes on as in (1358) it is
very doubtful whether it will then spend its’
violence, as in the gonorrhoea in men.
1360. In both sexes previous to the appearance 
of the discharge, the constitution will sometimes
become affected as in (1342) & a strange and 



357.
itself & we have no specific for the disease (  )
yet we can shorten its duration & lessen the symptoms
by proper remedies.
1363. Those remedies are divided into internal
& topical.
1364. The internal ones are either,
a Evacuants, or
b Astringents.
The topical ones are either,
a Injections, or
b Bougies.
1365. Mercury is the specific for the venereal 
disease, but it seems of no other use in the gonorrhoea,
than with a view to the absorption 
of the venereal matter in the part, thereby preventing’
its affecting the constitution; but this we
have observed rarely happens, & we have no 
reason to believe mercury has any specific power 
on the affection of the membrane of the urethra.
1366. Keeping the bowells regular is necessary
I health, & therefore useful in this complaint,
though purging is not generally serviceable, yet
we have seen a brisk purge entirely cure the
affection in which case it must operate either 
by [illegible] or by sympathy. 
1367. Diuretics are so far useful as by their effects 
on the urinary secretion they may lessen the 
violence of the irritation; water is the best, but 
will require to be accompanied with some [???alignous] 
substance.


1368. Balsams & turpentines may be their specific
operation on the part affected procure also a 
change in its diseased action & consequently affect
a cure
1369. Astringents do not lessen the venereal
irritation, but they may prove of some service
by lessening the quantity of discharge.
1370. Topical applications (1364) must be either
fluid or solid, the fluids are injections, the
solids, bougies.
1371. The effects of the solid must be more permanent,
as it can be kept longer in contact with 
the parts affected however it produces so much 
irritation that is general its use is better omitted.
1372. Injections may be divided into
a Irritating.
b Astringent.
c Sedative
d Emollient injections.
1373. Injections curing the gonorrhoea suddenly 
have been supposed to look up the poison, & 
throw it into the constitution. But this opinion
is erroneous; for
1374. The effect of the Injection have is to stop 
the further secretion of matter, if then this be 
accomplished, it is evident that injections must
contribute rather to the prevention of the second
genus, their bringing it on, the common vehicle
of the poison being matter 


359.
1375. Injections may either take off the inflammation,
& the consequent increased secretion, or 
they may stop the secretion without removing
the venereal inflammation.
1376. The irritating injections are mostly astringent
when made weaker, & astringent injections
if made stronger will act as irritating.
1377. Injections are irritating when they produce
an irritation greater than that of the 
disease itself.
1378. Irritating injections are in general improper,
where the constitution is extremely irritable,
& the inflammation has spread beyond 
the venereal point, when used in this case, they 
have become the cause of fistula in perineo.
1379. When the disease is milder, they generally 
succeed in removing the symptoms sooner, for they 
produce the cure by giving an irritation greater
than that given by the disease, which being
overcome by a greater stimulus leaves the
part; they must therefore be improper, where
the parts cannot without danger of increased 
mischief bear a more powerful irritation
than that already present.
Q. A proper injection for this purpose is a weak
solution of sublimate in water, if it gives pain
it may still be farther dilated.
1380. Astringents may cure a slight disease, they 
not by lessening the discharge, & as they produce
an affection of the living solids, they may contribute 


to cure
1381. They make the vessels contract & lessen the
discharge, however, they often produce a lessening
of the discharge only, without forwarding the cure,
[illegible], they sometimes protract the cure.
Q. When a secretory surface has been inflamed, & 
the part has received a disposition to secrete,
the compleat action being taken on is a step
towards the cure; we therefore, [see] why astringents
by checking the secretion may sometimes 
retard a cure.
1382. Sedatives (  ) soothe pain & abate inflammation;
opium is undoubtedly the best & most general 
sedative, but does not agree universally.
1383. Emollients in violent inflammations are 
very useful, washing away the stimulating matter
& leaving the surface of the part soft & smooth.
1384. Sometimes the end of the canal & of the urethra
at the glans is contracted by inflammation,
which is a troublesome circumstance, & indicates
the omission for the present of bougies on injections.
1385. Other topical means, or mercurial ointment,
medicated poultices, fomentations etc. can
do little good, except when the external parts 
are the seat of the disease, [illegible] unless the glands 
of the urethra are so swollen as to be perceptible
externally, in which case we may use [illegible]
fact.
1386. In haemorrhage from the urethra, we have 
seen benefit afforded by the internal use of 



361.
turpentine, & balsams, injections are not useless
but hurtful here.
1387. Opium given internally has powerful [effects]
in preventing painful erections & soreness of
the penis.
1388. The chorde is in the beginning relieved by 
bleeding from the system it still more so by 
leeches applied to the part, & we are the more
encouraged to practice the latter, as we have
observed that a spontaneous hemorrhage
from the rupture of some vessel in the urethra,
has removed chordi, medicated poultices & 
camphor internally sometimes afford relief 
1384. Chordi after continues after inflammation 
of the parts has subsided from the coagulable 
lymph remaining extravasated; whatever then
will tend to produce absorption of the lymph, 
will carry it off. Mercurial ointment, electricity,
friction & cicuta are all found serviceable,
the affection will, however continue long after
the complaints have ceased & then [illegible] slowly.
1396. In the spasmodic chordi we have known 
bark singularly useful.
1391. If the glands of the urethra suppurate, they 
become of the nature & produce the effect of chancres
& as such they may be treated.
1392. When the bladder takes on the affections 
(1338). The complaint is rarely inflammatory,
but mostly sympathetic. Bleeding is rarely 
useful, & is, if employed at all, to be managed 


with caution, & in general, topically, the warm 
bath, pasters of opium to the perineum, and
to the origin of the nerves of the bladder, & 
glysters with opium will commonly succeed.
1393. This symptom, in general, is not hazardous,
but it is to be suspected that it lays sometimes
the foundation of future mischief.
1394. Blistering the perineum has sometimes
succeeded.
1395. When the testis is swelled (1393) rest in 
an horizontal position with the common 
treatment if inflammatory affections is to be 
insisted on.
1396. Vomits have sometimes great power in carrying
off this affection.
Q. Perhaps the practice of employing vomits arose
from relief having been given by a vomit,
administered to sure a sickness in the stomach
occasioned by inflammation of the testis.
1397. It is not determined how far mercury is 
useful in cases of swelled testicle, we have
reason to believe it may sometimes be efficacious 
after the inflammation is over. 
1398. Sometimes the testicle takes on the suppurative
inflammation & an abscess is formed, which 
however, requires no particular treatment,
as it is not venereal matter that is formed;
mercury is unnecessary.
1399. When resolution takes place, the swelling 


363.
of the testicle subsides but slowly, when it diminishes,
it grow gradually after, especially in 
the fore part, & which sometimes become even 
softer than natural.
1400. The epididymis, however generally 
continues hard, & it is to be suspected that in 
consequence of that circumstance, the testis is
sometimes rendered useless, yet in general no 
inconvenience is observed to arise from it.
1401. The cure of the gonorrhoea in women 
is still more simple than in men; worker & 
injections are proper have also when the vagina 
is the seat of the complaint, the internal 
surface of it should be several times [greeted] so 
high as can be reached by the finger, with mercurial
ointment.
1402. As the vagina is less irritable & sensible
than the male urethra, the injections to be 
used for the [illegible] may be prepared stronger.
1403. If the female urethra be affected, injections
will not be admissible, but mercurial ointment
may be insinuated into that canal; as
observed above, it is not easy to know when the
cure is completed.
1404. Should the inflammation spread & affect
cowper’s glands, the mercurial ointment may 
here also be used, if they suppurate, they are
to be considered & treated as suppuratory buboes.
1405. It is sometimes necessary to attend to the 
constitution in the cure of gonorrhoea.


1st If the constitution be strong & disposed
to fever, it may be right to bleed.
2d If the complaint should take place in 
a low weak, irritable habit, & when the inflammation 
has a disposition to diffuse itself (which 
sometimes it will even to the bladder) then evacuations
will be hurtful, & the liberal use
of bark will be adviseable to destroy the diseased 
irritability.
1406. It is generally found that the constitution
disposed to fever & inflammation (1405) admits 
most easily of the gonorrhoea being cured. 
1407. IN some irritable constitutions it has been 
observed that a fever arising, the symptoms have
gone off, & that when the fever has left the
patient the local symptoms have returned
again, in others the coming on of a fever even
when the disease was mild, has increased the 
gonorrhoea, & the fever again going off, the gonorrhoea 
has been cured.
1308. It is perhaps always right to have in view 
the possibility of the absorption of venereal matter
into the habit, especially when the disease has 
been of long standing. therefore
1409. Although mercury has no specific action in 
the inflammation of the urethra, yet with a
view to prevent the ill effects that may arise
from venereal matter being absorbed with the 
system, it is right to administer it, especially 



365.
towards the latter end of the cure, & when the
process of absorption must be nearly at an end.
Q. It is difficult to say whether giving mercury 
will always prove a preventative to the second
genus, but it is the more sure means we know
of at present, & therefore to be advised, the 
mercurius calcinatus or ointment are recommended.
1410. We judge of the gonorrhoeas advancing to 
a cure, when the cherry color of the glans
changes to a pale hue, & other symptoms also
abate, as the running decreasing in quantity & 
becoming more slimy, pain & tenderness of the
penis going off etc.
1411. It often happens that the symptoms will
leave the patient; he will continue well even
for a month, & then this shall return; but it
is probable that they will not be found to 
be venereal, when they appear a second time
Q. We have remarked that there is perhaps
a possibility of distinguishing between a 
gleet & a gonorhoea, we shall observe the
following cases.
Case 1.
A gentleman in April 1780 got a gonorrhoea,
swelled testicle etc. in June all his 
symptoms left him except now & then a little
discharge of slimy mucus. Sept 1. He married & 
gave his wife a clap. It is to be observed that 
he met with some difficulty in entering the 


vagina, & that perhaps from the force be exerted
his inflammatory symptoms returned.
Case 2d
A gentleman had a gonorrhoea, two weeks
after he lost every symptom except a gleet,
he lay with & clapped his wife. We know that
in some the inflammation & running have
been kept up even for twelve months, & yet
the patients have not clapped the women, with 
whom during that time they have been connected.
1412. Strong sensations in the urethra & glans, 
especially when the bladder has been affected,
will often be perceived by the patient after
the gonorrhoea is gone off.  There will sometimes
be obstinate & troublesome, & two commonly 
render the dissatisfied & credulous patient
a dupe to quacks.
1413. An obstinate gleet will sometimes be cured 
by means similar to those which give rise to it,
namely, a new inflammation.
1414. Among the complaints which will remain
after a gonorrhoea is cured are these (1411./1412).
swelling of the testicle, & hardness of the epididymis,
wasting of the testicle, affections of the bladder,
strictures in the urethra, carbuncles, fistulae
in perineo, swelling of the prostate gland, paralysis
of the urethra & paralysis of the bladder.
1415. Gleet has nothing specific in its nature, nor 



