ARMY MEDICAL LIBRARY FOUNDED 1836 WASHINGTON, D.C. SURGICAL AND PHYSIOLOGICAL WORKS JOHN ABjgjRNETHY,F.R.S. HONORART MEMBER OF THE ROTAL COLLEGE OF SURGEONS IN IRELAND; OF THE ROYAL MEDICAL SOCIETY OF EDINBURGH ; CORRESPONDING MEMBER. OF THE SOCIETY OF THE FACULTT OB MEDICINE IN PARIS. AND OF THE MEDICAL SOCIETIES OF ABERDEEN, PARIS, BOURDEAOX, PHILADELPHIA, &C. ; .* SURGEON TO ST. BARTHOLOMEW'S AND CHRIST'S HOSPITALS. FROM THE SIXTH LONDON EDITION. EMBRACING REFLECTIONS GALL AND SPURZHEIMS SYSTEM OF PHYSIOGNOMY AND PHRENOLOGY. Complete in two Volumes. vol- i. 'Illtflt LONDON: PRINTED BY LONG MAX, HURST, REES, ORME & BROWN. HARTFORD: REPRINTED BY OLIVER D. COOKE & CO. 1826. Ll'r-y U 4 V VIO CONTENTS. VOL. I PAGE. On the Constitutional Origin and Treatment of Local Diseases . 9 On Nervous and Muscular Disorders......61 On the Effects of Disorders of the Digestive Organs attending inju- ries of the Head ■74 On undefined and undenominated local Diseases arising from Disor- ders of the Constitution........%~ On more defined Diseases, as Carbuncle and Scrofula, arising from Disorder of the Constitution.......97 On Diseases of various Glands, arising from Disorders of the Consti- tution •..........107 On Disorders of Parts which have a Continuity of Surface with the Alimentary Canal ........■*"' On the Causation of other Diseases by those of the Digestive Organs 132 On Aneurisms..........***' On the Origin, Symptoms, and Treatment of Diseases produced by the Ahsorption of Morbific Animal Matter, and which in appear- ance frequently resemble Syphilis . . ■ • • .180 On Pseudo-Syphilitic Diseases becoming well spontaneously ! . 19$" On the Constitutional Origin of Pseudo-Syphilitic Diseases . . 224 On the Effects of Mercury in Pseudo-Syphilitic Diseases . . 231 On Burrowing Sores ......... 246 On Sloughing Sores.........252 On Sores which become indurated in their circumference . . 257 On the Treatment of Pseudo-Syphilitic Diseases .... 265 On Diseases of the Urethra; particularly that part which is sur- rounded by the Prostate Gland.......275 On the Constitutional Origin and Treatment of Diseases of the Ure- thra ............291 On some Effects of Diseases of the Urethra.....296 On Injuries of the Head.........311 On Injuries of the Head, attended with Extravasation of Blood upon the Dura Mater.......... 330 Of Cases of Fungus, or Hernia Cerebri . ... . . 338 On the Concussion of the Brain.......347 On Inflammation of the Pia Mater......362 On Diseases of the Bone and Dura Mater.....367 On the 111 Consequences sometimes succeeding to Venesection . 383 IV CONTENTS. On Inflammation of the Integuments, and Subjacent Cellular Sub- stances ...... ...... 384 On Inflammation of the Absorbing Vessels.....384 On Inflammation of the Fascia of the Fore-Arm . ^92 On the 111 Consequences succeeding to a Wounded Nerve . . 395 On Emphysema..........405 CONTENTS OF VOL. II On the Operation of Puncturing the Urinary Bladder ... 5 On the Tic Doloureux.........1? On the Removal of Loose Substances from the Knee-Joint . . 26 On the Treatment of One Species of the Na-vi Materni . . 34 On Hemorrhoidal Diseases....... . 40 On Fistula; in the Perinseum....... . 50 On Tumours . ........ 63 On Common Vascular, or Organized Sarcoma ... .74 On Adipose Sarcoma ......... 79 On Pancreatic Sarcoma ......... 83 On Cystic Sarcoma . . ■ . . . • . • .89 On Mammary Sarcoma . ........91 On Tuberculated Sarcoma . . . • .* . • • .94 On Pulpy or Medullary Sarcoma .......97 On Carcinomatous Sarcoma . ..... . 104 On Encysted Tumours......... 127 On Chronic and Lumbar Abscesses ...... 143 Cases of Lumbar Abscesses dispersed without being opened . . 161 Cases of Lumbar Abscesses that have been dispersed after their con- tents have been discharged........163 Cases of Lumbar Abscesses becoming permanently open . . . 171 Hunterian Oration, delivered before the Royal College of Surgeons in London.....•.....3 Reflections on Gall and Spurzheiin's System of Physiognomy and Phrenology...........41 PHYSIOLOGICAL LECTURES, delivered before the Royal College of Surgeons in London. INTRODUCTORY LECTURES, on the Theory of Life and Diseases. PHYSIOLOGICAL LECTURES, exhibiting a General View of Mr. Hunter's Physiology, and of his Researches in Comparative Anatomy. CONSTITUTIONAL ORIGIN AND TREATMENT OF LOCAL DISEASES 5 ON ANEURISMS, AND ON DISEASES OF THE URETHRA BY JOHN ABERNETHY, F.R.S. HONORART MEMBER OF THE ROTAL COLLEGE OF SURGEONS IN IRELAND ', OF THE ROTAL MEDICAL SOCIETY OF EDINBURGH ; CORRESPONDING MEMBER OF THE SOCIETY OF THE FACULTY OF MEDICINE IN PARIS J AND OF THE MEDICAL SOCIETIES OF ABERDEEN, PARIS, BOURDEAUX, PHILADELPHIA, &C. ; SURGEON TO ST. BARTHOLOMEW'S AND CHRIST'S HOSPITALS. " Chirurgo neceaaariam esse cognitionem Physices, Chimia, Logicea, omnis " (fere) ambitus Medicina; neque aolo manua exercitio veroa chirurgos "fieri." Herm. Boerhaav. Method. Stud. Med. locupletata ab Alb. von Haller. Vol. I. ! r PREFACE. The best mode of obtaining and extending medi- cal and surgical knowledge is, in my opinion, to pay that strict attention to diseases, which qualifies us to note even the slighter shades of difference that dis- tinguish them from each other. Such discrimination leads us to form some regular arrangement of them, which, even if it be not correct, may ultimately enable us to discover their natural series and order. This method I have pursued from the beginning of my professional studies. Whenever the opinions on subjects of importance, which an attention to cases had impressed upon my mind, differed from those which seemed to prevail among other practitioners, I published the facts, and the inferences which I drew from them, because I thought that the former at least deserved attention, and that the latter would either be confirmed or confuted by the result of general experience. It is more, however, on account of the cases, than of the conclusions which they suggested, that I am desirous of republishing my surgical writings. Va- rious advantages result even from the publication of opinions; for though we are very liable to error in forming them, yet their promulgation, by exciting investigation, and pointing out the deficiencies of PREFACE. our information, cannot be otherwise than useful in the promotion of science. The publication of the opinions which naturally arise in the mind of the surgeon, from the cases submitted to his observation, possesses the farther utility of rendering a prolix detail of circumstances unnecessary. It would be almost impossible to re- late every minute occurrence, that tended to impress certain conclusions on the mind of the observer ; or to relate every trifling particular of treatment, by which the surgeon endeavoured to accomplish his object. Such a dull and tedious narrative, which would weary and disgust the reader, may indeed be well spared; because the practitioner may, and must, repeatedly peruse the case at large in the book of nature. The writer merely points out those signs by which any disease may be discrimi- nated from others, and identified as one of the par- ticular class to which he is desirous of exciting the public attention. With regard to the cases, which I consider as the valuable part of the book, I may observe, that it is not to be expected that the records of them will make so strong an impression on the minds of the readers, as the observance of them has done on that of the writer; but when the same oc- currences are met with in practice, then will the impression become more vivid, and knowledge arise, as it usually does, from personal experience. If the facts contained in these volumes occurred so rarely, that others could not be expected to meet with them, their relation would be of little value. They may, however, not improperly be compared PREFACE. •j to certain species of plants, by no means uncommon, which are liable to be confounded with others by an inattentive observer; but when their discriminating characters are once pointed out, they may be so readily distinguished, collected, and examined, as to render a more minute description of them unne- cessary. If diseases could, like other objects which we mean to delineate, be placed in various points of view, and illuminated at pleasure, so as to show dis- tinctly their different parts, one accurate represen- tation would suffice; but we see them obscurely, and as knowledge increases, it serves, like light shining from different places, to illuminate the vari- ous parts of the objects of our examination. For, as I have expressed it in the first edition of these writings, " in proportion as we advance in knowledge, we are led to remark many circum- stances in the progress of a disorder which had before passed without notice ; but which, if known and duly attended to, would clearly point out the nature of the complaint. Hence the records of former cases are of much less value ; as the symp- toms about which we are now anxious to inquire, have in them been entirely overlooked." It there- fore becomes necessary that each writer should state those circumstances to which he has been par- ticularly attentive; nor need he further delineate the case than by a general outline, so as to render it intelligible. The relation of cases may be compared to the representations which an artist gives of natural ob- jects, and which are valuable only in as much as they are correct or vivid delineations of reality. Such 6 PREFACE. portraits/sketched by a person of dull perception or by one whose optics are perverted by prejudice and theory, are either valueless or deceptive; and hence perhaps, has arisen that objection to books of cases which I find to be very prevalent. In the imperfect sketches which I have laid before the public, my chief object has been to touch up and bring into view some parts of the subjects which have not been so clearly seen or strongly delineated by former draftsmen. When books of this kind are published, mutual forbearance is requisite on the part both of the writer and the reader. The former should not ex- pect his work to be approved of, till the latter has examined whether his representation of diseases be correct, and his conclusions legitimately drawn from the facts which he has observed and collected. Neither should the reader condemn the work till he has examined the subject, and is in consequence able to point out the errors of the premises or con- clusions. The author's view of a subject may indeed be correctly formed from the facts which he himself has witnessed ; but it may differ from that which more extensive experience would have suggested. For this difference, no blame can properly be at- tached to him ; he relates what has fallen under his own observation, and invites others to attend to the same facts. I have been induced thus to offer my sentiments respecting the design, mode, and probable advan- tages of recording cases, not with a view of vindi- cating the plan which I have pursued, for that indeed cannot be necessary, since it is the same that has PREFACE. 7 been followed by the best authors on surgery. My object, by these remarks, has been to induce others to reflect how they may most effectually promote medical knowledge. No one can have thorougly studied his profession without perceiving how sus- ceptible it is of improvement, without discerning how inadequate the efforts of an individual must be towards the accomplishment of this purpose, and consequently without feeling an earnest wish to en- gage general co-operation in this desirable object. In republishing my former writings, I have left out all that part which relates to physiology. The surgical facts contained in them will now be found incorporated with my later publications, under the same general head of Surgical Observations. I have also made those alterations and enlargements which a greater share of experience has dictated. The subjects have likewise been transposed. I have put at the beginning of the book those cases which show how much local diseases depend upon the general state of the patient's health, because I shall have frequent occasion to refer to this subject in the succeeding parts of the work. I feel much gratified in finding, that, though a larger portion of experience has enabled me to add some new and striking facts to this edition, it has not shown me any thing that I ought to retract or mate- rially to alter. This, indeed must be the case in a book containing only facts, and opinions not incau- tiously deduced from them. Several of the papers contained in these volumes met with very general and strong objection, which I considered as the greatest compliment that could be paid to them. s PREFACE. For if the views which I had taken of various prac- tical subjects were different from those of others, and were ultimately found to be correct, the greater was the necessity for their publication. SURGICAL OBSERVATIONS. ON THE CONSTITUTIONAL ORIGIN, AND TREATMENT OF LOCAL DISEASES. An evil seems to me to have arisen frorr. the artificial divi- sion of the healing art into the medical and surgical depart- ments. This division has caused the attention of the physi- cian and the surgeon to be too exclusively directed to those diseases which custom has arbitrarily allotted to their care. The effects of local disorders upon the constitution have, in consequence, been too little attended to ; and indeed I know of no book, to which I can refer a surgical student for a satis- factory account of those febrile and nervous affections which local disease produces, except that of Mr. Hunter. * The reciprocal operation of constitutional disorders upon local diseases has obtained still less attention. To investigate more particularly some parts of these subjects, and to sub- mit them to public notice, are the proposed objects of the present paper. No part of the animal body can in general be very con- siderably disordered without occasioning a correspondent derangement in other parts of the system. Such disorder has been considered by Mr. Hunter as the result of universal sympathy. This consent of the whole constitution with its parts manifests itself, in particular instances, by a greater disturbance of the functions of some organs than of those of others; and from this circumstance diseases have derived * Treatise on the Blood, Inflammation, &c Vol. 1. 2 10 ON THE CONSTITUTIONAL ORIGIN, the appellations, by which they are commonly distinguished. If the actions of the sanguiferous system be principally dis- turbed, and the temperature of the body subject to unusual variations, the disease is termed fever: if the nervous sys- tem be chiefly affected, a state of vigilance or of delirium may be produced : and when the functions of the muscular system are more particularly disordered, convulsions and tetanus take place. Though the disorder of particular or- gans thus gives a character and denomination to the dis- ease, it is sufficiently evident, in the instances adduced, that the whole constitution is disturbed ; while certain parts are chiefly affected, perhaps from unknown circumstances rela- tive to the nervous system, or from a predisposition to disor- der existing in the affected parts. It seems to be ascertained, that persons of particular constitutions are predisposed to those febrile actions of the sanguiferous system, which con- stitute the inflammatory fever; that there is a propensity to convulsions in children ; and to tetanus in the inhabitants of warm climates. It may be a fit subject for inquiry, whether it be possible for particular organs to become affected otherwise, than through the medium of the nervous system in general. Though some instances of sympathy are strange, and per- haps inexplicable, there are strong reasons for believing that the inflammatory fever, the state of vigilance and delirium, convulsions and tetanus, which arise in consequence of in- juries of the limbs, are produced by irritation imparted to the brain, which, by a kind of reflected operation, occasions a greater disorder of some of the organs of the body than of others, and thus gives a character and denomination to the disease.* * Mr. Hunter, who, with that patience and industry for>hich he was so re- markable, collected and examined all the facts which he had observed relative to the subject of sympathy, has divided it into continuous, contiguous, and re- mote. It is the remote sympathies, according to his division, of which I am now speaking. The observation's of Dr. Darwin on ocular spectra, and indeed the considera- AND TREATMENT OF LOCAL DISEASES. i 1 That the stomach and bowels are disordered by injuries and diseases of parts of the body, has been remarked by various persons ; but the subject has never been extensively surveyed, nor viewed with that accuracy of observation, which its high importance merits. It has been observed that sprains of tendinous or ligamentous parts produce sudden sickness ; and Mr. Hunter has attributed that shivering which is consequent to accidents, and attendant on some diseases, to the state of the stomach. It is known that in some local in- juries from accident or operations, the stomach has appeared to be the part principally affected. But remarks on the affec- tions thus induced in the digestive organs have been made only in a cursory manner; and it is my intention to examine the subject more particularly. It also appears to me that the connexion of local diseases with the state of the constitution in general is either not sufficiently understood, or not duly regarded, by the generality of practitioners ; and I likewise mean to claim their particular attention to this subject. I shall in the first place select a case to show how the stomach and bowels, or, to speak yet more extensively, the digestive organs, may be affected from local disorder. tion of the nervous functions in general, render it highly probable that sensa- tion is not produced merely by impulses made on the nerves, but by means of actions excited by such impulses, which actions are continued to the senso- rium. Nervous actions, then, may take place without the usually exciting causes: such actions may be continued through the medium of the reticular communications of nerves, and thus physiologically we may explain the conti- nuous and contiguous sympathies. Actions also productive of sympathetic sensations may be supposed to take place through the media of ganglia or plexuses. In remote sympathies, however, we must suppose the actions which originate in an injured or diseased part of the body to be continued to the sen- sorium, and there to excite the actions of other nerves, &c. For a more full account of Mr. Hunter's opinions on these subjects, see the third lecture deli- vered in the Royal College of Surgeons, in London. 12 ON THE CONSTITUTIONAL ORIGIN, Sudden and violent local Irritation will sometimes produce an equally sudden and vehement Disorder of the digestive Organs. CASE I. A healthy gentleman, about twenty-five years of age, was induced to submit to an operation for the return of an adhe- rent omental hernia, rather in order to remove the incon- venience and apprehension which the disorder occasioned, than from any urgent necessity ; for any increased exertion in walking, or riding, produced the descent of a portion of in- testine behind the thickened omentum, and obliged him to stop, and replace it: and he frequently could not accomplish the reduction without considerable difficulty. The applica- tion of trusses had been quite ineffectual in obviating these alarming inconveniences. The patient's diet on the day pre- ceding the operation was scanty, and consisted of fluid sub- stances. He took on the morning of the operation some Epsom salts and manna, which purged him twice, and seemed to have emptied his bowels. A portion of the omentum was cut off, and after two vessels had been tied, the remainder was returned. The operation was followed by general dis- order of the system, manifested by a full and strong pulse, furred tongue, great anxiety, restlessness, and total want of sleep. The stomach was particularly affected, being distend- ed, uneasy on compression, and rejecting every thing that was swallowed. He was bled largely in the evening, and took saline medicines, but could not be prevailed on to swallow any thing else, except some toast and water. The sickness had in some degree abated on the next day. A solution of sulphat of magnesia in mint-water was prescribed in small doses, given at regular intervals, in order to relieve the disorder and distension of the stomach, by procuring dis- charges from the bowels.* In the course of the day he took * It is most probably the disorder of the brain first affects the stomach; but the reaction of the latter affection is liable to increase and maintain the AND TREATMENT OF LOCAL DISEASES. 13 an ounce of the salts, which were not rejected by the , stomach ; yet he could scarcely be prevailed upon to take any thing else. The tongue was still covered by a thick yellow fur ; the skin was hot and dry, and the pulse frequent. As there was no particular tenderness about the hypogastric region, he was not again bled. The second night passed without any sleep. As the salts had produced no effect, the same medicine was ordered in an infusion of senna, with the addition of some of the tincture, which, by being given in Very small doses, was retained. When, however, it seemed likely that no effect would result from this medicine, a grain of calomel was given at night, and repeated on the following morning. Still the loathing of food continued. The third night passed, like the former ones, without sleep, and in great anxiety. On the next morning, two pills, containing five grains of the pil. colocynth. and the same quantity of the pil. aloet. cum myrrha, were given every fourth hour. These procured no stool, nor produced any sensation which inclined the patient to believe that they would operate. Again he passed a sleepless night; but, towards the morning, he felt his bowels apparently filling, to use his own expression, and a profuse discharge ensued. A dozen copious, fetid, and black evacuations took place between five and ten o'clock, and he had several others in the course of the day ; after which his appetite returned, his tongue became clean, and a sound and continued sleep succeeded. That the chylopoietic organs were the parts chiefly affect- former, by which it had itself been produced. The effects that result from the sympathy of the whole constitution with local disorder vary greatly both in na- ture and degree. Sometimes the brain is the part chiefly affected , on these occasions the nervous energy appears to be much impaired ; and in some in- stances of this description, the patient gradually sinks, little fever or reaction of the constitution being observed; in other instances, however, there is a low delirium, with a slight degree of febrile action ; and in others again, the delirium is more violent, and is accompanied with a proportional increase of fever, subsultus of the muscles, and convulsions. Sometimes other parts of the body or particular organs seem to be principally affected : indeed the va- riety of effects produced under the circumstances alluded to is such as to baflk description. u ON THE CONSTITUTIONAL ORIGIN, ed in this case can scarcely be questioned. The sickness, the tenderness of the parts in the epigastric region, the aversion to food, and the state of the tongue, all indicate that the sto- mach was much disordered. Th insusceptibility of the bowels to thr action of medicines, which would ordinarily have pro- duced discharges from them, and the profuse evacuations which subsequently relieved the patient, prove that these vis- cera participated in the affection. The black colour of the discharges shows, I think, that the secretion of the bile was not healthy, and that the liver was affected with the other chylopoietic viscera. It may be supposed, that the injury done to the omentum might contribute to produce the disorder of these organs, rather than of others. We do not, however, find that such effects commonly succeed to similar operations. The con- sequences in the present case were more severe than might have been expected, if it were not known, that an operation performed on a healthy patient is more apt to produce con- siderable disorder, then when performed on one whose con- stitution has previously sustained the irritation of a disease, for which the operation becomes necessary. It is probable also that the restlessness and anxiety of the patient were aggravated, if not principally caused, by the state of the chylopoietic viscera ; since the relief which took place in those parts on the renewal of secretions into them, certainly removed the nervous and febrile symptoms. That the discharges were the effect of secretion is proved by the absence of alimentary matter in the bowels, in consequence of the action of the purgative administered on the morning of the operation, and the abstinence both before and after that period.* I could relate numerous cases in support of the inferences, which I have drawn from the preceding history; that local * Two instances are recorded in Mr. Pott's works, of the operation for th:; reduction of an hernia being performed where no strangulation existed. See Pott's works vol. iii. pp. 295, 299. edition of 1783. The operation in the case juat related was undertaken upon the authority of AND TREATMENT OF LOCAL DISEASES. 15 irritation acting on the nervous system may affect the di- gestive organs in a very serious manner, and thereby create great disorder of the whole constitution, which is afterward alleviated in proportion to the amendment that ensues in the state of those viscera. Such consequences of great local ir- ritation must frequently occur to every one ; it is therefore unnecessary to adduce more instances to support the opinions here delivered. With respect to the treatment of cases of this description, it may be right to add, that the primary object should be to produce secretion from the irritable organs. In the case which has been related, and in many others recorded in this volume, the effect of secretions occurring from the disordered organs in relieving their irritable state is very manifest. In many instances opium will not prevent continual efforts to vomit, yet when by sulphat of magnesia, or purgatives admi- nistered in the form of pills, and clysters, stools are procured, the vomiting ceases, the stomach retains both food and medi- cine, and general tranquillity of constitution is as suddenly restored. CASE II.* A gentleman fell with his leg between the bars of an iron grating, which served as a window to a cellar. The part was much bruised, the skin grazed, and the tibia broken these cases, which were both successful. I performed a similar operation on a patient whose life had been twice in imminent hazard from strangulation in a case of adherent epiplocele, in which a truss did not keep up the hernia, and (he operation was followed by violent peritonitis, which could only be subdued by such copious and repeated venesection, as endangered the patient's life. These two cases have made such an impression on my mind, that I should be very averse in future to undertake similar experiments. * This Case was printed in the first edition of this paper, but afterward sup- pressed as superfluous. It is now reprinted, because it is a striking evidence of the inexplicable disturbance of the vital energies, which is often the result of various fatal occurrences, though their immediate effects do not seem at all adequate to produce such general disorder. lti ON THE CONSTITUTIONAL ORIGIN, into three or four pieces at its upper extremity. The limb was put up in splints by a neighbouring surgeon, and the next day the patient requested to see me in consultation. I attended for a few days, but every thing went on so well, that I discontinued my regular visits, and only called occa- sionally, without seeing the limb. There was no inflam- mation ; the swelling which had been occasioned by the bruise had subsided, and where the skin had been grazed, two or three trivial ulcers had taken place, which obliged the surgeon to open the bandages and dress them daily. The patient's health had been so good, that about the middle of the fourth week after the accident, he had some friends to dine with him in his room, and afterward played at cards with them, and parted with them, in the evening, in high spirits. In the middle of the same night, the patient sud- denly became delirious, and I was sent for to meet the other surgeon in consultation. The delirium was then so great, that the patient knew not the persons in the room. On looking at the leg, with a view to inquire into the cause of this unexpected occurrence, it was found, that one of the ulcers of the skin on the outside of the limb, on which his position had produced some pressure, had become deep, and apparently penetrated the fascia, so as to communicate with the fractured bone, and thus had converted a simple into a compound fracture. To this event we could not but at- tribute the sudden irritation of the constitution, and the delirium. Opium was immediately given, which quieted this disturbance in a considerable degree ; so that on the next day the pulse was more tranquil, and there was no delirium. On the following day his stomach became affect- ed ; he was sick, could take nothing by the mouth, had the hiccough, and his abdomen was distended like that of a per- son in tympanitis ; whilst the senses and intellect were not disordered as they had been. In this state he continued about twenty-four hours, when his sufferings were ter- minated by death. As some suspicions had arisen that the head or abdomen might have been hurt at the lime of the AND TREATMENT OF LOCAL DISEASES. 17 accident, the body was inspected ; but no injnry of these parts was discovered. Upon examining the leg, it was found that the external wound communicated with the fractured tibia, which was broke into several pieces; some of the fractures, ascending in a perpendicular direction, communi- cated with the joint of the knee. In this case the disease was of too short duration for observations to be made re- specting the secretions of the chylopoietic organs ; but it was evident that there was a complete atony of the stomach and intestines. A slighter Degree of continued local Irritation will produce a less violent Disorder of the digestive Organs. If, then, vehement local irritation can produce a violent disturbance of the chylopoietic organs, it may be expected that a less degree of a similar cause will produce slighter effects of the same nature. Indeed, the foregoing case was related not merely because it seemed worthy of record by itself, but chiefly to prepare the reader for the observations which are to follow. This slighter degree of disorder occurs in the advanced stages of lumbar abscess, diseased joints, compound fractures, and all kinds of local disease, which impart considerable and continued irritation to the whole constitution. We. also find a less important disease, as for instance, a fretful ulcer, keep up a disorder of the system in general, and of the digestive organs in particular, which subsides as the irritable state of the ulcer diminishes. But as practitioners in general may not perhaps havesoattentively remarked these circumstances as to be familiarly acquainted with them, it may be useful to notice a very common occurrence, which cannot have es- caped observation. I allude to the effects of the irritation of teething upon the health of children. The brain is some- times so affected as to cause convulsions; the digestive or- gans are almost constantly disordered. The appetite fails; 9 Vol. I 3 IS ON THE CONSTITUTIONAL ORIGIN, the tongue is furred ; the secretions of the liver are either suspended, diminished, or vitiated. The bowels are either purged or costive, and the faeces fetid. The faecal matter is often mixed with mucous and othersecretions. There is also frequently a very troublesome cough. Such symptoms gene- rally subside when the local irritation ceases, but sometimes the disorder of the digestive organs, thus excited, continues and disturbs the general health of the patient. If local irritation be capable of disordering the bowels, it seems natural to conclude that it acts upon them through the medium of the brain. If also the brain and nervous system should be disordered, without any apparent local disease, similar derangements may be expected to take place in the functions of the digestive organs. In cases, where some morbific poison has been absorbed, producing effects similar to those of syphilis, we usually find the irritation of the con- stitution which ensues, to be accompanied with this slighter disorder of the chylopoietic organs. Whenever, also, the nervous energy and general powers of the constitution have been weakened and disordered by any violent disease, as fever, smallpox, measles, hooping-cough, &c. the digestive organs are frequently affected in conse- quence, and such affection becomes, as will afterward be ex- plain ed, the cause of many secondary diseases. In persons, likewise, who have naturally a weak or irritable state of the nervous system, we find the digestive organs dis- ordered in a similar manner. Improprieties in diet will also produce a similar state of irritation, weakness, and disorder of the functions of the digestive organs. This slighter disorder of the chylopoietic organs is, in general, manifested by a diminution of the appetite and di- gestion, flatulence, and unnatural colour and foetor of the excretions, which are generally deficient in quantity. The tongue is dry, whitish, or furred, particularly at the back part; this symptom is most apparent in the morning. The fur is greatest at the back part, and extends along the middle of the tongue to the tip. the edges remaining clean. A? the AND TREATMENT OF LOCAL DISEASES. 19 disease advances, a tenderness is felt when the epigastric re- gion is compressed, and the patient breathes more by the ribs, and less by the diaphragm than in the healthy state. The urine is frequently turbid. In this general enumeration of the symptoms, several cir- cumstances are omitted which occur occasionally, and which ma), when the subject shall be better understood, denote pe- culiarities in the disease, and require corresponding peculiari- ties in the medical treatment. I shall here notice a kw of them. The appetite is sometimes moderately good, when the digestion is imperfect; and the latter may not be defective, although the disease still exists. In some instances, indeed, the appetite is inordinate. Tenderness of the epigastric re- gion on pressure, is not always an attendant, even in advanced stages of the disease. The bowels are alternately costive, and lax even to purging.* The urine is sometimes pale-co- loured, and copious like that of hysterical patients. Patients affected in the mannerabove described commonly declare they are in good health, except that they feel dis- turbed by their local complaints; yet they are found, on in- quiry, to have all the symptoms, which characterize a disor- dered state of the digestive organs. The mind is also fre- quently irritable and despondent; anxiety and languor are expressed in the countenance. The pulse is frequent or fee- ble ; and slight exercise produces considerable perspiration and fatigue. The patients are sometimes restless at night, but when they sleep soundly they awaken unrefreshed, with lassitude, and sometimes a sensation, as if they were incapa- ble of moving. Slight noises generally cause them to start, - and they are, to use their own expression, very nervous. These circumstances seem to me to indicate weakness and irrita- bility of the nervous and muscular systems ; which, in addi- * I have known persons whose bowels were ordinarily costive, and whose general health was much deranged by disorder of the digestive organs, though they were unconscious of its existence, feel pleased that their bowels were in a comfortably lax state ; yet on observing the stools, they resembled pitch in co- lour and consistence. 20 ON THE CONSTITUTIONAL ORIGIN, tion to the disorder of the digestive organs, that has been described, are the chief circumstances observable relative to the general health of those patients, whose cases are related in the following part of this paper. By correcting the obvi- ous errors in the state of the digestive organs, local diseases, which had baffled all attempts at cure by local means, have speedily been removed, and the patient has acknowledged that such an alteration has taken place in his general health, as greatly excited his surprise* A Review of the natural Functions of the digestive Organs^ and an Inquiry into the Signs which denote them to be in a healthy or disordered State. Before I proceed, I may be allowed to enter more fully into a consideration of the symptoms which denote disorder of the digestive organs ; in order to induce surgeons to pay that strict attention to them, which the importance of the subject so well deserves. It would indeed be impossible for the reader to understand, without such prefatory observa- tions, my object in the treatment of the cases which will pre- sently be related, or the opinions which I have formed, rela- tive to their mode of cure. The changes which the food undergoes in the digestive organs of the more complicated animals are threefold ; and distinct organs are allotted to each of the three processes. Digestion takes place in the stomach; chylification in the small intestines: and a third process, hitherto undenomi- nated, is performed in the large intestines. It is probable that in some cases, one set of organs may be more disor- dered than the others, and of course one of these processes may fail more than the rest. For inslancc, the stomach may digest the food in a healthy manner, although the intestines do not perform their share of the changes, which they ought to effect. The food is converted in the stomach into a viscid semi- AND TREATMENT OF LOCAL DISEASES. %\ transparent substance called chyme; and that this change is effected by the agency of the succus gastricus, is a point as well ascertained as any in physiology.* In a state of health this conversion takes place without any appearance of that natural decomposition which animal and vegetable matter Would ordinarily undergo in a warm and moist place. When, however, digestion is imperfect, gaseous fluids are extricated from the alimentary matter. Vegetable food becomes acid, and oils become rancid. Uneasy sensations are also felt, and undigested aliment may be observed in the faeces. Disorder of the stomach is however more readily per- ceived by adverting to the state of the tongue, which often indicates an irritable and unhealthy condition of the stomach, when no manifest symptoms of indigestion occur. If there be no fever to disturb the secretions in general, the change which is visible in the tongue can be imputed to no other causes than its local disease, or a participation in a disorder of the stomach or lungs. Local irritation or mental anxiety will cause a white and dry tongue; but does not this effect arise through the medium of an affection of the stomach ? For although the secretions of the tongue must partake of the general disturbance which prevails in fever, their espe- cial disorder may be, in that case also, not improperly at- tributed to the state of the stomach. The state of the tongue is, in general, an infallible crite- rion of a disordered condition of the stomach; but it does not point out the kind and degree of that disorder. In re- cent and considerable affections, where the appetite is lost, and the digestive powers are greatly impaired, the appear- ances of the tongue are by no means so strikingly unhealthy as in more confirmed cases, where neither the appetite nor digestion appear materially deficient. It is probable that a continuance of irritation in the stomach may so affect the tongue, as to render unnatural secretions habitual to the part, and that these exist independently of the original cause, or * Vide the Fourth Physiological Lecture. $2 ON THE CONSTITUTIONAL ORIGIN, may be reproduced by trivial degrees of disorder. Nay? sometimes the cuticle of the tongue seems to have lost its transparency, and to become permanently white, in conse- quence of continued irritation.* After making the allowances, which such circumstances require, we may in general be enabled to detect a disordered state of the stomach by observation made on the tongue ; and, as it is of consequence to ascertain such disorder at an early period, when the symptoms are probably slight, this organ should be observed in the morning, when it will be found much furred, particularly at the part next the throat. Its appearance may vary in different parts of the day from varieties in the state of the stomach, depending on the ex- citement which is derived from food, or a state of irritation arising from too long fasting. The tongues of many persons with disorder of the stomach look moderately healthy during the day, though they have been so much furred in the morn- ing, that it has been deemed necessary to scrape them. A disordered state of secretion, either as to quantity or quality, will be the natural effect of irritation of a secreting organ. This is evidently the case with the tongue ; and we may, with great probability, conjecture that the same conse- quence also takes place in the stomach. As likewise the juices of the stomach are the immediate agents in digestion, that process must be disturbed in proportion as its secretions are deficient or vitiated. If undigested matter pass from the stomach into the intes- tines, it can scarcely be supposed that their powers are capa- ble of converting it into chyle ; and it may become irritating to those organs in consequence of the chymical changes, which it may then undergo. When digestion is imperfect, animal and vegetable substances experience considerable chymical changes before they leave the stomach; and similar * In hectic fever, although the stomach may be very weak, the tongue is generally clean; it is therefore probable that the foulness of the tongue denotes irritation of the stomach, and not mere weakness when accompanied with tran- quillity of that organ. AND TREATMENT OF LOCAL DISEASES. 23 changes may continue to take place during the time they are detained in the bowels, unless counteracted by the powers of the digestive organs ; powers which seem chiefly to belong to the fluids which are secreted into them. The extent of the power which the intestines possess of converting what they receive from the stomach into chyle, or of preventing chymical changes, is unknown. It is pro- bable that much undigested matter is absorbed by the lac- teals, when the digestive powers fail in their functions. This is apparently the case in diabetes, where the vegetable mat- ter floats in the serum of the blood, rendering it turbid, and afterward combines so as to form a substance resembling sugar in its passage through the kidneys. The 6trong odour, which various kinds of food impart to the urine, indicates that different substances are absorbed indiscriminately from the intestines. It is probable that a turbid state of the urine, and variations from its natural colour, and odour when healthy, may very frequently arise from a similar cause ; viz. from the imperfect action of the digestive organs, in conse- quence of which, unassimilated matter is taken up by the lacteals, and afterward separated from the blood in the kid- neys. It may be reasonably conjectured that the same pow- ers, by which the kidneys convert the old materials of our body into that peculiar modification of animal matter, which is dissolved in the water of the urine, and which has been called by the French chymists uree, may also enable it, in a healthy and vigorous state, to dispose of much unassimilated substance in the same way. The further consideration of the subject would, however, lead to a discussion foreign to the purpose of the present paper: it will be sufficient to remark at present, that the state of the urine may afford assistance in ascertaining the existence of disorder of the digestive or- gans, and in indicating its nature. It has been already men- tioned in the brief account of the symptoms, that the urine is frequently turbid. It should, however, also be observed, that the quality of the urine geatly depends on the state of the nervous system. It is frequently, in the disorders of 24 ON THE CONSTITUTIONAL ORIGIN, which I am speaking, pale-coloured and copious; which is probably owing to a state of nervous irritation, such as exists in hysteria. It is probable that disorders of the digestive organs, by causing the frequent secretion of unnatural urine, may produce irritation, and subsequent disease of the kid- neys, and other urinary organs.* Modern physiologists seem to agree in the opinion that the succus gastricus is the agent, by which digestion is effect- ed ; but they are not so unanimous as to the immediate cause of chylification. It is not improbable that the succus intes- tinalis is a principal agent, although its qualities have not yet been inquired into ; for, indeed, the investigation would be attended with difficulties almost insuperable. Since the bile and pancreatic liquor are poured into the intestines, at a small distance from the stomach, it is natural to consider these fluids as useful in effecting the change, which the alimentary matter undergoes in the small intestines, namely, its conversion into Chyle. The chyme, or aliment digested by the stomach, being viscid, the pancreatic juice has been considered as a useful and necessary diluent, and perhaps this fluid may have other properties with which we are unacquainted. The uses of the bile have of late much engaged the atten- tion of physiologists. Mr. Hunter observed that it did not seem to incorporate with the chyle : and it certainly cannot do so and retain its own nature, since its colour and taste are so intense, that it would impart these properties to the chyle, if mixed with it in the smallest quantity. The difficulty of conceiving that the two fluids can be agitated together by the peristaltic motion of the intestines, without becoming in- corporated, has led to an opinion that the bile may combine with the alimentary matter, and lose its original properties ; but nothing of this kind is ascertained. Fourcroy thinks that * I have met with several cases in which a temporary suppression, or want of secretion of urine took place, in consequence of disorders of the digestive organs. As the splachnic ganglions supply both the digestive organs and kid- ney?, a community of disorder in them might naturally be expected. AND TREATMENT OF LOCAL DISEASES. 25 the alkali and saline ingredients of the bile may combine with the chyle, and render it more fluid, while its gelatinous and resinous parts may combine with the excrementitious matter. It is, indeed, evident that the bile combines either totally or partially with something separated from the chyle, and exists formally in it, and in a state of health uniformly dies it of its peculiar colour; and therefore it has of late been supposed, that the bile may serve to purify the chyle, by precipitating and combining with its feculent parts.* It has been said in the brief and general recital that has been given of the symptoms, which characterize disorder in the chylopoietic organs, that the stools are of an unnatural colour and odour. Medical men entertain various opinions respecting the colour of the faeces : to me this property seems generally to depend on the kind and quantity of the bile. All the healthy secretions, which are poured into the alimen- tary canal, except the bile, are colourless or white ; if, there- fore, this fluid were wanting, the residue of the aliment would be of the colour, which might be expected to result from its undigested parts combined together. When, for instance, the secretion of bile is stopped by the irritation of teething in children, whose diet is chiefly bread and milk, the faeces are white; when this secretion is obstructed in adults, the stools are pale, like whitish-brown paper. In cases of disease, however, coloured excretions may take place from the bowels. There is great reason for ascribing the discharges in the disease called meleena to a vitiated secretion from the surface of the alimentary canal. I was intimately acquainted with a patient, who suffered repeated and increasing attacks of constitutional irritation. When the disorder was wrought up, as it were to a crisis, he was * In the inquiry into the probable uses of the bile, it ought to be observed, that in many persons, in whom that secretion is either for a considerable time wholly suppressed, very deficient, or much depraved, it does not appear that the nutrition of the body is defective. A further account of the digestive pro- cesses may be found in the fourth of the Physiological Lectures, delivered be- fore the college of Surgeons, in 1817. Vol. I. ' 26 ON THE CONSTITUTIONAL ORIGIN, forewarned by a sensation, as if his stomach was filling, ot the occurrence that was about to take place. In less than a quarter of an hour he would vomit more than two quarts of a fluid resembling coffee grounds in colour and consis- tence. Shortly afterward very copious discharges of a similar darker coloured and offensive matter took place from the bowels : but a green viscid bile, appearing distinct and uncombined, was intermixed with this. These eva- cuations ceased in a day or two, and the constitutional irrita- tion disappeared with them. I examined the bodies of several persons, who died under attacks of this nature, and found the villous coat of the ali- mentary canal highly inflamed, tumid, and pulpy. Bloody specks were observed in various parts; and sphacelation had actually taken place in one instance. The liver was healthy in some cases, and diseased in others. I con- clude, therefore, that these diseases, which were termed haematemesis and melaena, arose from a violent disorder, and consequent diseased secretion of the internal coat of the bowels : and that the blood, discharged when the affection was at its height, did not flow from any single vessel, but from various points of the diseased surface. Indeed I think it probahle, that the profuse discharges, which sometimes follow the continued exhibition of purga- tives, consist of morbid secretions from the bowels them- selves, and not of the residue of alimentary matter detained in those organs. Such evacuations, either occurring spon- taneously, or excited by medicine, generally relieve irrita- tion of the chylopoietic viscera. * * As a direct proof of the secretions of the bowels resembling faeces, I insert the following case, which occurred to Mr. Hallam, an intelligent and experi- enced practitioner residing in Wolworth Road. He delivered a patient of a fine muscular, fat, and healthy child, but which had an impervious oesophagus, so that no food ever passed into its stomach. The cuild lived for thirteen days, and was so wasted that its skin hung like a loose garment, and could be folded and lapped over its limbs. At first the child discharged the usual quan- tity of meconium from the bowels, and afterward had, during eight days, one or two alvine evacuations, in quantity, colour, and consistence, not distinguish- AND TREATMENT OF LOCAL DISEASES. 27 • It seems probable that the stools which resemble "pitch are principally composed of diseased secretions from the internal surface of the intestines, since they do not seem either like the residue of the food or discharges from the liver. Can we suppose that all the black and fetid matter which was discharged from the bowels, in the first case that I have related, was poured forth solely from the liver ? The subject of morbid secretions is however particularly illustrated by that well-known alvine discharge, which so much resembles yeast in colour and consistence, that it can- not be confounded with faeces, with blood, or with a vitiated secretion from the liver. A medical man of my acquaint- ance took, for some disorder in his stomach and bowels, an aperient medicine, which apparently emptied those organs. He ate nothing but a little bread in broth for his dinner, and a small quantity with his tea in the evening. He expe- rienced an uneasiness in his bowels, and an inclination to evacuate them after he had gone to bed ; but he resisted this desire till four o'clock in the morning, when its urgency ferced him to rise. He then discharged, what he supposed to amount in quantity to a gallon, of a matter exactly like yeast, unmixed with any bile or faeces. When he arose in the morning, he had a similar evacuation of about a quart; and on the succeeding day there was a solid stool, apparent- ly of the same substance, coloured of a light green from an admixture of bile. He had a natural stool the next day: bis appetite returned, and the uneasy sensations subsided, upon the yeast-like discharge taking place. An unhealthy colour of the faeces may further be attributed to some degeneracy in the quality of the alimentary matter; such as may be supposed to take place when the digestive organs fail in the performance of their offices, and different alimentary substances are in consequence detained in the bowels, where they may pass through chymical decompo- able from the stools of children who take food in the usual fmanner. After the eighth day the discharges per anum became more scanty and less frequent, but they continued to the last. 2» ON THE CONSTITUTIONAL ORIGIN, sitions, and recombinations. B t, though I am inclined to allow the full operation of these causes, the following rea- sons lead me to believe that the colour of the faeces generally depends on the kind and quantity of the bile. In the natu- ral state of the digestive organs, when ther is no peculiarity of diet, and no medicine is taken, the bile alone colours the residue of the food. The fasces voided during a state of disorder of the digestive organs are sometimes partially co- loured ; which circumstance cannot be well accounted for upon any other supposition than that of an irregular secre- tion of the bile. Fluids secreted from the intestines do not usually enter into combination with the faecal matter, but appear distinctly when excreted. Thus we find mucus and jelly discharged from the bowels, unmixed with the faeces. Medicines which affect the liver produce a very sudden change in the colour of the faeces. Small doses of mercury, without any alteration of diet, sometimes change the stools immediately from a blackish to a light yellow colour, which indicates a healthy but deficient secretion of bile. The appearance of healthy bile in the human subject is that of a deep brown, resembling a mass of powdered rhu- barb when just moistened with water. Yet if bile be drop- ped into water, a single drop will die a large quantity of water of a bright yellow, so that the deep brown appearance is the effect of the intensity of the yellow colour. In health there ought to be so much bile poured into the bowels, as when commixed with the residue of the food, to die it of the peculiar colour of bile. It is right, however, to say that the colour of the bile may vary considerably without any ap- parent disorder of the organ which prepares it, or of the health in general. Sometimes, indeed, we find green bile in the gall-bladder, when the liver is not diseased. I cannot, however, but think that the natural colour is a yellow, so intense as to appear brown. Green bile is usually poured out in circumstances where there is evident disorder of the di- gestive organs; and we cannot well suppose that there are two kinds of healthy bile. The quantity of this fluid should AND TREATMSNT OF LOCAL DISEASLb. 291 be such as completely to tinge the excrement of its peculiar colour. By attending, therefore, to the colour of the faeces, the kind and quantity of bile, which the liver excretes, may in general be ascertained. The colour of the alvine excretions in disordered states of the viscera is various. Sometimes they appear to consist of the residue of the food, untinged by bile. Sometimes they are of a light yellow colour, which denotes a very de- ficient quantity of healthy biliary secretion ; they may also be of a deep olive, of a clay brown, and of a blackish brown, all which show a vitiated state of the biliary secretion. Any kind of brown, which dilution will not convert into yellow, I should consider as unhealthy, since the colour of healthy bile is a bright yellow, which by concentration appears brown. Such are the circumstances which I have collected from my own observation, and the reports of others, relative to the alvine excretions, in the disorders which have been de* scribed. I have dwelt thus particularly upon the subject of the biliary secretion, from a belief that its quantity and quality can, in general, be ascertained by inspection, and will there- fore 6erve to indicate the presence of disorder. Whether the foregoing opinions be correct or not, it will, I think, be generally granted that the excretions from the bowels com- monly indicate the healthy or disordered state of the digestive organs. By the state of the faeces we may judge how far digestion has been effected ; and gelatinous, mucous, and other matters being mixed with them, denote irritation or dis- ease of the bowels. The effects, which medicine or diet may have upon the colour of the faeces, ought, however, to be considered. When the food is coloured, and this colour is not altered by di- gestion, it will, of course, appear in the faeces ; hence, if it sliould be thought desirable to know accurately the state of the biliary secretion, it would be right to restrict patients fo f\ diet that is not likely to colour the faeces. The green 3U ON THE CONSTITUTIONAL ORIGIN, colour of vegetables tinges the faecal residue of the food. Steel also is known to blacken the faeces. It should, too, be remarked, that the exposure of the faeces to air after their expulsion, will, in some instances, cause a considerable altera- tion in their colour. In our endeavours, therefore, to ascer- tain whether the liver is performing its office rightly, by ob- serving the colour of the faeces, attention should be paid to these circumstances. I conclude this review of the opinions entertained respect- ing chylification, by observing, that if the succus intestinalis be an agent in this function, disorder of the intestines is likely to affect its secretion, and thus impede this second important part of the process of assimilation. The residue of the alimentary matter, mixed with the bile, passes from the small into the large intestines, and there un- dergoes a sudden change; it acquires a peculiar foetor, and becomes what we denominate faeces. This change is so sudden, that it cannot be ascribed to spontaneous chymical alterations (which would be gradual,) but it must be attributed to some new animal agency. If the contents of the small intestines at their termination, and of the large at their com- mencement, be examined, they will be found totally different, even within a line of each other; the former being with- out foetor, and the latter being in all respects what is denomi- nated faeces. Though chymists, then, might speak of the fe- culent matter of chyle as faeces, yet physiologists would ra- ther apply that term to the change in the residue of the food, which takes place in the large intestines, and which seems to be effected by the vital powers of those organs. The faeces quickly suffer chymical decomposition out of the body, al- though they often remain in the bowels without undergoing the same kind of change. Their chymical decomposition is attended with the sudden formation of ammonia; yet if they be examined when recent, they are found to contain acids, which ammonia would neutralize. The inference, therefore, naturally arises, that this third process, I mean the conversion of the residue of the aliment into faeces, may, among other AND TREATMENT OF LOCAL DISEASES. 31 puposes, be designed so to modify that residue, as to prevent it from undergoing those various chymical changes which might be stimulating to the containing organs, as well as in- jurious to the general health. In a perfectly healthy state of the digestive organs, pro- bably no chymical decomposition, even of the faeces, takes place; yet such changes happen,-in some degree, without apparently producing any injurious consequences. To chy- mical changes we may probably attribute the extrication of inflammable air, and the various and unhealthy odours of the faecal matter, which are observable in disordered states of the digestive viscera. The means by which this modification of the residue of the food, which takes place in the lar^e intestines, is effected, are but little known. Analogy leads us to r< fer it to the ef- fects of a secretion from the lining of those intestines in which it occurs. Now if this secretion deviates from the healthy state, in consequence of an irritated or disordered condition of those organs, we may reasonably expect a corresponding failure of the process, by which the residue of the food is converted into faeces ; and consequently, great irritation will be excited in the lower bowels by their putrefying contents. which may produce especial disease in them.* * The public attention has of late been much directed by Mr. White, of Bath, and others, to the numerous instances of contraction in tLe lower part of the bowels, produced in consequence of this greater degree of disorder occurring in them. To show how much such contractions depend upon the general con- dition of the alimentary organs, and are curable by its correction, I relate the following case, which happened about twenty years ago. A gentleman, who supposed all his complaints arose from piles, applied to me for advice. He had a contraction in the rectum, as high up as I could reach, into which I could scarcely introduce the point of my finger. His tongue was much furred, and the biliary discharges very faulty. When he arose in the morning he immedi- ately felt an urgent desire to void the excrement, and parted with but a small portion, extenuated to the size of a common quill, which was smeared over with mucus and sometimes with a little blood. This urgency to discharge the con- tents of his bowels lasted till about three o'clock of the day, when, after twenty or thirty efforts, he had voided as much faeces as equalled in bulk a scanty diurnal discharge, occurring in the ordinary manner. He then had a respite from his labour and annoyance till the following morninc. He slept well durina 32 ' ON THE CONSTITUTIONAL ORIGIN, Farther Inquiry into the Nature and Effects of that Disorder of the digestive Organsythe Symptoms of which have been recited at Pages 17, 18. Having taken this general view of the functions of the chylopoietic viscera, in order to facilitate the forming a judg- ment relative to those circumstances which indicate their disorder, I return to speak more fully of that affection of them, which I have described, as arising from causes recited at page 17, &c. This subject, it must be acknowledged, is very important, if it can be shown that disorders of the digestive organs are the cause of a great number of other diseases. the night, but as soon as he changed the position of his body from the horizon- tal to the perpendicular direction, his daily disquiet and labour were renewed. I recommended the patient to take a dessert spoonful of castor-oil every night, in order to excite the bowels to carry down the faecal matter in a state likely to pass the stricture, and also to take five grains of the pilul. hydrarg. every second night. I advised him further to throw up as much thin gruel and oil as he could get to ascend every morning before he arose from his bed, in order to liquify the faecal matter and facilitate its passage. This was accomplished by means of a syringe, with double valves, admitting fluid in one direction and propelling it in another, having one pipe immersed in a large basin containing the clyster, and another which was introduced into the rectum. He said he felt the clyster fill the lower part of his bowel and gradually ascend through the stricture, and then he pumped up a little more, till by degrees so much had been injected as to create an uncontrollable desire to evacuate the bowels. This augmentation of the contents of the bowels above the stricture probably induced a more effi- cient action of them, for he never failed to obtain so copious a discharge of fe- culent matter as left him in quietude till the following morning. The patient afterward threw up a small opiate clyster, and lay in a horizontal position till the bowels appeared to be tranquil, when he rose, and felt no disturbance during the day. This practice was not continued more than four or five weeks, as it did not appear necessary, for the bowels then relieved themselves in the usual manner. I occasionally saw the gentleman whose case I have just related, for twelve years afterward, and he had no return of the affection of his bowels, though he was not in good health, and often consulted physicians, on account of irregular actions of his heart, and of renal disorder. I may mention, that it is sometimes necessary to introduce a varnished catheter through the stricture, in order to inject a clyster. In relating this case I do not mean to undervalue the use of tents, or bougies, which seem to do the same kind of good that they do in strictures of the urethra, and which should be employed for the same purposes upon the same principles. AND TREATMENT OF LOCAL DISEASES. ^. 33 The inquiry would then not only lead us to discover the source of many disturbances of the constitution, which origi- nate in those of the digestive organs, (for patients have no suspicion of any disorder existing in them,) but would also lead to the prevention and cure of many secondary diseases of a more vexatious and sometimes of a more fatal nature; than those from which they originated. If the tongue be furred at its back part in the morning, when there is no fever, it is reasonable to infer in general that the state of the tongue is owing to its participating in the irritation of the stomach. Such participation produces an alteration in the secretions of the tongue ; they are either deficient in quantity, or vitiated in quality. A state of irri- tation in any secreting surface is, indeed, likely to be attend- ed with the same consequences. It is, therefore, fair to infer, that, when a general disorder of the digestive organs takes place, those fluids, which produce the changes that the food undergoes in them, are deficient or depraved, and consequently that digestion and the subsequent processes must be imper- fectly performed. The liver is likely to participate in the disorder, and the biliary secretion to be diminished or vitiated. This circumstance admits of ocular demonstration ; and I have, therefore, considered it as an evidence of a more or less general disorder of the digestive organs. A very reasonable objection may, however, be made to considering the derangement of the functions of the liver as a criterion of those of the stomach and intestines : since the liver is independent of the latter organs, and may be the subject of a disorder confined to itself. In some cases, also, the alimen- tary canal maybe affected without disturbing the liver. Such circumstances may happen occasionally; but they are not ordinary occurrences, and should be considered as exceptions to general rules, which do not militate against their common operation. In general, affections of the former, influence the functions of the latter; and the state of the biliary se- cretion affords a very useful evidence of a more or Ies? Vol. I. 5 34 ON THE CONSTITUTIONAL ORIGIN, general disorder of the chylopoietic viscera, and should excite our attention to investigate its kind and degree. I have stated, in describing the symptoms which denote disorder of the digestive organs, that the faeces are generally deficient in quantity. This circumstance may be accounted for in various ways. It may be ascribed to diminished or unhealthy secretion of bile, which does not precipitate the usual proportion of feculent matter from the chyle. Persons whose bowels are lax, and not inactive in carrying down- wards the feculent matter, void it daily in deficient quantities. It may be supposed, too, that, either from the deficiency of bile, and consequent want of excitement, or from the effects of disorder, a torpid state of the bowels may exist, which causes them to carry downwards the feculent matter in small quantities. This circumstance may produce a greater ab- sorption of the faeces than what is natural, or an accumulation of them in the colon. That the digestive organs in general were affected in the cases of local disease which I am about to record, is most evident; but I am aware that many varieties of disorder may be included in the general description of the symptoms which I have given. Future observations may lead to further dis- tinctions : but I see no impropriety at present in speaking of the disordered state as general, since it is probable that no material disorder can ordinarily take place in one of the di- gestive organs, without disturbing the functions of the others. When digestion is imperfectly performed, the functions of the intestinal canal will soon participate in the disorder of the stomach. Under these circumstances, the secretion of bile will also probably become irregular. Should disease com- mence in the large intestines, as about the rectum, it disturbs the functions of the stomach, and secretion of the liver, and becomes augmented in its turn by its sympathy with these parts. Should the liver be disordered in the first instance, the stomach and bowels may not immediately sympathize, although they will probably soon become affected. I feel further warranted in considering the symptoms which AND TREATMENT OF LOCAL DISEASES. 35 have been recited in the former part of this paper, as arising from a general disturbance of the functions of the digestive organs, from contemplating the effects of blows on different parts of the belly, which do not seem to have injured the structure of any single abdominal viscus, but yet produce effects denoting a general disorder of these organs. The symptoms have varied in severity, in proportion to the vio- lence of the blow received. In the cases which were the consequence of the more forcible injuries, the symptoms were, a furred tongue; great vomiting, so that the stomach could retain no food ; difficulty of affecting the bowels by medicine; great fever, and even delirium. Indeed, all those effects were produced, which I have represented as arising from vehement local irritation of remote parts of the body. The disorder has generally terminated by a profuse discharge of black and fetid stools, after which the patient has perfectly recovered. On the contrary, where the symptoms consequent on the blow have been less violent, so as not to claim such strict attention, the disorder has continued. Persons who had been previously in perfect health, have become hypochon- driacal, and have had all those symptoms of disorder of the digestive organs, which have been already enumerated as arising from a less degree of local irritation, with such conse- quent diseases as originate from such disorder, and which will be mentioned in the subsequent part of this paper. In order to inquire more particularly into the nature of this disorder of the digestive organs, I have examined the bo- dies of a considerable number of persons who have died of diseased joints, lumbar abscesses, and other great local dis- eases. I knew that these patients had their digestive organs disordered in the manner that I have described, and that in many of them the secretion of bile had been suppressed for a great length of time ; and, when it was renewed, that it was very deficient in quantity, and faulty in quality : yet, on dis- section, no alteration was discovered in the structure of the chylopoietic viscera which could be decidedly pronounced to be the effect of disease. It naturally excites surprise, that such 36 ON THE CONSTITUTIONAL ORIGIN, a state of irritation, and imperfect performance of the natural functions of these parts, should exist for so long a time, as in many cases it is known to do, without producing organic dis- ease ; still I believe it may be set down as a truth, (which has been verified by every observation I have made,) that a state of irritation leads to those diseased vascular actions, which pro- duce an alteration of structure in the irritated parts. However, where the disordered state of the bowels had been of longer duration, I have found the villous coat of the intestines tumid, turgid with blood, and apparently inflamed, and sometimes ulcerated ; and these appearances have been most manifest in the large intestines. Having observed re- peatedly, in dissections of these cases, that the large intes- tines were more diseased than the small ones, it occurred to me that the fact might be accounted for in the following man- ner : If digestion is incomplete, the undigested food must be liable to chymical changes, and the products resulting from this cause are likely to be most stimulating to the large intes- tines. Indeed, in advanced stages of this disorder, mucus and jelly, tinged with blood, are discharged ; and it seems proba- ble that a kind of chronic dysentery may be thus induced. In some instances, where the disorder had existed for many years, the bowels have been diseased throughout their sub- stance ; the internal coat being ulcerated, and the peritoneal covering inflamed, so that the convolutions of the intestines were agglutinated to each other. In these cases the liver, and sometimes the spleen also, were much diseased, being tuberculated in every part. Such is the result of the infor- mation which I have obtained by dissection. Accurate attention to the subject, especially in medical cases, may lead to important subdivisions, which 1 have not yet been able to make. But when I find that irritation of the nervous system, however it may originate, deranges the chylo- poietic organs, and affects the stomach, bowels, and liver ap- parently at the same time, I think it fair to infer that these or- gans are equally operated on by the same cause. Disorders of the brain may affect the chylopoietic organs; and it is well AND TREATMENT OF LOCAL DISEASES. 37 known that this influence is reciprocal. The stomach is said to be chiefly concerned in producing these effects; but the causes of the sympathetic affection are probably more general. A fit of passion has produced jaundice ; and the irritation of teething, in children, frequently suspends the secretion of bile ; so that the stools are not in the least degree tinged with that fluid. If the head can thus affect the liver, it is reason- able to infer that the liver may reciprocally affect the head. It is very difficult to form an opinion relative to this subject; for, in the instances which have been mentioned, the affection of the liver may take place, only because it forms a part of the digestive organs, and not from a direct sympathy existing between it and the head. Still, however, I do not think it unreasonable to conclude that irritation of the other chylo- poietic organs may, as well as that of the stomach, disorder the source of sensation. To display how much hepatic irritation may affect the sen- sorium, and consequently the whole nervous system, I insert the following case. CASE III. A gentleman applied to me with a thickened and tender state of the periosteum of his tibia. This disease had trou- bled him for more than a year, but became at last so ex- tremely painful that he declared he had not slept for three months, and that his life was so intolerable that he resolved to undergo a course of mercury, even though, in the opinion of those surgeons whom he had consulted, his disease was not venereal. The duration of the disease, as it had made no greater progress, induced me to coincide in the opinion which had been given him. His tongue was much furred, his appe- tite was moderate, and he was not conscious that his digestion was otherwise than good. His bowels were perfectly regular. I desired him to take five grains of the pilul. hydrarg. every second night; but before he took them, to remark the colour of the discharges from his bowels, and to observe whether thf 38 ON THE CONSTITUTIONAL ORIGIN, medicine produced any change. In a week's time he called upon me, and said, " I come to tell you the strangest thing that perhaps you ever heard, which is, that I actually do not know the precise spot where the lump on my shin was situa- ted, and doubtless these pills which you directed are a most wonderful compound of opium. The first gave me sleep, which I had not had for three months. After having taken a second, I have slept soundly all night, and felt myself alert in the day. Every other preparation of opium which I have taken, failed in producing sleep, and made me ill during the succeeding day. After all," continued he, " it cannot be the pills that have made me well, for they have had no perceptible effect on me." I asked him, had he, as I requested him, re- marked the colour of the alvine discharges ? He replied, he had, and that before he took the medicine they were (to use the patient's own words) as black as his hat, and now they were the colour of a ripe Seville orange. The great relief arising from the correction of the biliary secretion was not to me so strange as the patient expected. It is doubtless such remarks that have impressed some medical men with the opi- nion, that the liver was the root of the evil in all disorders of the digestive organs. Cases like the present, (and several similar ones will be found recorded in this work,) appear to me highly valuable on many accounts. They show that hepatic disorder may disturb the sensorium, either immediately, or intermediately, by disordering other organs concerned in digestion ; they show how disorders of the abdominal viscera may become the cause of various other diseases, by disturbing the source of sensation and nervous energy; and they further show that unirritating and undebilitating doses of mercury have, proba- bly by their local action in the bowels, a great influence in correcting the secretion of bile, and by this means of relieving hepatic irritation.* * To show how stomachic irritation may induce or maintain a general dis- turbed state of the nervous system, I shall briefly relate the chief circumstances of a disorder which occurred in my own person. Having, in consequence of AND TREATMENT OF LOCAL DISEASES. 39 Nothing in pathology is more generally admitted, than the reciprocal operation of disorders of the head and of the diges- tive organs on each other: yet the exceptions to this general rule deserve to be remarked in a comprehensive examination of the subject. Some persons have great disorder of the di- gestive organs, without any apparent affection of the nervous system ; and even diseases of a fatal nature may take place in the former organs without affecting the latter. Indeed, if we examine any of the most evidently sympathetic affections, we shall find the same exceptions. The stomach generally sympathizes with disorder of the uterus, but it does not inva- riably do so. Many of the symptoms recorded in the description of the state of health of those persons who are affected by disorder in the digestive organs, denote a disturbance of the nervous and muscular powers. When we observe this compound dis- order, we can seldom determine which were the primarily dissection, had some morbific animal-matter imbibed from a cut on my finger, I suffered at first from severe fever, which, subsiding, left me much indisposed. I then became subject, occasionally, to considerable and painful ulcerations of my throat, and to severe rheumatic pains, which almost prevented me from go- ing about. These symptoms left me in the summer, and returned in the win- ter, during three succeeding years. In the second winter, when their recur- rence seemed to have arisen in consequence of catching cold, the rheumatic symptoms rendered me almost a cripple for three months; nor were they miti- gated by any medicine which I took. Exercise on horseback relieved them in a very great degree. I could not exercise on foot, for the plantar fasciae were affected, as were my ankles, knees, elbows, and the muscles of my back. Du- ring the whole of this illness I had no appetite, yet I ate food when it was put on the table. The want of appetite excited no surprise, for I thought it was a natural consequence of general indisposition. At the end of three months, I one day felt sick at stomach for about an hour, but not to that degree as to in- duce vomiting; and whilst this sensation continued, I had not the slightest rheumatic pain about me. I now resolved not to eat till my appetite returned, and even then I gratified it very sparingly, eating only vegetable food, and drinking only water. In one week my appetite became keen, my digestion easy, my stomach tranquil, and I was as free from rheumatism, (a disorder to which I never had been subject,) as at any period of my life. It is also suffi- ciently manifest how much uncomfortable feelings of the bowels affect the nervous system, and how immediately and completely the general disorder is relieved by an alvine evacuation. 40 ON THE CONSTITUTIONAL ORIGIN, affected organs. General nervous irritation may have pre- ceded the disorder of the stomach and bowels, or may have been caused by it. The history will generally show, that the derangement of the digestive organs is secondary. When it arises from local irritation, it can be produced only through the medium of the sensorium. When it is idiopathic, it fre- quently originates in causes which affect the nervous system primarily ; such as anxiety, too great exertion of mind or body, and impure air. Sedentary habits and irregularities of diet are causes which may be supposed to act locally on the digestive organs themselves. Nervous irritability and weak- ness are not perhaps susceptible of a direct cure by medi- cine ; but the disorders of the digestive organs are more cor- rigible by medical remedies. In practice, these require our chief attention ; and if their disorders be corrected, all ner- vous irritation frequently ceases, and health is restored. In many instances the nervous irritation which has induced the disease is trivial, and would soon cease, were it not kept up by the reaction of its effects. Whether this disorder of the digestive organs be primary or secondary, it generally produces irritation in the brain; and thus may cause in many instances actual disease of that organ, as will be stated in the conclusion of this paper. But derangement of the digestive organs arises, in many cases, from established nervous disorder; indeed, there is often reason to suppose that it is dependent on, or connected with, actual disease of the brain. In such cases, the correction of the disordered function of the digestive organs cannot be ac- complished ; and even if it were practicable, it would not cure the nervous disease. It is however highly necessary and advantageous to attend to the disorder of the digestive organs, where it is only a symptom of nervous disease. The relief of the former will often mitigate, though it cannot cure the latter.* * The ingenious Mr. John Bell has of late published an opinion that all ner- vous disorders depend on the circulation of blood in the brain. The opinion is founded on this dogma ; the brain being insensible, there can be no such thing a? AND TREATMENT OF LOCAL DISEASES. 41 The connexion of local disease with general disorder has been often remarked ; it has been formerly attributed to im- purity of the fluids ; a theory which is not irrational. Imper- fect digestion must influence the qualities of the blood, and all parts of the body may be affected from this source. But in accounting for the reciprocal influence of disorders of the head and the digestive organs on each other, the modern ex- planation of these phenomena, by means of sympathies, is perhaps preferable. Afflicting intelligence will destroy the appetite and produce a white tongue in a healthy person; and a blow on the stomach disorders the head. These phe- nomena take place independently of the blood, and can only be explained by admitting that disturbance of one organ im- mediately affects another. The writings of the ancients abound with passages, in which local diseases are attributed to affections of the abdominal viscera, and the same fact has been noticed by several of the moderns. The French surgeons appear to be very solicitous to keep the bowels in a cool and tranquil state ; and Dessault ascribes the origin of erysipelas to a bilious cause. The German surgeons, Richter and Schmucker, attribute many local diseases to gastric affections ; and in Italy, Scarpa views the subject in the same light. The English practitioners seem to have been less attentive to this class of disorders; insomuch that Fischer, a Gerrrfan, who published an account of the state of medicine in this country, expresses his surprise, nervous irritation. Believing similar opinions to be prevalent in the profession, I think it worth inquiring, whether, if the motion of a worm in the stomach produces temporary blindness or convulsions, there be not some nervous irrita- tion ? If a man has his leg amputated on account of a compound fracture, and afterward becomes delirious and dies; I grant that fulness of the vessels of the head will be found on dissection ; but was not the vascular action caused by preceding nervous irritation ? The same fulness of vessels and signs of inflammation are found in those who die of fevers ; but do not the miasmata which cause them affect the brain, and suddenly impair and disturb its energy, and is not then the vascular action a consequence ? I would ask too, practi- cally, docs blood-letting cure disorders in which there is a fulness of the ves- sels of the head ? It must be granted, that in many instances it temporarily alleviates ihem, but in others it fails to relieve, and even aggravates them. Vol. I. 