365.
it produce in others a similar disease; it differs
from gonorrhoea, is 
a That the true gleet is never infectious,
b The discharge [illegible] its globules, but the
globules swim in mucus not in serum.
1416. It is incidental to all constitutions, 
the strong as well as the weak; it arises from 
various causes beside gonorrhoea.
1417. It sometimes goes off naturally, but whether
from some change taking place in the state of
the parts which are the seat of the disease, or
from the want of power to continue the discharge 
we do not determine.
1418. It generally takes its rise from habits
of action in the parts & almost always accompanies
strictures in the urethra.
1419. We attempt to cure it by art in three
ways, namely,
a Constitutionally.
b Locally.
c Sympathetically.
1426. The constitutional cure may be divided 
into
a Specific.
b Strengthening
1421. Specific medicines are bals: [illegible] etc., of
they do service it will generally be prevented
immediately, but should no benefit be found
for five or six days, they should be left off;
should they relieve they should be persisted in 


for a length of time, for if discontinued the complaint
will not uncommonly return.
1422. The strengthening medicines act upon the disposition
of the parts in question, or in common with that
of the habit is general.
1423. Medicinal applications may affect locally,
1st As specifics, & these have more influence
when applied locally, then when by means of 
the system. (1421)
2d As astringents, as decoction of bark, solution 
of white vitriol, alum etc., these produce their effects 
by causing a peculiar tonic action in the parts, 
their use should be long persevered in to produce
a cure.
3d Local medicines may produce a cure by 
the violence they offer to the parts, but their use
should be deferred until other methods have been
tried; they are followed by an increase of the discharge
from the urethra; of this kind are very simulating
injections, as solution of sublimate & 
bougies either simple or medicated; as to the time
there should be employed; if the injections be very
irritating, two or three times will be enough, if
less irritating, a week or two; bougies may be used 
five or six weeks, for bougies made irritating a much 
shorter time will suffice.
1424. The third general method is by means of sympathy 
or perhaps derivation, as a gleet being cured
by two chancres being formed on the glans penis,
or by applying a blister to the underside of the urethra, 


367.
or by elasticity etc.
1425. Uneasy sensations of the bladder & urethra
have been removed by blisters applied to 
the perineum or loins; the use of hemlock, injections
of sublimate & other means, but blisters to 
the perineum have seemed eminently useful.
Cases.
Sir Charles Banbury’s servant had, for a complaint
of the kind, consulted Dr Warren, Messrs [illegible]
& [Gunning] without relief, Mr Hunter applied a
blister to the perineum, which soon cured him,
it was kept open six days.
Case 2
A Portuguese gentleman had, for two years after
having had a gonorrhoea, such unease somehow
in his urethra & bladder as to give suspicion 
of a stone. Mr Hunter examined him [illegible]
as well as by sounding, but found nothing
unnatural; a blister was applied to the perineum,
which cured him almost immediately.
Two weeks after he got a part clap, but no extraordinary
circumstances attended it, nor did
his old complaint return.
1426. In the gleet, rest in general, should be 
recommended, though sometimes the complaint 
has been removed by riding on horseback, regularity
& temperance are also generally necessary
though there are not wanting instances of their opposites
affecting a cure.
1427. IN women the vagina is the seat of the





gleet, the treatment recommended in men,
will here also apply, the use of bougies excepted.
1428. Chordi remaining after the other symptoms 
have ceased, [and] the parts externally with ungt.
mercur: joined with camphor; elasticity may 
also be had recourse to.
1429. Hardness of the epididymis, after a swelling
of the testicle will sometimes remain through
life, without any ill consequences; sometimes 
relieve has been afforded by rubbing the scrotum 
with mercurial ointment, sitting on the stream 
of water etc. 
1430. The testicles are subject to spontaneous
disease, more than most other parts of the body;
like the teeth they are added only for particular
purpose, & they will be (similar to the thymus
gland or membrana papillaris) sometimes created
& at length entirely obviated. This may 
happen at my age.
Case 1.
A surgeon had a gonorrhoea & bubo, the
testicle on one side, entirely disappeared.
Case 2. 
A young gentleman aged eighteen, without
any clap, had a spontaneous inflammation 
of the testis, on one side it was wasted gradually 
to the size of a horse [illegible], the spermatic chord
unaltered; he had afterwards a similar attack
up on the other testis, which continued wasting 


369
untill not a vestige of it, except a few loose fibres,
could be found.
1431. Skin absorption of the testicle will follow an
inflammation of the testis, hydrocele & hernia
[??italis], & sometimes will take place without
any preceding disease at all.
1432. Obstructions to the free passage of the urine
through the urethra may arise from different
causes, namely,
1st Excrescences in the canal.
2d Tumor without the urethra passing in its
sides & hindering it for dilatation.
3d Strictures of the urethra.
1433. If when the urine passes off only in a small 
stream & with difficulty, we pass a moderate sized
bougie, & find we can not introduce it with ease we 
have no reason to suspect a tumor (1432-2)
1434 [caruncles] or fleshy excrescences (1432) growing
in the urethra are seldom, though they are sometimes 
known to exist, probably they are a kind of internal
wart, ulcers in the urethra we have never met with.
1435. Strictures in the urethra (1432-3) are of three
kinds
1. Permanent.
2 Spasmodic
3 Mixed.
1436. All canals whatever are subject to strictures,
consequently the urethra is not exempt, & indeed this 



canal is subject to them not particularly as the consequences
of gonorrhoea because they frequently 
take place in the urethra without any venereal
symptoms whatever preceding.
1437. The seat of the gonorrhoea is commonly very 
near the orifice of the urethra, the seat of the stricture
is commonly in the membranous portion.
1438. They do not seem to arise from the use of injections,
nor do bougies ever produce them.
1439. Ulcers in the urethra have been supposed to be
causes of them, but we have never met with such a 
cure.
1440. We do not understand properly the causes of strictures 
in the urethra, any more than we understand
why they should occur in other canals.
1441. When a gleet remains obstinate, & the urine 
flows in a small er stream than common, or in divided
streams, or is [illegible] with difficulty, there
is reason to suspect a stricture & we should examine
by passing a bougie.
1442. Permanent strictures may take place in the 
whole circumference of the urethra, masking an
annular stricture & lessening the area of the canal,
as though a piece [illegible] as though a piece of chord was 
drawn tightly round the urethra; or they must 
occupy one side of the urethra, in which case the
contraction will not be circular, but only on one 
side, & then the area will not be so much diminished,
as in the other case, but the general dilatation 


371
of the urethra being resisted, the figure of the 
canal will necessarily be altered. The extent of
the strictures will also differ in length, more or less 
of the urethra being occupied by them.
1443. The number of strictures will also be different
in different urethrae, sometimes only one, sometimes
four, five or six.
1444. The portion of the urethra in which the permanent 
strictures take place, will be whiter & 
harder than the rest of the canal.
1445. Permanent strictures will continue to a 
great length of time, even years, their formation
& progress are slow, they are generally, for obvious  
reasons, overlooked, untill they have become considerable.
1446. They are generally more troublesome in cold 
weather, than in warm, & therefore are worse in 
winter than in summer.
Q. This proves that the urethra has something of
a muscular power.
1447. Permanent stricture continuing for years,
teases the patient & at length gives rise to the 
worst diseases, irregular enlargements in the urethra,
diseases of the bladder, fistula in perioneo  
etc.
1448. To understand properly why those circumstances
should arise from strictures of the urethra,
as also the nature of spasmodic strictures,
we should have a clear idea of the structure and
functions of the bladder & the urethra.



1449 The bladder is a muscular bag & has a power
of contraction for expelling the urine, it can contract
itself to the smallest size.
1450 The urethra is also a muscular bag & can 
contract itself so as to [illegible] its canal entirely.
1451. In a natural & healthy state of both urethra
& bladder, the following circumstances must be 
present
1st The actions of the bladder & urethra must
be alternate, that is, while the bladder is contracting
itself to expell the urine, it is necessary that 
the urethra should dilate itself or become relaxed 
in order to admit of the free & regular exit 
of the urine.
2d When the bladder has ceased from acting,
then it is requisite that the urethra, should contract 
itself to prevent the dribbling away of urine
while the bladder is in a state of relaxation.
3d The area of the urethra when dilated must
bear a certain proportion to the force with which
the bladder acts in the expulsion of the urine.
4th The disposition of the bladder to contract
& the disposition of the urethra universally to 
be dilated, must take place in the same point of
time, & the strength of the disposition is [illegible],
must be always in a certain & exact proportion 
one to the other.
1452. From considering what is a advanced (1449-56-51) 
we readily foresee,
that as a resistance given to the actions 



373.
of any muscular body, greater than it can overcome,
& that frequently repeated, either increases its
susceptibility of a disposition to act, or otherwise
produces a distention of the muscular powers,
& so renders it paralytic; if by the urethra
not receiving or being insusceptible of a disposition
to relax then, the bladder is contrasting, or
not relaxing & dilating in the proportion of time
& to a proper size of canal, either an increased
Irritability & susceptibility of action in the bladder
must take place, or its muscular powers being 
destroyed, a paralysis must occur.
1453. The urethra not dilating in due time or to 
a proper size (1451-4) & resistance being thereby 
made to the action of the bladder, the latter increases 
the violence of its action to overcome the
resistance & this resistance being repeated every 
time the bladder has a disposition to act, the 
viscus becomes thickened, for the bladder like all
other muscular parts increases in density from
frequent action, & for a time at least in strength,
it also becomes more irritable.
Q. The muscular coat of the bladder has by these
irritations been [illegible] a quarter of an inch thick;
the stone in the bladder also produces a similar
state of it, by acting & dilating irregularly it 
often becomes fasciculated, hence sacs are formed
in which calculi are sometimes lodged.
1454. If the resistance made in the bladder be
so great, that it cannot increase it, but continues 



a length of time, untill the urethra is either 
spontaneously or artificially dilated, & [illegible]
unconquerable resistance often repeated, the muscular
power of the bladder is destroyed and a 
paralysis of that organ succeeds.
1455. In consequence of inflammation, partial
contraction in the urethra etc., the upper part of
the urethra loses its power of contraction, a paralysis
of its muscular powers takes place, the urethra
is paralysed & no contraction of the urethra
attends the dilatation of the bladder, & urine
is continually dribbling off.
1456. If the area of any portion of the canal of
the urethra be diminished by permanent strictures 
of the urethra, or any tumor compressing its sides
so that although the urethra has a disposition
in due time to become dilated, yet the urine
not being evacuated with speed proportionable 
to the force with which the bladder
acts, will induce an irritable bladder & a thickening
of its coats.
1457. The urethra may receive a disposition to 
contract irregularly, with the alteration of its
stricture, & that only in particular parts, this
constitutes the spasmodic stricture. (1435-2).
1458. The urethra may be permanently dilated
in particular parts, & contracted in others, by 
this means its surface will be unequal and often
rough.