'J 42 ON THE CONSTITUTIONAL ORIGIN, that the English should be so little acquainted with gastric diseases. I know not exactly what ideas these gentlemen may annex to the terms gastric and bilious disorders, since they do not particularly describe them. I have represented the subject in the foregoing pages, as it has appeared to me on the most attentive examination. There is also an excellent dissertation, in which the effects and treatment of disorders of the digestive organs are par- ticularly described, inserted in the eighth volume of the Me- moires de la Societe Royale de Medicine, of Paris, for the year 1806, at page 310, entitled Reflections sur le Traitment de la Manie atrabilaire compare a celui de plusieurs autres Maladies chroniques, et sur les Advantages de la Methode evacuante, par M. Halle. After describing the discharges from the bowels in atrabiliary mania, he observes, that a similar state of those organs is found in other diseases, namely, dropsy, hypochondriasis, accompanied with difficulty of breathing and palpitation, obstinate coughs, and a great number of very different diseases; to all of which the same treatment is applicable. That the extremely prejudicial con- sequences of disorders of the stomach and bowels have been noticed at all times by persons of observation, and particu- larly by those who are in the habit of judging of their state by their excretions, is sufficiently evident. The ancients sought to correct the error by purging with hellebore, and the moderns by more compound purges, to use the words of M. Halle, par le melange de purgatifs resineux et des mer- curiaux. I have not, however, met with any physiological investigation of the nature of these diseases, nor of the ra- tional objects of cure. It is to promote such an investiga- tion, that I have laid before the public the facts which have come under my observation, and the reflections to which they have given rise. In investigating the connexion between local diseases and disorder of the health in general, I can perceive, that failure in the functions and irritation of the digestive organs may act prejudicially on the system in general in various ways. AND TREATMENT OF LOCAL DISEASES. 43 They may produce weakness, for strength and vigour seem to arise from the conversion of our food into perfect blood. They may produce an impure state of that fluid, and they may produce great irritation of the brain, and thus influence the whole body. However, what 1 have to observe respecting the causes and cure of local diseases, will be most properly introduced and best understood after the cases have been re- corded, upon which the opinions have been founded. The result of all these observations, which I havebeen able to make, relative to this subject, has induced me to believe that the disorder of the digestive organs, caused by the va- rious circumstances which have been recited, consists in a weakness and irritability of the affected parts, accompanied by a deficiency or depravity of the fluids secreted by them, and upon the healthy qualities of which the due perform- ance of their functions seems to depend. This opinion is deduced immediately from the consideration of the symp- toms, and confirmed by all the collateral evidence, which we can collect. The duration of the affection, without fatal consequences, shows that it is a disorder of functions, and not a disease of structure. Dissections confirm the opinion. Blows which excite general irritation of the digestive organs, produce also the symptoms which charac- terize the like disorder, when it arises from nervous irrita- tion, or is excited by intemperance. I doubt not but every one will, on reflection, consider the disorders of the diges- tive organs to be of the first importance, and will perceive the propriety of diligently inquiring into their nature, that we may know them when they exist, and that our attempts to remedy them may be conducted on rational principles. This consideration will, I trust, vindicate me for employing so much time in an investigation which, perhaps, some may consider as tedious and unprofitable. 44 ON THE CONSTIUTIONAL ORIGIN, Occasional Effects of Disorder of the digestive Organs. It is generally admitted, that disorders of the chylopoietic viscera will affect the source of sensation, and consequently the whole body ; but the variety of diseases, which may result from this cause, has not been duly considered. It may produce in the nervous system a diminution of the functions of the brain, even so as to occasion apoplexy and hemiplegia, or a state of excitation, causing delirium ; par- tial nervous inactivity and insensibility, or the opposite state of irritation and pain. It may produce in the muscular system weakness, tremors, and palsy ; or the contrary affec- tions of spasm and convulsions. It may excite fever by disturbing the actions of the sanguiferous system ; and cause various local diseases by the nervous irritation which it produces, and by the weakness which is consequent on nervous disorder or imperfect chylification.* Or if local diseases occur in a constitution deranged in the manner which I have described, they will become peculiar in their nature and progress, and difficult of cure. Affections of all those parts which have a continuity of surface with the stomach ; as the throat, mouth, lips, skin, eyes, nose, and ears, may be caused or aggravated by this complaint. I must observe, before I proceed to the relation of cases, that such a disorder of the digestive organs as I have de- scribed existed in every instance. I do not take upon my- self to say that it was the primary cause of the general derangement of the constitution, with which the local dis- ease appeared to be connected; it might have been the consequence, as indeed has been stated in these preliminary observations. * The liability of parts to become diseased in consequence of general disor* der, will probably be in proportion to their weakness, susceptibility, or compli- cation of structure and function. We know that bones, ligaments, and glands, are very liable to be thus affected; and in the Third Lecture at the College, I AND TREATMENT OF LOCAL DISEASES. 4$ Treatment. I shall now proceed to mention the plan which I hare pursued in the treatment of disorders of the digestive organs, when they have been connected with surgical diseases ; and with what degree of success, the following cases will demon- strate. I do not feel altonether competent to give full direc- tions relative to this subject; because I have never attended to medical cases with that degree of observation which would lead me properly to appreciate the efficacy of different medicines, when administered either in their simple or compound forms. The subject is so important, that the public would be highly indebted to any practitioner, who would point out the varieties of these diseases, and the ap- propriate modes of cure. The method of treatment which I have adopted, is simple, and founded on the opinions ] have formed of the nature of the disease, and on physiologi- cal views of the functions of the affected organs. Believing the disordered parts to be in a state of weakness and of ir- ritability, my object has been to diminish the former and! allay the latter. Believing also that the secretions into the stomach and bowels, upon the healthy state of which the due performance of their functions depends, were, in conse- quence of such disorder, either deficient in quantity or de- praved in quality, I have endeavoured to excite, by means of medicine, more copious or healthy secretions. It is a principal object of medicine to give strength and tranquillity to the system at large, which must have a bene- ficial influence on all its parts, and greatly promote the well-doing of every local disease. We cannot reasonably expect tranquillity of the nervous system whilst there is disor- der of the digestive organs. As we can perceive no perma- bave endeavoured to show how dissimilar, or much diversified, diseases may re* •iult from the same general causes. Page 121. 44 ON THE CONSTITUTIONAL ORIGIN, nent source of strength but from the digestion of our food, it becomes important on this account that we should attend to its quantity, quality, and the periods of taking it, with a view to ensure its perfect digestion. First, With respect to quantity : There can be no advan- tage in putting more food into the stomach than it is compe- tent to digest, for the surplus can never afford nourishment to the body ; on the contrary, it will be productive of various evils. Being in a warm and moist place, the undigested food will undergo those chymical changes natural to dead vegetable and animal matter ; the vegetable food will ferment and be- come acid, the animal will grow rancid and putrid ; this is only rendered evident occasionally, when a disordered stomach rejects some of its contents ; then the teeth are roughened and set on edge by the corrosive qualities of the acid, and the throat feels burnt by the acrimony of the ran- cid oil. These effects, though occasionally made apparent, must constantly take place, unless by the digestive powers of the stomach the food is converted into a new substance which is not liable to these chymical changes. Such new and irritating compounds may not indeed materially injure a healthy stomach, but cannot fail to be detrimental to one that is weak and irritable, as well as to the whole tract of the alimentary canal, and thus maintain and aggravate its disor- der. Part of the food thus changed will be imbibed from the bowels, and render the blood impure, from which there is no outlet for various kinds of matter but through the kidneys ; and this ma) prove a cause of foul urine, as well as of the pre- sence of many substances in that fluid not natural to it, and be productive of serious diseases in the urinary organs. Observing the evils resulting from undigested aliment, we surely ought cautiously to guard against them by proportion- ing the quantity of our food to the digestive powers. Nature seems to have formed animals to live and enjoy health upon a scanty and precarious supply of food ; but man in civilized society, having food always at command, and finding gratifica- tion from its taste, and a temporary hilarity and energy re- AND TREATMENT OF LOCAL DISEASES. tf suit from the excitement of his stomach, which he can at'plea- sure produce, eats and drinks an enormous deal more than is necessary for his wants or welfare ; he fills his stomach and bowels with food which actually putrifies in those organs; he fills also his blood-vessels till he oppresses them, and in- duces diseases in them as well as in his heart. If his digestion be imperfect, he fills them with unassimilated substances, from which nutriment cani.ot be drawn, and which must be injurious. In proportion as the powers of the stomach are weak, so ought we to diminish the quantity of our food, and take care that it should be as nutritive and easy of diges- tion as possible. By adopting an abstinent plan of diet, with respect to the quantity of our food, even to a degree that produces a sensation of want in the system, we do that which is most likely to create appetite and increase the powers of digestion. In how great a degree want effects these objects, is evident in those who have been obliged to fast from necessity, or have been much reduced by hae- morrhage. Secondly, As to quality : It is not my intention to discuss the question as to the nature of the food proper for mankind. When the stomach is weak, it seems particularly necessary that it should be nutritive and easy of digestion. I may further observe, that its qualities should be adapted to the feelmgs of the stomach. In proof of this proposition, nu- merous instances might be mentioned of apparently unfit substances agreeing with the stomach, being digested and even quieting an irritable state of stomach, merely because they were suitable to its feelings. Instances might also be mentioned of changes in diet producing a tranquil and healthy state of stomach in cases where medicines had been tried in vain. Neither can such occurrences excite surprise ; for as digestion and the consequent tranquillity of the stomach de- pends on a proper quantity of healthy juices being secreted and commixed with the food, such secretions are likely to be produced by whatever agreeably excites it, and obstructed by whatever has a contrary tendency. 48 ON THE CONSTITUTIONAL ORIGIN, Thirdly, As to the times of taking food : It is evidently the intention of nature that we should put into the stomach a certain portion of food, the excitement of which inducing a secretion of gastric fluid, by its action becomes digested. This office of the stomach being effected, it should be left in a state of repose till its powers are restored and accumu- lated, and thi? return of energy would in health be denoted by a return of appetite. It is probable that three hours may elapse in health before the digestion of a moderate meal is effected, so that the stomach is empty and in a state of re- pose. It is therefore reasonable to allot the same portion of time for the same purpose when the organ is disordered, whilst we have diminished the quantity of our food in order to proportion it to the diminished powers of the organ ; yet instead of pursuing this rational plan of diet, many persons are taking food every third or fourth hour, pleading in excuse for such conduct that they cannot do without it. The truth is, that when the stomach is disordered, the exertion of di- gesting a single meal after its excitement and efforts have ceased, is productive of sensations of languor, sinking, and inquietude, which ought to be calmed or counteracted by medicines and not by food, for a second meal cannot be di- gested in this state of the stomach. We also often tease and disorder our stomachs by fasting for too long a period ; and when we have thus brought on what I may call a discontented state of the organ, unfitting it for its office, we sit to a meal, and fill it to its utmost, regardless of its powers or its feelings. The rules, then, for diet may be thus summarily expressed. We should proportion the quantity of food to the powers of the stomach, adapt its quality to the feelings of the organ, and take it at regular intervals of six or seven hours thrice during the day. It would be well if the public woull follow the advice of Mr. Addison, given in the Spectator, of reading the writings of L. Cornaro, who having naturally a weak constitution, which he seemed to have ruined by intemper- ance, so that he was expected to die at the age of thirty-five, did at that period adopt a strict regimen, allowing himself AND TREATMENT OF LOCAL DISEASES. ' 49 only twelve ounces of food daily.* By this plan of diet he lived to more than one hundred years ; and it is delightful to observe the tranquil,cheerful, and energetic state of mind accompanying his bodily health, and in a great degree in- duced by it. Cornaro found that as the powers of his stomach declined with the powers of life in general, it was necessary he should diminish the quantity of his food, and by so doing he retained to the last the feelings of health. Every thing which we take into the stomach, except food, maybe considered in two points of view; either as a diluent or a medicine. Water is the only diluent, and we are in the habit of mixing alimentary matter and stimulants with it. Diluents probably ought not to be taken during or immedi- ately after our meals, since they would be likely to render the juices of the stomach less efficacious in the digestion of our food. Hunger and thirst seem to be incompatible sensa- tions : a hungry animal would eat to satiety, and the sti- mulus of the food would bring on a discharge of the juices of the stomach, which have the power of digesting the food ; nor is it probable that the sensation of thirst would be expe- rienced till this operation of the stomach is effected. If the sensation of thirst then occurred, water would appease it, with- out frustrating the digestive functions, and being absorbed from the alimentary canal, a certain portion of it would be furnished to the blood, and the surplus would pass off from * I could relate many instances of persons who were much emaciated, some of whom were of considerable stature, becoming muscular and fat upon four ounces of the most nourishing and easily digestible food, taken three times a day. A patient lately gave me the following account of his own proceeding, with respect to diet. He said, When thou toldest me to weigh my food, I did not tell thee that I was in the habit of weighing myself, and that I had lost 14 lbs. weight per month, for many months before I saw thee. By following thine ad- vice I have got rid of what thou didst consider as a very formidable local mala- dy ; and, upon thy allowance of food, I have regained my flesh, and feel as competent to exertion as formerly, though I am not indeed so fat as I used to be. I own to thee, that as I got better, I thought thy allowance was very scan- ty, and being strongly tempted to take more food, I did so ; but I continued in the practice of weighing myself, and found that I regularly lost weight upon an increased quantity of food ; wherefore I returned to that which was prescribed to me. 50 ON THE CONSTITUTIONAL OKIGLN, the skin, lungs, and kidneys. Animals also rest during the digestion of their food, and drink when this is accomplished; and it would be right for patients to imitate this example. How much exertion of body or mind is capable of impeding digestion, is shown in the fourth lecture at the College. Di- luents being requisite, and in many cases particularly useful, toast and water, mint and balm tea, light ginger tea, (when the stomach requires a stimulus,) marsh mallow, and linseed tea, (when mucilage is likely to be useful,) China tea, (when it agrees with the stomach,) may be drank three or more hours after each meal during the night, or early in the morning; for we should take diluents at such times as not to let fluids be in the stomach when the food is received, nor during its di- gestion. By drinking at proper times thirst will be prevent- ed at improper ones, and we shall have no temptation to fill the stomach with liquids when we have taken our food; thus setting it afloat, and diluting the juices of the stomach, upon the agency of which its digestion entirely depends. All stimulants must be regarded as medicines ; vinous li- quors are of this class, and being suitable to the feelings of the stomach, are in many cases very useful, yet they are very liable quickly to pass into a state of acetous fermentation, and to promote that change in the vegetable food contained in a disordered stomach, and thus produce a strong and in- jurious acid. The rule for taking vinous liquors in persons to whom habit has rendered them necessary, may be thus briefly stated. They should not take them during "their meals, lest the temporary excitement they produce should induce them to take more food than the powers of the stomach are capa- ble of digesting, but afterward they may be allowed so much of them as may be required to induce agreeable feelings, or to express the fact more clearly, as is necessary to prevent those uncomfortable sensations which the want of them may occasion; and it may be added, the less they take the better. People deceive themselves on this point. A disordered sto- mach will feel uncomfortable after eating; fermented liquors remove for a time the unpleasant sensations. Potion after AND TREATMENT OF LOCAL DISEASES. 51 potion is swallowed on this account, often without producing permanent tranquillity, and much to the injury of the stomach. Wine-drinkers do not drink wine after every meal, which proves that wine is not necessary to their digestion; and many who confided in this belief have been convinced of their error, by leaving it off, and finding that they digested their food as well when deprived of it, and that such privation greatly contributed to their eventual restoration to health. When stimulants seem requisite, and fermented liquors run into the acetous fermentation in the stomach, spicy and arro- matic vegetables should be substituted,such as ginger,pepper, mustard, &c. Stomachic medicines are given to strengthen a weak sto- mach, to tranquillize an irritable one, or to counteract some morbid peculiarity in the feelings and actions of that organ. There is a time when stomachic medicines seem to be par- ticularly required. About three hours after a meal, when the stomach is exhausted by the labour of digestion, when its morbid propensities are increased by the languor consequent to fatigue; at this period, when persons are in the habit, through ignorance of taking food to appease their distress, they ought, as has been said, to take these kinds of medicines. Even our food must however be considered as exerting a medicinal influence in disorders of the stomach. When that organ is irritable, a vegetable diet and abstinence from fer- mented liquors may tend to tranquillize it. On the contrary, when it is weak as well as irritable, that aliment which is most readily digested is to be preferred, and cordials are some- times beneficial. The effects of food and medicine can never be considered as resulting from their operation on the stomach solely, but from their conjoint influence upon it and the ner- vous system in general. Irritability of the stomach may arise from that of the brain, and unstimulating diet may tend to tranquillize the latter organ, and thereby alleviate the disor- der of the former. On the contrary, a more generous diet may, by exciting the nervous system, produce that degree of energy in its actions, which invigorates the stomach, and tran- quillizes its disorder. It may further be observed in some 52 ON THE CONSTITUTIONAL ORIGIN, cases, that the kind of medicines or diet which is servicea- ble to the stomach, may aggravate the nervous disorder; and on the contrary, that those means which seem to tranquillize nervous irritation tend to diminish the powers of the stomach. Vegetable diet-drinks appear to me very useful in tran- quillizing and correcting disorders of the stomach and bowels, for this is the manner in which they seem to be efficacious in the cure of local diseases. The vegetables prescribed in the different formulae are so dissimilar, that we can scarcely suppose that they act specifically upon the local disease. Even sweet-wort has obtained considerable celebrity. When diet-drinks fail to correct the disorders of the digestive organs, they also fail to produce any amendment on local diseases. Such observations have induced me to believe that they have the utility, which I have ascribed to them, of tranquillizing and correcting disorders of the stomach and bowels. It is allowable to form an opinion from such observations, though 1 am sensible of their invalidity as arguments to prove its truth. Whilst thus, on the one hand, by endeavouring exactly to proportion the quantity of food to the powers of digestion, by adopting an abstinent system of diet, and taking medicines suitable to the condition of the stomach, we endeavour to foster the powers and ensure the tranquillity of this important organ, we ought on the other most carefully to attend to the regulation of the action of the bowels with a view to ensure their tranquillity, for we cannot expect that the stomach will be tranquil if the bowels be otherwise. To produce tran- quillity of the bowels when they are in a disordered state, it is necessary that the residue of the food be daily carried down and discharged from those organs; this is their natural function, and if they fail in its performance, they should be excited by appropriate medicines, yet without teasing them so as to induce what is ordinarily called purging. Purging, occurring spontaneously, shows that the bowels are irritable, and the aqueous and other discharges which take place from them in that condition often relieves their irritability. When purging occurs in consequence of taking medicine, it shows AND TREATMENT OF LOCAL DISEASES. 53 that the bowels have been irritated, and have relieved them- selves in their usual manner. Persons may be purged without having their bowels cleared of the faecal matter which may be detained in them; we should therefore endeavour to ascertain what kind or combination of purgative medicines will excite a healthy action of the bowels, without teasing them or producing discharges from the organs themselves. The best mode of proportioning the degree of excitement to the end designed is to take a dose of a suitable medicine at night, but short of that which may prove irritating; if it fails sufficiently to excite the organs, a similar dose may be taken in the morning ; which also failing, it may be repeated at regular intervals during the day. The principle that should govern our conduct in the administration of purgatives, may be briefly stated, the excitement is to be repeated till the requisite action is induced, yet no single excitement being such as may prove an irritant to the organs. Purging medicines sometimes relieve unpleasant sensa- tions; but they do not in general produce even this effect; and all active purges seem to me to increase disorder. It is natural to suppose that strong stimuli will aggravate the unhealthy condition of weak and irritable parts. I have already expressed my opinion of the manner in which the continuance of purgative medicines, in such doses as do not immediately purge, relieve disorders of the di- gestive organs, by producing morbid secretions which afford considerable relief, both when they occur spontaneously or are thus induced. This plan of practice is what Dr. Hamilton has suggested, and the utility of which he has so successfully elucidated. 1 am aware that laxative medicines may relieve irritation merely by augmenting the natural secretions of the viscera, and thus unloading their vessels ; and also by deter- mining the fluids from the head, when the nervous symptoms are aggravated by a plenitude of the vessels of the brain. As I have found the lenient plan of treatment (that of exciting the peristaltic action of the bowels, so as to induce them to clear out the whole of their contents, without irritating them, so as to produce what is ordinarily called 54 ON THE CONSTITUTIONAL ORIGIN, purging) particularly successful, I have rarely deviated from it. I am not, therefore, warranted from experience in speaking decisively respecting the more free use of purgative medicines. It is difficult, in many cases, to regulate the actions of the bowels either by diet or medicine. They are costive for a time, and then fits of purging come on. The former state must be obviated in order to prevent the latter. Medicines which excite a healthy action of the bowels in one person, are either inert or too active in another. Doses, which would have no effect in a state of health, become purgative in this disorder; a circumstance which shows that the bowels are irritable. There are also instances of the contrary, in which it is exceedingly difficult to excite the actions and secretions of these viscera. At the same time, I have not been inattentive to the error in the biliary secretions which exists in the greater number of these cases. I have endeavoured to correct this error by the administration of such small doses of mercury, as do not irritate the bowels, and are not likely to affect the constitu- tion, even though persevered in for a considerable time. In this state of the digestive organs, calomel, in small quantities, sometimes proves irritating. I have combined it as in Plum- mer's pill, and given one grain every second night. Where this dose produced uneasy sensations, or acted as an ape- rient, five grains of the pil. hydrarg. were substituted in its place ; and even this quantity has been diminished in some cases. When the bowels are very irritable, the hydrarg. c creta has been given.* When it appeared necessary, on account of the biliary secretion, and when the calomel did not irritate the bowels, I have increased the dose. The relief, which arises from the increase or correction of the biliary secretion, in a great number of these cases, shows how much the liver is concerned in causing or aggravating the symptoms in these diseases. * I have mentioned in the second part of these observations, that the pilul. hydrarg. are very uncertain in their effects. AND TREATMENT OF LOCAL DISEASES. 55 There are numerous and undoubted proofs of the utility of Mercury, in correcting and augmenting the biliary secre- tion ; but the mode of administering it has not, perhaps, been sufficiently attended to. I have known patients, who had voided nothing but blackish stools for some months, dis- charge faeces of a light yellow colour, denoting a healthy, but deficient secretion of bile, immediately upon taking such small doses of mercury. The effect of this change on the constitution and spirits has been surprisingly great; though the state o{ the stomach did not appear to be altered. The use of mercury by inunction sometimes acts beneficially in correcting the biliary secretion ; but if the constitution be irritated and weakened by that medicine, the actions of the liver and of the digestive organs in general become disor- dered. Mercury, in my opinion, acts most certainly and effi- caciously, when taken into the bowels, and a much smaller quantity will suffice, when its application is in this manner rendered chiefly local. Facts are wanting to enable us to ascertain whether mer- cury meliorates and augments the secretion of the other di- gestive organs, as it does that of the liver. The stomach fre- quently appears worse during its employment, whilst the stools are considerably better; I have in such cases, discon- tinued the medicine, and returned to it again if the state of the liver made it necessary. When benefit is obtained from a small quantity of medicine, we naturally expect an increased advantage from an augmented dose ; this is so natural an error, that an admonition against it appears necessary. I have observed in some instances, where small doses of mer- cury have unexpectedly affected the mouth, that considerable benefit seemed to arise from this circumstance. Yet it is wrong, in general, to augment the dose of the medicine, so as to create even local irritation in the bowels by it. The various effects of mercury in disorders of the digestive or- gans cannot, I think, be understood, but by considering, not merely its local operation on these organs, but also its action on the constitution at large. When we see the biliary secre- 56 ON THE CONSTITUTIONAL ORIGIN, tion corrected by a few grains of the pilul. hydrarg. as in the second case, we cannot but believe its action to be local* When the medicine is given in larger doses, it exerts an in- fluence on the whole constitution, and alters the state of the nervous system. It thus controls diseases dependent on an irritable and disturbed state of the nervous functions : this I think I shall be able to show by cases related in that part of this book which treats on diseases induced by the absorption of morbific animal poisons ; and thus mercury may relieve dis- orders of the digestive organs by relieving the nervous dis- order which caused them. But when mercury is given in still larger doses, as it is for the cure of syphilis, it never fails to irritate and weaken the constitution, and thus to disorder the digestive organs. Persons who are salivated have, as far as I have remarked, the functions of the liver and digestive organs constantly disturbed by that process. I cannot, therefore, but think that it is wrong to use mercury in hepatic affections to that extent, which would disorder the functions of the liver, if they were previously healthy. In the majority of cases, the disorder has existed for a long time, and has become habitual; therefore it is not likely to be cured suddenly. For this reason, we should adapt our treatment to the more rational expectation of effecting a gradual recovery than a sudden cure. 1 have also known many cases where the liberal use of mercury has completely failed, in which the functions of the liver were even in a short space of time restored by alterative doses of that medi- cine. It seems to me that it is by the persevering use of innocent excitement that this object is soonest accomplished. The most judicious treatment will not remedy the disease if the exciting causes continue to operate ; such as improprie- ties of diet, agitation of mind, sedentary habits, or impure air. Although experience has made me think very highly of the efficacy of small doses of mercury, in exciting and cor- recting the biliary secretion; yet it ought to be mentioned, that in some few cases this medicine fails to produce its AND TREATMENT OF LOCAL DISEASES. 04 usual effects, and that the biliary secretion becomes healthy without its administration. Nor is this surprising, for in general disorders of the digestive organs, one organ is more disordered than the rest, and appears to have been the cause of the whole affection. Thus the liver may disturb the functions of the stomach and bowels, or it may be dis- turbed by them. When the liver is disturbed by the sto- mach its function will become right without mercury, upon the stomach regaining tranquillity and health. The following cases will afford sufficient testimony of the efficacy of such simple treatment as 1 have recommended, and which appears to be well adapted to gradually restoring the healthy actions of the digestive organs in cases of chronic disorder and disease. The treatment must be considered very deficient, as a general account of what can be effected by medicine. In acute disorders of the digestive organs, we know that nauseating medicines, by exciting the secre- tions, often relieve stomachic irritation, and that emetics and other remedies which suddenly and powerfully affect the sto- mach, produce great changes in the state of that organ and of the nervous system, as well as corresponding alterations in local diseases. In some inveterate cases, apparently depending on established nervous disorder, this simple treat- ment has been ineffectual. Under such circumstances, the nervous affection appears to require the principal attention. In investigating the treatment of these disorders, it is necessary to ascertain, not only what medicine is beneficial, but also what change it produces in the circumstances of the disorder. The administration of a medicine may in one case be succeeded by a discharge of bile, and a striking relief from long-continued and distressful feelings; yet the same medicine may be given in many other instances, with- out the same consequence. Was the change, then, in this instance accidental ? or must it be attributed to some un- noticed peculiarity in the disease or constitution ? I have generally explained to the patients the objects which I had in view, in correcting disorders of the digestive organs, Vol. I. n 58 ON THE CONSTITUTIONAL ORIGIN, by saying that there are three things which I consider as right and necessary to the cure of disorder. First, that the stomach should thoroughly digest all the food that is put into it. The patient perceiving the necessity of obtaining this end, be- comes attentive to his diet, and observes the effect which the quantity and quality of his food and medicines have upon his feelings, and the apparent powers of his stomach. Second- ly, that the residue of the food should be daily discharged from the bowels : here, too, the patient, apprised of the de- sign, notes what kind and dose of purgative medicine best effect the intention ; and whether it answers better if taken at once, or at intervals. Thirdly, that the secretion of bile should be right, both with respect to quantity and quality. In cases wherein the secretion of bile has been for a long time deficient or faulty, I recommend, as I have said, unir- ritating and undebilitating doses of mercury to be taken every second or third night, till the stools become of the wet rhubarb colour; that is, of a deep brown formed by the intensity of the yellow colour. This mode of exhibiting the medicine has at least the advantage of being innocent, and if months elapse before the object is accomplished, we cannot wonder at the tardiness of the cure, when we consider the probable dura- tion of the disorder, prior to our attempts to correct it. The patient is relieved in proportion as the end is accomplished, which feelingly induces him to persevere in such innocent mea- sures. By thus engaging the co-operation of the patient, the practitioner will, in my opinion, derive considerable advan- tage in the treatment of the case. Whenever circumstances would permit, I have recommend- ed the patients to take as much exercise as they could, short of producing fatigue : to live much in the open air; and if possible, not to suffer their minds to be agitated by anxiety or fatigued by exertion. The advantages of exercise in ner- vous disorders, upon which those of the digestive organs in ge- neral so greatly depend, appear to me very striking. It were to be wished that we had some index to denote the strength and irritability of the nervous system, serving as the pulse AND TREATMENT OF LOCAL DISEASES. 59 does with regard to the sanguiferous organs. Perhaps the strength, agility, and indefatigability of the muscles may be regarded as the surest evidence of energy of nervous power and bodily vigour. If this were granted, however, it would follow that ma >v persons, possessing great nervous power, have nevertheless great nervous irritability. Many people who are extremely irritable and hypochondriacal, and are constantly obliged to take medicines to regulate their bowels whilst they live an inactive life, no longer suffer from ner- vous irritation, or require aperient medicines, when they use exercise to a decree that would be excessive in ordinary constitutions. The inference which I draw from cases of this description is, that nervous tranquillity is restored in consequence of the superfluous energy being exhausted by its proper channels, the muscles. When, on the contrary, the nervous system is weak and irritable, exercise seems equally beneficial; but caution is here requisite as to the degree in which it should be taken. A weak and irritable patient may not be able to walk more than half a mile without nearly faint- ing with fatigue on the first day of the experiment ; but by persevering in the effort, he will be able to undergo con- siderable muscular exertion without weariness. Does not this imply a considerable increase of bodily strength, and is not the acquisition of strength the chief desideratum in the cure of many disorders ? The nervous irritability, also, when dependent on weakness alone, will proportionably diminish with its cause. In the latter case, the nervous energy seems to be augmented in consequence of our increasing the demand for it. I am induced to make these observations, from a belief that exercise is not employed as a medical agent, to the extent that its efficacy seems to deserve ; of its medical effects I en- tertain a high opinion ; it is however right to direct patients with regard to its use, not to exert themselves for some time previous to a meal, nor for three hours after. I would pre- scribe to my patients the following rules: They should rise early when their powers have been refreshed by sleep, and actively exercise themselves in the open air, till they felt a £0 OF THE CONSTITUTIONAL ORIGIN, slight degree of fatigue: they should rest one hour, then break- fast, and rest three hours, in order that the energies of the constitution should be concentred in the work of digestion ; then take active exercise again for two hours, rest one, then taking their dinner they should rest for three hours, exercise two, rest one, and take their third slight meal. 1 do not al- low the state of the weather to be urged as an objection to the prosecution of measures so essential to health, since it is in the power of every one to protect themselves from cold by clothing, and the exercise may be taken in a chamber with the windows thrown open, by walking actively backwards and forwards as sailors do on ship-board. I also caution pa- tients against sleeping too much ; waking from sleep indicates that the bodily powers are refreshed ; many persons upon first waking, feel alert and disposed to rise, when upon taking a second sleep they become lethargic, can scarcely be awaken- ed, and feel oppressed and indisposed to exertion for some time after they have risen. When the disorders which have been the subject of this paper, have been long continued, they do not admit of a speedy cure ; hence attention to diet, air, exercise, and mental tranquillity, are more decidedly beneficial than medicines. Surgeons in London meet with frequent and convincing instances of the efficacy of pure air. Patients un- der the irritation of a local disease, who scarcely eat or sleep in town, recover their appetite, digestion, and sleep, so sud- denly on their removal into the country, as to leave no room for doubting, that the change of air has produced this beneficial alteration in their health. The whole of the plan of treat- ment which is here recommended is so simple and apparently so inefficient, that its power might reasonably be doubted, did not facts attest its utility. I should not have thought it right to have thus related it in detail, but for the purpose of avoid- ing repetition in the ricital of the cases which are to follow ; and also because it seemed right to state as explicitly as pos- sible to the younger part of the profession what are the cura- tive intentions in disorders of this nature.* Affpr I had written the above account of the treatment which I had found AND TREATMENT OF LOCAL DISEASES. 