375.
1459. The state of the bladder may be rendered such 
by the distension of it & resistance of its contraction, 
that it cannot admit the influx of part urine by 
 the ureters; hence those tubes shall be distended with 
urine, & the distension & enlargement of these, shall
be continued even to the pelvis of the kidney,
which shall itself also become distended.
Q. Sometimes matter has been discharged from the 
kidneys, perhaps from the irritation, & this without
our finding any ulcer on dissection.
1460. It frequently happens that there shall be not 
only a permanent stricture lessening the size of 
the canal of the urethra, but also in the same urethra
a disposition to spasmodic contraction;
this constitutes the mixed stricture (1451-3).
1461. The urethra has sometimes a disposition to 
contract & close its canal independent of any 
alteration in its structure, & loses not the disposition
when the bladder gets into action, this being
in fact a spasm of the urethra we call
it spasmodic stricture.
1462. Another cause of obstruction to the free passage
of urine, may be a swelling of the prostate gland.
1463. The use of the prostate gland is not understand,
it is evident that a swelling of it, must produce 
an alteration in the state of the urethra.
1464 When it is enlarged, it stretches the urethra
anteriorly & posterialy, & flattens & narrows
it laterally, the small portion at the back 


of it will act as a valve to the canal, hindering
the free egress of the urine.
1465. When greatly enlarged, little or no urine
will be voided, & all the symptoms of an irritable 
bladder will come on.
1466. When there is no symptom of disease in 
the urinary canal & we can find neither
stricture nor stone, we should be led to examine
the state of the prostate gland.
1467. Pass the finger in ano as far as the first 
joint, if a hardness be felt extending higher than 
the finger can react, we may believe it to be 
a disease of the gland.
1468. We may find this disease in two stages, viz
1st When the obstruction is not so great but a
bougie or catheter may still be passed into
the bladder.
2d When neither of them can be introduced.
1469. We have noticed (1464) that a small posteri
portion of the prostate projecting into the urethra
sometimes acts as a valve, through this projecting
substance a catheter has been sometimes forced
into the bladder, which has ultimately terminated 
in death.
Q. A gentleman labored under a complaint 
of this kind, by forcing the catheter into the bladder
as haemorrhage ensued, the blood coagulating 
stopped up the holes of the catheter; when 
afterwards introduced into the bladder, the water 



377.
could not be drawn off & the patient died.
1478. Permanent strictures in the urethra give
rise also to fistulae in perineo; nature endeavors 
to get rid of the stricture by producing an
ulcer in the part it occupies.
1471. But this is not always the case, the seat of 
the ulceration will not infrequently be between
the stricture & the bladder, whichever is the
case the ulceration directs its course from 
within outwards, to give an exit to the urine,
as ulceration as in an abscess observes a similar 
course to give an exit to pus, with this difference 
however, that in the present instance, the process 
is slow with little or now inflammation; hence the 
urine will insinuate itself into the cellular
substance & corpus spongiosum of the urethra, so
that the openings formed in the skin shall not
correspond with the openings in the urethra.
1472. This latter remark will, however, only hold
good, when the seat of the stricture is before the 
membranous part of the urethra, when more posteriorly,
the ulceration is more regular & more
similar to a common abscess.
1473. By the insinuation of the urine into the cellular
substance, inflammation of considerable extent,
followed by suppurations or even gangrene may 
be induced.
1474. The prostate gland, copwer’s glands, the bulbous
parts of the urethra, as well as the cellular
substance may partake of the suppuration and the 


matter point externally. 
1475. When an abscess forms in perineo from this
cause there is generally a free passage for the
urine into the abscess & both its growing from 
the urethra & its external opening will not unusually
admit a catheter with the cavity.
1476. As in other fistulae so in those of the perineum
the ulcer in the skin has generally a 
stronger disposition to heal that that of the
deeper seated parts; hence, the external orifice
will sometimes close, & then the urine insinuating
itself [diffusively] into the cellular substance of 
the surrounding parts, will at length make its way 
through a number of orifices formed by ulceration
in the skin if the perinaeum, scrotum, and 
even inside of the thighs, which are commonly
the mouths of an equal number of sinus’s.
1477. Seminal weakness is considered as a consequence 
of gonorrhoea virulenta.
1478. The disease which commonly goes by this
name is a copious discharge of a dry [like]
mucus, at the end of making urine, & at straining 
in going to stool, in which case there is often a
copious discharge of mucus, which is considered
as semen.


379
1480. As a proof that this is no discharge of semen,
we observe that it is common to old men, & that
those who are afflicted with it [illegible] no diminution
of their venereal diseases, or of their powers,
that the quantity evacuated is often more than 
the quantity of semen the patient emits, that
to produce in some violent efforts are required,
as straining at stool, as in evacuating the last
drys of urine, & lastly that patients, immediately
after this discharge has come away, have been 
able to emit a part & natural quantity of semen,
which had the first been really so, it would have 
been impossible for them to have done.
1481. It generally prays must open the mind
& imagination of the patient, & hence rather than
from its proper effects on the constitution renders 
him weak & debilitated.
1482. But real involuntary discharges of semen 
may attend some patients & this a matter of serious
consideration.
1483. The organs of generation like many other
organs consist of two parts.
1st Those whose action is primary, as the testis.
2d Those whose action is secondary, as the penis.
The actions of the second should always follow
those of the first irregularity in this circumstance 
is productive of disease.
1484. When the penis takes on action without the 



disposition of action in the testis being increased,
we have involuntary erections of the penis, which 
may be similar to chordi, except that it is attended
with no pain, or at most with only a sense 
of uneasiness similar to that which we experience
in the part after coition.
1485. Involuntary erections of the penis may 
be spontaneous, or may arise from visible irritation
of the member, as virulent gonorrhoea.
Q. Perhaps Mr Hunter means in this place [illegible]
of the penis taking place without any libidinous
ideas being first excited in the mind.
1486. These erections are to be considered as spasmodic
affections of the muscular powers of the
penis, & therefore similar in their nature to spasm 
of any other muscular part.
1487. But the penis may not only act, without 
any previous corresponding disposition in 
the testis, but the testis may also act without
any corresponding action in the penis.
1488. This is the reverse of the other disease, 
the semen will here be discharged or [illegible], even
the slightest occasion; the least friction of the 
glans penis, as in walking will occasion it, without
an erection of the penis, so will the most 
simple thought [illegible] venereal matters, a disease 
in the last degree [illegible] etc., & here the semen
runs off like the stools or urine.
1489. Caruncles (1478) we may attempt to cure by 



381
producing ulceration of the [illegible], whether
this can be done by the bougie is doubtful,
[when] it fails the caustic should be used in the
[illegible], hereafter described in the treatment
of strictures.
1490. The permanent stricture is to be cured 
either by 
a Dilatation or
b Ulceration.
1491. The method (a) is by means of bougies, in the 
use of which we must attend to certain circumstances
have laid down.
1492. We are to be extremely careful not to make 
a false or new passage by means of the bougie,
& we are also to ascertain, if possible, whether
any false passage has already been made for the 
bougie
1493. If open enquiry we learn from the patient
that bougies have already been used, & that ground
was gained in the length of the bougie which 
was last introduced, without, however, getting
clear of the stricture, we have reason to fear a 
false passage is already made.
1494. Near the orifice in the glans penis a bougie 
may by chance be thrust into the mouth of a 
lacuna; this should be attended to, because it 
scarcely can happen that strictures so low 
down obstruct the passage of the bougie
1495. We should at first attempt to introduce a moderate 



sized bougie, if that will not pass, we have
recourse to a smaller & smaller, untill we came 
down to one of a minute size.
1496. The great inconvenience of using a small
bougie is, that it bends in the urethra, & so 
doubles; we should in our introduction of the
instrument endeavor to ascertain this; least
we think the bougie is advancing when it is
only doubling.
1497. When a bougie is introduced, if it be doubling,
it will generally recoil if the hand be removed,
if it be really advanced with the urethra, the 	
length that it seems to be, it will not recoil, if
by taking away the gland we case we put it
forwards.
1498. When a bougie hesitates in its passage but 
does not recoil, we should stroke the perineum 
with one hand, at the sometime that with the 
other we gently part on the instrument.
1499. Sometimes an advantage is gained by giving
the bougie the natural bond of the urethra,
before it is introduced.
1500. If we can introduce the smallest bougie,
the cure of the patient is generally in our hands,
as by increasing the size of the bougie in future
introductions, we can produce the necessary dilatation.
1501. We suffer the bougie to remain in the urethra
a longer or shorter time, according as the
patient can endure the presence from five or ten 


383
minutes to two or three hours, & this we at first repeat
daily untill a large bougie can be easily 
passed & no obstruction to the stream of urine
remains; we then pass it less frequently, but as there
is always a possibility of the complaint returning
those therefore who have been afflicted with the strictures
should never pass any great length of time
without introducing a bougie.
1502. The most convenient season for using the
bougie will be a little before [bad] [time], or an hour
or two before the patient gets up in a morning.
1503. If the weather be very cold, the stricture
may be more violent, so as to prevent any 
urine passing off or the introduction of the smallest
bougie; hence we are to make the of such remedies
as are temporary relaxants, as the warm bath,
glysters with opium, blisters to the perinaeum
etc.
1504. A bougie sometimes cannot be introduced
beyond the stricture the first time; in that case 
we are to introduce it gently as far in to the 
urethra as we can, & lean it there for some 
time; by several repetitions of this practice, we
may expect in general to get beyond the stricture.
1505. From an increase in the disposition of the urethra 
to contracts it will sometimes happen that we
may be able this day to pass a bougie, & quite unable
the next.
1506 The passage through the stricture is not always
strait, this we shall judge of from the appearance 



of the bougie, after it is withdrawn.
1507. The bougie does not act in the cure of
strictures simply as a wedge, that is in a manner
it would do in a lead urethra, but it acts upon 
& produces a reaction of the living parts, and
the cure is accomplished either by the parts habituating
themselves to the pressure or by interstitial
absorption being excited.
1508. We also attempt to cure strictures in the
urethra by ulceration, & this is affected either 
by the irritation of a large bougie continued
untill ulceration absorption arises, or by means
of a caustic
Q. Formulae for bougies.
[illegible] [illegible]
[shel] [lac]
When bougies are introduced care should be taken
to prevent their slipping into the bladder, 
by tying threat or narrow type round their upper
end & bending it over the glans penis.
Some persons have such a disposition to
form calcareous concretions, that a bougie
cannot remain in their bladder a few 
hours without being inserted with calcareous 
matter; such persons should use a great deal of
exercises
Mr Bronfield cut a bougie out of a young
man’s bladder, when it had remained two weeks 


385.
& a large quantity of calcareous earth had crystallized 
upon it.
In passing a bougie it may be stopped by a lacuna, 
draw it back in that case, turn it & you 
will avoid the orifice.
1509. Although the stricture is not an originally
formed and therefore being a weak part, may be
without much difficulty made to ulcerate, yet
great
care must be taken that the bougie is
not forced into the corpus spongiosum urethrae,
which has been done & the instrument parked
even through the cellular substance to the rectum.
1510. It may not be useless to reject the remark, 
that if in passing a bougie it seems to make considerable
progress & at the same to be confined by 
the stricture, there is reason to support that a new
passage is forced open
1511 Of this, as well as of softening a bougie to slip 
into the bladder, the surgeon should even be extremely
cautious.
1512. The cure by ulceration, is, generally speaking,
to that part of the urethra which is strait, & then 
in cases of strictures not readily yielding to 
the pressure of the bougie, it may be properly had 
recourse to.
1513. The matter of producing ulceration by means
of the caustic may be employed when the bougie
cannot be passed, & the stricture is in the strait
part of the urethra.


1514. The following instruments are necessary.
1. A silver canula
2 A [stillet]; one end of which is solid like  
a blunt probe, the other made of gold, like a
part [crayon], & in the gold end a piece of caustic
is to be fixed.
1515. In the operation, the canula inclosing the stillet
with the probe end downwards is to be introduced
up the urethra, untill the probe strikes
against the stricture, the stillet is then to be 
withdrawn, and turning the end armed with the
 caustic downwards is to be again introduced 
through the canula, untill the caustic comes in 
contact with the stricture, where it is to be held 
for a minute or two & then withdrawn within
the canula, which is next to be removed, this process
is to be repeated every other day, untill 
the [illegible] is accomplished.
Q. Mr Hunter observes that in some cases of stricture
in the urethra, he has succeeded by means of
caustic beyond all expectation.
In one case where the stricture was between 
the membranous part of the urethra & the glans
penis, a few touches of the caustic enabled him to 
pass the bougie
In two other cases in which the stricture had
produced fistula in perineo & one of which
suffered no urine to pass by the penis, the caustic
produced a cure. 