61 CASES. SECTION I. On Nervous and Muscular Disorders. Long before my attention was excited to disorders of the digestive organs, I had remarked that there was a paralytic affection of the lower extremities, resembling that which is produced by a disorder of the medulla spinalis, in consequence of disease of the bodies of the vertebrae. This paralytic affection also appeared to me to vary with the state of the patient's health. These observations led me to propose a method of treat- ment, which proved successful in the cases of two young ladies, who were affected in this manner. The issues, which had been ineffectually kept open in the back, were healed ; and the state of the health in general was amended by country air, exercise, attention to diet, and a few simple medicines. . The use of the limbs returned in proportion as the health became established. Such were the observations which I had made relative to this subject, when I met with the following cases. CASE IV. A young lady, whose stomach and bowels were disordered in the manner already described, became gradually affected the most successful in the correction of disordered states of the digestive organs, I was much gratified by the perusal uf Dr. Hamilton's publication on the Effects of Purgative Medicines. I think there is a great coincidence in the mode of treatment which I have described, and that which is sanctioned by his more extensive experience. He prescribes purgative medicines to act as eccoprotici, to excite but not to stimulate the bowels ; and he combines with them generally unirritating doses of mercury. Dr. Hamilton's plan of treating these diseases also accords very much with that of M. Halle, to whose Memoir I havo rrfi:rrcd the reader. 62 ON THE CONSTITUTIONAL ORIGIN, with weakness of the lower extremities, and pain in the loins. The pain became at length very severe, and was aggravated in a manner almost insupportable by the agitation of a car- riage. This lady could scarcely walk, and gave a description of the state of her limbs, so exactly resembling that which is sometimes consequent to diseases of the vertebrae, that I thought it right to examine the spine. 1 struck with my finger the spinous process of each lumbar vertebra, and upon touching one in particular, the patient complained of great pain; but pressure on the contiguous vertebrae also caused much uneasiness. Under these circumstances I placed a blister on each side of the spine, and kept up a discharge from the surface by dressing it with savine cerate. These means, with rest, relieved her sufferings; but, as her health declined, she went into the country, where she soon became much better. The blisters were now suffered to heal, and she shortly afterward had recovered so much, as to take long rides on a rough-going horse. She returned from the country in good health, and was both muscular and fat. About a year afterward she was so ill, in the same way, that she wished to have issues made in the back: but I would not consent to this from knowing that the bone could not be diseased. Of this return of pain in the back, and weakness in the lower extremities, she again got well, upon amend- ment of her health in general. Since that period, she has been sometimes very well, at others pale and emaciated; and these changes have corresponded with the healthy or dis- ordered state of her bowels. This lady, who was uncommon- ly healthy and strong, except when disturbed by disordered digestive organs, and who, when so circumstanced, had rheu- matism, dysury, and other local maladies, which are in my opinion caused by such excitement, died about seventeen years afterward, very unexpectedly, of constipation, which could not be relieved by the most judicious treatment. The body was not examined, yet no doubt could be enter- tained of there having been mechanical obstruction; for just before her death a surprising extent of the bowels were pro- truded per anum. AND TREATMENT OF LOCAL DISEASES. 63 CASE V. I was consulted on the case of a young lady, who had been blistered severely for a pain at the bottom of her back, which was chiefly felt at the junction of the ilium and sacrum. It was supposed, that disease had taken place in the bone from some injury, and had affected the sacral nerves: she could not stand without support, so great was the weakness in the front of the thighs. There was no projection of the vertebra?. If the sacral nerves had been affected, the leg ought to have suffered the greatest share of pain and weak- ness ; but that was not the case. She had no appetite; her tongue was greatly furred ; her bowels costive ; and pulse generally 110. I strongly objected to making issues in this case ; but as the patient's sufferings increased, it was done. She went into the country, and died in four or five months. The bone was found, upon examination, to be perfectly healthy; but the mesenteric glands and lungs were diseased, and it was concluded that she died of consumption. I could not learn the state of the liver, nor do I know whether its appearances were particularly attended to. CASE VI. A young lady had been confined about six months to her chamber, on account of pain in the loins, and weakness of the lower extremities, which prevented her from standing or walking. The weakness of her limbs had been gradually increasing for a year and a half, before it became so bad as to make her incapable of moving about. Issues had been kept open during that time, on each side of the spine; but as the patient received no benefit, my opinion was asked re- specting the seat of the disease of the bone ; for it was con- cluded, that the issues had only failed from not having been made in the right place. I found, upon inquiry, that the chief seat of her pain was in the posterior edge of the liver, 0*4 ON THE CONSTITUTIONAL ORIGIN, Indeed, that viscus was enlarged, so as to be felt in the epi- gastric region, and was so tender as to cause much pain on being compressed, at any part, along the cartilages of the ribs. Her tongue was furred ; her appetite deficient; di- gestion bad ; bowels costive ; and stools black, or else un- tinged with bile. I had no hesitation in advising, that the issues should be discontinued ; and that attention should be chiefly directed to rectify the disorder of the chylopoietic viscera. Mild mercurials and aperients were given, by which, with other means, she got materially better in health, and was able to walk about as well as ever. The gentleman who attended this patient, met me accidentally, two months afterward, and informed me that she was quite well. I said, that as her disease had been a long time in forming, it could hardly be expected that she should recover so suddenly. He considered this expression as implying some doubt of his ac- curacy, and, therefore, sent the patient to me in the morning. She came from Lambeth, in a hackney coach, and looked very well; she observed, that long before her confinement, she could not have borne the agitation of a carriage ; but that now, she did not feel it.* I have been informed, by several intelligent students, that similar cases have occurred in the hospital: as I was not a witness of these, I shall not relate them. I shall, however, mention one which I saw, and superintended myself, although it is, in some measure, im- perfect, as the patient quitted the hospital suddenly, without our knowing where he went to. * It can scarcely be doubted but that in this case the functions of the lum- bar nerves were disturbed by disorder of the digestive organs; and I have seen many similar cases. In one which occurred lately, the circumference of the abdomen was benumbed so, that the patient said he knew not that he had any bowels. After his recovery to a certain extent, expressing his surprise and exultation at his amendment, he said, " Sir, I now know that I have bowels; and see, I can walk and stand as firmly as ever." But when I asked him to try if he could stand with his knees a little bent, he found that he was unable, for the muscles on the front of the thighs, which are altogether supplied from the lumbar nerves, had not regained their proper power. \ND TREATMENT OF LOCAL i>iSLASES. 65 CASE VII. Thomas Crighton, aged twenty-three, was admitted into St. Bartholomew's Hospital, on account of a palsy of his limbs. About a year before, while the use of his limbs was yet unimpaired, he was attacked repeatedly with violent pains in the bowels; uniformly preceded by costiveness, and, generally, terminated by a copious discharge of loose, fetid, black stools. The relief afforded by the diarrhoea was speedy and uniform. In the course of six months his lower extremities became affected with occasional twitchings, and he found that he could not regulate their motions in walk- ing ; this increased to such a degree as to make him inca- pable of taking any exercise. He had, at the commencement of his illness, a confusion of vision; and a constant and vio- lent pain in the head. The former symptom increased so much, that he could discern no object distinctly ; a candle, for instance, although held near him, appeared as large as the moon. The sensation of his lower extremities conti- nued perfect; but the actions of the bladder were no longer under the control of the will; the urine sometimes flowing involuntarily ; and, at others, being retained for some hours, with considerable pain. He afterward began to lose the use of his upper extremities ; the left hand and arm were more affected than the right; but there was no difference in the affection of the leg on the same side. His speech, also, be- came much impaired ; he hesitated and faultered considera- bly, and the tones of his voice were irregular, so that at length he could scarcely make himself understood. At the time of his admission into the hospital, there was an entire loss of voluntary motion of the lower extremities, and a great diminution of that of the upper. The bowels were disordered ; there was constant headach; the speech was very indistinct; and vision so imperfect, that he could not read the largest print. An issue was made in the neck, and some medicines were prescribed, under the direction of the Vol. I. 0 66 ON THE CONSTITUTIONAL ORIGIN, physician. As the treatment did not prove beneficial, I was desired to examine the spine, and found such a curvitureand projection of the spinous processes of the upper lumbar and lower dorsal vertebrae, that I thought the bodies of those bones must be diseased. I was, therefore, inclined to attri- bute the paralysis of the lower extremities to this disease of the spine ; and consequently directed, that issues should be made on each side of the projecting vertebras. As this sup- position would not account for the paralytic affection of the parts above, and as the bowels were disordered, I ordered two grains of calomel with eight of rhubarb, to be taken twice a week, and some infusion of gentian with senna, oc- casionally. After using these medicines for about three weeks, his bowels became regular, the biliary secretion healthy, and his appetite good. He could move his hands and arms nearly as well as ever ; and his eyesight was so much improved that he could read a newspaper; indeed, it was nearly well. The functions of the bladder were com- pletely restored ;* his speech became articulate ; and his general health, in every respect, much improved. He remain- ed in the hospital about two months, but with very little amend- ment in the state of the lower extremities, when his friends suddenly removed him, on account of some disagreement with the nurses, and I was unable to learn whither they had conveyed him. The history of the preceding case was taken by Mr. Crutt- Well, who practised afterward as a surgeon in Bath, who had been for several years a most industrious student at the hos- pital, and whose accurate observation and extensive infor- mation induce me to place entire confidence in any statement of a case which I receive from him. To that gentleman I am also indebted for the following particulars relating to a patient, who died some little time ago in the hospital, and * I have seen several cases which induce me to believe that the weakness or irritation of the bladder, which occasions young persons to void their urine during1 sleep, very frequently arises from the same cause. AND TREATMENT OF LOCAL DISEASES. 67 whose body was examined. The dissection serves still fur- ther to elucidate my present subject. CASE VIII. Elizabeth Griffin, twenty years of age, was admitted into St Bartholomew's Hospital in August, 1805, on account of an inability to move her lower limbs, which was supposed to originate from a disease of the spine. On examination, how- ever, there were no appearances which indicated caries of the vertebra;. Her voice was, at times, considerably affected; and she was subject to occasional attacks, resembling, in 6ome degree, epileptic paroxysms. The affection of the limbs was liable to considerable variations. At times, as she assured me, she could walk across the ward with very little difficulty, at others she could not even stand without assist- ance. Her tongue was extremely, and 1 believe constantly white ; her pulse natural. Her bowels were, generally, cos- tive, and it was necessary to employ active medicines in order to procure stools, which were always of a dark colour. A slight temporary diarrhoea sometimes happened, and she invariably remarked, that the ease or difficulty with which she could walk, and the pain in her head with which she was troubled, were in exact conformity to the state of the bowels, all the symptoms being relieved by the diarrhoea, and return- ing as the bowels became again costive. There was an ap- pearance of irritability and languor in the eye, which I have before observed in these cases, and the pupils were generally much dilated. After the patient had continued in the hos- pital about seven weeks, she was attacked with fever, and died. To this brief account of the symptoms, I now sub- join the dissection. No diseased appearances were observed in the brain, though it was examined with the most particular attention: neither was there any disease of the vertebras. No disease, inshort, was observed exceptin the abdominal viscera. The ohief morbid appearance, in them, consisted in an ulcerated 6b ON THE CONSTITUTIONAL ORIGIN, state of the villous coat of the ilium near to its termination in the cascum. The ulcers were numerous, and situated where the mucous glands are chiefly found. The internal coat of the large intestines, also, appeared inflamed. The liver was healthy in its structure. In the gall-bladder about one ounce and a half of a light green serous fluid was found, which had not in the least degree the soapy or mucila- ginous feel of bile. Cases, like those which have been related, are not, if I may judge from my own experience, at all uncommon. They sufficiently prove, in my opinion, that local nervous disorders and muscular debility may arise from a general disorder of the health, in which the digestive organs are chiefly affected. This disorder, as has been stated in the preliminary observa- tions, may, sometimes, be the cause, and sometimes the con- sequence of the nervous affection. In either case, however, its correction is of high importance in the medical treatment of the disease. In the fifth and sixth cases, a disorder of the digestive organs must, I think, be allowed to be the cause of the nervous affection, from the sudden and complete cessation of the latter, when the cure of the former was accomplished. Decisive instances like these are particularly valuable ; they show that great nervous disorder may be produced by that of the digestive organs, and consequently how much the latter disorder is likely to aggravate the former, when it occurs even secondarily as its effect. I have seen a considerable number of such cases, which 1 cannot relate with precision, because I had not sufficient opportunities of observing the patients, to enable me to note the progress of the disease with accuracy. Of these I can only observe, in general terms, that 1 have seen several instances of pain, imbecility, and wasting of the muscles in one of the lower extremities, which were consi- dered as the effect of disease about the hip-joint; yet the event proved that there was no organic affection of that part. The complaint was connected with that state of constitution which 1 have described, and was amended as the health in general improved. I have also seen several instances of AND TREATMENT OF LOCAL DISEASES. 69 wasting of the muscles of one of the upper extremities in children ; so much indeed were the muscles shrunk, that the bones and joints could be as distinctly examined as in a ske- leton. The local affection in these cases came on suddenly. I lately saw a little boy who had an attack of this kind in his left arm several years ago, and on whose case I was at that time cpnsulted. The bowels had been violently disordered previous to the paralytic affection, and were, at the time I saw him, in an extremely unhealthy state ; I recommended that the chief attention should be paid to correct the disorder of these organs, and that the arm should be supported by a sling. The limb gradually recovered, and though it is not at present quite so large and strong as the other, yet the differ- ence is so slight, that it would not attract the attention of a common observer. About six months ago 1 saw a little boy in very similar circumstances, and in his case, the arm quick- ly recovered its powers of motion, as the state of the digestive organs became healthy.* I have also seen cases in children, in whom, after some general disorder of the health, accompanied by derangement of the stomach and bowels, an affection of the muscles of the extremities has taken place, like that which produces the va- rus and valgus ; I mean a predominance of the actions of some muscles over others, producing distortion of the limb. This has happened sometimes in one, sometimes in both the the lower extremities. I have also seen the muscles of the arm and hand similarly affected. That the local symptoms in these cases, as well as in those which have been more fully detailed, arise from some remote nervous affection, and not from any local cause, acting on the nerves of the affected part, will, I believe, on due considera- tion, be granted. 1 suspect, however, that some persons may hesitate to admit such an opinion, from the belief that general * I have, however, met with a considerable number of cases, in which a wast- ing of the muscles of the arm and scapula has been connected with a disease of the shoulder-joint. 76 UN THE CONSTITUTIONAL ORIGIN, disorder must operate generally, and not partially, on the nervous system. Perhaps the contemplation of the conse- quences of slight apoplectic effusions in the brain, may assist us in forming just notions on this subject. Such slight effu- sions of blood, occurring in various parts of the brain, have been known to paralyze one leg or one arm, or the muscles of the tongue, or of one half of the face, without affecting the rest of the nervous or muscular system. Another opinion which I wish to be considered is, whether, when there is considerable and continued paralysis, there must necessarily exist some pressure or organic disease in the brain. That this exists in many instances is undoubted ; but the number of cases in which the paralytic affection is merely nervous, and independent of visible disease, is, in my opinion, very considerable. The instances which have been related, warrant this conclusion, and show such cases to be more fre- quent than is generally supposed. When there is organic disease of the brain, the case is very hopeless ; and probably no considerable alleviation of the symptoms will take place, by that attention to the state of the digestive organs which I have recommended. In dubious cases, and such, on the first examination of them, the majority of these instances will probably be, it seems right to try the effect of correcting dis- order of the digestive organs, with a view to alleviate nervous irritation, before we proceed to those severer methods, which the belief of the existence of organic or vascular disease in the brain would induce us to institute. For if blood-letting and counter-irritation be employed, in order to diminish vas- cular action ; or if mercury be used to some extent in order to induce the absorption of deposited substance ; these mea- sures must aggravate that disorder of the general health, upon which, in many instances, the uervous affection depends. My object, in the recital of the foregoing cases, is to point out a cause of paralysis in particuLu muscles, which, from its locality, would, I suspect, be generally attributed to some lo- cal disorder of the nerves of the affected part, and therefore be treated erroneously. If my opinion of the nature of these AND TREATMENT OF LOCAL DISEASES. 71 tases be correct, they can only be successfully treated by means which operate upon the constitution in general. I have particularly recommended that our efforts should be directed to correct any errors that may exist in the functions of the prima? viae, for reasons that have been stated in the prelimi- nary observations. Of the efficacy of such endeavours I have seen many more instances than I have brought forward: indeed the propriety of such attempts seems go obvious, that I doubt not but they will be made, and the effect of them will, by that means, be generally demonstrated. It is right, however, to mention, that in some cases to which I have at- tended, 1 have been foiled in my endeavours to correct, by the simple measures which 1 have related in the introductory remarks, the disorders of the digestive organs ; probably be- cause their derangement depended on some established dis- ease in the brain. In other cases, when the functions of the digestive organs had been partially restored, the nervous and muscular affec- tions were mitigated, but not cured. 1 have also met with one instance in which the bowels became moderately correct in their functions, without any evident amendmeut in the state of the limbs ; and 1 have known two instances of per- sons who were suddenly seized with paralysis of the lower extremities, apparently dependent on general nervous disor- der, in which the digestive organs scarcely seemed affected. In several of the cases which I have related, there were nervous pains in the affected limbs. That this symptom may arise from general nervous disorder seems to me very proba- ble ; at least, I can affirm that I have known such pains cured by correcting the state of the digestive organs. In the cases of tic douloureux, which have fallen under my observation, the digestive organs have been greatly disordered ; and I have cured patients of the former malady by correcting the latter.* * I insert the following case as a striking evidence of this fact. A gentle- man who had suffered for fifteen years with violent tic douloureux in his face, became completely relieved in the course of a few weeks, by attention to diet, and the regulation of the functions of the digestive organs. Tic afterward 72 ON THE CONSTITUTIONAL ORIGIN, I wish, finally, to excite the attention of surgeons to the state of the bowels in tetanus. The occurrence of this dis- order occasionally, when the wound which produced it is healing, seems to indicate that the effects, which have been produced by its irritation, continue. It has been, 1 think, fully shown, that local irritation may disorder the digestive organs ; which disorder continuing, and aggravating the affec- tion of the sensorium, may possibly lead to the production of tetanus, at a time when the Wound is no longer irritable. In four cases of tetanus, in which 1 had an opportunity of in- quiring into the state of the bowels, the evacuations from them were not like faeces. In investigating the cause of te- tanus, I wish to propose, as a question, What is the state of the bowels between the infliction of the injury and the occur- rence of that dreadful malady ?* evinced the degree of his amendment, and his exultation at his recovery, by telling me the following story. " When I returned home, I one day met," said he, " my doctor in the market-place, where I had just bought some good pears. I gave him half of tbem, and told him I would lay him a wager that I would eat my share first. The doctor," continued he, " was astonished, for he knew that I might as easily, (Jike Mutius Scajvola) have put my right hand into the fire as a cold pear into my mouth during the last fifteen years." The relief, indeed, was not permanent, for the means by which it was procured were not perse- vered in. * All the experience which I have had relative to the treatment of tetanus, since the first publication of these observations, has convinced me that more benefit is obtained by correcting the errors of the digestive organs than by any other means. It may probably be useful to insert one case as a striking proof of this fact. A man who had been wounded in the foot, but not badly, was brought, about ten days after the accident, to the admission-room of the hospi- tal, and so violent and general were the spasms, that it was scarcely expected he could be taken to his bed alive. The jaw was fast clenched, and the muscles of his back and belly rigid. Convulsive actions came on frequently, and then all his limbs were violently affected. His bowels had not been relieved for many days. A grain of calomel and ten of jalap mixed with treacle, were given every fourth hour. It seemed also necessary to give him opium to mitigate his spasms, but it was mixed with an equal quantity of calomel. When, after twen- ty hours, his bowels were purged, the discharges were not like faeces, and so extremely offensive, that the patients could not stay in the ward. From this time, however, there was so complete a subsidence of the spasms that no more opium was necessary ; and the patient recovered seemingly in proportion as the digestive organs regained their healthy functions. \ND TREATMENT OF LOCAL DISEASES. 73 Such cases as I have related in this section, with others that it would be fo- reign to my present purpose to mention, have impressed the opinion on my mind, that disorders of the digestive organs may originally cause, or may se- condarily aggravate, a nervous disorder, and produce, as has been mentioned, " in the nervous system, a diminution of the functions of the brain ; or a state of excitation causing delirium, partial nervous inactivity and insensibility; or the opposite state of irritation and pain : in the muscular system, weakness, tremors, and palsy; or the contrary affections of spasms and convulsions." Could these circumstances be proved, it would be scarcely necessary to add, that those painful affections of parts, to which perhaps some predisposition exists, may be excited in a similar manner : such as gout and rheumatism. In- deed rheumatic pains are very usually concomitant upon that state of constitu- tion which existed in the patients whose cases I am relating. No considerable progress could, however, be expected to be made in the stu- dy of the origin of sympathetic diseases, whilst the brain was regarded as the sole source or centre of the nervous energy. Now that the experiments of M. Le Gallois have extended our knowledge of the nervous system, and shown that the different portions of the medulla spinalis form also centres from which the nervous actions of corresponding parts of the body proceed, and to which they tend, considerable increase of knowledge is likely to result from attentive observation and accurate dissections. It is in my opinion sufficiently evident, that disorders of the digestive organs sometimes affect the different portions of the medulla spinalis, and produce sympathetic disorders of the body and limbs, without operating through the medium of the brain, as was formerly supposed. A female patient, about 27 years of age, was lately admitted into the hospital with paralysis of the arm, which had come on suddenly. She complained of much pain when pressure was made along the outer margin of the scalene mus- cles, where the nerves emerge that form the axillary plexus. Her digestive or- gans were greatly disordered, and in one week, by means that could only ope- rate directly on those organs, she regained the use of her arm. A gentleman of the medical profession, whose digestive organs had been long disordered, sud- denly lost the use of his right arm, without any apparent disturbance of the cerebrum. A professional friend asserting that the paralysis was a consequence of disorder of the chylopoietic viscera, the patient promised strictly to adhere to any plan of diet or course of medicine that his friend would prescribe. The only medicines ordered were pills, containing two grains of calomel at night, and moderate purges on the following morning, for one week. The bowels were cleared daily, but not materially disturbed. On the sixth day, however, several copious dark-coloured and offensive discharges took place, and the pa- tient immediately regained the use of his arm. Vol. I. 10 74 ON THE CONSTITUTIONAL ORIGIN, CASES. SECTION II. On the Effects of Disorders of the digestive Organs attending Injuries of the Head. I shall next speak of those cases in which local disor- ders of the head, produced by blows, are kept up and ag- gravated by affections of the digestive organs. After what has been observed respecting the reciprocal influence of the diseases of the brain, and of the chylopoietic viscera, it will readily be admitted, that an injury of the former may disturb the functions of the latter, Thus, concussion of the brain occasions vomiting as one of its immediate consequences, and will also be found to produce almost constantly, at a more remote period, that disturbance of the digestive organs which I have described in this paper. If the disturbance be only moderate in degree, but continued, it will often react upon the head, so as to occasion an irritable state of the injured parts, and impede their recovery. In many cases of blows upon the head, a slow inflammatory affection continues in the parts chiefly injured, and ultimate- ly produces destructive diseases. The bone sometimes becomes diseased, or an exostosis grows from its internal table ; the dura mater becomes thickened, or matter slowly collects on its surface. Such local disorders produce others of a more general nature, and destroy the patient. These occurrences are, however, in my opinion, rare in comparison with the cases first described; in which a painful state of the injured parts is kept up by means of disorder existing in the digestive organs. The necessity for an accurate discrimina- tion between these disorders, must strike us on the most superficial view of the subject: for the lowering treatment AND TREATMENT OF LOCAL DISEASES. 75 which is necessary in the first and rarer case, would be detrimental in the second and more frequent one. By attending to the state of the digestive organs in these du- bious cases, we may be enabled to form a probable opi- nion of the nature of the local complaint; for if there be nothing wrong in the general health to excite or maintain it, we may reasonably conclude that it was merely local; on the other hand, the inefficacy of evacuations in curing the local disease would naturally suggest the opinion, that it proceeds from irritation, and is dependent on a disorder of the health in general. It should be further observed, that when the local disease is of an inflammatory nature, and likely to induce morbid alterations in the structure of the affected parts, still it may be maintained and aggravated by disorder of the digestive organs. I have very frequently seen patients suffer so severely as to warrant a suspicion, that local dis- ease of the most formidable nature existed; in these the usual methods of treatment were ineffectual; and they re- covered suddenly or slowly, in proportion as the state of the digestive organs was corrected. I shall relate some exam- ples of the disease under consideration, which will enable the reader to identify the case, when it occurs in practice. CASE IX. A young gentleman, about ten years of age, fell out of a window, six feet high, and struck the back part of his head against some stones. He was stunned by the blow, but perfectly recovered from the effects of the accident by bleeding, purging, and a low diet. He caught the scarlet fever about six weeks afterward and recovered from that also. But, whilst he was convalescent, the pains returned in that part of the head which had been struck with so much violence, as to induce the belief that some serious local mischief would ensue. After they had continued without abatement for a few days, I was desired to see him. He was lying in bed, and could scarcely be prevailed on to lift 76 ON THE CONSTITUTIONAL ORIGIN, his head from the pillow. The integuments of the occiput were so tender, that he would hardly allow me to examine the part; I ascertained, however, that there was no fluid under the scalp, nor any inequality in the bone. He dozed a good deal, and lay in a comatose state, but was occasionally rest- less. His pulse was very frequent, his skin hot and dry,and his tongue covered with a thick yellow fur. He breathed almost without moving the diaphragm, and complained much if the epigastric region was compressed. He loathed food; his bowels were costive, and his stools of a blackish colour. He was ordered to take small doses of calomel at night, and draughts with rhubarb and sulphat of potash in the morning. The tongue soon became clean, and the stools natural; his appetite and spirits returned, and he no longer complained of any uneasiness in the head. This case presents us with a striking example of what I believe to be a common occurrence; I mean a disordered state of the digestive organs taking place subsequently to a considerable febrile affection. Indeed, when we reflect in how weak and irritable a state the brain must be left upon the subsidence of such a disorder, and how much the chylopoietic viscera must suffer from impaired and disordered energy of the brain, we might naturally expect such a derangement of the functions of the digestive organs to ensue. When such disorder happens in this manner, it frequently produces many local diseases, to which the constitution may perhaps be predisposed ; a circumstance I shall speak of in a future part of this paper. In the present case it brought on a pain- ful state of parts recently injured, with a considerable degree of fever. That the morbid state of the stomach and bowels was the cause of both, is fairly to be inferred from their ceasing so immediately, when the disorder of the digestive organs was corrected. A case of this kind, presenting an example of sudden recovery, is particularly valuable, because it clearly demonstrates the cause and the effect in such dis- eases. The cause can indeed be seldom so suddenly re- moved ; and the gradual cessation of it under any plan of AND TREATMENT OF LOCAL DISEASES. 77 treatment, leaves room for a variety of conjectures as to the mode of cure or of recovery from those disorders which I have considered as effects. I could relate many cases of similar but less severe symptoms produced by the same cause, which gradually got well, in proportion as the disor- ders of the digestive organs were corrected. As it does not, however, appear to me necessary to accumulate instances to prove so obvious a fact, I shall content myself with adducing two more cases to exhibit such effects in different points of view. CASE X. A lady fell down in frosty weather, in consequence of her feet slipping from under her, and the occiput struck against a smooth stone-pavement. She was stunned by the fall, but soon recovered ; nor had she for some weeks the severe symptoms which appeared in the sequel. This circumstance shows that there was nothing produced by the blow that ne- cessarily caused the subsequent symptoms; which must, therefore, be attributed to inflammation or irritation taking place afterward. When some weeks had elapsed from the time of the accident, the parts which had been struck became extremely painful ; and the pain extended forwards over the scalp to the right eye, the sight of which became imperfect. The integuments upon which the blow had been received were extremely tender, and the patient became faint when they were examined even slightly. These circumstances na- turally induced a belief that some disease was taking place ; and bleeding and purging were employed to prevent its pro- gress. The symptoms were mitigated for a time by these means, but the) quickly returned with as much severity as before. After three months the patient came to London, fully persuaded that nothing but an operation would be of perma- nent benefit. When 1 first saw her, she tottered in moving from one chair to another, and replied to questions with hesi- 78 ON THE CONSTITUTIONAL ORIGIN, tation and effort. Her eyesight was so much affected, that she could not read; and she entertained an apprehension that she should lose her senses. Her tongue was but slightly furred ; her bowels were habitually costive, and the stools dark-coloured. It was evident where the injury had been received ; for the aponeurosis had been separated from the pericranium by an effusion of blood ; and, though this blood had been absorbed, the detachment of the scalp was distin- guishable by the touch. No inequality was perceptible in the surface of the bone. When I mentioned my suspicion that these symptoms were rather the effect of irritability of con- stitution, dependent on the state of the stomach and bowels, than of local mischief, she gave not the least credit to the opinion ; but said she was persuaded that the bone was star- red, and that three fissures extended in different directions. I ordered her to take five grains of the pilul.hydrarg. every second night, and a draught twice a day, containing one ounce of the compound infusion of gentian, two drachms of the in- fusion of senna, and one drachm of the compound tincture of cardamoms. These medicines produced a considerable purgative effect. On the second day there was but little pain in the head ; the patient walked about the room very steadily, and had read a newspaper in the morning. When I asked her opinion of this surprising alteration, she imputed it to the evacuations which had taken place; but she was still persuaded that the bone was injured, and still apprehensive that with- out some operation, she should ultimately lose her senses. The medicines were continued in such quantity as to procure only one alvine evacuation daily. A fortnight elapsed under this plan of treatment, during which the stools became nearly of a natural and the patient's health was considerably amended. ..ie were times when no uneasiness was felt in the head ; and, during some nights, the pain was so trivial as to give but little interruption to her sleep. It was, how- ever, occasionally disturbed by pains, which were, in her opi- nion, as intense as at any former period of the complaint Her pulse was good, and her muscular strength greatly im- AND TREATMENT OF LOCAL DISEASES. 79 proved. The occurrence of the pain in paroxysms, strongly impressed me with the belief that it was nervous, rather than depending upon local disease. Under these circumstances all ideas of an operation were dismissed from my mind, but it was far otherwise with respect to the patient. Being obliged to return into the country, she considered the possibility of a relapse with horror ; and was so convinced that the bone had been injured, that she earnestly requested it might be examined, were it merely to ascertain what was the fact. I saw no objection to this examination, but thought, on the con- trary, that advantage* might possibly arise from an incision, which would loosen the tension of the scalp, and produce a discharge that might relieve the irritation of the part. I ac- cordingly made an incision of a semicircular form, extending farther back than the part which had been struck, and turned up a portion of the scalp, so as to see the bone, covered by its pericranium, to the extent of a crown piece. The bone was uninjured, and, together with the pericranium, appeared perfectly natural. The scalp being replaced, the wound was dressed superficially, without any attempt to favour the union of the parts. If they united under these circumstances, there would be an additional reason for believing, that neither the bone nor the subjacent parts were diseased. The pain was as severe for the two first days and nights after this ex- amination as it had been at any former period; it abated when the wound began to discharge, and had entirely ceased on the fifth day. This state of tranquillity continued as long as the patient remained in town, which was about three weeks after the division of the scalp. The wound at that time had nearly healed. She has since had occasional re- turns of pain in the head when her general health has been disordered, but never to that degree as to induce a suspi- cion that any local vascular disease existed. To exhibit the effects of the reaction of disorders of the digestive organs upon those of the head in another point of view, I subjoin the following case. 80 ON THE CONSTIUTIONAL ORIGIN, CASE XI. May 29, 1805, a labouring man, aged forty-five, fell from a considerable height upon his head, and was immediately brought to St. Bartholomew's Hospital. No fracture of the skull could be discerned : and the patient seemed to labour under the effects of violent concussion of the brain. By ve- nesection, and other antiphlogistic means, he soon recovered his senses. Every thing went on very favourably for three days, when he was attacked with shivering, nausea, pain in the head, impatience of light, and other symptoms, which are usually considered as denoting inflammation of the membranes of the brain. He was consequently bled ; and had a blister applied on the head. He was suddenly seized in the evening with a more excruciating pain in the head, which, after lasting half an hour, was succeeded by convulsions, so violent, that three men could scarcely hold him. When the fit abated, he ex- pressed himself much relieved, and said that he was easier than before its accession. Some calomel and rhubarb were given to obviate a costive state of his bowels. On the next morning (June 2d) he had a return of the pain and convul- sions ; and the symptoms were so violent, that he was bled four times in the course of the day. This treatment, how- ever, had no effect in diminishing the pain and other symp- toms, and another fit of convulsions took place in the eve- ning. The purgative operated on the succeeding night, and brought away a large quantity of highly offensive feculent matter of a light greenish-yellow colour. On the 3d of June his breath was extremely offensive ; his skin hot and dry; his pulse quick ; his tongue thickly furred ; and he had great tenderness in the epigastric region, and right hypochondrium. He was ordered to take two grains of calomel immediately, and a saline medicine at intervals ; this produced two mo- tions in the course of the day. By pursuing this plan for a few days, the state of the bowels was rendered more regular. and the discharges acquired a healthy colour; in proportion AM) TREATMENT OF LOCAL DISEASES. 81 ' as this was effected, the tenderness of the abdomen was re- moved, and the tongue became clean. He had no return of convulsions, the pain and other symptoms subsided ; and in a short time, when the digestive organs had been restored to a natural state, he went out of the hospital perfectly well. Cases of this description have been noted from the ear- liest ages. Many passages in the works of Galen show that he was well acquainted with the circumstances that have been stated in this section. Bertrandi* has related instances of abscesses taking place in the liver, consequent to injuries of the head. Andouillef relates additional cases, and makes further observations on the same subject. Of late, Richter| has delivered similar opinions, and has directed the prac- tice which should be pursued, when the head is disordered by the reaction of affections of the digestive organs. Still, however, these circumstances seern to me to be stated rather as occasional, than ns occurrences which are common and naturally to be expected; and I therefore think myself war- ranted in supposing, that they have not made a sufficient im- pression on the minds of surgeons, in this country at least. || I beg leave, in the conclusion of this section, to repeat what was said in the former one, viz. that 1 consider the dis- ease as depending on nervous irritation in the parts affected, which is either caused, maintained, or aggravated by dis- orders of the digestive organs, let as the local disease must be regarded as chiefly nervous, it might, in some rare in- stances, exist independently of any manifest disorder of those organs. I may further add, that much nervous irritation in any part generally excites vascular action. It becomes therefore highly important to attend to the nature and cure of such disorder, as it might ultimately lead to the produc- tion of organic disease, which would destroy the patient. * M6moires de l'Academie de Chirurgie, torn. iii. p. 484. t Ibid. p. 506. X Chirurg. Biblioth. b. viii. p. 538. || In Doctor Cheston's Pathological Observations, however, cases ofihis de- scription are noticed. Vol. I. 11 S2 ON THE CONSTITUTIONAL ORIGIN, C A S E S. SECTION III. On undefined and undenominated local Diseases arising from Disorder of the Constitution. The next class of cases, to which I shall call the reader's attention, is that of unhealthy indurations, abscesses, and sores. Sometimes but one local disease of this description exists, but in general they break out in succession in different parts of the body. The circumstance of their successive forma- tion is, I think, a proof that they depend upon some error in the health in general; and 1 have accordingly observed that they are seldom, if ever, unattended with disorder of the di- gestive organs. The imperfect history which the patients' generally give of their previous state of health, will not enable us to determine with certainty, that the disorder of the bowels was the cause of their ill health and subsequent local diseases ; but I can confidently affirm, that those dis- eases in general become tractable, in proportion as the dis- order of the viscera is corrected ; and that frequently no new local symptoms occur, after some attention has been paid to the state of the digestive organs. The diseases to which I allude, have not been described in books of surgery ; and indeed it is scarcely possible to delineate with precision their various appearances. It would be quite impracticable to describe all the diseases which make the subject of the present section; namely, unhealthy indurations, abscesses, and sores. They may be compared, not improperly, in va- riety and number, with the infinitely diversified combinations and shades of colour. Yet a brief and general description of them will assist to recall them to the remembrance of the AND TREATMENT OF LOCAL DISEASES. 83 experienced surgeon ; and to enable the inexperienced prac- titioner to recognise them when they occur. Some of these affections are quite superficial, occupying merely the skin. The first that I shall describe is, I believe, well known to surgeons, as a disease, which is frequently, though not constantly, cured by giving mercury carried to such an extent as slightly to affect the constitution. A small induration or tubercle takes place in the skin, and this is followed by the successive formation of others at small dis- tances from the original one. The skin between these tubercles becomes thickened. Chord-like substances, which are probably indurated absorbents, may sometimes be felt, extended along the thickened skin. The tubercles ulcerate, and form foul sores, which heal slowly and break out again. Another species of superficial or cutaneous ulcer begins generally in one point, and extends in every direction. The chasm of the ulcer is formed either by a very sudden ulcera- tion, or by sloughing. A sore is left, which first secretes a sanious, and then an ichorous fluid. Granulations afterward arise, and the sore heals. The granulations are however in- durated and unsound ; and when the patient supposes that the sore is cured, it is suddenly reproduced by a process similar to that by which it was originally occasioned. After some time the ulcer again heals, and again breaks out. Whilst these processes are going on in the middle, the sore enlarges in its circumference ; the edges which are thickened become at times highly inflamed, and either ulcerate or slough. The disposition to disease is aggravated by fits, and there are in- tervals when it is apparently tranquil. When this sore has enlarged to a considerable extent, in the manner already des- cribed, the central parts, which have healed unsoundly, break out into separate ulcers ; and thus present an appearance of several sores, connected with each other by indurated skin or newly formed substance. 1 shall briefly mention some of the principal circumstances relating to the last sore of this description, which came under my care. The patient, who had been ill for more than two 84 ON THL CONSTITUTIONAL ORIGIN, years, and had taken a great deal of mercury, came from the country in very bad health, and with his digestive organs much disordered. The sore was so painful, particularly at night, that he was in the habit of taking large doses of opium to procure rest. It occupied the back of the hand and wrist. He had had somewhat similar sores on his head and face; but they were nearly healed, though disposed to ulcerate again. By that attention to the state of the bowels which I have described, and by dressing the sore with an aqueous solution of opium, the greater part of it was healed in the space of three weeks; and the remainder was so much amended, and so little painful, that he had left off his opium shortly after the commencement of this treatment. As the patient's circumstances made it inconvenient to him to re- main in town, he went into the country, where the sore broke out again. He then applied to a person who sold a famous diet-drink ; and before he had taken twelve bottles, the sore was perfectly healed, and has not since broke out. The diet- drink, he says, had no sensible operation ; but his bowels became regular and comfortable, and his appetite amended by taking it. Another variety of these sores originates in a more deeply seated disease. The cellular substance under the skin becomes thickened, and an unhealthy abscess follows; after the bursting of which, a foul sore is formed. In consequence of this process, the fascia of the limb is sometimes exposed to view, and seems to have sloughed : when the slough has separated, the disease may get well slowly. In many cases, however, there is no exposure, nor separation of the fascia. Sometimes the sore does not extend beyond the limits of the original induration, but heals slowly ; while other diseases of the same kind occur in succession in various parts of the body. In other cases, the ulceration of the original sore spreads along the contiguous parts, whilst those which were first affected get well; and thus the sore assumes an herpetic character. In many cases the ulceration extends from the whole circumference of the sore, and thus the scar and AND TREATMENT OF LOCAL DISEASES 85 ulcerated edges have a circular or oval form; in others, the disease is propagated in particular directions, so that the ulcerated surface presents the most irregular and singular figures. These diseases sometimes are small in extent in the be- ginning, but enlarge considerably before the skin gives way ; and, when this happens, it proves a kind of crisis to the disease, which afterward heals slowly. In these cases it becomes the object of surgery to bring the disease to a crisis, whilst it is yet of small extent; which may be effected by producing ulceration of the skin by means of caustic. Some of these sores are formed from diseases beginning in the absorbent glands; in which case the gland, having first been indurated, suppurates and bursts, and ulceration ensues. When this has taken place, in an absorbent gland of the neck for instance, another ulcer may form, in the manner above stated, in the skin and subjacent parts, without any gland being involved in it. A third ulcer,having a diseased gland for its cause, may form in the vicinity ; and thus the disease proceeds, but without any regularity. I once thought it a necessary but most difficult task for a surgeon to remark the varieties of these diseases, in order to understand his profession, and contribute to its improve- ment. But since 1 have found that these diseases indicate some disorder of the health in general, the correction of which is the great object in their cure and prevention, I have perceived that there is less necessity for undertaking this most arduous investigation ; which, indeed, could never be accomplished without very extensive opportunities and inde- fatigable diligence. It will be found in the majority of these peculiar diseases, that the patient had been indisposed for some time before the occurrence of the complaint, and that afterward the health had become more evidently deranged. The digestive organs are disordered. The tongue is furred at the back part, chiefly in the morning; and the biliary secretion is deficient or depraved. My attention has been directed to 86 ON THE CONSTITUTIONAL ORIGIN, the correction of this disorder; and the most beneficial effects have resulted from this attention. The sores have healed readily in some instances ; and, in those cases where many had previously formed in succession, no new disease has in general taken place. In some few instances, new sores have formed after the medical treatment of the disor- der had commenced, and even after it had been for some time continued. This probably arises from the difficulty which is experienced in correcting an habitual and long- continued constitutional disorder. In some still rarer cases I have found similar but much milder diseases arise, after the disorder of the digestive organs had been in a great degree corrected. Whilst I am writing this, there are four patients, whom I have attended in St. Bartholomew's Hospital, with these diseases ; which I mention, to show the younger part of the profession how frequent they are. The health of these patients has been surprisingly amended in a very short period, by employing the means which I have described 5 and the sores have healed rapidly, although nothing but sim- ple dressings have been applied to them. It is not meant by these observations to depreciate the utility of topical applications to unhealthy ulcers, but merely to show how much they depend on the state of the health in general; for some of them, which have remained uncorrected by a great variety of local applications, will get well under simple dressings, when the state of the constitution is amend- ed. It is not, however, to be expected that this will gene- rally happen: for local diseased actions having been excited, become established, and may continue independently of the cause which produced them. Topical remedies will, under these circumstances, be employed with the greatest advan- tage. Again, topical applications are of the highest utility in general practice, because an irritable sore affects the whole constitution, and aggravates and maintains that disorder by which it might have, been originally caused. The disorder of the digestive organs cannot in many instances be corrected, AND TREATMENT OF LOCAL DISEASES. 87 till the fretful state of the local disease is diminished. I may further mention, with relation to this subject, that I have seen patients, who scarcely ever slept from the pain of the local disease, whose stomachs were greatly disordered, and who had a distressing purging, which could only be control- led by opium, sleep without interruption during the night, regaining their appetite, and have their bowels become tranquil and regular, when after various trials, a dressing has at last been applied, which quieted the irritable state of the sore. It is right however to mention, that the effects of such an application are not, in general, permanent: but after a time the sore becomes again fretful, and requires some new dressing to sooth or control its irritability. I have seen some cases of such diseased sores as I have described, in consultation with other surgeons, who have become convinced that my opinions are well founded. Others have occurred, even in the persons of medical men, whose feelings co-operated to render their conviction more strong. Having thus, from general observation, acquired the opi- nion that the peculiarities of local disease depend chiefly on the state of the constitution, 1 shall relate some cases, which were treated in conformity with the principles which such an opinion would naturally suggest. I must, however, previously caution the reader against inferring, that I attri- bute all local diseases to some general error in the state of the health. I have seen local diseases, which could not be deduced from any general indisposition, nor corrected by remedies which act simply on the constitution at large. I wish to guard against the suspicion of being inclined to make general assertions ; while I avow at the same time, that my observations induce me to believe, that the peculiarities of local disease generally depend upon constitutional causes. Reason also suggests the same opinion ; for if sores of the same character break out in succession in different parts of the body, can we doubt that they arise from the state of the health in general7 »8 ON THE CONSTITUTIONAL ORIGIN, There appears to me a combination of nervous irritability and weakness, and to such a combination 1 am inclined to attribute the peculiarities of these variable and unclassed local diseases. Perhaps I may explain my meaning further, by adverting to what happens not unfrequently in cases of venereal and other buboes. The part and the constitution have been both weakened by the disease that has occurred; they have been further debilitated by the mercury employed for its correction. The disease subsides, but a new disease and action commences ; a trivial wound frets out into a phagedenic sore, which is very difficult of cure. The sores, in different cases, are nearly as various in appearance as those of which 1 have been speaking. To what are we to attribute these dissimilar, perplexing, peculiar sores, if not to irritation occurring in weak and irritable parts? As the peculiar diseased actions of these sores originate chiefly from the weakness and irritability of the parts, induced by the previous disorder which they have undergone ; so in their advanced stages they frequently present the best instance that can perhaps be adduced, of a peculiar local disease exist- ing independently of constitutional disorder. It is true they affect the health in general; but it may, by attention, be kept in a moderately right state, and yet the sore remains unamended. The diseased actions of these sores some- times gradually, and sometimes suddenly cease; when healthy actions succeeding, the sore heals. I remember a sore of this description, to which almost every variety of dressing had been tried without benefit. It was very extensive, and had burrowed in various directions beneath the skin. The ulceration at length became stationary; but after nine months the sore still remained as foul and fretful as it had been for a considerable time; when in the course of one week it perfectly cicatrized, leaving the hollows which I have described ; for it had thrown out no granulations to fill these chasms. Having thus stated the opinions which I have formed rela- tive to these kinds of local diseases, and which have been. AND TREATMENT OF LOCAL DISEASES. 89 deduced from cases too numerous to record, of which 1 have preserved no accurate accounts, 1 proceed to relate some cases treated in conformity to these opinions, which will, I trust, be sufficient to exemplify and illustrate the present subject. CASE XII. A gentleman's servant, between thirty and forty years of age, was sent to me with a bad ulcer in his cheek, situated between the nose and under eyelid. The surrounding parts were inflamed, swoln, and indurated, so as to rise fully half an inch above their natural level. The sore was of an oval figure, measuring about an inch and a half in length, and half an inch in breadth and depth : indeed I could scarcely see its bottom. The surface was covered by adhering matter of a greenish hue. The cuticle around the margin was thick- ened, and had in some parts scaled off. The patient had been rubbing in the mercurial ointment for this complaint. He declared that he had had no chancre for many years, but had contracted a gonorrhoea about a year before his present disorder. His health was much disturbed ; he had no appe- tite ; his tongue was much furred and tremulous ; his bowels alternately costive and lax; his fasces blackish. I advised him to take five grains of rhubarb about an hour before din- ner, and five grains of the pilul. hydrarg. every second night, with castor-oil or senna-tea occasionally, so as to procure a motion daily. The sore was dressed with spermaceti cerate. I saw him again in three days, when he said that he felt him- self under the greatest obligations to me. He had been en- tirely free from pain and distressful sensations since he began to take the medicines, although he declared that before that time, he should have been thankful to any one who would have destroyed him. I mention this, because I have often remarked in these cases, the surprisingly great relief and comfort which have arisen from a change, produced by means apparently insignificant and inadequate. The bowels now Voi,. I. 12 a*J ON THE CONSTITUTIONAL ORIGIN, acted regularly, and the stools were more copious and of a more natural colour; and to this correction of the biliary secretion I am inclined to impute that relief which he so for- cibly depicted. The sore had discharged profusely; the surrounding swelling and inflammation were much lessened. He pursued the same plan of treatment for a month, during which time he recovered his appetite; his tongue became clean ; his bowels regular, and the biliary secretion natural. The sore had contracted into a small compass, but without the appearance of granulations ; and the surrounding parts were not swoln, though still red. His health became at this time again much disordered, in consequence of his catching cold from exposure to rain. He had pain in the bowels, with a slight purging ; his appetite failed ; his tongue was furred, and he had a severe cough, attended with copious expecto- ration. The sore on the cheek also enlarged to about one half of its former size, and the surrounding parts became tumid. I had the patient admitted into St. Bartholomew's hospital, where he took the decoction of cascarilla with squills. His cough became materially better in a short time: the state of his stomach and bowels also greatly improved. The sore again diminished in size. About a fortnight after his admission into the hospital, an eruption came out over his whole body. The spots were of a copperish hue, but rather smaller, and more elevated, than venereal eruptions generally are.* Some of the eruptions gradually disappeared ; and, in about a fortnight, it was certain that many were entirely gone. About this time he began to complain of his throat; and an ulcer, of the size of a shilling, formed in each tonsil. The edges of these sores were elevated and uneven, without any appearance of granulations; the surface was covered with yellow adhering matter. The patient now again caught cold: he was attacked with pain in the bowels and purging, which obliged him to get up frequently in the night, and to remain 1 Many persons who saw the patient did not entertain a doubt but that all ihe symptoms arose from syphilis : it was their progress alone which evinced •h<*. confrarv AND TREATMENT OF LOCAL DISL^M.S y| lor some time out of bed. The cough and expectoration re- turned : he lost his appetite, and he had a furred tongue. Dr. Roberts, whom I met at the hospital, did me the favour to prescribe for him. in a day or two afterward, an erysipe- latous inflammation appeared on the right side of his face, opposite to the situation of the sore. The eyelids were so tumid that he could not open them ; the erysipelas spread to the other side of the face ; and the other eye was equally closed. The fever also ran very high, and the patient became delirious ; so that he was obliged, for many days, to be con- fined by a strait waistcoat. These symptoms gradually abated, and he recovered, so as to be in better health than I had ever seen him. He was discharged in about six weeks, in a state of convalescence, and attended by Dr. Roberts as an out-patient. The eruption and sore throat had entirely disappeared; the original ulcer was firmly healed ; and the contiguous skin had become soft and natural, though it was still discoloured. A year has since elapsed, and he hars had no return of his complaints. It is, I think, sufficiently evident, in the present instance, that the peculiarities of the local diseases had their origin in the state of the constitution. CASE XIII. I was consulted by a medical gentleman in my neighbour- hood, on the case of a lady about forty years of age, who had been long subject to dyspepsia, and severe headachs. Her present and chief complaint had been of about three months' duration. It began with weakness, and an apparent irregu- larity in the motions of the lower extremities, attended with considerable pains resembling rheumatism, and rigidity of the calves of the legs. These symptoms increasing, she was una- able, in the course of a month, to move about at all, but was obliged to be lifted in and out of bed. At this time an indu- ration of the muscles of the calf of each leg had taken place. The indurated substance was about three inches in length. 9^ ON THE CONSTITUTIONAL ORIGIN, and between two and three in breadth. It was severely pain- ful at times, and the integuments covering it were occasion- ally inflamed. There was also pain and some swelling in the ham. Leeches, sedative lotions, and mercurial ointment had been applied; cicuta and tonics had been given, but without al- leviating the symptoms. 1 first saw the patient about six weeks after she had been obliged to keep her bed entirely ; and the peculiarities of the present case led me at once to refer its origin to the state of the health in general. The appetite and digestion were impaired, the tongue was much furred, and the fasces blackish. I merely recommended fomenta- tions to the indurated parts, considering it the primary object to correct the morbid state of the digestive organs. With this view the compound infusion of gentian with the infusion of senna and tincture of cardamoms was given in such doses as to procure an adequate evacuation daily, and five grains of the pil. hydrag. were taken every second night. These simple medicines were completely successful : after taking them a short time, the discharges from the bowels were natural, and properly coloured with bile. The appetite re- turned ; the tongue became clean, and the pains almost im- mediately ceased. No cutaneous inflammation, indicating a disposition to suppuration, appeared again over the indurated parts, which gradually recovered their natural state. In a fortnight the patient could go about with a stick, and in two months could walk as well as before her complaint. She has enjoyed better health since this time, than for many years before .* * The state of the indurated muscles, in this case, was such as would lead to the belief that suppuration would take place in different parts of the hardness : indeed, I have seen many cases less formidable in appearance terminate in that manner. Seeing how much the irritability of muscles is disordered by that state of constitution which I have been describing, I think it is allowable to conclude that diseases of muscles, productive of alterations in their natural structure, originate from this cause. AND TREATMENT OF LOCAL DISEASES. J}.1-} CASE XIV. A gentleman, thirty-two years of age, who had been subject for several years to occasional attacks of severe pain in the bowels, was seized, about the end of August, with a violent purging, which continued for a fortnight, and was attended with fever. About a month afterward, he felt pain in his leg at night, which gradually became continued even during the day, and obliged him to confine himself to bed. In the beginning of October a swelling was perceived near the inner ankle, which suppurated, and was opened on the twentieth of the same month. Two large tea-cups full of dark brown matter were evacuated. The discharge continued profuse for some time, and afterward diminished. Four other small gatherings then took place in succession, and, bursting, continued to dis- charge ; each aperture fretting out into a foul sore. About the beginning of February I first saw this case, which was considered as a disease of the bone. The five sores had aper» tures in them leading to sinuses, which communicated with each other. A probe introduced into one of these near the bottom of the tibia, could be moved upwards and downwards along the surface of the bone, which was not, however, de- nuded. From an upper ulcer the probe could be passed be- hind the bone, and under the muscles of the calf; this indeed seemed to be the original seat of the abscess, from which the sinuses proceeded to their different outlets. The integuments were oedematous, and firm to the touch, so that I could not distinctly feel the outline of the tibia ; but 1 thought that the bone was not altered either in form or size. The firmness with which the patient stood upon the limb, and the want of aching pain in the bone, contributed also to make me believe that it was not diseased, and that the whole disorder consisted in an unhealthy abscess, the discharge from which issued from the various sinuses in the manner already described. I could not but attribute such a disease to a general disorder of the health; and indeed the patient's countenance and appearance •J4 ON THE CONSTITUTIONAL ORIGIN, indicated a constitution much weakened and harassed by ill- ness. His tongue was furred, and the discharges from the bowels were irregular, deficient in quantity, and of a blackish colour. With a view to the correction of these symptoms, I directed the patient to take five grains of the pil. hydrarg. every second night, and the infusion of gentian with senna, so as to procure one motion daily. But little benefit was ob- tained by these measures; and in about a fortnight afterward a thickening of the integuments took place over the fibula ; a considerable swelling gradually arose, and another abscess formed, which burst in about three weeks, and discharged a considerable quantity of brownish matter mixed with blood. Daring this time the limb was merely poulticed, and the pa- tient could not leave his bed. His pain was extreme, and he had no rest at night. The use of opium was necessary to al- leviate his sufferings, and opening medicines occasionally, to procure stools. He took but little nourishment, and his health greatly declined. The disordered state of the stomach and bowels was much aggravated by this local irritation. In- deed the situation of my patient was now particularly per- plexing. The local disease made the general health worse ; and the aggravation of this general disorder, which appeared to have been the cause of the local disease and of its conti- nuance, proportionately increased the latter malady. The confinement to bed afforded an additional obstacle to reco- very ; yet it was impossible to remove him in his present state, on account of the pain which motion occasioned. The leg was insupportably painful in a dependent posture. As change of air and exercise seemed essential to his recovery, I was induced to try if Mr. Baynton's excellent bandage, by supporting the weakened vessels, would prevent their disten- sion, and the consequent pain. The sores were dressed, af- ter as much matter had been expressed from the sinuses as could be done without occasioning pain. Strips of sticking- plaster were applied after the manner of a many-tailed band- age ; and the limb was afterward rolled with a calico-roller. The patient felt comfortable, and found his limb strengthened. AND TREATMENT OF LOCAL DISEASES. 90 He was directed to wet the roller, if the parts became heated. The effect of this treatment was surprising both to the patient and myself. The pain, which had been constant before pres- sure had been employed, ceased from the time of dressing till five o'clock on the following morning, but from that time it gradually increased till noon, when the dressings were re- newed. The cause of this occurrence now became manifest; for upon opening the bandage, more than a tea-cup full of matter was discharged from the different sinuses. I dressed the limb as before, cutting holes for the escape of the matter opposite to two of the chief sinuses. I desired the patient to put his leg to the ground, in order to ascertain the effect of the perpendicular position when the vessels were supported, and he experienced no inconvenience. The second day passed, as the former, without pain ; and as the matter poured into the sinuses readily escaped, he had no uneasiness from its detention. I recommended him to sit up, and put his leg to the ground several times in the day, in order to accustom it to that position. After I had dressed it on the third morn- ing, the patient stood up, and took two or three steps very feebly; but this was rather the effect of general weakness than of particular infirmity in the diseased limb. I now ad- vised him to go a little way out of town in a carriage. The air and exercise, together with the freedom from pain, pro- duced a very beneficial effect. He began to recover his ap- petite, to sleep at night, and acquired so much strength, that he was able in a week to go about his house, and to resume his attention to business. The discharge from the sinuses was very trifling, and the sores looked much better. The patient now undertook to dress his leg himself, and hired a lodging out of town, so that I only saw him occasionally. His limb was so much amended in the course of a fortnight, that it caused no more trouble than that of daily dressing. But his health was not good. His countenance had the same ex- pression of illness as when I first saw him ; his tongue was white and dry ; his bowels costive ; and the stools of an un- healthy colour. 1 therefore recommended him to take again 9b" ON THE CONSTITUTIONAL ORIGIN, the same medicines which I had formerly ordered him. His health now improved ; his tongue became moister, and less furred; the bowels more regular, and the fasces coloured with a more healthy bile. He continued recovering till the mid- dle of April, when he began to complain of the trouble of applying the sticking-plaster, and used the calico roller alone. I did not see him for three weeks, and then found him in a very desponding state. He complained of the tedious- ness of his confinement, which had lasted more than half a year, and said that he would willingly submit to have the sinuses laid open, if that would make him well. I found his leg well, excepting two orifices near the tibia ; three ulcers, which formed the apertures of as many sinuses, had healed ; the outline of the bone could be distinctly felt; and there was no alteration of it in form or size. 1 was unable at first to account for this despondency under such favourable cir- cumstances ; but I soon discovered that it was the effect of hypochondnacism, for his tongue was much furred and dry ; and at the same time that he left off the bandage, he had also discontinued his medicines. 1 urged him to return to them immediately, and called on him again in ten days, when he perceived clearly the absurdity of his late despondency, as well as its cause. He called on me on the 10th of July, with a new swelling near the upper part of the tibia, which threat- ened to form an abscess similar to those which had formerly taken place. I covered the limb with the bandage of sticking- plaster, as at first. The new disease disappeared entirely, and the old ones were so much benefited by the exact and equal pressure, that the patient felt no difference between the sound and the affected limb. The ulcers gradually healed, and his health is better than it has been for some years ; yet still there is an evident tendency to disorder of the digestive organs. \ND TREATMENT OF LOCAL DISEASE.-. 97 CASES. SECTION V. On more defined Diseases, as Carbuncle and Scrofula, arising from Disorder of the Constitution. If, upon an extensive and accurate examination of the subject, it were to appear that many very peculiar and very dissimilar local diseases originate from a common cause, namely, from weakness and irritability of the system in general, our inquiry would be further extended, and we should feel anxious to know whether similar causes may not operate in the production of more common and more fre- quent local disorders. As far as my late observations have enabled me to determine, that state of the digestive organs, which I consider as causing or denoting constitutional dis- order, exists prior to the formation of a carbuncle; and is exacerbated during the progress of that disease. This opi- nion indeed will appear probable, if we consider the kind of persons who are attacked with carbuncles and the considera- ble derangement of health which even a trivial local disease of this nature occasions. I shall mention but one case in sup- port of this opinion, though I have made similar remarks in several other instances. CASE XV. 1 attended a gentleman who was afflicted with carbuncles, during three successive attacks, at the interval of about a year between each. I made an incision through the indurated skin, down to the subjacent sloughy cellular substance, and thus brought the local disease to a crisis. This treatment Vol. I. 13 *»8 ON THE CONSTITUTIONAL ORIGIN, was sufficient in the first two attacks ; the extension of the disease was prevented ; the sloughs separated, and the wound healed. The patient, whose mode of life was intemperate, had cough ; difficult respiration ; fulness and tenderness of the parts situated in the epigastric region ; unhealthy secre- tion of bile; and, in short, all those symptoms which denote a very considerable degree of disorder of the digestive or- gans : it is probable indeed that some organic disease of the chylopoietic viscera existed. After he had recovered from the carbuncle, I told him that the most important disease still existed; and urged him to be attentive to his diet, and to the directions of his medical attendants. He still how- ever continued to live intemperately, and his disorder in- creased. He was indeed nearly dying from diseased viscera, when he was attacked with carbuncle for the third time. The division of the parts produced a temporary cessation of the disease ; but it began again to spread in every direction from its circumference, and he died. It will not, I believe, be doubted, that biles are a slighter degree, with some variation, of the same disease which causes anthrax and carbuncle; and it is almost unnecessary to re- mark, that some persons are subject to a successive forma- tion of very large and troublesome biles from the least irri- tation of the skin. I have seen many persons thus affected; and there has been, in every instance, disorder of the diges- tive organs, the correction of which has prevented the return of these vexatious local diseases. One gentleman, who had been tormented for many years by the quick successive formation of biles as large as eggs, has been free from them for some years ; though he has had other disorders, which denote such a condition of the constitution as it has been my object to describe in this paper. I have remarked in many instances that diseases of the absorbent glands, such as are usually denominated scrofulous, occurring in adults, have apparently originated from the dis- order which I have described. In several cases the local disease was of long duration, and had become worse rather And treatment of local diseases. 99 than better under various plans of medical treatment; yet it amended regularly, and sometimes even quickly, in propor- tion as the state of the digestive organs was corrected. I need not detail any cases on this occasion, since every sur- geon must know them familiarly. The patients are com- monly sent to the sea-side, or into the country; where enlarged glands subside, and those which have suppurated and ulce- rated heal; and the local disease recovers, in proportion as the health in general is amended. There are cases of scrofulous diseases occurring suddenlv, and in various parts of the body at the same time, which seem to originate in that state of the constitution which is occasioned by disorder of the digestive organs. I have chiefly observed these cases in children; and they have followed some violent febrile affection. In two cases which I shall particularly mention, the smallpox was the antecedent dis- ease. I have already stated, that when the health has been considerably disordered by some violent disease, the digestive organs may become subsequently affected ; and that this dis- order proves a cause of many secondary diseases. CASE XVI. A child of two years old had the smallpox, from which he did not seem to recover, but on the contrary fell into a very bad state of health. The absorbent glands on the right side of the neck became enlarged in succession, so as to form altogether a very considerable tumour, which extended down to the collar-bone. The axillary glands then became affected in the same manner ; the swelling was unusually great, and seemed to extend under the pectoral muscle, elevating it, and forming by this means a continuation of tumour with the glands of the neck. These swellings had partially suppu- rated, and had broken in two places, viz. in the neck, and about the margin of the pectoral muscle ; but no relief fol- lowed ; on the contrary, the mass of disease seemed to be rapidly increasing. The child was bowed forward, so that 100 ON THE CONSTITUTIONAL ORIGIN, the spine was much curved in the loins; the left leg appeared paralytic; and a swelling was perceived in the abdomen, which I could not but ascribe to an enlargement of the ex- ternal iliac glands. The child was extremely emaciated ; his skin felt hot and dry; his tongue was covered with a brown fur; and the stools were black and highly offensive. As there was no expectation that he could survive this despe- rate state, those medicines onjy were prescribed that seemed likely to correct the state of the digestive organs : such as occasional doses of calomel and rhubarb. A strict attention to diet was also recommended. Under this treatment the stools gradually became natural, and the tongue clean. The disease seemed to stop immediately. As the health was re- stored, the swellings rapidly subsided, and the child became one of the healthiest and stoutest of the family. CASE XVII. A female child, after having had the smallpox, got into bad health from disorder of the digestive organs. She was then suddenly attacked with a scrofulous affection of the knee and elbow of the opposite sides of the body. Two collections of fluid had taken place beneath the fascia of the leg and thigh. The joints were greatly enlarged, and the swelling was appa- rently caused by an increase in the size of the bones. Had I seen either joint, as a single case of disease, I should have said that it would leave the child a cripple. It was manifest in the present instance, that these local diseases were the consequence of general ill health; and that the first object was to correct the disorder of the system. The functions of the digestive organs, which had been deranged, were restored to their natural, state by employing the same diet and medi- cines which had been so signally successful in the preceding case. By these means the health was re-established, and the local diseases gradually disappeared. I have heard it remarked by surgeons of great experience, that patients often recover when many scrofulous diseases AND TREATMENT OF LOCAL DISEASES. 101 yppear at the same time ; although some of them may be so considerable, that they would seem to warrant amputation had they appeared singly. The cases which I have related afford a most clear and satisfactory account of the mode of recovery. General irritation and weakness bring on diseases, to which perhaps a predisposition may exist, in several parts of the body; these cease when their exciting cause is re- moved. Of late indeed I have been equally surprised and rejoiced to see swellings of the absorbent glands in children readily dispersed by that medical attention to correct errors in the functions of the digestive organs, which I have described. Some of these swellings came on rapidly, and some slowly; but these were so large and so much inflamed, that if any person had formerly told me they might be dispersed by such mea- sures, I should have thought the assertion an absolute absur- dity, from its direct contradiction to my former experience. From among a considerable number of cases I shall relate the following: CASE XVIII. The son of one of my friends had gradually fallen into a very bad state of health. The child was about six years of age, and had been unwell for several months ; when in con- clusion, two glands in the neck became gradually enlarged, till each had attained the size of a large walnut. The child's tongue was much furred, his appetite very deficient, and capricious ; his bowels had a costive tendency ; his stools were never of a proper colour. His flesh was wasted and flabby, his countenance pale, his pulse feeble and fre- quent ; and his general demeanour languid and irritable. I told his father, that I could advise nothing as a local applica- tion better than a poultice of bread and water; and that the chief object of attention was the coiruction of the disorier under which the child had long laboured, so that his constitu- tion might regain its natural tranquillity and stre.