387
He further remarks that it is safer to use the caustic
than to preserve too long in irritating the
stricture with the bougie, or force in the latter case
is so easily production of a new passage.
1516. The patient should make water immediately 
after the stillet in withdrawn, or the warm 
water should be gently injected to wash off any 
portions of caustic that may be left in the urethra.
1517. A slight ischuria sometimes follows this
method of cure, which readily yields to the common 
remedies 
1518. We have said (1515) that this is to be repeated
every other day; some time is to be allowed
for the separation of any slough which may 
be formed.
1519. The ill effects that may follow the use of
bougies, besides making false passages are
1st That the first or second time that the bougie
is introduced, many patients will be affected 
with sickness & syncope, but this goes off of its own
accord, & does not return or subsequent repetition
of the use of the bougie.
2d A discharge of pus from the urethra, when 
before there was none, & an increase of that secretion 
when before existing, this is however an 
effect of but little consequence.
3d An inflammation & swelling of the
testicle, in which the common treatment is to be 
had recourse to.


4th A sympathetic swelling of the original glands.
5th A bougie slipping into the bladder may from 
a nucleus for a stone, should it slip so far that it
cannot be taken hold of in the urethra, it must
be extracted by the operation of lithotomy.
Q. If it slip within the urethra so far that it 
cannot be taken hold of with the finger is forceps,
endeavor by grasping the penis tight in one
hand to prevent its getting farther towards 
the bladder, & with the other hand gently draw
the penis forwards, then backwards, so as if possible
to work the end of the bougie upwards,
untill it comes within the reach of the finger 
or the forceps; should this be ineffectual, the
bougie must be fixed steadily in the urethra,
cut down upon & extracted.
1520. The bougie making a new passage is not in 
general productive of new disease, as the mischief
done is generally early discovered, but it
will impede the cure of the present.
1521. If the bougie have made its way through
the spongy body of the urethra, it will pass inwards 
towards the rectum, if it the membranous portion,
it will take any direction.
1522. The remedy for, in cure of the new passage 
is to be performed by incision.
Q Pass a staff into the urethra as for as it will
go, which will in general be to the bottom of
the new passage & beyond the stricture, then feed 


369.
for the end of the instrument externally, & cut down 
into the groove, making a wound of an inch or an
inch & a half long, & carrying the incision a little
way into the scrotum; then take a probe & pass
it through the wound into the urethra to the 
stricture, if it meet with an obstruction pass two 
canula, one or each side of the obstruction, untill
they are brought as near to each other as
possible, then thrust a [piercer] from within on e
canula through the obstruction with the other
canula, & withdrawing it supply the place with 
a bougie; next remove the lower canula & the 
upper canula & introduce the bougie along
the canal of the urethra into the bladder, it
may be right then to lay the new passage open
through the whole of its extent, that all may heal
together & least the new passage should in future
receive the end of the bougie & prove a hindrance 
to the cure.
As it may difficult to introduce a second
bougie after withdrawing the first, the 
first should be suffered to remain in the bladder 
for some time, or perhaps as it may be better to cure
the first time a flexible catheter, afterwards the 
bougies should be increased in size, & their use
persisted in, untill a cure be obtained.
1523 In the performing of which it must be a principle 


that the urethra is to be fairly incised beyond 
the extent of the stricture.
1524. In the spasmodic stricture, if the symptoms be urgent,
we must here recourse at once to the bougie
or the catheter, the bougie is the least hazardous, & 
a large one can often be easily passed, & will then 
readily relieve the patient, even when we can not
pass it, by conveying it as for as we can without
force & then leaving it; the stimulus its presence given
to the urethra will take off the stricture & permit 
the urine to pass.
1525. We may internally administer opium & the 
turpentines, camphor may relieve this spasm as
well as stranguary produced by cantharides, externally 
we may rise
Fomentations.
Warm bath.
Streams of warm water
Blisters to the perineum or loins etc.
1526. There will rarely be permanent strictures
producing urgent symptoms, without spasmodic affections
of the urethra also taking place. In the mixed
stricture we shall find sufficient directions for [illegible]
by attending to what has been said on the
two other species, the permanent & the spasmodic.
1527. In endeavouring to relieve the bladder,
rendered morbidly irritable, we should observe
the following directions. 


391.
1st We should endeavor to remove all obstructions
to the free exit of the urine
2d We should instruct the patient never to suppress 
an inclination to make water
3d We should endeavor to relieve, the present
urgent symptoms by giving opium internally,
glysters etc. and 
4th We should try the effects of a new irritation,
as a blister to the perineum or the to the 
loins.
1528. In case of paralysis of the bladder, the catheter
should be often introduced to keep the bladder 
from distending, & when we are evacuating
the urine, pressure should be made by the gland 
upon the belly, we should also apply blisters
to the perineum or the loins, & give stimulating 
medicines internally.
1529. In paralysis of the urethra, which is a more
rare complaint, a similar treatment is to be
adopted, especially the application of a blister
to the perineum.
1536. Hemlock has scorned to be serviceable in 
the complaint, attended with a discharge of the
liquor of the prostate & vesicula seminales,
falsely called seminal [illegible] (   ) bark & other
astringents & strengthens are also proper.
1531. Involuntary erections of the penis being a nervous
& spasmodic complaint, antispasmodic remedies 


may with propriety be called in, such are 
warm & cold bathing, opium etc.
1532. In cases of real seminal weakness (   ) opium 
has afforded singular relief & may be and both 
internally & externally, that is applied to the scrotum.
1533. The enlarge prostate (  ) is most incidental 
to old men, although young men have sometimes
been affected with it.
1534. No cure is known for this complaint, hemlock
& sea bathing may be beneficial, as the diseases
may not impossibly be owing to scrophula, opiate
glysters should be frequently thrown up to relieve 
the pain & lessen the irritation.
Q. Catheters employed for drawing off the urine should 
be considerably curved at the end, & should be introduced
carefully, yet with some expedition, a flexible
catheter is to be preferred.
As the female urethra is short & strait no
obstacle will arise to the use of the caustic, but
should bougies be used, it will be requisite to endeavor
to retain these in their proper place & 
situation by means of the T bandage.
1535. In strictures of the female urethra we can
more easily succeed by the use of caustic than 
bougies, from the difficulty of retaining the catheter,
& from the impracticability of their being
passed by the patient herself.
1536. When in consequence of obstruction to the exit 


393.
of urine, nature has made new passages for [illegible]
fluids by the ulceration of the urethra & the formation
of fistula in perineo & we are to attempt 
the cure by carrying in our minds the general 
principles of the treatments of fistula & also what has been already
laid down concerning the cure of new passages formed
by an unskillful introduction of the bougie
(1522).
1537. In the cure the staff is to be introduced in 
the manner before mentioned, upon which we are
to cut down into the urethra, than from the urethra
we are to pass a probe or flexible director 
the urethra & lay them all upon as far as we can 
follow them.
Q. As the diseased parts are in general in a very
diseased & callous state, we are not to be very delicate
or sparing in using the knife upon them, but
if possible proceed so far as to make the several openings 
into one & to cut the urethra beyond the
stricture; if the seat of the stricture be not already
destroyed by ulceration.
1538. A hollow bougie is then to be introduced into 
the bladder & the wound healed over it, but there
is a disadvantage attending the use of the hollow 
bougie, which is that its base is too small to admit
of the exit of the urine with a velocity proportioned
to the force with which the bladder acts. (   ).
Q. We have already considered the consequences of a 


venereal irritation, applied to a secreting or some 
cuticular surface; we now proceed to consider its
effects when the matter is applied to a non secreting
surface or cuticular one, the primary effects of 
which constitute the second species of the first genus,
(  ) or local disease.
1539. If any irritating matter be applied to a secreting
surface, & the irritation is carried to a certain
degree, then a change of that secretion and a 
discharge of pus or the suppurative inflammation
must take place.
1540. Irritation to a certain degree applied to a 
nonsecreting surface, suppuration must also 
follow, but that must be preceded by ulceration.
1541 We see therefore, that if venereal matter
be applied to the skin & its application be continued
a sufficient length of time, ulcerative absorption
of a small portion of the skin takes place
& a chancre is formed.
1542. We have shown (1254) that there are three
ways in which a chancre may be formed.
1543. The second species, like the first, is generally 
caught in coition, it is not so common as the first
species; we calculate that the first species is contracted
four times for once that the second is, for 
the [illegible], in general, prevents its action on 
the cutis, untill the venereal matter is somehow
worked off.
1544. The prepuce & glans penis are the ordinary 


395.
sects of it, but the most common is the [illegible]
as the angle between it & the glans, & this from 
the irregularity of the surface.
1545. The distance of time between the infection
& the appearance of the chancre is uncertain, it
generally however makes its appearance later
than the gonorrhoea.
1546. We have known a chancre appear thirty 
six hours after coition; we have known seven
weeks elapse between the time of coition and
the time of ulceration, we have known also an 
interval of the months. 
1547. It begins with an itching of the parts affected,
if its seat be the glans, there is not much tumefaction,
if in the prepuce, there is a little discharge
from the beginning, at least more so than 
when on the glans, as being a [larger] part, the
parts ulcerate, or a simple pimple is formed, or a 
little abscess, especially if the glans be the seat
of it, a little hardness, round about the pimple or
ulceration is noticed.
1348. Should the chancre be situated on the body 
of the penis, it generally begins with a pimple, [illegible]
[illegible] & being little attended to at first, scabs, the 
scab is then picked or rubbed off & a large one forms, 
here the inflammation is more considerable than 
of the chancre begins on the glans, less however
than it begin as the prepuce a hardness generally 
surrounds it. 


1549. The canal of the urethra often sympathizes
with the external parts, so far at least as smarting,
itching & tingling; whether a discharge will arise
from this simply sympathetic affection, we do not
affirm, possibly, however not all gonorrhoeas which
are preceded by a chancre, are specific.
1550. The sympathy of the neighbouring parts with
the seat of the chancre, is sometimes so strong,
that even touching the hairs on the pubis will 
create uneasiness.
1551. The chancre will be attended with more
or less pain and inflammation, according to the
peculiar habit & disposition of the patient
1552. The local disease will spread with greater 
or less violence; sometimes considerable & [illegible]
slough will form [early] & there will be gangrene 
of some extent. The ulceration will sometimes penetrate
so deep as to open the canal of the urethra.
1553. The prepuce is only a doubling of the skin of
the penis, that it may be loose & convenient for erection;
the prognosis or stricture confining it 
over the end of the glans, so that it cannot be
retracted is a frequent consequence of chancre.
1554. The phymosis often precedes the paraphymosis,
& is in fact frequently the cause of the latter, for 
patients attempting to get the skin, it will sometimes
be made to slip behind the root of the 
glans, & will then take on a stricture, strangulating 



395
the glans.
1555. The phymosis in some patients so entirely 
passes up the end of the prepuce, as even to prevent 
the exit of the urine, often it has passed through
the urethra.
1556. In this disease there is a thickening of the
cellular substance of the prepuce, & often an adhesion
is formed between it & the glans.
1557. It has often for its cause or disposition of
the erysipelatous kind, accompanying the venereal
inflammation.
1550. The phymosis, if severe, produces such a swelling
of the prepuce, as shall press violently against 
the end of the glans, & if there be sores & chancres
underneath it, which is not uncommonly the case,
the matter issuing from there will be confined, from’
which & from the pressure on the penis, the [illegible]
consequence will ensue, even mortification of the penis.
1559. The paraphymosis strangulating the glans,
will if not relieved, sometimes produce a gangrene
of the part strangulated & even a separation
of the whole diseased part.
Q. A young man with chancres had a paraphymosis, 
he came into St George’s Hospital, the entire
glans & all the diseased parts gangrened
& sloughed away , the patient recovered.
1560. IN women chancres are apt to be more
numerous than in man & to spread to a larger size, 
became the surface they have to spread over is
of larger extant. In them the perineum is more 


subject to chancres than in man, from the facility
with which the matter will in their chancres, run
down to that part.
1561. Chancres are frequently attended with some
peculiarities, independent of the specific affections,
& therefore some variety in their treatment
may be necessary, consequently it is requisite to
attend to concomitant symptoms & circumstances
whether local or of the constitution.
1562. Two modes of local cure of the chancre, are
practised, the one by extirpation, the other by 
altering the nature of the irritation.
1563. In extirpating, the objection not only to cure 
the chancre, but also to prevent any communication
of the virus to the system.
1564. Two methods of extirpation have been practised,
one by [illegible] out the chancre, the other
by destroying the diseased part by caustic.
1565. When the glans is the seat of the chancre,
the caustic is undoubtedly preferable.
Q. Lunar caustic is recommended, as most convenient,
it should be pointed like a pencil and
the [illegible] with it once or twice a day, untill 
they [illegible] & red & healthy appearance of
a common healing [illegible].
1566. Chancres may be [dissected] off the prepuce etc.
with a knife; whether dissection or caustic be employed,
it is proper afterwards to [illegible] the sore 
with mercurial ointments, as by that means [can]
destroy any venereal affection that may remain



397.
1567. Extirpation is improper when the chancre is
large.
1568. The other mode of local cure is by means of altering
the nature of the ulcer which is done by mercurial
ointment, in which there is no destruction 
of parts, but only a destruction of venereal irritation.
1569. Mercury, although it does not cure the first
species, is a specific for the other, second. (  ).
q. Mercury is applied either in the form of an
ointment; or by means of a watery vehicle, the 
latter from its ready [miscibility] with the animal 
fluids, is probably most efficacious, but it should 
be a rule to change the application often, as any 
one dressing will have its efficacy diminished, as
the sore becomes more & more habituated to its
action.
1570. Chancres to their specific disposition will often
have superadated, either indolence or irritability:
in the former mercurials should be mixed with 
stimulating balsams, in the latter mercurials 
should be mixed with opium, & the oftener the
latter and dressed, the better.
1571. If a patient with a phymosis cannot submit
to keeping his bed, a circumstance to be desired, he 
should use a proper suspenory bandage.
1572. Between the prepuce & glans an injection 
should often be thrown, prepared wither of calomel,
gum arabic & water, or of mercurial ointment incorporated
by mucilage of gum arabic with water, between 



the times of injecting, mercurial ointment
may be rubbed on the outside, sometimes a poultice
of vegeto mineral water & linseed meal, affords relief.
1573. An Haemorrhage, the consequence of ulceration
will sometimes happen, & is an extremely troublesome
symptoms.
Q. Oil of turpentine is the best styptic we are acquainted
with.
1574. When the inflammation abates, move the 
prepuce over the glans frequently to prevent adhesions
which would subject the patient to a permanent
inconvenience
1575. Should it happen that an ulceration of the
surfaces of both glans & prepuce has taken place,
we must then endeavor to prevent adhesions
by the frequent use of injections, thrown between
the glans & the prepuce.
1576. If the proportions be drawn much over the 
glans & contracted & the opening of the urethra or
be in a strait line with the end of the prepuce,
pass a bougie with the canal, in order to prevent
the ill consequences of the passage of the urine
being obstructed by the [illegible] adhering to 
the end of the glans, & closing itself over the orifice 
of the urethra.
1577. In this latter case, or in case of the orifice of
the urethra be not in a right line with the end
of the [illegible], we must slit open the prepuce 
& expose the orifice. 


399
Q. many have recommended us not to open the 
prepuce by one longitudinal incision, the whole 
length of it, but to make two slits one on each side,
which they say will save the necessity of making so long a 
wound, but they have drawn their reasoning from 
the natural phymosis, which will by no means 
apply to the phymosis from disease in which the 
prepuce is very much tightened & incapable of yielding
& stretching as in the natural phymosis.
Whenever disease makes it necessary to operate,
the prepuce should be slit up its whole length.
1578. In many cases the operation for the phymosis is
not adviseable, as where the inflammation is violent 
or there is much tendency to gangrene as the 
additional violence of the operation must tend to 
increase both.
1599. When matter is collected & confined in any 
part from the adhesion of the prepuce to the glans,
a wound by a lancet should be made & the 
matter discharged, or if the fears of the patient object
to the lancet, a small caustic may be employed.
1580. Mortification sometimes takes place in phymosis
& we have seen cases in which the whole 
of the prepuce has sloughed away.
1581. Hence we may suspect a faulty constitution 
& that the inflammation was of the erysipelatous
kind.
1582. In those cases bark should be administered 
with mercury, thereby attacking at once the veneral 


infection & the constitutional disposition.
Q. It sometimes, however, happens that mercury
increases the tendency to gangrene, under which 
circumstance bark should be administered [alone].
1583. A necessity for performing the operation
for the phymosis will appear to arise
1st When the prepuce is so contracted over the 
orifice of the urethra, as to become the cause of hindering
the exit of the urine; and
2d When added to this inconvenience or
without it, the matter form chancres, concealed
by the prepuce, becomes confined & cannot be evacuated,
or evacuations made to the chancres
without dividing the prepuce.
1584. An operation of the relief of the paraphymosis
becomes oftener necessary than in the phymosis,
& danger of gangrene & form this stricture
will more often occur.
1585. The operation consists in drawing up the 
integuments as much or may be with the fingers
& thumb & then passing a crooked bistory through 
the most strictured part & bringing it through from 
within outwards.
1586. In consequence of the inflammation of the prepuce
in phymosis in paraphymosis it will be often 
much elongated & thickened, or as to be much inconvenience
to the patient.
1587. If by proper applications as the stream
of warm water, the fumes of cinnabar, or hemlock 


401.
Fomentations we cannot reduce the swelling, it
will be right to perform circumcision.
1588. Or we should at least remove as much of the 
prepuce as projects behind the glans, taking care, 
however, not to include any part of the glans in 
the extirpation of the prepuce, & is healing the
wound we should direct the patient often to draw
the prepuce up & down to prevent the cicatrix
contracting 7 forming a phymosis, or stricture over 
the end of the glans.
1589. Warts are no sign of a pox, they arise in gonorrhoea
from the discharge from the urethra 
touching any of the neighbouring parts; chancres 
heal into warts, warts, warts have an increasing power 
in themselves, often bleed & are frequently painful.
1590. Mercury has been applied for their [illegible] & 
it is asserted, will remove them, but our experience
does not warrant us to affirm this to be the cure.
1591. As being new formed parts, it is evident that
their powers of supporting action must be weak, by 
exciting a strong action in them & the surrounding
parts by means of powerful stimulants, we may 
produce in them a disposition to decay, as a more
violent action will be then [exerted] than they are able 
to support.
1592. Rust of copper, mixed with powdered [illegible]
found to answer this purpose (1591).
1593. They may also be extirpated by means of ligature,


excision or caustic, but it is often found 
that by what means [illegible] they are removed,
they will frequently sprout up apart, in this case 
a repetition of the former process will become
necessary.
1594. Although chances may in general be cured 
by the local means above described, yet the 
introduction of mercury into the system is advisable
& generally to be insisted on, both as forwarding
the cure of local disease & as [illegible]
the effects of virus, if absorbed with the system.
1595. As we have remarked (1556) some variety 
will be necessary in the mode of treating chancres,
according to the concomitant disposition of the constitution 
or the part, & this internally as well as 
externally: thus if there be a disposition to indolence,
stimulating medicines, as the balsam 
with mercury will be necessary if to irritability,
opium, bark etc.
1596. The quantity of mercury to be introduced
into the constitution, should be in proportion to 
the number of chancres, their size & the time they 
have continued; it will be right to produce a 
slight spitting as a criterion of the mercury having 
acted on the system.
1597. Mercury may be carried into the system, as
those from the stomach or the skin; when all
the hardness is softened & the sore is skinned 
over, the cure may in general be supposed to be 



403.
accomplished.
1598. This rule should however be applied to a
large rather than to a small chancre, for in the
former the virus must in general be destroyed
before the chancre will heal, yet in the latter 
the sore will sometimes skin over before the venereal
virus is destroyed.
1599. It is better for the most part to continue the 
mercury for some time after the chancre is healed,
to prevent any further action of the venereal 
virus by mans of the constitution.
1600. Chancres in women should frequently be 
washed with solutions of corrosive sublimate, & 
mercurial ointment should be applied to them. 
1601. The quantity of mercury admitted into the
constitution should be greater in these than in ‘
others, because their chancres are commonly larger
& more numerous.
1602. When the ulcers spread considerably, if the
seat of them be in the vagina, some extraneous 
body or seat etc. should be kept between its sides
to prevent their cohering, straightning & closing
the passage through the vagina, an accident which 
has been known to take place
1603. New diseased dispositions not venereal may 
arise during the cure of chancres & remain after the 
venereal virus is destroyed.
1604. In some there will be a diffused inflammation
of a purplish hue, about the sire, which will 


be rugged & assume a cancerous appearance, these
have been commonly considered as cancers, but
for the most part only scrophulous. In others there 
is a swelling & hardness with an indolent disposition.
1605. freely used in these cases has proved
serviceable, the Lisbon diet drink, has also been
found of singular utility: extract of hemlock has
done service, so has sea bathing & opium, used externally;
if the disease extend near to the orifice of the
urethra, care should be taken to prevent its closing,
by means of a bougie; extirpation of the diseased part,
if indolent, may sometimes be requisite.
1606. The cicatrices of chancres after all the virus
is eradicated, will sometimes break out again, such 
are generally but falsely considered as venereal, 
the cure of those ulcerations is uncertain.
Q. Mr Hunter has once known them to heal [illegible]
in [two] months; these ulcerations do not always
appear immediately where the original chancres
were situated, but at a very small distance from 
the cicatrix.
1607. We recommend sea bathing as highly useful
in this diseased affection, having experienced its efficacy
in such cases. 
1608. From whatever surface the venereal virus
is absorbed, the effect is ultimately the same
1609. The constitution may be affected by venereal
virus in four ways.


405.
1st By venereal matter applied to a surface
& absorbed into the system, without any previous
local effect.
2d By Gonorrhoea.
3d By venereal ulcer whether chancre or bubo.
4th By a wound.
The most general way by far is the third, the
first scarcely ever happens.
Q. Mr Hunger calculates the proportions of infection 
in the second way to the first as 100 to 1. &
the third to the second as 100 to 1 also.
1610. The venereal matter being taken up (1609)
by the absorbents, may previous to any constitutional 
affection give rise to the bubo or local
consequent (1252-1263).
1611. The venereal bubo may be divided into
a That in which the absorbent vessels themselves
being contaminated, are the seat of the
disease.
b Where the lymphatic gland in the line of absorption
is the part affected.
1612. The first very rarely occurs, when it does it is
known by its resemblance to a hard chord, running
along the dorsum penis, & leading to a gland
1613. The hardness is occasioned by a thickening of 
the coats of the inflamed vessels; the absorbents sometimes
suppurate, & from a chain of abscesses along 
the penis, similar to the abscesses of [veins] (543), when 
suppurating they are to be considered as chancres. 