-uih. Upon 102 ON THE CONSTITUTIONAL ORIGIN, this subject I promised to speak to the gentleman who had hi- therto attended the child. In about two days a deep redness came over the most prominent part of each gland, denoting, as I concluded, a disposition in the internal parts to suppurate. The child took half a grain of calomel with five of rhubarb every second night, and ten drops of the acid, sulphur, dilut. three times a day. In about a week, an evident amendment was observed in the appetite, spirits, and colour of the excre- tions from the bowels. In a fortnight, the spirits of the child became, to use the words of the parents, ungovernable ; and an evident amendment of the health in general took place. In a month, the child might be said to be well; though he still remained thin. After another fortnight, he discontinued all medicine, except the occasional use of the powders, for at this time all vestiges of enlargement in the glands had disap- peared. I do not relate this case as extraordinary, for I have seen several worse cases cured by the same means; and as I have said, some of the swellings have come on tardily, and others rapidly. It is related merely, because in the same family another child had suppuration of the glands, which left a sore that healed slowly. It cannot indeed be proved that these cases would have been strumous ; it can only be said, that to all appearance they were the same as others which I have formerly seen suppurate, and form sores slow in healing, and such as are generally denominated scrofulous. CASE XIX. A slender child about five years of age had five swollen glands on the right side of the neck, and three on the left. Their magnitude was considerable, and the child's appear- ance sickly; and the disorder had so threatening an appear- ance, that the gentleman who attended the family requested the parents to take some additional opinion on the case. The tongue was furred, and the bowels so habitually costive, that sometimes a week elapsed without any alvine evacua- tion. As the child was feverish, he took at first some saline AND TREATMENT OF LOCAL DISEASES. 103 medicine in a state of effervescence, which was afterward changed for the diluted vitriolic acid. He also took half a grain of calomel, every second night, which gradually brought about a regular secretion of healthy bile, and in about three weeks the child might be said to be well, for his bowels acted regularly when no medicine was taken, and the discharges from them were properly tinctured with bile. The use of calomel was now only recommended, if the appearance of * the stools varied from the rhubarb colour. The swollen « glands disappeared, nothing but a bread and water poultice having been applied to them. The bodily powers of the child were considerably augmented, and his aspect became healthy. CASE XX. A boy between seven and eight years of age had a lame- ness about the,hip, which was so considerable as greatly to alarm his parents. There was no tenderness when the joint was compressed either in front or from behind. The tongue was furred, and he had been subject to slight paroxysms of fever, resembling an intermittent. I recommended half a grain of calomel with a few grains of rhubarb every other night. In a short time the lameness so entirely disappeared, that I was no further consulted on his case. About eight months af- terward, however, I was desired to see him with three con- siderably enlarged absorbent glands on one side of his neck, and two on the other. They had for many days continued to increase. He was at that time feverish, and I now became more acquainted with the state of his health in general. I learned that he eat rather voraciously, and could not be restrained from taking very highly seasoned food; that though his bowels regularly enough evacuated the residue of the food, the stools were of various, and always of faulty colours, and very offensive ; that he perspired profusely upon the slightest exertion. His skin was covered every where with scurf and eruptions, and his hands were hard, harsh, and 104 ON THE CONSTITUTIONAL ORIGIN, chapped. He took the medicines, as in the preceding case, for about the same length of time, when the glandular complaint was well. He continued the half grain of calomel, however, for three months, for the secretion of bile had not even in that time become healthy in quantity and quality. His skin was, however, perfectly smooth and free from erup- tions. His hands only retained in a slight degree their former feel. I have also seen instances of sores apparently scrofulous left after the suppuration and ulceration of diseased glands, which had continued for more than a year, heal rapidly under the same kind of treatment. 1 have, however, seen other instances, in which the sores did not appear to be amended by such constitutional treatment. I have also observed several instances of strumous affec- tions of the fingers in children get well in proportion as the general health has become established by correcting disor- ders of the digestive organs. I need not however detail them. These diseases were, in my opinion, strictly scrofu- lous. The nature of the disease in the following case will not I think be doubted, and on this account I relate it. CASE XXI. A child about five years of age, after having had the measles, got into a bad state of health, and had several scro- fulous abscesses form on the fore-arm. They became sores of various sizes, but in general about that of a shilling ; the surrounding skin was thickened and of a purplish hue. The sores were foul, and without granulations. In this state they were when I first saw the patient, and had continued with occasional amendment and deterioration for two years. The child's countenance sufficiently indicated that he was ill, also his tongue was furred, his appetite deficient, his bowels cos- tive, and their discharges faulty. The same medicines were prescribed as in the former cases. In about six weeks the ehild got into remarkably good health, which it had not en- AND TREATMENT OF LOCAL DISEASES; 10-? loyed from the time of its first indisposition, and the sores ra- pidly and soundly healed. My observations have led me to believe, that most local diseases are preceded by general indisposition, of which the disordered state of the digestive organs is an evidence, and may have been a cause. The relief arising from the correc- tion of this disorder is indeed surprising, and the general knowledge of this fact I have deemed my duty to promote to the utmost of my power. When the appetite has been deficient, I have been accustomed to recommend acids as me- dicines, when on the contrary it has been good, and the diges- tion difficult and imperfect, I have recommended bitters and alkalies. I mention this to account for my giving the sulphuric acid in these cases. It is, in addition to its medical properties, so pleasant, that even spoiled children will take it without agitating themselves, and distressing their parents. It pleases me to be able to give proofs of its utility; because, I think, they will be allowed to disprove that any specific good arises from the administration of alkalies. Alkalies may be useful occasionally in dyspeptic cases; but that they have no specific action in the cure of scrofula, I have long thought, from some experiments which I made on this subject at the hospital. In cases of scrofulous glands, I gave soda in doses which were gradually increased till they affected the qualities of the urine, without perceiving any benefit to accrue to the local disease from its use. The pleasure which I feel in thus endeavouring to disprove the specific virtues of alkalies arises from this circumstance:—That if 1 am right in my notion, that they are chiefly useful by their operation in the stomach and bowels, it shows how much better it is to be informed of what ought to be done for the cure of diseases, than of the means by which it may occasionally be accomplished; or in other words, it shows how much superior the rational is to the empirical practice of medicine. Thaterysipelatous inflammation is the consequence of a dis- turbed state of the system.caused or maintained bv disorder Vor,. T. 14 106 ON THE CONSTITUTIONAL ORIGIN, of the digestive organs, and that this inflammation is curable by means which correct the latter disorder, could be proved by numerous and indisputable cases; yet it is not necessary to adduce them, because the public opinion seems already de- cided on this subject. If, then, numerous and very dissimilar diseases may result from the same causes, is it not probable that they are adequate to produce every variety ? It must, how- ever, be admitted, that these may be hereditary predispositions to certain diseased actions. We have instances of gout oc- curring in very early childhood ; and it is also highly probable, that unhealthy states of the circulating fluids may conduce to excite peculiar morbid actions. AND TREATMENT OF LOCAL DISEASES.. U»7 CASES. SECTION V. On Diseases of various Glands, arising from Disorders of the Constitution. I have also observed that diseases of particular organs seem to originate, in many instances, from disorder of the system in general. The testis of the male subject, and breast of the female, have furnished me with examples of this observation. In the cases to which I allude, the testes were alternately af- fected, enlarging considerably, and then subsiding.* I have met with numerous and interesting cases of such diseases of the breast; however, the relation of a few will be sufficient to inform the reader of all that I know concerning this subject. CASE XXII. A lady came to London, to submit to the removal of a diseased breast, if it should be judged necessary. The dis- ease had existed for more than two years. The breast of the affected side was one-third larger than the other ; indu- rated in several parts ; and so much enlarged and hardened in one place, that this might have been taken for a distinct tumour on a hasty and inattentive examination.! This part * The cause which excites and maintains alternate irritation and disease of the testes, generally resides in the urethra ; but there was no disease of that part in the cases which I now mention. The patients first became unhealthy, and disorder of the testes followed. Similar affections are not uncommon in pseudo-syphilis. t It may not be improper to observe here, for the instruction of the younger part of the profession, that if a breast containing a portion which is particularly indurated be examined by the points of the fingers placed circularly, the disease will feel like a separate tumour; but if the flat surface of the fingers be moved over it, its true nature vill brcorac manifest. 10$ ON THE CONSTITUTIONAL ORIGIN; was situated near the margin of the pectoral muscle. The dis- ease had resisted the various means employed with a view to disperse it, such as leeches, lotions, mercurial ointment, &c. It was occasionally painful, and caused the patient so much mental anxiety, that the surgeon, who attended her in the country, thought it should be removed. The mammary gland of the opposite side was far from being in a perfectly healthy state ; which circumstance appeared to forbid an operation, since the same disease might take place afterward in the opposite breast. The patient's general health was much impaired, her tongue was furred, her appetite deficient, her digestion imperfect; the biliary secretion was disordered, and the bowels costive. I ordered her to take a compound calomel pill every other night, five grains of rhubarb half an hour before dinner, and the infusion of gentian with senna, so as to procure a sufficient evacuation of the bowels daily. Linen, moistened in water, was applied to the part in the evening, or when it felt painful and heated. This plan of treatment reduced the bulk of the diseased gland by at least one-third in the course of a fortnight. The patient went after- ward into the country, still employing the same medicines; and was entirely free from the disease in three months, though she felt occasionally shooting pains, which probably indicated that her health was not completely re-established. CASE XXIII. A lady consulted me on account of a considerable swelling of the breast, attended with much pain. It had come on suddenly, and had been painful about a week; but she thought that a lump had existed previous to this time. The principal tumour was on the side next the sternum, and was as large as a hen's egg; it seemed to be distinct; yet there was a general swelling, with partial induration of the substance of the gland. The tongue was furred, the bowels costive, and the pulse frequent; and she was, to use her own expression, very nervous. 1 directed her to use the same means as AM) TREATMENT OF LOCAL DISEASES. J09 were mentioned in the preceding case. Small doses of mercury act beneficially on the bowels, by inducing regular and healthy secretions ; and I know no better method of ad- ministering it as a discutient. The general induration of the breast and tumefaction of the integuments subsided quickly under this treatment, and left the lump in the same 6tate which I supposed it to have been in before the attack of general swelling and pain. In another week this ap- parently distinct tumour was flattened on its surface, diminish- ed in size, and confused with the substance of the mammary gland. Its form varied each successive week; it first became oblong, and afterward seemed to separate into two parts; but in less than six weeks no trace of it could be felt. CASE XXIV. A medical man, who resides in the country, brought his daughter to town for advice. She had apparently a tumour in her left breast, between the nipple and the axilla; in which part she had felt a good deal of pain. The swelling was of very considerable size, and the breast so tender, that I could not exactly make out whether it arose from distinct tumour, or from a partial enlargement of the mammary gland. Want of time prevented the patient's father from showing the case to another surgeon. I could only give him this opinion; that in the present circumstances no one would think of an operation. I recommended the application of the lotio ammon. acetat. when the part felt heated ; and as the patient had disorder of the stomach and bowels to a great degree, that the chief attention should be paid to the state of these organs. A grain of calomel was directed to be taken every second night ; rhubarb before dinner, and infus. gen- tian and senna, if necessary. About two months afterward, having occasion to be in that part of the country where the patient resided, I called on her. Her father then told me that the swelling had subsided considerably, after his daughter's return into the 110 ON THE eONSTttJTIONAL ORIGIN, country ; and that of late he had not examined the complaint. as she told him she felt no uneasiness from it. When I now examined the breast, I could not perceive any difference between it and the other. No vestige was left of a disorder, which had been of such a magnitude, as to occasion considerable alarm ; a circumstance that ex- rited the greatest surprise in the mind of her father, who was a practitioner of much experience.* Before I had paid attention to those complaints which arise from or are aggravated by constitutional causes, I could not have believed that such considerable local diseases, after resisting various topical and general means, should give way so readily and completely to small doses of medi- cine. It is, only by considering the manner in which this effect is produced, that the subject can be placed in a proper point of view. An attention to the state of the bowels is indispensably necessary, even in the common practice of surgery. A simple cut of the finger frets into a bad phagedenic sore, which resists every local remedy so long, that amputation is at last proposed. This ulcer is the consequence of bad health, which in its turn is aggravated by the irritation of the sore. The patient has a furred tongue, with other symp- toms of disordered digestive organs. An attention to this disorder corrects the painful state of the sore, which now heals rapidly under simple dressings. A patient has a disorder in the urethra, almost too trivial for surgical attention ; yet producing much inconvenience. The functions of the digestive organs are impaired, and he is hypochondriacal. He consults a physician, under whose care his general health is amended, and he no longer feels or thinks of the local disease. * I have also known cases of induration and suppuration of the salivary glands, apparently caused by the. same general disorder, and cured by the same treatment. AND TREATMENT OF LOCAL DISEASES. \\l An erysipelatous inflammation of the leg is imputed to some trivial cause ; as for instance a gnat-bite. It becomes worse under the common remedies. The health has been long declining, and the chylopoietic viscera are obviously deranged. The erysipelas is quickly cured by medicines prescribed for that disorder. A patient has a trivial sore on his leg which the surgeon finds a difficulty in curing by the usual methods. The pa- tient feels indisposed, and has a manifest disorder of his digestive organs. The sore begins to slough, and becomes very painful. The disorder of the stomach and bowels is augmented ; so great is the indigestion, that the small quan- tity of food which the patient thinks it necessary to swallow for sustenance, feels weighty and uncomfortable in the sto- mach ; and the vegetable food becomes almost corrosively acid. Opium fails to procure sleep, or even to give ease. When the mortification has spread so as to occupy almost one-fourth of the integuments of the leg, many very co- pious pultaceous stools of a greenish-brown colour are dis- charged from the bowels in the course of the night, and the patient's feelings undergo an entire revolution. Before this, the stools procured by medicine were watery and dark coloured. The patient now sleeps like one long harassed by pain and watching; his stomach is tranquil, and willingly receives aliment, which now produces no uneasy sensations. The skin, which had been hot and dry, becomes moistened with a gentle perspiration, and the pulse beats with its natu- ral frequency, and in a tranquil manner. The effects of this favourable crisis being maintained by medical treatment, the sloughs are thrown off, and the sore heals with a rapidity indicative of considerable vigour of constitution, and further demonstrative of the sloughing not having been the effect of vascular weakness, but of nervous irritation. I could relate numerous cases of erysipelatous inflammation terminating in sloughing, in which the disease arose from a similar consti- tutional cause. 11} ON THE CONSTITUTIONAL ORIGIN, In order further to elucidate this subject, I subjoin the chief circumstances of a case which occurred since the publication of the second edition of this book. A gentleman who once had a pimple on his leg spread by 6loughing, so as to produce a considerable chasm both in cir- cumference and depth, was much alarmed when another equally trivial complaint manifested the same disposition. He was at this time in London on a visit, and desired me to attend him. The patient was about 50 years of age, and a robust healthy-looking man ; his pulse was remarkably vi- gorous, and in all respects right; his tongue was slightly furred and his bowels regular. To me his apprehensions seemed unfounded ; he was however confined to a sofa, and a linseed poultice applied for nearly three weeks, without any aug- mentation of the disease, or any separation in the circum- ference of the eschar. The slough had split into portions, and a foetid matter oozed from it; at that time the poultice was changed to one made with stale beer, with a view to ex- cite a little action in the indolent parts. It produced, how- ever, irritation, and in one night the sloughing of the integu- ments increased to one-third more than its former extent. The linseed poultice was again employed, and after some weeks were elapsed, as no separation had occurred in the circumference of the slough, and it appearing penetrable by medical applications, weak acids, infusions of bark, diluted spirits, and resinous tinctures were tried, to learn the effect upon the slough and contiguous parts ; some of the slough had by this time separated, and new flesh of no unhealthy appearance presented itself beneath the sloughing part, which extended no deeper than the skin. None of the applications seemed of any material benefit, and any thing of an irritating nature appeared to produce irritation, with a slight increase in the circumference of the slough. As the sloughing of the skin seemed to be the effect of disease extending in it while the cuticle was entire, and when, consequently, no applica- tion could have any peculiar effect, but would act as a simple stimulus ; and as all stimulants appeared injurious. I content* AInD TREATMENT OF LOCAL DISEASES. US cd myself in future with the application of the linseed poul- tice and simple dressings. Under their use the sloughing of the skin continued to spread during a period of about six months, when the patient died.—The disease began about the middle of the tibial side of the leg, and extended towards the front and outside till it occupied about three-fourths of its circum- ference ; it extended also towards the ankle, and to within about two inches of the upper end of the tibia. At one time it spread by a dusky-coloured inflammation, suddenly occu- pying a considerable extent of skin, yet in this district there were parts more discoloured, and presenting an appearance similar to that arising from the transudation of blood from the veins in dead bodies. The parts so discoloured first sloughed, leaving several insular portions of skin, still preserving its vitality. Some of these portions slowly perished, others never completely mortified. At other times the mortifica- tions spread slowly, and merely from the circumference, without any previous disease in the skin being apparent: every new extension was preceded by constitutional dis- turbance : and when the patient felt well and was tranquil, the disease continued stationary at times for a fortnight or three weeks. As the sloughs successively separated in the order in which they took place, a healthy granulated surface appeared beneath them, which cicatrized ; and cicatrization also taking place from those portions of skin which did not completely perish, the sore healed with more than usual celerity, so that a short time before the patient's death, there was much less slough and appearance of disease than at former periods. Having described the local treatment of this unfortunate case, I have only to relate the circumstances ob- served relative to the system at large, and the medical treat- ment which was instituted. The patient had been accus- tomed to eat a well-cooked dinner, and to drink a liberal quantity of wine afterward. About four months preceding this attack, he had very much diminished his quantity of wine ; and from this time he thought that he became nervous and uncomfortable. His nervous feelings were manifested bv Vol. I. 15 114 OF THE CONSTITUTIONAL ORIGIN anxious looks and inquiries, and by impatience to have things done at the moment and in the manner he wished ; he was also apprehensive and solicitous about others in cases which warranted no such feelings. He was thirsty, and generally had a tumbler of water on the table, which he supped occa- sionally, though he did not indulge himself in drinking it. He ate his breakfast and dinner with appetite, and in moderate quantity. His bowels were regular; and the biliary discharges, althougth not right, were not materially otherwise. The first attentions were paid to the digestive organs, in the manner described in the introductory remarks ; but when the morti- fication was extending, nitric acid and bark were exhibited. When the bark was increased to a moderately large dose in order to ascertain whether it was likely to be of service to the local disease, it rendered the patient slightly feverish, in- creased his thirst, and caused the tongue to become dry and brown. These medicines were changed for cordials, as cam- phor, julep, with aromatic confection, which seemed to an- swer better. Opium was tried, and seemed to be beneficial in moderate doses, administered at regular intervals; but in larger doses it seemed injurious. The patient throughout suffered very little pain, and slept well, except at those times when a temporary disturbance of his health, that has been mentioned, occurred. At those times also the white part of the eye assumed a yellowish tint, and there was an expression of languor and disquiet in his countenance ; as cordials agreed with him, a liberal quantity of wine was permitted ; never- theless he gradually became feebler and his flesh wasted, whilst his belly enlarged; of this enlargement he took notice himself; it first appeared to be merely tympanitic, but sub- sequently water was evidently effused. The right foot and ankle became considerably oedematous ; of the left or dis- eased limb they were but slightly so ; he had but little pain, and talked of returning into the country; he was good-hu- moured and cheerful almost to the last. A short time before his death his memory failed, and he thought but little even on his own case. At last he was seized with profuse diarrhoea, AND TREATMENT OF LOCAL DISEASES. \ DlSI'ASF.s part of this paper : and at present to corroborate this fact by the testimony of another, I shall relate a case which was communicated to me by an eminent and accurate surgeon in this town. CASE nr. A gentleman, lately married, complained to his surgeon of a running from the urethra, which so strikingly resembled a venereal gonorrhoea that the latter could not but ascribe it to infection. He had afterward a swelling of the prepuce, and sores on that part, which confirmed the surgeon in his opinion, and produced a kind of dissension between his pa- tient and him, the one affirming that the disease was venereal, the other that it could not possibly be so, as his wife had no disease, and he had had connexion with no other woman. The effect of this litigation was, that the surgeon would not urge the taking of mercury, nor would the patient require the administration of that medicine, though a bubo, sore throat, and eruptions succeeded, which could not be distin- guished from similar complaints of a syphilitic nature, but all of which spontaneously got well, The narrative of the following case was lately sent to me by Mr. Watson, of Stourport, It is an instance of the nurse being infected from the child, and similar instances in this respect are not unfrequently met with. Yet it contains some interesting circumstances which are explanatory of my pre- sent subject, and I, therefore, take the liberty of inserting it in this place. CASE IV. Mrs. F., after suckling a nurse child about four months, perceived a small ulcer on the breast near the nipple, which she believed she caught from the child, as it had a bad nose and sore lips. At this time the ulcer was about the size of an almond, and of the shape of one. As it did not RESEMBLING SYPHILIS. i*!t heal from simple dressings, the surface of the sore was rubbed with argent, nitrat., and a wash of calomel in lime water was afterward applied. Under this treatment the ulcer healed, and a gland in the axilla, which had enlarged, subsided. This happened about three weeks after the patient had first con- sulted me. Two months afterward the patient had a severe febrile attack, accompanied with sore throat, of which she soon recovered. To this succeeded a copper-coloured erup- tion, which came out on all parts of the body. No medicine was given at first, but as the patient became uneasy, some compound calomel pills, with small doses of nitric acid were directed. She took about 12 pills, and small doses of the nitric acid for the same length of time, when they were dis- continued. In about two months all the eruptions had disap- peared, except some white blisters, which had lately formed about the labia pudendi, and which gave her pain, when she walked. This complaint was removed in a few days by a solution of sulphat of zinc. About a week afterward, her husband showed me a sore on the penis, covered by a black scab. It was about the size of a sixpence, the surrounding skin was much inflamed, but the base of the sore was neither hard nor thickened. In a few days, a second sore appeared in the course of the absorbents between the first and the groin. The inguinal glands now became enlarged, and one of them suppurated. In about three weeks from the first appearance of the sore on the penis, the patient was attacked with feverish symptoms, which were followed by an eruption different from that which his wife had been affected with, but very similar to the erythema papulatum syphiliticum, repre- sented by Dr. Willan. The sores on the penis spread ra- pidly for some days, but did not penetrate deeper than the skin, and after being twice touched with argent, nitrat. they soon healed with the use of calomel and lime water. The abscess in the groin was opened by a lancet, and the wound ulcerated considerably, but afterward healed by the same means, that had been serviceable to the other sores. ] 90 "N' DISEASES This patient never took any mercury, except once, when some calomel was given, with other aperients, as a purge. It may be rationally supposed that the discharges from such sores as I have described, as well as the discharges from secreting surfaces not in a state of ulceration, may prove morbific and excite local diseases, or, if absorbed, may contaminate the constitution. Cases which render these opinions probable, are so frequent, that every surgeon must, I think, have remarked them. In consequence, however, of his preconceived opinions, he might distrust the veracity of his patients, and treat the disease as if it were syphilitic, and the consequences of such conduct will be displayed in the subsequent part or this paper. After these preliminary observations, which are designed to show how sores on the genitals may arise from sexual in- tercourse at present as they did even in the time of Celsus j I may further remark that from the time of the breaking out of the lues venerea, it is probable such sores continued to occur, and were confounded with the sores induced by that disease; thus we may account for the opinions delivered by old authors, of even syphilis getting well spontaneously, or by the administration of medicines of acknowledged ineffi- cacy. Every surgeon must have seen cases of syphilis get- ting progressively worse, till corrected by mercury, and re- gularly yielding to the effect of that medicine, and being permanently cured by one adequate mercurial course; so that his observations will induce him to admit the accuracy and justness of the description of that disease which Mr. Hun- ter has given in a great number of instances. Further, when from the insensibility of the constitution to the operation of mercury it has been difficult to excite its specific effect, how numerous are the cases of chancres, ulcers in the throat, and nodes, that have remained stationary and unvarying under a long use of mercury, and yet have yielded and become per- fectly well,when by more energetic measures the constitution has at length been affected by this medicine. To identify what I consider as true syphilis, and to excite the reader's RESEMBLING SYPHILIS. 191 attention to that disease, so that he may contrast it with those which make the subject of the present publication, I shall here insert a case which was related in the first edition of my surgical and physiological essays, to show the efficacy of mercurial fumigations in affecting the constitution, when other modes of administering mercury had failed to produce its specific effect.* CASE V. A young man had a chancre by the side of the fraenum preputii, which had all the characters of true syphilis. It was of a circular form, with a thickened edge and base; there were no granulations, and matter adhered to the sur- face. For this, he took mercurial pills in large quantities, which never affected his mouth, though occasionally they produced griping pains, and made him feel very unwell. He was obliged at this time to travel pretty constantly, so that he could not conveniently rub in mercurial ointment. When the mercury was taken in such quantities as to make him feel ill, and to disorder his bowels, the sore looked red on the surface, and seemed disposed to heal, but when he diminished the quantity of the medicine the sore assumed its former diseased characters. After the chancre had continu- ed for two months, a small bubo formed, suppurated, and burst. By persevering in the internal use of mercury to the greatest extent that he could do, the chancre healed and the *» It is not my intention to republish the cases in proof of this fact, because I think that the present one is sufficient to evince its truth. It seems, however, right to mention that my opinions on this subject are unaltered, and to repeat, that I have found mercurial fumigations employed in the manner recommended by the Chevalier Lalonette, a physician in Paris, in 1776, to be, in the majority of instances, a more powerful and innocent means of producing a mercurial af- fection of the constitution than in unction or the internal use of mercury, and equally certain of radically curing the disease for which it has been thus administered. The fumigating powder which I have used instead of Lalonette'a is calomel washed ill water, containing a small quantity of ammonia, so that the powder may be deprived of its muriatic acid, and assume a dark grav notour. 19i ^iS DISEASES bubo got well about the same time. This happened four months after the occurrence of the chancre, and six weeks after the breaking of the bubo. As at last having got the chancre to heal by pushing the use of mercury to an extent that made him feel very uncomfortable, and much indisposed, he left off the medicine sooner than he ought to have done. In two months more, his former occupations ceasing, he re- turned to London, where he afterward remained. Shortly after his return, which was in September, 1788, one of his tonsils seemed a little enlarged, indurated, and tender, so as to occasion a difficulty in deglutition. In the course of a week it ulcerated, and the ulcer acquired by degrees all the characters of syphilis. It was of an oval form, excavated, without granulations, and with matter adhering to its surface. The same circumstances took place in the opposite tonsil, and an exactly similar sore formed in it. As the history as well as the appearances of the primary chancre left no doubt of its nature, and as the secondary symptoms were equally unequivocal, he immediately began a mercurial course: being healthy, and his bowels not easily disturbed, he took, on an average, from two to three grains of calcined quicksilver, or calomel joined with opium, every day for three months ; and also used mercurial ointment during the same period, beginning with two drachms, and gradually in- creasing it to an ounce daily; besides which, he had for a short time taken a solution of hydrargyrus muriatus. Yet all this scarcely produced any soreness of his gums, or caused any visible amendment in the ulcers of his throat; the only effect it had being that of preventing them from be- coming worse. His bowels, indeed, were occasionally dis- turbed by the medicines, but were easily quieted by opium. To rub in the quantity of mercurial ointment used towards the latter part of the course, the patient spent nearly an hour and half every night and morning ; but as he became weaker, he perspired considerably in consequence of this exercise, which tended to frustrate his endeavours, by pre- KKsKMBLING SYPHILIS. 193 venting, or at least greatly diminishing, the absorption of th< medicine. No ground being gained by pursuing this plan, Sir Charles Blicke recommended mercurial fumigation according to La- lonette's method, which he had occasionally employed with success, and which would not only relieve the patient from the fatigue of rubbing in the ointment, but prevent any farther irritation of his bowels, by superseding the internal use of mercury. The patient was accordingly exposed, for half an hour each night, to the fumes produced from half an ounce of.the powder ; by which means, in less than a fort- night, his constitution and mouth became properly affected by the mercury ; the ulcers healed soon afterward ; and in about a month he was permitted to discontinue the remedy. In this case the disease in all its circumstances precisely agreed with the description of syphilis given by Mr. Hunter. It was unchangeable in its characters ; it regularly and pro- gressively got worse when no mercury was employed ; it was stationary when opposed by that medicine, and it was per- manently cured by an adequate mercurial affection of the constitution. Having been educated in the old school, under professors who prided themselves in possessing the Tactus and Visus eruditus, 1 was anxious to obtain that happy discrimination of colour that should enable me to pronounce from the cop- perish tint of an eruption that it was undoubtedly venereal. But my endeavours were ineffectual; and much was I grati- fied by the publication of Mr. Hunter's book, which furnish- ed me with a clue to guide me through the labyrinth in which I had been bewildered. All my observations, while a stu- dent, corresponded with Mr. H.'s; and when I experienced as well as witnessed the perplexities of practice in these diseases, I saw nothing contrary to his description. I saw cases of true syphilitic disease, which had been regular in their progress and increase, when no mercury was used, re- gularly and permanently cured by that medicine. I also saw diseases resembling the venereal, which were neither regular Vol. 1. 25 191 ON DISEASES in their progress nor cure. Each year additional facts pre- sented themselves to establish these opinions, and none ap- peared to contradict them. The following case in particular of a medical student of the hospital, made a strong impres- sion upon my mind. CASE VI. This gentleman thought that he had infected a slight cut on his hand (which was situated in front and just below the little finger) with the discharge from a bubo in the groin that he had opened. The wound fretted out into a sore about the size of a sixpence, which he showed me, and which I affirmed had not the thickened edge and base, and other characters of a venereal chancre. I therefore recommended him to try the effect of local means, and not to use mercury. In about a month the sore, which had spread a little, be- came again contracted in its dimensions, and assumed a heal- ing appearance. At this time pain was felt extending up the arm, and suddenly a considerable tumour arose over the ab- sorbing vessels, which proceed along the inner edge of the biceps muscle. This tumour became nearly as big as a small orange. As the original sore seemed now disposed to heal, and as there was no surrounding induration, 1 could not believe it syphilitic, and therefore recommended him still to abstain from mercury, and apply leeches, and linen moist- ened in the aq : litharg : acet: comp : to the tumour formed over the inflamed absorbents. Under this treatment the tumour was discussed, and the sore at the same time healed. About three weeks afterward the patient called on me, and said that there were venereal ulcers in his throat; and in each tonsil there was an ulcer deeply excavated, with irregular edges, and with a surface covered by adhering matter ; ulcers, in short, which every surgeon, who depends on his sight as his guide, would have pronounced to be syphilitic. Shortly after, also, some cop- per-coloured eruptions appeared on his face and breast. He RESEMBLING SYPHILIS. 195 showed his diseases to several surgeons, on whose opinion he relied, who, without hesitation, affirmed that they were syphilitic, and that the mercurial course had been impro- perly delayed. ^, Whilst the patient was looking out for lodgings, in order that he might go through the mercurial process, a circum- scribed thickening and elevation of the pericranium covering the frontal bone appeared ; it was of the circumference of a half-crown piece; and was, in short, what every surgeon, who is guided only by his sight and touch, would, without hesitation, have called a true corona veneris. I now told the patient that I was still more inclined to believe his dis- ease was not syphilitic, from the sudden and simultaneous occurrence of this node with the sore throat, &c. Other surgeons thought differently ; and I believe this very sensible and amiable young man imagined that his health would be- come a sacrifice if he any longer attended to my opinion. He was preparing to submit to a mercurial course, when very important concerns called him instantly into the coun- try. He went with great reluctance, taking with him mer- curial ointment, &c.: and after a fortnight I received a letter from him, saying that he found his complaints benefited by his journey ; that business had prevented him from beginning * the use of mercury for a few days ; that he now found it was unnecessary, for his symptoms had almost disappeared; and shortly afterward he became well. At the time, and ever since, I considered this case as meriting publication, as being a most unequivocal instance of a disease occurring, which could not, from appearance, be distinguished by surgeons of the greatest experience from syphilis, and which, however, was undoubtedly of a different nature; and 1 believe that there is no one, who would not have decided on this case, as those did who declared it to be syphilitic, unless they had had an opportunity of watching its progress very attentively. This case probably made me more scrupulous than I should otherwise have been in admit- ting diseases to be syphilitic, till their unabating progres« 19'J ON DISEASES established their nature beyond the possibility of doubt; and from this hesitation in deciding I have been enabled to prove, that a great number of cases, in which mercury would have been empkyed, have got well without the use of that medi- cine. ^P In the course of practice, I frequently met with cases of a nature similar to the foregoing. In these, I had opportuni- ties of tracing constitutional symptoms from the primary sores which had caused them ; a circumstance which cannot frequently be done in hospital practice. I saw that the primary sores had not the character of syphilis, notwith- standing the secondary symptoms often strongly resembled those of that disease. As, however, I did not meet with other surgeons who thought as Mr. Hunter did on this subject, and as my observations so strictly coincided with his, I thought it right in the first volume of my Surgical Observa- tions, published in 1804, to excite the public attention to these cases by laying before it the following Essay ; but previously I inquired of the best surgeons in London, whether constitutional symptoms of syphilis do ever spontaneously amend? To this inquiry no one decidedly replied in the affirmative; whilst all without hesitation agreed that they were generally, if not constantly, progressive, unless checked by the operation of mercury. In consequence of this opinion, so concurrent with Mr. Hunter's description of the disease, I was induced to publish the following cases and remarks. RESEMBLING SYPHILIS. 