1614. The first species is so rare, that it is not noticed
in speaking generally of bubo (1252)
1615. In the second kind, which we commonly call
bubo, the venereal matter is carried by the absorbents
to the nearest of the lymphatic glands.
1616. The lymphatic glands consist of a convolution 
of vessels, constructed so as very much to [favor]
the [stay] of venereal matter in them, a sufficient
time to produce their contamination.
1617. The lymphatic glands nearest in order to 
the source of the matter, are the parts affected, those
of the second in order, scarce ever. 
Q. First in order inguinal.
Second in order glands of the back.,
It would appear from this that the matter is
dilated in its passage, the more probable reason
however, is that the second in order are not so 
easily irritated as the first being deeper seated.
1618. In man the seat of the bubo will in the
lymphatic glands of the groin, but as the situation
of the lymphatic glands is not always the
some precisely, & the nearest lymphatic gland 
will not be in the groin, but just above [illegible]
ligament, near to the os pubis, that will sometimes
be the seat of the bubo.
1619. In case the bubo arises from gonorrhoea,
the seat of the tumor may be on either side, if
from a chancre, the bubo will form on the same
side with the chancre, but if the chancre be in 



407.
the middle of the penis, than the bubo may arise on 
either side.
1620. In women the surface of absorption being larger 
than in men, these are [illegible] different 
parts which a bubo may occupy, & that dependent
on the state of the chancre.
1621. If the chancre appear on the labia or nymphae,
the venereal matter will press on when absorbed
in the course of the ligamentum rotundum,
& just below where that ligament enters the abdominal
ring, the bubo will form but never within 
the ring.
1622. This bubo we refer to the first kind, not considering’
it as glandular, but as an inflammation 
of the absorbing vessels only, & this strengthens our
opinion that deep seated & internal parts are
not readily susceptible of the venereal irritation,
& that a bubo can only be external (1617).
1623. If the chancre be situated further backwards 
than the bubo will form between the labia & 
the groin, or as in man in the groin.
1624. Absorption of venereal matter goes on more
readily from some surfaces than from others; e.g.
it is more frequently taken up from the [illegible]
from the glans penis.
Q. This is because the surface of the glans approaches
nearer to a secretory surface than that if the
prepuce: we see absorption goes on slowly from secreting
surfaces.



1625. The first notice given to a patient of the formation
of a bubo, is a sense of pain in the part affected,
in which upon examination he feels a hard tumor.
1626. This tumor is generally of the common inflammatory 
kind, & often advances to suppuration speedily.
1627. Sometimes the tumor is more of an indolent
disposition, & then will be long in coming to [maturation].
1628. When the bubo is of the truly inflammatory
kind, the pain attending the suppuration will be
very considerable, when the indolent nature, 
it will be less acute, more dull & heavy; a
disposition to indolence especially prevails
in patients of scrophulous dispositions.
1629 The inflammation of the bubo will however, 
sometimes be found of the erysipelatous kind,
& then though the pain may be considerable, 
the inflammation will not be considerable & the
part oedematous.
1630. Inflammations & swellings of the inguinal
glands are not always venereal great will be 
the difficulty, however, sometimes in ascertaining
the nature of an inguinal bubo.
1631. If a gland in the groin swell without 
visible cause, be painful & go on to suppuration
quickly, venereal matter should be suspended,
& mercury given, as in cases of [illegible]
1632. But of the tumor have an indolent nature


409
with a cold & feverish disposition, & arise without 
any visible cause, we may, for the most part,
consider it as scrophulous.
Q. It is however, doubtful whether we do not
often meet with cases in which the venereal 
disposition is mixed with the scrophulous, in this
we are to attack the predominate disposition 
be it scrophulous, or syphilitic
Case.
Calomel W- had a gonorrhoea preceded by 
buboes, which suppurated, they were opened, & 
for a time wen ton healing kindly, but at length
became stationary. Mr Hunter suspected that a 
new disposition was taking place therefore ordered
sea bathing etc., when the new disposition 
which was scrophulous abated, the venereal 
disposition increased, so that it was necessary to return
top mercury.
1633. Buboes both in men & women are entirely 
local & are no more connected with the constitution
than the preceding local affection of 
which they are the consequence. 
1634. They are not critical deposits from the 
constitutions. as has been by some supposed.
Q. If buboes were critical deposits from the 
constitution, why do they not arise in some other
glands, as those of the neck & [illegible] the
sympathetic glands of the groin, or always in 


the nearest to this source of absorption; again,
if critical, why should it be necessary to administer
mercury when they form?
1635. In order to the cure of buboes, after having
ascertained their being venereal, we have recourse
to the exhibition of mercury.
1636. We are always to desire the restoration 
of the bubo & to avoid suppuration, for the bubo
when it forms matter is similar to a chancre
& has equal power of contaminating the system.
1637. It is necessary to observe that in the case 
of the bubo, mercury should be employed, but as
that will only destroy the specific disposition of 
the gland, it is necessary to attend also to the nature
of the concomitant inflammation, whether 
common, scrophulous, or erysipelatous.
1638. In the first we have recourse to bleeding
& purging according to the violence of the inflammation.
For the second, or scrophulous, cicuta, sea bathing etc.
For the third bark.
1639. Vomiting has been known to produce resolution
of the bubo, even when suppuration
had taken place, acting upon the principle of 
resolution, vomits also powerfully excite the action
of the absorbents.
Q. A gentleman had a suppuration considerably 
advanced, he went to sea, the sea sickness
came on & the consequent vomiting caused an 


absorption of the matter & the cure of the abscess.
1640. In the cure of bubo we can much increase
the powers of our remedies by the
manner of applying these, & it should be a rule
to endeavor to produce an action if the mercury 
is the part, before we produce its action 
on the system.
1641. We should therefore cause mercurial ointment
to be rubbed on the surface from which 
the absorbents begin, that pass through the affected
part, & as near the part from which the first absorption 
of the venereal matter, as may be, thus
introducing mercury into the system by the 
same road which the virus pursued, & as it were
making the antidote tread on the h eels of the poison.
Q. Thus if a chancre on the prepuce preceded
the bubo, mercurial ointment should be rubbed
on the side of the penis where the chancre formed
itself & on the inside of the thigh, or the scrotum,
belly etc., as the lymphatics from these parts 
take [their] rout through the inguinal glands.
1642. By the early [illegible] of mercury in the manner
recommended (1641) the suppuration of buboes
will commonly be prevented, but should they 
notwithstanding happen to form matter, or should
the matter be formed before the surgeon is consulted;
mercury should be used during the whole
time of maturation, though in a more moderate 
quantity than before, as well as after the bubo


is opened or has burst
Q. Of all the patients Mr Hunter has had under
his care for sixteen years past, only three have 
had buboes, which suppurated, that is of those who
applied to him at the commencement of the
bubo.
1643. If the bubo be to be opened by art, the 
skin should be permitted to come exceedingly 
thin, before the operation is performed, that a 
disposition may have taken place to heal from 
the bottom, previous to exposing the abscess.
1644. The opening may be made either by the
lancet or by the caustic, according to the inclination
of the patient, it should however be small;
when left to the advice of the surgeon, if the skin
be very loose he may use a caustic & the lapis
infernatis is to be preferred, if the skin be not
loose, the lance is best, as thereby none will be 
destroyed; the wound is to be dressed according 
to the nature of the discharge.
1645. Mercury should be thrown into the constitution,
during the whole of the time, from 
the ulceration, untill after the healing of the bubo,
or at least untill the bubo has lost its venereal
appearance, which the experienced surgeon
alone will be able to determine.
1646 Some exceptions to this, are, however, found 
to arise, sometimes the bubo takes on a new
diseased disposition, which mercury increases, the
sore will continue obstinately spreading, and 


413.
the more freely mercury is administered, the 
more progress the ulceration will make. In this
case we perhaps have a scrophulous or scorbutic
habit to encounter, & we shall find benefit,
probably from the use of hemlock & sea bathing,
& from orange & lemon juice.
Q. Sir William Fordyce first recommended
orange & lemon juice, which Mr Hunter has
since prescribed to advantage. gold bacteris water
is in use at the [Lock] Hospital & sometimes
does service.
1647. In some of these cases we have found no 
medicine of any utility, but the disposition has 
at length worn itself out & the ulcer healed.
Q. Case.
A gentleman had a bubo which was opened,
he used mercury two months, still the ulcer continued
without the least disposition to heal.
MR Hunter considering his constitution as too much 
of a mercurial one, & therefore little affected
by that remedy, he left it off, & confined him to 
milk diet etc. for some time; he then [returned]
to mercury again & continued its use for two 
months, when the ulcer became stationary; he 
then again discontinued it, returned to the 
milk & gave cicuta; the ulcer was [sinuous],
the sinuosities were laid open & the patient was
sent to sea, he pursued this plan four months


and returned home without benefit; mercury 
was again ineffectually administered, the
patient at last left off all medicines & at 
length got well.
1648. Another exception to the constant use of
mercury, is that the patients constitution may 
become so habituated to it, that it shall lose 
its power of acting on a specific, in this case we
should discontinue the mercury for a few
weeks & then have recourse to it again.
1649. As the venereal disease may be communicated
by other means than lotion, so buboes
may be formed in other glands as well as in 
those in the vicinity of the parts of generation;
if the infection were received on the lip, the 
bubo would be seated in the neck; if venereal
matter were absorbed from an ulcer or wound
in the finger, we should find the bubo in the
axilla.
1650. In the cure of these, the same principles is
to be kept in view, as if they had formed in the 
groin. (1636-1640)
1651. Some uncertainty must prevail as to the
precise quantity of mercury necessary to be used
for the removal of buboes; where the resolution 
is obstinate, the quantity of mercury should 
be pushed so as to affect the mouth, in general
we may begin with half a drachma of ointment
& increase or diminish according as the bubo 



415.
is affected by it.
1652. When the venereal virus has been absorbed
into the habit & the second genus [advances] 
a variety of appearances are produced,
& there will be according to the following
circumstances.
1653. 1st The time since it was absorbed into the 
constitution.
2d The peculiarities of the constitution.
3d The different solids affected by it.
4th The different dispositions the solids 
were in when they first became affected 
with it.
1654. The time in which the second appearances 
take place after the infection, depends upon the 
nature of the constitution; at a medium the period 
is found to be about six weeks, in some it 
is sooner, in others much later.
Q. A case occurred in which almost the whole
body was covered with general eruptions after the 
breaking out of a chancre.
1655. The deep seated parts, or parts second in order
of susceptibility (1298) do not always come later in 
the action than the superficial parts (1297). as we
have known the periosteum to become diseased 
without any previous affection of the skin or
throat.
1656. We have accounted for the reasons why parts
shall fall into the venereal action, after
other parts labouring under the same diseased 


action shall be cured. (1301, 1304).
1657. We have also shown that venereal matter
does not continue circulating in the blood for 
any length of time, that the secretions are not
contaminated by the venereal matter, nor the
blood rendered capable of communicating the
infection to other persons. But that after the
absorption into the system, it circulates for a short
time with the common mass of fluids, gives a 
venereal disposition to the different solids, having
first undergone a change in its nature & 
is soon thrown out by the different excretions.
1658. The first appearance after absorption is
generally upon the skin, throat or mouth, the
appearance in the throat often precedes the others.
1659. In some the eruption upon the skin appears
in distinct blotches, not very observable untill
scurfs are forming upon them, at other times as
small pimples with inflammation & the pimples 
filled with matter.
Q. In some persons copper colored dry scurfs, or
as it were, cuticles appear, which were thrown 
off from time to time & spread at times to the
size of a sixpence.
1660. When skin is opposed to skin as in the axilla
etc., the above described appearances never take
place, but the skin rises white & smooth, & a whitish
kind of matter is secreted, & they are attended 


417.
with more pain than the former whether
this attends the disease in question only, we will 
not pretend to say.
1661. The hair falls off the parts that are attacked
with it, & so long as the disease continues the [illegible]
hair cannot grow. The fingers are sometimes the 
seat of the disease, & then the nails fall off.
1662. When the throat, inside of the mouth, and
tongue are the seats of the venereal action, an 
ulcer rapid in its progress but without much 
tumefaction is formed; it is foul & has thickened 
or bordered edges, but this is a circumstance attending
all sores that have no disposition to heal.
1663. These ulcers are painful, though much less so
than common inflammation of these parts, & oblige
the patient to speak thick & muffle.
1664. The matter secreted upon [illegible] does not remain
to form a scab, but is worked off in swallowing.
1665. The eyes sometimes become the seat of this
disease, & a venereal opthalmia is produced,
which with difficulty can be distinguished from 
the common opthalmia 
1666. When the disease has been affecting the constitution
for some time, then the parts second 
in order may show the action of the virus, or the
same effect may occur, when it had first appeared
in the external part, & the diseased appearances


there had been cured.
1667. A total deafness is not uncommon at this
time, now & then attended with pain & suppuration
in the ears.
1668. A node often appears several months after
any possible infection; the progress of this is very 
slow, & the consequence of any suppuration is a 
very slimy matter instead of pus.
1669. When the periosteum becomes affected, the 
pain is very considerable, but not always so.
1670. Nodes will sometimes continue several 
years before they [illegible] to suppuration, the inflammation 
being very slow.
1671. Venereal pains are periodical, being more 
particularly severe at night, & in this respect
they resemble rheumatic.
1672. The effects of the venereal disease upon the 
constitution are similar to the effects of all other 
irritations, whether local, or constitutional.
1679. In some a slow kind of nervous fever,
with loss of appetite is produced, as those are
rigors, frequent hot fits, head ach, etc.
1674. In the cure of the disease it may be considered 
as in two extremes, not different in their
nature but requiring a more mild or more severe 
treatment.
1675. In the first genus our senses will generally 
inform us, when a cure is completed, but in the
second genus we labour under great difficulties, 


419
as the virus has circulated in the blood, & we 
know the contaminated solids only by their
showing a diseased action.
1676. The effects arising from the constitution
are local & may be cured locally, but as other
parts may have received the venereal disposition,
although they have yet not come into action,
we must attack [illegible] as now containing the
poison, but as the vehicle carrying the specific
through all the solids of the body, curing present
diseased effects & destroying dispositions which
would have produced future ones. 
1677. It is not clear whether parts which have first
been attacked are easier to cure than those which
took on diseased action later.
1678. If parts be susceptible of cure in proportion
to their susceptibility of diseased action, then the 
parts which are second in order being cured, it must
follow that the parts first in order must have
their diseased disposition & action removed.
1679. The second in order may appear diseased,
when the first have been cured, but the order is
rarely reversed.
1680. Mercury is the true specific remedy for the 
disease, & some other whatever can be depended
on; when taken into the constitution it arises
later with the juices, cures those parts which are
diseased & little affects those which are not 


1681. There are two modes of administering it,
namely,
By the stomach
By the skin.
1682. Like other substances it is more readily 
absorbed from some surfaces than from others.
Q. Mr Hunter observes that a smaller quantity of
calomel is sufficient to salivate by the bowels
than by the skin, & again that using praeciptate
to sores has salivated patients.
1683. In the administration of mercury it is necessary 
to consider 
a The constitution of the patient.
b The quantity of mercury necessary.
c The proportion that will best agree with 
the patient.
d The mode of giving it.
e The regimen necessary to be observed
by the patient during his mercurial
course.
1684. As to the constitution we should endeavor 
to learn whether it be very much disposed
to irritability or indolence; if possible whether 
it be easily or difficultly affected with mercury,
& again the time the constitution has been contaminated.
1685. With respect to the second circumstance
belonging to the constitution, we may, in general, 



421.
Take the history given us of the degree in which 
it has been affected by a given quantity of mercury
on any former occasion, as a guide for our
practice; for it rarely happens that the constitution 
varies much in this particular.
1686. The quantity of mercury must be equal 
to the violence of the disease; but it becomes 
necessary at the same time to consider the
period of time within which a given quantity is
introduced into the system, & the effects of
that quantity on the constitution. Thus on a ounce
of mercurial ointment rubbed into the skin in 
two days, will have more effect on the constitution
& secretions, than two ounces rubbed in 
within ten days.
1687. A large quantity of mercury being introduced 
into the system, a sudden alarm is given, & its
effects are rendered mostly local, consisting in 
the unusual excitement of some sensation.
1688. But if we introduce the mercury slowly 
a very considerable quantity may be thrown 
in, without visibly affecting the constitution.
1689. From a knowledge of these circumstances 
we find mercury a safer & more manageable
remedy than it was supposed to be.
1690. Mercury when first applied affects the
system much more readily, than when the patient j



has been some time accustomed to its use,
we are therefore enabled by beginning with a 
small quantity & going on gradually to throw into
the constitution a much larger quantity than
could other otherwise have been borne by the
patient.
1691. If given with care so as to [illegible] stimulating
any secretory part to action, & thus producing
evacuation, any quantity of mercury
may be introduced that the disease can require.
1692. The effects of mercury are generally in the 
following order.
1st On the salivary glands.
2d On the intestinal glands.
3d On the skin.
4th On the kidneys.
1693. These are sometimes affected singly, sometimes
more than once sometimes all together.
1694. Soreness of the mouth must commonly though
not always, attend the increased secretion of the 
salivary glands.
Q. All parts do not become sore together, but 
severally; the lips may alone become thick & 
inflamed, & the cheeks, or gums become sore
1695. Evacuations by any of the secretions
are of no use in curing the disease, they only 
slow the susceptibility of the secretory organ
to be affected by the remedy; however, they 



423.
afford some evidence of the constitutions being
acted upon by the mercury.
1696. If the secretory organs be too susceptible
of the stimulus of the mercury, it will be difficult
to cure the disease; because the patient will
not bear a sufficient quantity of the specific
to be introduced with the circulation.
Q. A gentleman had a chancre & a bubo, he
rubbed in mercurial ointment once, his mouth
became affected, a slavering came on, the spitting 
was kept up during a month, in which time
the chancre & bubo got well: soon after his
throat became affected with the disease, this 
Mr. Hunter attributed to the too great susceptibility 
of stimulus in the salivary glands, which 
suffered the mercury to be evacuated so fast,
that it has not time or power to affect all the
other parts of the system.
1697. The too ready susceptibility of any secretory
organ should be avoided by proper astringents,
here after to be mentioned.
1690. Mercury can act only upon the constitution 
& upon the poison.
1699. Upon the poison either by destroying its
properties & decomposing it, as.
a By attracting it & carrying it out of the
circulation, together with itself, or
b  By counteracting the venereal irritation 
& producing a new & opposite irritation 



1700. If the latter conjecture be true, then the
readiest way of curing the disease must be
giving mercury so as to produce visible effects
on the disease, yet in such a quantity, as to produce
a different disposition in the system.
1701. It should be given slowly, so as to produce
at length some local effects, yet, however, in 
such a manner, that a quantity may be introduced
into the system, sufficient to cure the
disease.
1702. As a general rule it is right & necessary
to give mercury in such quantities as shall 
produce good effects in the disease yet no ill
ones on the constitution & to continue its exhibition
untill some local irritation is produced.
1703. Of the two modes of throwing mercury [into]
the constitution, if the patients way of life & circumstances
render it convenient, that of rubbing
it into the skin is most eligible & most certain 
in its effects.
1704. If the patient have been unused to mercury,
he should begin with a sample or half a drachm
of the ointment, & rub that quantity in every 
night for four or six nights, & then he may increase 
the quantity to a drachm, & some gradually 
untill two drachms are rubbed in every 
night.
1765. If the symptoms disappear gradually, it 


425.
is right in general to continue the medicine
a fortnight after their removal.
1706. When the mouth becomes affected with 
the mercury we must suspend its administration,
untill the soreness abates.
1707 If the mercury run off by any of the secretions
they should be restrained, no danger
arises from checking a too violent secretion,
although that increased secretion does not arise
from the constitution.
1708. Sulphur has certainly been serviceable
in diminishing too violent a secretion of the salivary 
glands; it what manner it produces this
effect we do not determine; it can only act
upon the mercury after the latter has got into
the blood; probably it is a kind of [illegible]
stimulus; has it any powers of chemically combining
with the mercury in the circulation?
1709 We should distinguish a mercurial salivation 
from a salivation which goes on from habit after
the mercury is evacuated.
1716. Paying has probably no power in diminishing 
a mercurial salivation.
Q. Should it be found that purging has any power
in diminishing salivation, it might be right to
give sulphur in sufficient quantities to act as 
a purgative.
1711. Sulphur certainly enters the blood unchanged
& as sulphur


1712. Should the secretion by the bowels be violent,
we restrain it by opium, which seldom fails
in removing the irritation of those parts, the violent
action of mercury on which is by far more
dangerous than on any of the other secretory organs.
1713. Mercurial sweatings or evacuations by the 
skin we check with most success by the use of 
Peruvian bark.
1714. The increased secretions of the kidneys is not
near so troublesome as the others; bark may be
given as its corrector; but it will sometimes go on 
whatever means are sued to check it.
1715. Mercury probably cures most of the symptoms
of the first stage locally, that is applied to 
the parts by means of some of the secretions; thus
it probably cures the sore throat locally, the 
saliva loaded with mercury moving an anti 
venereal gargle; so also in cutaneous affections
being applied to the skin by means of the 
sweat.
1716. Mercury cannot cut open the venereal 
or any other disease, but in a state of solution
& that in the animal juices.
Q. Mercury cannot act in the body as it does 
out of the body, all the preparations of it undergo 
a change, & after being taken into the system,
a new combination peculiar to the animal 
body is formed, & that is the same whatever 


427.
may be the preparation of mercury employed.
Did mercury act when in the system as it
does on the primae viae, or applied externally, 
the preparations would have different effects; E.G.
[illegible] mineral when in the blood would act
as an emetic in the same manner as ipecac
[illegible] does when thrown into the blood vessels,
but all the preparations of mercury after they 
are dissolved in the animal juices, from one
particular combinations, when dissolved in the 
saliva they have all the same taste.
Mr Hunter held [illegible] mercury in the mouth
for some time, it was very slow in giving the 
proper metallic taste to the saliva, which showed
that it dissolved in the mouth & gave the same
taste.
Calomel did the same, corrosive sublimate held
in the mouth for a time, the acid taste was prevalent,
but that going off; the proper mercurial taste,
similar to that of mercur: calcin: argent [illegible]
etc. took place; introduced by means of the skin in 
to the system, they have all one common effect 
though some are quicker in producing that effect 
than others.
1717. It is however certain that different preparations
of mercury will produce effects upon the systems



& upon the secretory organs at different periods
of time, & will affect different individuals in 
different manners, & that those who are not cured
by one preparation of mercury will bey another,
therefore it is right to try different preparations
when the disease is obstinate.
1718. All the preparations of mercury are readily 
soluble in saliva, mercurias calcinatus is the
most simple & most easily dissolved in the mouth,
mixed with a quantity of opium it makes one of the
most efficacious internal remedies. 
1719. Calomel is in proportion as to the strength & its
effects on the constitution to mercurias calcinatus
as one to three. One grain of calcined mercury 
is equally powerful with three of calomel.
1720. Corrosive sublimate is a powerful preparation
of mercury; its action in curing any diseased
part is mostly local, as being carried to these by means
of some secreted fluid; it cures ulcers in the throat
sooner than any medicine, acting perhaps as 
a gargle. A cure by it, however, is not to be [illegible]
depended upon, as it does not sores to have any 
great powers in the constitution, & relapses more
frequently happen after a supposed cure by corrosive
sublimate, than are by any other preparation
of mercury.