197 SECTION II. On Pseudo-syphilitic Diseases becoming well spontaneously. Mr. Hunter, in his excellent Treatise on the Venereal Disease, has related several cases supposed to be sy pbilitic, and some of which were certainly not so, as they got well without mercury; but in the greater number the employ- ment of this medicine rendered their nature doubtful. Mr. Hunter, also, who was as cautious in drawing conclusions as he was accurate in making observations, expresses himself in many instances so diffidently on the subject, as, in my opinion, not sufficiently to impress the minds of his readers with the certainty, importance, and frequency of such facts. He concludes his observations by intimating " that unde- scribed diseases, resembling the venereal, are very numerous, and that what he has said is rather to be considered as hints for others to prosecute this inquiry further, than as a com- plete account of the subject." As it has occurred to me very frequently to meet with such cases, and as the neces- sity for discriminating them from syphilitic diseases appears to me of the highest importance, I shall prosecute the sub- ject by relating some unequivocal cases of diseases striking- ly resembling syphilis, but which, however, were disorders of a different nature, provided it be admitted that syphilis does not spontaneously get well without the aid of medicine. The necessity for discrimination between these diseases will appear upon a slight consideration of the subject. If a surgeon, who does not see that extent of practice which oc- curs in a metropolis, administers mercury in one of the diseases resembling syphilis, he finds, perhaps, that the symptoms yield slowly ; and even after a considerable and debilitating course of that medicine they may recur. They are then counteracted by a still more severe use of mercury, till they, perhaps, spontaneously cease, which may not happen till the patient's constitution is so enfeebled, that if it do not fall 198 ON DISEASES into other state of disease, it very slowly regains the stand' ard of health. Such cases would induce the surgeon to con- sider the venereal disease as peculiarly difficult to cure, and liable to recur on the remission of even a severe course of mercury. «\The consequence of this opinion is, that he em- ploys mercury to an unnecessary and injurious degree in his general practice. I do not mean, however, by these remarks to imply, that in my opinion, syphilitic diseases are equally susceptible of cure in every instance by mercury; nor am I an advocate for what has been termed an alterative course of this medi- cine. Cases which frequently occur have convinced me that it requires a very considerable mercurial effect to cure syphilis in some instances ; and that this effect must be con- tinued for a considerable time in order to ensure a cure. Mr Hunter probably wished the subject of diseases resem- bling syphilis to be prosecuted, in hopes that some distinctive characters might be discovered as peculiar to them ; but the following cases show that these diseases ensue from primary infected sores of very dissimilar appearances, and sometimes arise without any primary sore having been observed. Whilst, then, the primary symptoms are thus variable, and such as may perhaps in the greater number of cases be dis- tinguished from those of syphilis, the secondary or constitu- tional symptoms often so strikingly resemble those of that disease, as not to be discriminated from them by sight, though in general they may be by their progress. I have kept no particular account of the numerous cases which I have met with; but the five following instances hap- pened in my own private practice within a few months, and the circumstances of them are still fresh in my memory. The cases are drawn up from narratives which I requested the patients themselves to make out of their own diseases. KESEMBLING SYPHILIS. 199 CASE VII. A gentleman had a sore on the lower part of the prepuce near the frcenum, which was much irritated by travelling from the country. When he came to town there was a good deal of surrounding inflammation, and a thickening ad- joining the edges of the sore which were irregular, and seem- ingly disposed to spread. An appearance of granulations hadtaken place on the surface of the ulcer, which was atthis time as large as a shilling. I gave him the pilulae hydrargyri, whilst I tried by local means to quiet the irritation of the sore, and of the surrounding parts. As the sore appeared to heal slowly, and seemingly in proportion to the quantity of mercury taken, the patient rubbed in at the same time some mercurial ointment, and continued to do so till after the sore was well, which was in about a month. In three weeks af- ter he had left off these medicines, this patient applied to me on account of an ulceration on the velum pendulum palati, and on the surface of one tonsil; and soon afterward ulcers took place on the edges of the tongue, and on the inside of the lips and cheeks. Copper-coloured spots also came out on his arms and legs, and all over his body. They were very numerous, but none appeared on his face. By waiting and watching the progress of the disease, I found that some of the ulcers amended spontaneously, and that the palate got well. I therefore exhorted him to refrain from mercurial medicine, and he went into the country. A medical gentle- man, whom the patient consulted, was very anxious to try something to cure this disease, when his patient was seized with a severe febrile complaint, during the continuance of which all these doubtful symptoms disappeared, and there has not been any return of disease since that time. 200 ON D1SEASE> CASE VIII. A gentleman had a small sore on the prepuce, at a little distance behind the corona glandis, which did not appear like a venereal chancre, and therefore no mercury was used. After about a fortnight, during which time it could scarcely be said to be better or worse, it suddenly became considera- bly indurated in its circumference, and the surrounding parts became inflamed. The hardness was so considerable that it resembled one of those indurated chancres which so frequently occur; and in consequence of this striking resem- blance, another surgeon, whom the patient consulted at this time, insisted on his confining himself to his chamber, and using mercury attentively. The quietude of the patient, with some little attention in regard to local applications, soon removed the inflammation and hardness, and the patient, who was controlled by nothing but his fears, discontinued his medicine after thrice using some mercurial ointment, and returned to his former mode of life. About a month afterward, he called on me with an ulcer in each tonsil, one of which was deeply excavated, with ir- regular edges, and covered by adhering matter. Shortly afterward, copper-coloured spots appeared on his body, but these diseases all disappeared in about a month, without using mercury. CASE IX, A gentleman applied to me with a very irritable sore, or rather excoriation, extending itself over the left half of the corona glandis. It jvas uolike a syphilitic sore, as may be supposed from this description, yet, as the patient was young and healthy, I advised him to take some of the pilulae hy- drargyri to guard against the possible consequences of ab- sorption, and to bathe the parts affected with the aq. litharg. RESEMBLING SYPHILIS. "JOl acet. comp. c. opio, and to apply folded linen moistened with the wash round the penis. The prepuce soon became swollen and inflamed, so that he was unable to retract it, and the attempt gave him great pain. He was, therefore, direct- ed to cleanse the part by injecting frequently the decoction of white poppy headsof a lukewarm temperature. After a week he tried a very weak solution of vitriolated zinc, and other me- tallic salts, but they all increased his pain, and he was ob- liged to return to the use of the anodyne wash. When he had persevered in this course three weeks without any evident amendment, he consulted another surgeon, who recom- mended the discontinuance of the mercurial medicine, and in lieu of it, the free use of the bark. This medicine he took for a week without any amendment; he then tried the nitrious acid for ten days, and afterward took cicuta. In about two months he was able to retract the foreskin, and then the solution of vitriolated zinc appeared to lessen the irritability and contribute to the skinning of the sore, which was merely on the surface, not having been attended with any loss of substance. Afterward the penis being subjected to some accidental irritation, the same kind of soreness spread over the other half of the corona glandis ; but this disease was not accom- panied with so much tenderness as the former one, and got well in less than a month. As soon as it was well, the patient had an ulceration of the velum pendulum palati, round which the cuticle assumed a whitish colour; the ulceration spread across the palate, but it was evident that the part first affected got better, whilst the ulcer became worse in the parts last affected. Two or three ulcers took place upon each edge of the tongue, and some on the inside of the lips. At the same time many copper-coloured spots appeared on the face, breast, arms, and lower extremities ; they came out in succession, were of an oval shape, about the size of a sixpence, and had a strikingly syphilitic aspect. Believing that the primary symptoms of this disease were not syphilitic,and observing that some part of the ulcei w.r.;f. v. i)Q2 ON DISEASES on the palate healed, and that some of the sores on the tongue and lips got better, whilst new ones broke out, I recommended the patient to use no mercury. He went into the country, where all these maladies gradually disappeared, and in about a month he was perfectly well, CASE X. A person, whose irregular habits of life gave reason to sus- pect the existence of syphilis in the constitution, had ulcers in the tonsils, not superficial but deep. These were accom- panied with copper-coloured spots on the face and breast, and eruptions on the head amidst the hair, accompanied with a great deal of scurf. These got well by anointing the head with ung. hydrarg. nitrat. mixed with simple ointment, which made me doubt whether the other diseases were really syphilitic, and caused me to delay the use of mercury. The complaints did not amend, nor did they get materially worse. There was attending these diseases a good deal of general indisposition; the appetite failed, and no sleep took place till the morning. At this time a tenderness and thickening of the perios- teum of the tibia took place. Though other medicines did not appear to be of any service, I still was averse to the use of mercury. Tired of delay, the patient consulted another surgeon, who declared the disease to be venereal, and de- sired that mercurial ointment might be used. The patient accordingly rubbed in two or three nights without feeling any effect from the medicine, and then set off on a party of pleasure to Brighton, where all the diseases gradually disap- peared without any further use of mcrcurv. RESEMBLING SYPHILIS. >0J CASE XL A gentleman had an enlargement of a gland in the groin, probably from the absorption of some infectious matter, though he was not conscious of having had any sore. A second and a third gland became enlarged, the integuments became thickened and inflamed, and a very large bubo formed. It suppurated and burst in three places. The general tumefac- tion subsided, but by no means dispersed, and sinuses remain- ed where the abscesses had been. About this time I saw the patient, which was two months after the first appearance of the disease. Shortly after this, he had an ulceration, which spread over the velum pendulum palati, and except that it was more superficial, much resembled a syphilitic ulceration. It con- tinued so long without amendment, that I began to think it was syphilitic. Bark was now given plentifully, and the ulcer evidently amended. The patient went afterward to the sea-side, where the bubo gradually dispersed : many months however elapsed before it entirely disappeared. The ulcerations of the velum pendulum palati also healed slowly ; and ulcers, which afterward appeared in the back part of the pharynx, got well likewise without mercury. These cases arc not related as being rare or curious, but because they all occurred to me within the space of a few months, and because sufficient time has elapsed since their occurrence to show that there is no probability that there will be any recurrence of these or similar symptoms. It must be allowed that they are incontestable instances of dis- eases getting well without mercury, which could not be dis- tinguished by mere inspection from similar diseases truly syphilitic. For though mercury was employed in some of the cases, it was used at such a time, or in such quantity, that it cannot in the least influence our decision as to this point. For instance, in the first case, though mercurv was employed 204 i>\ DISEASE.^ for the cure of the primary ulcer, and did apparently contri- bute to it; yet the secondary symptoms got well without mercury, which according to the opinions now prevailing among surgeons, is a proof that neither was syphilitic. It may indeed be supposed that the syphilitic poison may be modified by certain constitutions, and its effects spontaneously disappear; and some may question if the secondary symp- toms were the consequences of the sores or absorption to which I attribute them. What I have written is, I believe, in conformity to prevailing opinions, and I forbear to enter into uncertain discussions. These instances, however, though not selected for the pur- pose, show that the primary infected sores which are capable of producing secondary symptoms, strikingly resembling those of syphilis, do not themselves possess any uniform characters. In the first case the ulcer had no uncommon appearance ; it was of the size of a shilling, with fretful edges, and every where covered with granulations. In the second, there were no apparent granulations, and a great degree of induration suddenly surrounded it, giving it a striking resemblance to the indurated venereal chancre. In the third, the sore sur- face was extremely irritable ; but though the disease existed for a long lime, the ulcerative process did not eat into the part; and at the conclusion of the case, there was no loss of substance. In the fourth and fifth cases, the absorption of the matter, which caused the secondary symptoms, either took place without any breach of surface, or the primary sores were too insignificant to excite attention. I lately attended a gentleman who had an ulcerated throat, and eruptions on the head, which broke out between the second and third month after the appearance of a sore on the prepuce, which sore heal- ed in a few days with no other treatment than bathing it with a solution of acetated lead, and applying to it a piece of lint moistened with that liquor. This circumstance made him disregard the primary sore, but he was assured by a surgeon whom he consulted, that the secondary symptoms were sy« philitic ; they however got well without mercury. RESEMBLING SYPHILIS. 20.J It is probable, that the poison of syphilis is of so acrid a quality that it always excites local ulceration of a peculiar and progressive nature, whilst the morbific poisons which produce pseudo-syphilis may be absorbed without any evi- dent ulcer, or from a trivial ulcer, which may heal spon- taneously; and if the consequent constitutional symptoms are considered as the effects of the former disease, and treat- ed as such, I need not say what confusion must be produced in the mind of the surgeon who pursues this conduct, and how bewildered his opinions must be respecting venereal diseases. If, for instance, in the eleventh case, a surgeon had considered the secondary symptoms as syphilitic, and employed mercury successfully for their cure, he would set this down as a case of syphilitic bubo occurring without a previous chancre, and be inclined in his general practice to use mercury in all cases of buboes without chancre, lest constitutional diseases should ensue. There, however, does not appear any thing that should exempt the glands of the groin from enlargement, and diseases to which other absorb- ent glands are subject, whilst they are particularly liable to irritation and consequent disease from disorders of the urethra and other parts, to which they are connected by means of their vessels. The use of mercury as a specific, therefore, in enlargement of these glands, unless they have been preceded by a chancre, must, I think, be considered as improper. I have met with many similar cases since those five that have been related, and of which, from their sudden and al- most simultaneous occurrence, I was induced to take a writ- ten account; within these two months I have seen two cases of eruptions and three of sore throats. The eruptions took place particularly about the hands and feet: in one case, the patient has been salivated for them; the disease, how- ever, recurred, and afterward got well without the use of mercury. * In the other, there were warts and sores on the prepuce, and buboes in the groin, which suppurated and burst: the eruptions so strikingly resembled those of syphilis. ^Ob" ON DISEASES that all the medical men, who accidentally saw the patient, ex- claimed that they were so, with a confidence proportioned to their professional skill and accuracy of observation. Indeed in this case, and in others, I have been almost impelled to use mercury, in consequence of the opinion and wishes of the patient and those of his friends. The history, however, of this disease did not accord with that of syphilis ; the warts had preceded the sores ; some sores healed, and others broke out; and at last, some of the eruptions began to get well, and the rest gradually disappeared. The third patient had a sore throat for which he had been salivated; it afterward recurred, when it got well without mercury. The fourth and fifth had ulcers in the throat and on the lips and tongue. They all got well without mercury. One of the patients who had the sore throat had been salivated, but the disease recurred. In the other two, I forebore to use mercury, and I have reason to say they will do well without it. In one of the latter cases there were ulcers on the tongue and the inside of the lips. If, then, the occurrence of such cases be frequent, and the necessity of discriminating them from those of syphilis be of great importance, we may solicitously inquire by what circumstances we are to distinguish between diseases so similar in appearance, but so different in their nature. Mr. Hunter seemed to wish the prosecution of this subject, proba- bly from the expectation that some characters appropriate to these diseases might be detected: I have not, however, been able to discover any; the fictitious disease in appearance so exactly resembles syphilis that no observation, however acute, seems to be capable of deciding upon it£ nature. Although the ulcers in these ambiguous cases generally spread more extensively along the surface of the part which they affect, yet this does not constantly happen, as is shown in the eighth case. Inthis case, however, the induration which surrounded the chancre occurred suddenly, and went away as rapidly. The progress therefore of the two diseases was very dis- RESEMBLING SYPHILID 207 similar.* It must also be remarked, that true syphilitic spots and ulcers sometimes assume the appearance of other dis- eases, and do not possess their ordinary characteristics. Since, then, our senses fail us in our endeavours to dis- criminate between these two diseases, and since the most important circumstance is to distinguish whether the disease be syphilis or not, we may inquire whether there are any circumstance in the progress of these different diseases which will serve us in distinguishing one from the other. It ap- pears to me that there are; and these cases are published not merely to show the frequency of such occurrences, and the necessity for discrimination, but to engage a more general attention to the means by which such distinction may be made. A very simple fact has enabled me in most cases to distinguish between the two diseases ; yet, simple as it is, if it be generally true, it is very important; and if it were uni- versally true, it would be of the highest consequence. The fact alluded to is, that the constitutional symptoms of syphilis are generally progressive, and never disappear unless medi- cine be employed. It may be added too, they are as general- ly relieved under an adequate effect of mercury on the constitution. An attention to such plain and simple circum- stances has been of great use in directing the medical treat- ment which I have pursued, and I am induced to solicit the public attention to them, that others may determine the value of such remarks. * On the subject of induration surrounding chancres, I think it may be useful to relate the following case, and to mention that I have known similar ones in a less degree: A student in surgery showed me an indurated chancre, for the cure of which he had used a great quantity of mercury, which had affected bis mouth for a long time, though not severely. The sore so exactly resembled a bad indurated venereal chancre, that I did not hesitate to recommend him to remain at home, and rub in so as to produce a slight salivation. But as no amendment was perceived after a fortnight's confinement, and under a considerable affection of the mouth, I was induced to inquire more strictly into the local treatment of the ^ore, which I found he was constantly irritating by various stimulating appli- cations. He also affirmed that the hardness had several times gone away and returned again. By bathing the part with milk and water, and dressing it only night and morning with mild salve, the hardness quickly abated, and though Uf ■ letted from the mercurial course, it soon became perfectly wll. Jtii ON DISEASES I have asked the opinion of several surgeons of great prac- tice and abilities respecting this question ; Whether constitu- tional symptoms of syphilis do ever spontaneously amend ? and no one has decidedly replied in the affirmative, whilst all, without hesitation, agreed that they were generally progres- sive till checked by the effect of mercury. It seemed use- less to seek further information; for what surgeon is there at present, if he sees diseases that cannot be distinguished by the sight from syphilis, and hears that they arose in conse- quence of a chancre, that would suspend his judgment, and forbear to administer mercury ? If I have lived in the habit of so frequently detecting the imposing appearances of the se- condary effects of these diseases, it is because I have been upon the watch, and because they have occurred in patients in whom I have seen the primary sores, the appearance and progress of which have excited my suspicion as to their na- ture. 1 have stated the rule as general, but not universal ; for I could myself relate cases of diseases, in which, from the great abatement, and even disappearance of symptoms, I have concluded the disease was not syphilitic ; yet from the duration of the disorder, or from the subsequent aggravation of its symptoms, the patient has desired, and I have recom- mended the use of mercury, and the disease has been suc- cessfully treated as syphilitic without its real nature being ascertained. The rule which has been mentioned relates to the consti- tutional symptoms of the venereal disease, for the primary ones, chancres, do sometimes heal spontaneously, generally, however, though not constantly, leaving a thickening or in- duration of the affected part. They may also be induced to heal by topical means, without mercury, with similar events. Some enlargements of glands in the groin will also in like manner subside. It may be fairly supposed that if some chancres heal spon- taneously, constitutional diseases arising from the same cause may, in like manner, sometimes get well without mercury. The question can only be solved by experience. Delay will, KESEMBL1NG SYPHILIS. 209 1 am sure, frequently enable a surgeon to decide that the dis- ease is not syphilis ; but there are cases in which no amend- ment takes place, and the surgeon is as it were forced, from the progress of the disease, to employ mercury, though doubtful of its nature. In recommending prudent delay and attentive observation, 1 hope and believe that I am not recommending any thing likely to be of dangerous consequences. The venereal dis- ease is generally soon checked by the use of mercury; and in constitutions where much medicine is required to counter- act its effects, that medicine may be given with freedom. By delay and observation we perhaps may perceive that eruptions and sore throats, which could not from appear- ance be distinguished from venereal, spontaneously amend : that some eruptions scale and become well, and the probabi- lity will of course be that the rest will do so likewise ; or that an ulcer mends in one part though it may spread in another, when the natural inference is, that the diseased actions in the sore will gradually cease, and health return spontaneously; and that what has occurred in one part of an ulcer will suc- cessively take place in the others. In recommending delay it cannot, I suppose, be thought that I would advise any one to wait till an ulcer destroyed the velum pendulum palati, or did material injury to any im- portant part. There are cases where the progress of the disease obliges the surgeon to use mercury, even though he may be suspicious that it is not syphilitic. The effect of exciting a mercurial affection of the constitution, where we feel ourselves under the necessity of employing that medi- cine, in diseases resembling syphilis, is, as far as my observa- tion enables me to determine, very various. It sometimes cures them very suddenly, and very differently from the gra- dual amendment which it produces in truly syphilitic diseases. Sometimes, however, these diseases yield more slowly to its operation, and are Cured permanently. Sometimes the dis- eases recur in the same parts after a severe course of mer- cury ; sometimes mercury merely checks the disease, ajid Vol. I Tf 210 O.N DISEASES can scarcely be said to cure it; in which case it seems im- portant to support the strength of the constitution, and to keep up that mercurial effect which controls the disease, and can be borne without material derangement of the constitu- tion for a great length of time. Sometimes also the use of mercury aggravates these diseases. Again, in some constitutions, syphilitic disease may assume unusual characters, and be very difficult of cure. It must then be scarcely possible to discriminate between these ano- malous cases of syphilis and those of diseases resembling it,, unless some new distinctions are discovered. But I suppress any farther observation on the subject, hav- ing accomplished the intention of this paper, which was to depict a kind of cases which very frequently occurs in this metropolis, and which is, I believe, too commonly treated as syphilitic, but which may be distinguished not to be so by a little prudent delay and attentive observation. The frequent cases of such disorders which I have recently met with has suggested the idea that they are increasing of late ; nor is it improbable, since they are, like syphilis, propagated by pro- miscuous intercourse from secretions or sores not so readily curable by mercury as those that are syphilitic, and some of which are not from their nature so prohibitory of that inter- course. It is now many years since this paper was drawn out as a subject for discussion at a medical society ; and, after such an interval, the chance of any of the disorders which are de- scribed in it returning is diminished almost to nothing. I have since met with considerable numbers of similar diseases, which give confirmation to the opinion that they are frequent occurrences. In some later cases, when the disease has been long protracted, and the patient very anxious to get rid of it, I have given a little calomel for that purpose, but not so as to invalidate the opinion that the disease was not sy- philitic. Having waited, for instance, four months from tlie occurrence of a sore throat with eruptions, and being assured by the progress of the disorders that they were not RESEMBLING SYPHILIS.. 211 syphilitic, I have directed that the compound calomel pills* should be taken in such doses as to control the disease without weakening the constitution, which generally disposes the sores in the throat to heal, but 1 have taken care to remit the use of even this small quantity of mercury if it seemed to heal the sores too speedily; for it seems to me better to let the disease exhaust itself than suddenly to cure it, as in the latter case it is very likely to return. In confirmation of this opinion I may mention, that, about five years ago, a gentle- man applied to me to undergo a salivation for the cure of a sore throat, for which he had been salivated three times, once in each succeeding year. I need scarcely say that it was one of those ulcerated throats which have been described. All medicine was abstained from ; and in between three and four months the sores spontaneously became well, and have never since recurred. The whole of this paper has been written upon the presumption that diseases which spon- taneously get well are not syphilitic, which is, I believe, the general opinion. It may, perhaps, be questioned by some, whether the diseases here recorded may not be modifications of the venereal disease. The practical rules of conduct will not, however, be altered even if such a supposition were veri- fied, so that it does not seem necessary to discuss this point; it may however be right to remark, that there are cases which would induce the belief that ulcerated sore throats, eruptions, and nodes on the bones, similar to those descri- bed in this paper, may occur from a general disturbance of the constitution, without the absorption of any infectious matter. The object of this paper being simply to excite attention to such cases as are recorded in it, I did not think it necessary to enlarge much upon a circumstance which, however, is * The pill, as prescribed in the pharmacopeia of St. Bartholomew's Hospital, contains 1 grain of calomel, 1 grain of the precipitated sulphur of antimony, and 2 grains of powdered gum guaiacum, combined by soap. 212 ON D1SEASLS a strong evidence of the necessity of discriminating be- tween such diseases and true syphilis. The circumstance to which I allude is, that though a course of mercury may at the time remove all the symptoms for which it has been em- ployed, yet it will not cure the constitutional disease; for the symptoms will recur when the medicine has been dis- continued after repeated and severe courses of mercury, as will be fully shown, by cases which I shall afterward relate. Having written the foregoing account, I intended here to conclude, having, in my own opinion, accomplished my pur- pose, which was to prosecute in some degree the subject which Mr. Hunter deemed worthy of investigation, and to depict the circumstances of diseases which I believe very frequently occur, and which are often confounded with cases of syphilis, to the detriment of patients, and the discredit of our profession. But having requested the opinions of two of my medical friends on the foregoing paper, one of them said, that he thought the publication of it would be injurious, as it might induce the younger surgeons to abstain from the use of mercury, to the prejudice of their patients; the other gentleman said, that he thought more explicit descriptions should be given of the cases in which mercury should be withheld or employed. In consequence of these opinions, I am induced to take a closer comparative view of the dis- eases that are, and of those that are not, syphilitic. I undertake the task reluctantly, because the brevity with which I must speak of these subjects may render my opi- nions liable to misapprehension, and because I do not feel competent to its proper performance. Yet by this means, I think I shall do away the objection of one of my medical friends; for I believe that I am myself more likely to err in recommending the too free than the too sparing administra- tion of mercury in syphilitic diseases. Any surgeon who has observed the ruinous consequences of repeated mercu- rial courses in some constitutions, would probably err in the same manner; and his dislike to disorder the constitution bv RESEMBLING SYPHILID. 213 mercury would probably lead him even to use it more freely than might be absolutely necessary: this he would do in cases clearly syphilitic, in order to prevent the possibility of the recurrence of disease, and repetition of a mercurial course. In doubtful cases, which are cured by exciting the mercurial action in the constitution, he would adopt a similar mode of treatment, in order to suppress the disease for so long a time as to make it less likely to recur; or if any sub- sequent disease should take place, to render it highly proba- ble that this was not syphilitic, since it had broken out after such a course of mercury as must be considered to be ade- quate to the cure of almost any disease of that nature. By- undertaking this task I shall perhaps comply with the wishes of my other friends, in stating more explicitly the circum- stances which should induce a surgeon immediately to use or abstain from the administration of mercury, and, at the same time, contribute my mite of observation to those al- ready offered on this still obscure subject of venereal diseases. The most clearly marked syphilitic chancre has been ex- cellently described by Mr. Hunter. The striking characters of the disease are, an ulcerating inflammation without any reparation, attended with induration of the surrounding parts. The description is, a sore of a somewhat circular form, ex- cavated, without granulations, with matter adhering to the surface, and with a thickened base and edge. There is another species of chancre in which the disposi- tion to ulcerate is less than usual, and the disposition to indu- rate is greater; so that the ulcerated surface may heal, and leave an indurated knob or tubercle in the affected part. There are besides some chancres in which the diseased action seems to be very inert; in these the ulcer is superfi- cial, the thickening of the surrounding parts slight, and, after some time, the ulcerated surface acquires a state of health, and cicatrizes, without producing any perceptible granula- tions. I conclude that the truly syphilitic chancre some- times assumes the appearances just described, because I have repeatedly considered the constitutional symptoms which 214 ON DISEASES succeeded to such sores as truly syphilitic, yet 1 may have been deceived, for reasons which I shall afterward explain. But it is impossible to depict by words the various sores, some of which are of a very irritable nature, that are pro- duced by sexual intercourse, and through the medium of which the constitution becomes contaminated ; neither is it possible to know from local circumstances whether they be syphilitic or otherwise. It is from their effects upon the con- stitution alone, that we can judge whether they were syphi- litic or not. Many we know are not so, since they do not produce the constitutional effects of syphilis. The subject can alone be decided by future experience derived from watchful observation made by unbiassed men. Mr. Hunter thought that syphilitic poison might produce a sore which might be modified by the diseased propensities of the consti- tution and the part, and thus lose its distinctive characters. Influenced by this belief, he speaks but briefly on the sub- ject of chancres. I have also seen cases of constitutional disease, which I considered as syphilis originating from pri- mary sores which had not the usual character of syphilis : the more, however, that I see of the subject, the more I am inclined to doubt the correctness of my opinions on this point ; and of this I am certain, that the greater number of the con- stitutional diseases originating from sores, which have not the syphilitic character, differ materially in their progress and mode of getting well from those which are the consequences of true syphilis, and that they require a proportionate pecu- liarity of treatment. However, if, according to the opinion of Mr. Hunter, the action of a syphilitic chancre may be sometimes so modified by the diseased propensities of the constitution, or part, as to form an ulcer scarcely cognizable as a syphilitic one, it follows as a general rule of conduct in practice, that sur- geons are not to confide in their powers of discrimination, but in all cases of ulcers arising from impure intercourse, to act as if the sore was syphilitic, to give sufficient mercury slightly to affect the constitution, in order to guard against RESEMBLING SYPHILIS. 