429.
1721. For too small a quantity of mercury only, when 
we use sublimate can be introduced into the system 
to affect a proper change of the constitution, 
it too readily passes off by the skin etc.
1722. [illegible] mercury divided with any substance 
by [fricture] is the weaker of all the mercurial
preparations; fifteen grains of it being only equal 
to one grain of mercurias calcinatas.
1723. A grain of calcined mercury may be taken
every night, for five, six or seven nights; if an affection
of the mouth be thereby produced, the quantity
may be increased.
1724. Either of these may be joined by gum guaiacum 
(  ) in a dose & will in general produce
cure of the symptom in a month.
1725. If the symptoms disappear suddenly, for
instance in the first eight days, it will be still 
right to persist in the use of the remedy, a considerable
time, & even when the suppuration gradually 
decreases, it will not be improper to procure
in the use of the remedy for a fortnight
afterwards, & this whether the external or internal
matter be employed; for we should always 
consider the danger of having incurred a more
real disposition in some parts not yet come into
action. In the first stage it is much easier to 
[illegible] the symptoms than to rid the constitution of 



the specific disposition.
1726. If mercury be given internally in a saline
form or sublimate, or formed into a salt with any 
acid it may meet with in the stomach, regard
is to be had to the irritation it may produce
on the stomach & primae viae; if they be disposed
to irritability, opium & essential oil may be administered
with it, or alkaline medicines accompany
its exhibition.
Q. It is with this view probably that mercuries
is [presented]
1727. In general if mercury be properly administered 
the constitution may be cured in six weeks.
1728. In the second or worst stage as affections of
the periosteum, tendons, ligaments & bones, a 
more severe course is to be pursued, & mercury is
often required to be given in the largest quantities
that the patient can with safety bear.
1729. Here we must begin with a large quantity 
at first, in order as it were to surprise the system
& we should produce a sensible effect in five
or six days, & a soreness in the mouth in twelve 
days; here the quantity of mercury employed will
be so great, that it is scarcely possible to prevent
a salivation.
1730. In this case, more attention will be required
to the patients diet, as he will not be able 



431
to eat solid food from the soreness if his mouth
& yet will require his strength to be supported; [illegible]
wine, sage etc. will be proper viands.
1731. In our use of the mercury we are to observe
that in this stage it is easier to cure the constitution
necessary to persist in the use of mercury
untill all the local complaints are removed,
as the parts may remain in a diseased state
after every venereal disposition is removed.
1732. Topical remedies will be useful in this
stage, as will readily be perceived from (1731.
1737. Previous to beginning the mercurial course 
we must make the same enquiries as are directed
to be made preparatory to a less severe course
(  ), that is whether the patient has heretofore
taken mercury, whether lately, & in what quantities.
1734. If he have lately taken mercury, & this is to 
be considered as the continuation of a course already
began, we must begin with a large quantity as two 
drachms of ointment, rubbing the same quantity
into the skin every night if the patient can 
bear it, or even increasing it to ziii, or if he 
have heretofore borne a large quantity of mercury
without inconvenience, we may proceed
with similar boldness.
1735. But if the patient have not been used to 
mercury, or be weak & irritable, we must proceed
with more caution. One drachm of ointment


is as much as we should [illegible] to employ.
1736. Mercury in any stage can only cure the constitution 
by being absorbed into the system. This we
must be aware of, & therefore if the surface of
the skin will not absorb it, we must give it internally;
if the absorbents of the bowels will not 
take it up, no more than those of the skin, the case
of the patient is really deplorable, the cure
impossible.
1737. Some particular local affections in this
stage deserve attention, as 
Nodes
1738. If the affection of the periosteum or bone
have proceded no further than inflammation 
& swelling, in general no particular application
is necessary, but the venereal virus only will 
be required to be destroyed.
Q. We perhaps shall not be surprised at the length
of time which m ay elapse between a venereal 
disposition being given to a bone & the time of its 
action on a bone appearing; for we see not only 
that the venereal virus is slow in its operation,
but that processes of all kinds in bones go on
with tediousness & difficulty.
1739. Sometimes, however, it will be otherwise,
then they may be covered with mercurial plasters
or rubbed with the ointment, the latter is best. 
Q. Why does mercurial ointment cure nodes?



433.
It cannot be by the mercury acting locally by 
contact, it must be either by means of the system
or by sympathy.
1740. If these do not succeed we must try the
effect of a new inflammation; blisters applied
round the node have removed the pain & assisted
the cure. If blisters fail as incision should 
be freely made in the diseased part, that by the
processes of inflammation a new disposition m ay 
be found in the parts & the nature of a common 
sore produced.
1741. As parts may remain in a state of disease 
after the venereal virus is destroyed the constitution
cured, we may often very safely leave the
nodes to time, which will not uncommonly affect
a cure, but sometimes however a particular local
treatment will be necessary.
1742. Nodes are often blended with the abscesses, which 
seldom produce good matter, but generally a kind
of slime or mucus which lies flat on the bone & 
renders it difficult to determine whether there 
is a fluid underneath & of what kind. In this
cure there is but little of the adhesive inflammation.
1743 Inducing violence of action in the diseased
parts here, facilitates the cure by destroying the present
irritation, we should therefore make free openings.
Exfoliation may more readily take place 


is bone affected with the venereal disposition, than
with any other dispositions, because here we have
a specific remedy by which we can correct the present
disposition.
1744. When a node occurs in a tendon, if blistering
do not relieve. The tumor should be laid open, as
a ground work is laid for a very obstinate & disagreeable
swelling, which will neither yield to 
time nor medicine, & must therefore be attacked
locally.
1745. As in the other genus, so here also, new dispositions
may be taken by the parts affected, which 
it may be difficult to distinguish from the venereal 
dispositions, & therefore may render it difficult
to determine, when the cure of the venereal
virus is affected.
1746. To these new dispositions mercury may be 
a poison increasing instead of lessening the evil,
many of these will take on a cancerous appearance.
Q. A poor woman in St James’s Workhouse had
venereal complaints for which she underwent a 
course of mercury; she had ulcerations in her 
face which took on a new disposition, seeming 
cancerous: hemlock was applied internally 
& externally, & she got well after losing but part
of her nose & part of her right cheek; in twelve
months she relapsed, hemlock & other means were
tried in vain, for she died of the complaint.s



433.
1747 Ulcers in the mouth & throat often arise during
the use of mercury, these should be distinguished 
from venereal ulcers & treated with bark & 
opium, as gargles.’
Q. One drachm of opium dissolved in water
makes a very useful application to venereal
ulcers.
1748. In some persons the long use of mercury is
followed by great debility of constitution, with 
all its effects, as profuse sweats, an inclination 
to hectic etc. In this case the general strengthening
plan is to be pursued, bark is useful, but
is [illegible] specific. Scrophula seems to have something
to do in the present case, & this is rendered the
more probable by the disposition giving way.
1749. Sarsaparilla has no power over the venereal
virus, it is however very useful & seemingly
a specific for many of the new dispositions,
taking place after the virus is destroyed. It may 
be of use in preventing the formation of such
dispositions & may be exhibited with mercury.
It is best taken in substance & in large doses, or
its extract may be given.
Q. Mr Hunter has given power of sarsaparilla 
mixed with some farinaceous substances made
into a pudding, that the patient may take it in 
very large doses.
1750. Guaiacum has some specific powers over 



the venereal disease; how ar those powers extend
is not ascertained. We can however place
no dependence on this remedy in serious cases.
Mercury is the only true & universal specific, on
it alone can we depend, for it will cure in despight
of every unfavourable circumstances, as
irregularity in the patient, intemperance, [illegible]
etc.
Q. A young man had venereal eruptions and
ulcers in different parts of his body, under the 
arm pits, on his thighs, scrotum etc. some even of
the size of a halfpenny, a poultice of gum guaiacum
was applied to the right arm pit & 
poultice of sarsaparilla to be left, removed every 
day & continued for a fortnight; the sores in
the right arm pit were cured, those in the left
rather worse; left off the sarsaparilla & applied
the guaiacum to the left, which then healed
in a fortnight. Gum Guaiacum zfs joined with 
opium was given three times a day, by which 
means all the eruptions disappeared in a month.
He was allowed to stay in the hospital two or
three weeks after his seeming cure, at the end
of which time eruptions again appeared; recourse
was again had to the guaiacum, but
it had lost its powers. Mercury cured him; this
shows that guaiacum has some specific powers,
though weak ones, over the venereal virus.



437.
Mercury properly applied is the only true specific.
Mr Hunter does not object to his patients
indulging in the usual diet, or taking their usual
exercise, they may indulge in the sports
of the field by day & the bottle at night.
1751. Hemlock is frequently of utility in many 
of the new dispositions which form during or 
after the cure of the venereal disease, especially 
in such as in their appearance give cause
to suspect a cancer.
1752. A salivation will often go on from habit,
long after the mercury is eliminated from the system;
it will sometimes remain for months, though
this is now known rarely to be the case, as the
mercury is seldom given in such a manner as
to produce violent secretions by the salivary 
glands; it is to be considered as a gleet of these parts.
1757. Gargles prepared with Peruvian bark,
gargles of opium, sea bathing & good air are
beneficial. Dr Mead used to recommend tincture
of cantharides which may be tried.
1754. Sometimes the alveolar processes of the teeth 
becoming diseased, may be a cause of keeping up 
the spitting, when this happens we cannot hope 
for a cure untill exfoliation has taken place.
1755.Prevention of the venereal disease is
affected by applications previous to or immediately 
after exposure to infection. 



1756. Application to be used previous to exposure
are such substances as will not suffer the 
venereal matter to come in contact with the
skin.
1757. Venereal matter being immersible with oil
the part exposed may be defended by anointing it
with the most viscid oil that can be procured.
1758. Means to be applied after exposure, are
caustic alkali properly diluted, which will
dissolve the venereal matter, or Garlands extract
of lead, which is a powerful coagulation of 
animal juices & will coagulate the virus. A solution 
of corrosive sublimate is also said to have 
succeeded when other means have been inefficacious.
The End.
January 23d 1786 Edwd Rigby.