215 the consequences of absorption, and, by local and other ge- neral means, to cure as quickly as possible the local disease, and thus remove the source of contamination, and the ne- cessity for the continuance of medicine. The quantity of mercury necessary for the cure of a syphilitic chancre will never, I believe, be found to be so considerable as materially to disturb the constitution. We may, therefore, without he- sitation, employ it in almost all cases of primary ulcers, and be guided as to its continuance or cessation, its increase or diminution, by the effects which it produces in the sore or constitution. Mercury in small doses inclines other sores to heal, as well as those which are syphilitic ; it may therefore act beneficially when the disease is not syphilis, and, by con- tributing to the healing of the sore, remove the source of contamination and the necessity for the continuance of me- dicine. It is surely an object of importance to get the local disease well as soon as possible, and topical applications often greatly contribute to this desirable event; yet they should not be of a very irritating nature, for such means frequently aggravate the disease, as may be seen in some of the cases which are related ; nor should our applications be of an as- tringent nature, since by checking discharge, they incline the disease to become indurated, and it requires a longer conti- nuance of mercury to remove a small induration than to heal a large sore. This observation applies equally to sores of a syphilitic nature and to others. Whilst there remains an induration, we can never be sure that it may not ulcerate again, upon leaving off the use of mercury, nor can we be assured that it may not contaminate the constitution. In- deed, in the syphilitic chancre, it seems best to use none but the simplest dressings ; for when it heals by the effect of mercury on the constitution, we are assured of the adequate- ness of the quantity which is employed to the intended pur- pose, and we have reason to believe, that the constitutional mercurial affection which has subverted the local actions of the disease, will have prevented its contamination by any matter that may have been imbibed from it. If then we may, 21G ON DISEASES for the reasons above stated, employ mercury without hesi- tation in primary infected sores, being governed with respect to the degree and duration of its use by its effects, we ought, as has been shown in the preceding part of this chapter, to pursue the reverse conduct with respect to constitutional" symptoms. Here we are required to hesitate, that we may learn the nature of the disease previous to attempting its 'cure. It has appeared to me, that a longer and more active operation of mercury on the system is necessary for the permanent cure of constitutional symptoms in true syphilis, than for that of the primary chancre. Here, if we use mer- cury unhesitatingly, we may employ it to an injurious degree, where it is not wanted, and we generally fail in preventing a recurrence of symptoms. These are, I believe, the gene- ral rules of practice adopted by the best surgeons, and they appear to me, in the present state of our knowledge of these diseases, to be judicious. One advantage results from this plan of conduct, which is, that if constitutional symptoms follow from a sore treated in a manner that ought to have prevented contamination of the habithad the sore been syphi- litic, our suspicions are excited, and by attentive observation we may perhaps discover that the symptoms are of another nature. In cases of anomalous sores it may be inquired, if in those, where the event renders it probable that they were of a sy- philitic nature, the disease deviates materially from its com- mon characters, that of an ulcerative process without repa- ration, and extending in every direction. Do these sores enlarge by sloughing, or produce granulation or fungus ? Do they spread otherwise than nearly equally in their whole cir- cumference ? Does the ulceration extend in them only in particular directions ? Do they heal in one part and spread in another ? or do they suddenly amend and become worse without an adequate mercurial influence to produce such changes ? Those infected sores which are not syphilitic have such peculiarities, as have been shown in the first part nf this paper ; and as they are so very various, it becomes RESEMBLING SYPHILIS 217 necessary to distinguish them from those which are syphilitic, by accurately noting the progress of anomalous cases of the latter disease. It is extremely difficult to form any correct opinions on this subject on account of its intricacy, and the almost impossibility of abstaining from the use of mercury; but it is a subject highly deserving inquiry, and which never can be fairly investigated till it be known that the secondary symptoms arising from sores may not be syphilitic, though their appearances cannot be distinguished from such diseases by sight alone. With respect to sores that are not syphilitic, the dif- ficulties of investigation are greatly multiplied. If a des- cription cannot be given of syphilitic sores, it seems almost absurd to say any thing of those multiform sores produced by infectious matter, the qualities of which, it is probable, may be variously modified, and the effects of which appear equally liable to modification from peculiarities of constitu- tion. Yet in this intricate subject there are certain facts which can be distinctly observed, and deserve attention. Some of these sores spread by ulceration, and some by slough- ing, of which instances are related in the first section of this paper. Even Celsus has described several species of sores, which, as Dr. Adams has observed, we are acquainted with in the present day. I have never seen that phagedenic ulcer, which suddenly sloughs, affect the constitution ; neither do I believe that surgeons in general have remarked it; those who regard all these sores as syphilitic attribute the absence of secondary symptoms to the chancre having been removed by the sloughing of the surrounding parts. Yet in the case related by Mr. French in Mr. Hunter's Treatise on the Ve- nereal Disease, secondary symptoms did occur from a sore of this kind, and got well without mercury. It may there- fore, perhaps be doubted whether this disease be not an ag- gravated form of the sore which sloughs more slowly, and from which the constitution is much more frequently affect- ed. Though Dr. Adams has restricted the term phagedena to one kind of destructive sore, yet 1 feel more inclined to Vol. F. 28 218 ON DISEASES leave it as a generic term for all these destructive sores, and to divide them into species according to their peculiar cha- racters. Then we may describe them as ulcerating phage- denic sores, and sores which spread by sloughing. Again, the ulcerating or sloughing process may extend not in all but in particular directions, and the sloughs may take place from the edges or from the whole surface. As Dr. Adams has treated these subjects at large, I refer the reader to his book ; but I will take upon me to describe some species of sores which frequently occur, and are treated generally as syphilitic, but which I am convinced are not so. The sores, in one species alluded to, generally break out in succession, and sometimes after considerable intervals of time ; which circumstance, if remarked, would render it im- probable that they arose from infection of the ulcerated part, since such sores would probably be contemporary. The ulcer is at first inflamed, and spreads ordinarily to the size of the finger-nail; its circumference is thickened ; it throws out new flesh, which rises above the surrounding skin ; some times there is an appearance of several little cells or spaces in the interstices of the granulations, if they may be called so, owing to the whole ulcer not producing new flesh in an equal degree. The edges of the sore generally retain their diseased state after the middle has become healthy; from this cause the healing of the sore is retarded. These sores are slow in healing under any mode of treatment, and they generally get well in the same succession as they broke out They sometimes form in a circle round the orifice of the prepuce, and cause a contraction in that part after they have healed. I do not mean to say that all sores occupying this situation are not syphilitic, but merely to state, that some- times after a gonorrhoea of the prepuce, either originally oc- curring there, or having happened by a metastasis of disease from the urethra, sores do break out in this situation at a remote period from the reception of the infection, which are not syphilitic. The sores which I am endeavouring to de- scribe seem to be the consequence of an irritated state of the RESEMBLING SYTHILIS. r 219 prepuce, from which there is sometimes a slight general dis- charge, like that which takes place when the gonorrhoea shifts its situation from the mouth of the urethra, and becomes the gonorrhoea of the prepuce. The glands in the groin sometimes swell from irrita ion in these cases, and generally subside again, though I have ■-. nown them suppurate : but I never saw any secondary symptoms succeed to this species of ulcer. In the earlier part of my practice, in conformity to ge- neral rules, I used to give mercury in these ulcers to secure the constitution against infection, whilst I tried to heal the sores as speedily as I could by topical applications. Slightly destroying the surface with the argentum nitratum every se- cond day, and dressing with the solution of zincum vitriola- tum, were the local means which seemed to be most success- ful. An attention to the history of the disease, and frequent applications for advice from persons who had been severely and unavailingly sallivated for the cure of this species of sore, soon emboldened me to abstain from the use of mercury ; and I have never found, though I have met with a considera- ble number of instances, that I have in this respect acted wrong. I shall mention the circumstances of a case which occurred to me no long time ago. A gentleman had a slight irritation in the urethra, and after a few days, found the prepuce a little swollen, with a small discharge from beneath it. This was checked by a weak solution of zincum vitriolatum ; and af- terward three sores, such as I have described, broke out in succession, for which he used mercury so as to affect his mouth. The sores slowly healed, but two new ones made their appearance, and the mercurial course was perse- vered in. These sores also healed slowly, and a running came on from the urethra, no new sores having appeared. The mercury was left off, the gentleman came to town, and was much distressed to find that three other sores, exactly like the former ones, now broke out, but the discharge from the urethra had ceased. At this period he applied to me, and gave me the foregoing narrative of his disorder, with an as- 220 ON DISEASES surauce that he had exposed himself to no new risk of infecJ tion. I employed only local means for their cure, being sa- tisfied by the history as well as the appearance of the sores that they were not syphilitic. Near a month elapsed before any considerable amendment took place, when a swelling ap- peared in the groin, and the sores healed suddenly in a few days. Leeches and Goulard's wash were employed to dis- perse the bubo, but in vain : it suppurated, and formed a very unhealthy abscess. There was a great deal of surrounding erysipelatous inflammation, the cuticle separated from the surface of the bubo, the skin became livid, and gave discharge to the matter by a partly sloughing and partly ulcerating pro- cess. This, however, proved the crisis of the complaint: the abscess having thus broken filled up, and healed in the course of about three weeks, since which the patient has had no return of disease. This gentleman was liable to have sores break out spontaneously on the prepuce ; they got well readily by bathing them with a weak solution of zincum vitriol- atum ; and I believe that persons who have naturally an irri- table state of the prepuce are most obnoxious to such affec- tions. We must not, however, impute the occurrence of these peculiar sores to mere irritability, but to some specific contagion. The discharge from the urethra in such cases is not con- siderable, nor attended with much inflammation or chordee, nor does it increase in violence; it may, therefore, be easily distinguished from common gonorrhoea and its varieties. Sometimes, in a common gonorrhoea, the disease shifts its ground and attacks the foreskin, and sores form about the orifice of this part. These are of a different nature from the sores which I have been describing ; their surface is gene- rally glossy, not producing exuberant new flesh, and their colour is unhealthy. They generally get well as the disease returns to its original situation in the urethra. I merely mention these circumstances to induce attention, and to prevent surgeons from confounding the sores which I have been describing with any other similarly situated, but differ- ent in their nature. v RESEMBLING SYPHILIS. 221 I wish also to excite attention to another species of sores which I have frequently met with, and which differ consider- ably in their progress from those truly syphilitic. The first appearances of the sores are various, but in their progress a thickening in the surrounding parts takes place, whilst the centre is soft and less diseased than the circumference. I have seen the surrounding parts much elevated, and an open- ing leading into a cavity in the middle. 1 have seen them, on the contrary, heal with a flat surface, and acquire a circular hardness, the middle being quite soft, and the area of the circle gradually increase. I have known sores heal ap- parently well and smoothly, and afterward the edge has acquired a circular hardness like a ring of some firm sub- stance. In all these sores I have given mercury in doses short of producing a tenderness of the gums, and the disease has gra- dually but slowly got well. In the greater number of cases no constitutional affection has ensued. In some, however, it has, but it has got well without mercury, or with such small doses as would certainly not have cured syphilis. So that these observations concur with the history of the disease, in inducing me to believe that sores of this description are not syphilitic. Under this head of sores which occur on the genitals, and which are not syphilitic, I may mention one species that I have several times seen on the side of the penis, which is her- petic, affecting new parts whilst those first affected get well; so that the sore may exist a long time, and be very trouble- some, though its situations may have varied considerably. I have also seen a circle of small sores, like what takes place in tinea, occur on the outside of the prepuce in conse- quence of some acrimonious secretions being applied to it in sexual intercourse. Some diseases, whatever may be their primary nature, do, after a time, extend themselves between the integuments and the subjacent parts. I have known many diseases which burrow in this manner treated as sy- philitic, and, as the event of the cases has proved, improper- 222 ON DISEASES ly. Indeed, the progress of such diseases is so different from that of syphilis, that it is natural to discredit their being so. Diseases which proceed in this manner seem to be of an irritable nature, and to affect most those parts which have least powers of life, which appears to be the cause of their peculiar mode of extending themselves. To corroborate this remark, that sores which burrow are not likely to be syphilitic, I may mention the case of a gentle- man of the medical profession, who had a sore of this de- scription, which began on the dorsum penis, near to the pu- bes, for which he rubbed in two months, and had his consti- tution considerably affected; nevertheless^ the sore spread and burrowed under the integuments of the pubes, and the mercury was left off. The disease became communicated to a considerable district of the integuments of the bottom of the belly, and to those of the scrotum. The affected parts sometimes ulcerated, and sometimes healed. A great variety of local and general remidies were tried without benefit. No mercury was used except in very trivial quan- tity. The cavities beneath the skin were in some parts laid open, at different periods of the disease, but without much advantage. After two years and a half the disease became well, when nothing but simple dressings were applied, and when he took nothing but decoction of sarsaparilla and small doses of Vhubarb. I have in the foregoing pages endeavoured to represent briefly the circumstances of the primary ulcers of diseases which are, and of those which are not, syphilitic, and to state the general rules for the administration of mercury ; and, at the same time, I have described some sores which have not, as far as I know, been distinguished, and which, in my opinion, are not syphilitic, though they are generally treated as such. To take a similar comparative view of constitutional diseases arising from these various sores would render this paper too prolix. I hope it will be seen that I do not presume, nor do I see cause, to deviate from the established rules of practice founded on the general ex- RESEMBLING SYPHILIS. % 223 perience of surgeons. It would indeed, in my opinion, be presumptuous in an individual to form general rules drawn from his scanty experience ; I may be allowed, however, to remark, that individuals of the profession are likely to err by inferences drawn from their own practice ; and it appears to me that some professional men at present are inclined to be- lieve all sores arising from impure connexion to be syphili- tic, whilst others may be too scrupulous in expecting all sy- philitic sores to possess their common characters. The truth probably in this, as in other cases, lies between the ex- tremes. Much however, it must be acknowledged, remains to be ascertained, and I think that those surgeons would do essential service to science, who would give an accurate account of the irregularities of the venereal disease. But such an account never can be given by one, who esteems all diseases syphilitic which resemble them in appearance. The foregoing cases will, I think, at least prove this to be fact; and it was a principal incitement to their publication, that if this fact were generally admitted, it might excite that scrupulous attention and impartial observation of syphilitic diseases, which would probably lead to accurate distinctions, and the removal of that obscurity with which they have hitherto been surrounded. I have suppressed many observa- tions of my own on this subject, from a belief that it is bet- ter to say nothing than to offer opinions not fully confirmed by facts. The idea that syphilis is a most variable and Pro- teus-like disease, has probably arisen from those irregular diseases which I have described in the first section of this paper having been confounded with it. The opinion is however prejudicial, as it checks attentive observation by de- claring its inutility. If it should be in our power, as I should hope it may, by directing our attention to the history rather than to the appearances of these diseases, to distin- guish syphilis from other complaints, then we may also be able to describe the irregularities of this disease, and to in- form others when it assumes deceptive characters, and pursues an unusual track, wh^t disguise it nuts on, and what ■nurse? it follows. 224 ON DISEASES SECTION III. On the constitutional Origin of Pseudo-Syphilitic Diseases. In order further to elucidate the nature of pseudo-syphilitic diseases, I published some cases in which they originated spontaneously, or without there being any reasonable ground for supposing that morbific animal matter had been imbibed to contaminate the constitution. The cases included in this section were first published, among others which were de- signed to show the importance of correcting disorders of the digestive organs in attempting to cure local diseases. A dis- order of those organs constantly exists in these cases ; and produces, or at least aggravates and protracts a state of weakness and irritability of constitution; to which the origin of the disease must undoubtedly be referred. CASE XII. A gentleman residing in the country, who had been many years married, and whose moral character prevented any sus- picion of his having exposed himself to venereal infection, had an ulcer in the right tonsil, possessing every character of a truly syphilitic sore. The figure of the ulceration was oval; it had extended itself deeply, and presented a surface covered with adhering matter, and without the least appear- ance of granulations. It had continued three months with- out amendment, although various medicines had been em- ployed during that period. These circumstances impressed the minds of the medical attendants with an opinion, that the disease was syphilitic. On me they had a contrary effect. I thought that a syphilitic ulcer would have become materially worse in that time, as mercury had not been used to arrest its progress. Finding that the patient had a furred tongue, and disorder of the digestive organs, I recommended, RESEMBLING >VPHILIS. 22.J as the first object of attention, the correction of that de- rangement of the stomach, from which the sore-throat had probably originated. The patient went to the sea-side, where his throat was alternately better and worse ; but the dimen- sions of the ulcer were not enlarged. Tbree months elapsed before I saw the patient a second time ; when I told him that my argument against the complaint being syphilitic was great- ly strengthened. It was manifest that the disorder, to which I had imputed the sore, still existed. Being unwilling, how- ever, that the responsibility should rest entirely upon myself, I advised him to consult another surgeon, who, judg- ing of the nature of the sore from its appearance, (which indeed was strikingly characteristical of syphilitic disease,) recommended a course of mercury. The patient under- went, in consequence of this advice, a regular mercurial course ; during which the sore got well. Between two and three months afterward another sore formed in the palate, which had the characters of a syphilitic ulcer, in a still more striking degree, if possible, than the former. It was situated just where the soft palate proceeds from the bone. It was of a circular figure, and so deep as to expose the bone. The circumference of the ulcer was tumid and inflamed; its edges were not smooth, but had a tendency to ulcerate. There was no appearance of granulations, and the discharge adhered to the surface of the ulcer. The patient now ap- plied to me again; when 1 repeated my original opinion, that these sores depended on the state of the health in gene- ral. He consulted another surgeon, who recommended the use of the Lisbon Diet-Drink, with the application of the oxymel eruginis to the part; under which treatment, the ulcer healed ; and no other complaint has since occurred, though two years have elapsed. CASE XIII. A gentleman who was habitually subject in a great degree t j disorder of th<; digestive organs, had an excoriation of the 226 ON DISEASED prepuce, which had Continued about three weeks, when copper-coloured eruptions came out all over his body, so strikingly similar to those which are venereal, that some of his medical attendants recommended the immediate use of mercury. It was however agreed to delay the mercurial course for a little time ; and to give the patient half a grain of calomel, with three grains of hemlock night and morning, and a solution of magnesia vitriolata in mint-water, so as to keep the bowels freely open. The spots began to die away almost immediately, and soon disappeared altogether. The patient then mentioned that he had several times had the same kind of eruption, which had disappeared in like manner upon taking some opening medicines. In calling the reader's attention to those diseases of the bones which resemble syphilitic affections, I shall not pre- tend to relate any case in detail; for surgeons can seldom trace the progress of these diseases for themselves, but are obliged to rely on the doubtful history given by their patients. I shall endeavour to sketch the principal parts of the sub- ject, referring to particular cases, merely to show that the picture is not drawn from fancy, but is copied from nature. I have been frequently consulted on account of supposed venereal affections of the bones ; where the periosteum has been thickened and tender, and the bone enlarged, and the concomitant pains have been so much aggravated at night as to deprive the patient of rest. The history of the case has removed all suspicion of a venereal origin ; while general indisposition, a furred tongue, loss of appetite, and other at- tendant symptoms, have clearly indicated great disorder of the chylopoietic viscera. By attending to the state of the digestive organs in these cases, the patient's health is amend- ed ; thegeneral rheumatic pains are diminished ; sleep is pro- cured ; and the disease has receded almost entirely. After some time has elapsed, the bone may again swell, the swell- ing may again be checked, and return no more. Perhaps similar diseases may take place in other bones, at times very- remote from the first occurrence of the disorder. If mercury RESEMBLING SYPHILIS. 22? be not employed, there are decisive circumstances in the history of the case which proves that it is not syphilitic. Sometimes suppuration takes place, and exposes the bone : this occasionally proves a kind of crisis to the disease at that part. But the circumstances of these affections are so va- riable as to preclude a complete enumeration of their symp- toms. I shall briefly mention the cases of two patients, by whom I was consulted about the same time, in order to identify the diseases to which I allude. Both these gentlemen had been married for many years ; and there was not the least reason to suppose that any morbific poison had been imbibed. They became generally indisposed, had restless nights, pain in the head, and about the shoulders ; and a painful thickening of the periosteum of the tibia, with enlargement of the bone, took place. The chylopoietic viscera were disordered in both these cases. One gentleman had used mercury repeat- edly to a considerable extent, which produced a temporary alleviation of his disease; but his sufferings seemed to be augmented upon the cessation of the mercurial excitement. The other patient never used any mercury. They both ex- perienced a considerable mitigation of pain from those medi- cines, which corrected the state of the chylopoietic organs. Their diseases were checked, and never became again so bad as before attention had been paid to the state of the viscera. Both these patients were better or worse as the state of the bowels varied ; and they both gradually, but slowly, reco- vered. Similar diseases are so common, that I believe every sur- geon of experience will admit that affections of the bones, with wandering pains, often occur from general disorder of the health. I have never seen these cases unaccompanied by disorder of the chylopoietic organs; and I have ^always found them most benefited by whatever has tended to rectify the functions of these organs. There was no reason, in any of the cases alluded to, to suspect the absorption of poison. I will add another, to :28 ON DISEASES corroborate this statement. A gentleman, who had been married about eight years, and had no venereal disease during that period, was seized with a violent fever. Shortly after his recovery> a thickening of the periosteum on the parietal bone took place. The scalp was also much swollen, so as to threaten suppuration. He was at this time in ill health, and had great derangement of the digestive organs. By attention to this latter disorder, the swelling subsided, and no trace of it remained. The patient afterward went into the country, where his health was still more amended. In about twelve months he had several tumours of the same kind in different parts of the cranium; one alone threatened to suppurate : for these he underwent a mercurial course, which relieved them, so as to induce him to persevere in it to an extent, which almost constantly cures venereal disease. His health, during the latter part of the mercurial course, being much disordered by the medicine, his diseases became proportionally aggravated; he therefore desisted from the use of mercury; at which time his complaints were but little better than at their commencement. These diseases, however, gradually got well in the space of little more than a year ; still the patient continued in a bad state of health, the symptoms of which were a furred tongue, indigestion, and faulty biliary secretion. I add another case, which came under the observation of Dr. Baillie. A student of medicine, who attended the lectures in Windmill-street, was observed to look very much out of health ; and, on inquiry, it was found that he had nodes upon his shins, which so exactly resembled those that are venereal, that no doubt was entertained of their being of that nature. It was therefore earnestly recommended to him not to delay the mercurial course, which seemed requisite for the cure. He was very reluctant to comply with this advice, and de- clared upon his honour that he had similar swellings before he had had any sexual connexion. This declaration made this proposal to be laid aside ; and the nodes got well by a strong decoction of sarsaparilla, without a single grain of RESEMBLING SYPHILIS. 229 mercury being employed. Now, if this account be accurate, it shows that diseases like syphilis can arise from disorder of the health, even without any sexual intercourse. All surgeons of experience will, I believe, admit that diseases resembling syphilis occur from disorder of the health in general. In all the cases which I have instanced, there was not the least reason to suppose that any morbific poison had been imbibed to produce the diseases which existed. I wish much to have this point ascertained or refuted by the general experience of surgeons. The cases, which would tend to establish it, must be of rare occurrence. Most of the instances, to which I have alluded, occurred in men who had been long married, and on whose veracity I could rely. There is also, in my opinion, sufficient intrinsic evidence in each case to prove that the disease was not venereal. It was this kind of cases which I had in view in my last publication, in discussing the question whether those diseases, which may be denominated pseudo-syphilitic, arise from some modifica- tion of the venereal poison, or from a peculiarity of constitu- tion in the patients, who are exposed to the action of truly syphilitic virus. I have there said, that " it deserves to be observed that diseases resembling syphilis do occur, without any reason to suppose that any morbific poison has been admitted into the system." I have been induced to dwell upon this subject, which may, perhaps, be considered more speculative than useful, because if the opinion were verified, it would explain the occurrence of pseudo-syphilitic diseases in a very striking and satisfactory manner. If local diseases resembling syphilis may take place in the throat, skin, and bones, from a certain state of weakness, and irritability of constitution, then various modifications of animal matter being absorbed may so disorder the general health as to induce such a state of weakness and irritation, as is likely to produce those symptoms, and such symptoms are rather to be regarded as arising from the propensities of the constitution, than from the peculiar properties of the matter which has been im- bibed . It is shown in my former publication, that the poison 230 ON DISEASES which produces pseudo-syphilitic symptoms is sometimes absorbed without an evident breach of surface in the skin; sometimes from a trivial sore which soon heals; whilst, in other cases, it produces local sores of various and dissimilar characters. RESEMBLING SYPHILIS. 231 SECTION IV. On the Effects of Mercury in Pseudo-syphilitic Diseases. Having thus, by the publication of the cases related in the two preceding sections, endeavoured to excite a general investigation of a subject which I think every one will admit to be highly important, I proceed to relate some additional cases of diseases which I consider as pseudo-syphilitic, and in which mercury was employed for their cure, in order to show the effects resulting from its use. I was necessarily pre- cluded from bringing forward such cases in my first attempt to elucidate this subject, because my object at that time was merely to show, that diseases, which could not by sight be distinguished from syphilis, yet differed from it in the primary sores from which they originated, and also in their progress ; for they got well without the administration of mercury, and generally recurred after the severest course of that medi- cine. The latter fact will, indeed, be more strikingly manifested by the succeeding cases. I was also prevented from relating cases of this description, because the administration of mer- cury may be supposed to render the nature of the subsequent symptoms ambiguous; since they may be considered as the effect of that disorder of the constitution, which the poison and the antidote have conjointly produced. As the tide of public opinion seemed at that time to run stronsrly against me, I mentioned, that any experienced sur- geon, who regarded the cases in question as anomalous cases of syphilis, would do a most essential service to society, if he would lay down practical rules for the treatment of such diseases. As no one has undertaken this task, I shall endea- vour to accomplish it; for I think, that the cases which I shall relate will at least show what mercury will do, and what it will not do, in these diseases. An attempt to establish nilcs for the treatment of these diseases appears to me of" 232 ON DISEASES great importance; because discordance of opinion is both discreditable to the profession, and injurious to patients. Before, however, I relate the facts from which I mean to deduce the practical rules of treating these diseases, I wish briefly to recapitulate the reasons which induce me to think that they are not syphilitic ; and also to ad vert to the argu- ments which I have heard brought forward, by those who entertain a contrary opinion. I wish, also, to consider the effects likely to be produced on the constitution at large, by the absorption of morbific animal poisons ; and to discuss the probable effects of mercury, administered in different degrees ; because I think it necessary, that all these circumstances should be borne in mind, whilst the reader perus es the cases, in order that he may form a proper judgment of the nature and treatment of these perplexing diseases: I concur then with Mr. Hunter in opinion, that these dis- eases are the effects of kinds of animal poison different from that which produces syphilis, first, because they may be con- tracted from parties who have no syphilitic disease ; and that I perceive how they may be contracted at present, as they were in Rome, during the time of Celsus.* Secondly, be- cause I see such diseases occurring in persons whose constitution is disordered, but where there is no reason to suppose that any poison has been imbibed.f Thirdly, be- cause these diseases differ from syphilis, in often getting well without mercury, and in recurring after the severest courses of that medicine.^ Yet I wish, as a comment on the latter clause, to observe, that though it may be regarded as a general rule, it is not absolutely without exceptions. We have sometimes recourse to the use of mercury, on ac- count of the destructive progress of diseases, which we have the strongest reasons to believe, are not syphilitic ; and mer- nury sometimes cures these diseases, without relapse. It is. See the cases related in the preliminary remarks. 1 See the cases related in the 3d section. See the cases related in the 2d tction. RESEMBLING SYPHILIS. 233 indeed, not improbable, that the alteration, which mercury produces in the state of the constitution, may occasionally cure a disorder which is not syphilitic. Formerly, when I met with a case in which the constitutional symptoms were regularly progressive till mercury was employed ; if they yielded, and were cured by an adequate course of this medi- cine, I concluded that the disease was syphilitic ; and I re- garded, therefore, any deviation which I might have observed in the progress of the primary sore, as the effect of some peculiarity in the patient's constitution. Of late, however, 1 have thought this inference to be erroneous. I shall next advert to the arguments of those who think dif- ferently. First, it is said,that the spontaneous cure of these dis- eases is no proof that they are not syphilitic. Secondly, the peculiarity of the disease is accounted for by peculiarity of the patient's constitution, which may not only contribute to modify the disease, but also to prevent its ordinary cure by mercury ; because the constitution may be incapable of bearing at once so much mercury, as is necessary for its cure. Cases, however, stand in direct opposition to these opinions. For these diseases may be contracted by persons of very healthy constitutions; and I have known patients, who have contracted pseudo-syphilitic diseases, contract also real syphilis, both a short time before and after the pseudo-syphilitic affection. Further, in many persons who are the subjects.of pseudo-syphilitic diseases, the disease recurs without the intervention of any new exciting cause, even though a mercurial course has been submitted to, greater in degree and longer in duration than is necessary for the cure of true syphilis, even though the mercury has also acted on the patient's constitution, in the most regular and com- plete manner. It is, indeed, highly probable, and accordant to general observation, that these diseases will be greater and more obstinate in weak and irritable constitutions, than in those that are healthy, and this circumstance has probably given rise to the preceding suppositions. I wish also to consider the probable effects which would Voi,. I. 30 ZZl i>N DISEASES be produced on the constitution from the admission of mor- bific animal matter into the circulation. Such infectious matter is likely to produce irritability or weakness of the ner- vous system, and consequent general disorder. The nervous disorder is likely, more especially, to disturb the functions of the digestive organs, and by their reaction to become pro- longed and aggravated. In almost every case of pseudo-sy- philis, a disorder of the digestive organs is manifest, and in many, most evident benefit is derived from correcting this, as far as we are able. It is probable, that the disorder of the nervous system and constitution in general, will be more transient in some con- stitutions than in others ; and is likely to be prolonged by every thing that induces debility and irritability. Indeed, if we have no specific remedy, or means for counteracting the effects which the poison has produced; the rational indica- tions of treatment would be to tranquillize and strengthen the system, in the expectation, that the effects resulting from the action of the poison will gradually subside. Analogy would lead us to expect, that the disorder of the nervous system, induced by the operation of the poison, would, as it declined, become intermittent, and recur in paroxysms. I have pre- mised these observations, that the reader may bear them in his mind, during the perusal of the cases, assuring him, at the same time, that they are the result of practical remarks, I wish also to explain my ideas respecting the operation of mercury. First, small doses of that medicine do not seem to affect the constitution in general, but merely to act upon the digestive organs; yet by this operation they are often productive of the most important benefit, as has been shown by cases recorded in the first volume of these obser- vations. As in diseases produced by the absorption of mor- bific poisons, the digestive organs are disordered, in conse- quence of nervous irritation, and in some patients, in a most remarkable degree, owing probably to a predisposition to disorder in them, so an attention to keep these organs in as correctly natural a state as possible, is an object of primary RESEMBLING SVPHILIS. 2.35 importance. Secondly, mercury exhibited in larger doses, exerts an influence on the constitution in general, though scarcely perceptible by its effect upon the pulse or secre- tions ; but by affecting the nervous system, in a peculiar manner, and by inducing a specific state of constitution, it counteracts that morbid irritation which has before prevailed, and is the effect of the poison. Thus mercury relieves many other disorders, as well as those which are syphilitic. The dose which is necessary to produce such effects, must vary in different persons. Such a state of mercurial excitement, or action, as is necessary to produce these effects, may also be kept up without inducing debility ;—on the con- trary, patients frequently become stronger and more healthy under its influence, because it controls the irritation atten- dant on disease. Thirdly, a greater mercurial effect upon the constitution produces an acceleration of the pulse, ren- ders the constitution in general irritable and weak, and pro- duces a more evident and considerable disorder of particu- lar organs. Such an affection cures completely and radically syphilitic diseases ; whilst others, which had been checked and cured by a slight mercurial affection, often increase and break out again, under that which is greater in degree. This violent action of mercury never fails to weaken and dis- order the constitution in general ; and thus, with its powers impaired, and its functions deranged, it has still to endure the continuance of the disease. The cases, which I shall now bring forward, are selected, because I think they show as great a variety of circumstances incidental to these diseases, as could be displayed in an equal number of examples. I could have crowded the book with instances, tending more directly to illustrate and con- firm the opinions delivered in it. My object has, however, been, not to represent the subject as more clear than it will appear in practice. 23ti t>N DISEASES CASE XIV. A medical student had without any previous chancre, an indolent bubo, which had increased in the course of two months to the size of a small egg, at which time I first saw him. After about three weeks, it inflamed and suppurated. The inflammation was of an unhealthy nature, and the bubo ulcerated, forming a foul ulcer, about three inches and a half in length, and two and a half in breadth. During this pro- cess he was much disordered in his health, and he confined himself to his bed. Lint, moistened with a watery solution of opium, was applied to the sore ; it was covered by a dress- ing of spermaceti cerate, and linen moistened in some wash was applied over, all to regulate the temperature of the part. Under this treatment the sore granulated, cicatrized, and had contracted into a small compass, when the patient's health again became disordered, and an ulcer formed on the upper surface of the velum pendulum palati. He snuffled in speaking and blew from one nostril thick mucus, some matter, and occasionally blood. Pain extended in the course of the eustachian trumpet towards the ear. His disorder was so troublesome at night as to preclude sleep, and his situation was altogether so uncomfortable as to induce him to have recourse to mercury. He accord- ingly rubbed in two drachms of mercurial ointment, for ten successive nights. In this time the mercury produced a slight effect upon the gums, and relieved him so much, that he determined, notwithstanding my remonstrances, to dis- continue it, feeling himself perfectly well. In about six Weeks subsequent to this, he had a painful affection of the upper part of the tibia, attended with a collection of fluid under the fascia. He was feverish at night, and had but little sleep ; his stomach and bowels were during the whole of the disorder, affected in the manner I have described in the first paper ; he had no appetite, and when he was most indisposed his tongue was extremely furred. He again used RESEMBLING SYPHILIS. 237 mercury, but after having rubbed in about six times he dis- continued it, as he found himself worse, which he attributed to the use of the mercury. The disorder of his leg did not increase, but after some little time diminished still, however, it prevented him from walking about, and he had occasional- ly fits of pain in it, which after continuing for a few days, abated, so as to leave him comparatively easy. Thus his leg continued from about February to June, when he took lodg- ings in the country. He had, about a month after the affection of his leg a similar attack in the elbow, the progress of which was also similar. His health was improved by his residence in the country, and he was soon able to walk about, which contributed to his recovery. He for a few days took a little hydrarg: muriat: in decoct: sarse : but left it off by my desire, as I was convinced that his disease was not sy- philis : and as the symptoms were declining spontaneously. He was once or twice induced to besmear the skin with mercurial ointment; but excepting this, he used no mercury, and by the autumn of the year, all local disease had left him. His health, however, was not correctly, right his tongue re- maining furred, and his bowels irregular. He passed through the winter without any relapse. In about a year afterward he had some rheumatic complaints, from which he soon re- covered, and has continued well since, except that he has been subject to occasional returns of rheumatism.* * The chief circumstances, which seem to me to deserve attention in this case, are, that probably infectious matter was absorbed, without any evident breach of surface or primary sore pthat the constitutional symptoms were at first suddenly cured by a small quantity of mercury; that afterward the use of mer- cury rather aggravated them, in consequence of which it was discontinued ; that the disorder of the constitution afterward gradually subsided; and that the whole of the mercury employed seems quite insufficient for the cure of syphilis. 23* •»N DISEASE^ CASE XV. A gentleman about thirty years of age, of a healthy robust habit, had a sore behind the corona glandis, which I saw on the third or fourth day after its appearance. It was then nearly as large as the nail of the finger, and so deep as to descend to the ligamentous substance of the corpus caver- nosum penis. It was indurated in its circumference, and there was no appearance of any new growth from its surface. This ulcer appeared to me to have been too rapid in its progress to be syphilitic ; however, as it had most of the characters of sores of that nature, I recommended the patient to take fifteen grains of the pilul: hydragyr : daily, to bathe with milk and water, to be very gentle in the application of mild dressings, and to keep the penis surrounded by some linen moistened with a cooling lotion. After a fortnight had elapsed, an enlargement of the glands in the right groin took place ; and as the sore had not spread, I recommended him to rub two drachms, by measure, of mercurial ointment, into the right thigh every night, wishing to produce an evident mercurial affection of the constitution, with a view to discover what effect it would have on the sore. In about a week, the constitution was af- fected by the mercury, and the gums were slightly tender and swollen ; the sore was, however, rendered worse; it be- came enlarged, and inflammation took place round it. The inunction was therefore omitted, but tjp piH^were continued. As the mercurial irritation subsided, the sore became tran- quil, and the bubo stationary. In about five or six weeks from the beginning, granulations appeared and the sore began to heal, so that by the seventh week it was quite well. In healing, that edge which was next the body got well first, while the other rather spread, so as to encroach a little on the back edge of the corona glandis. The bubo gradually subsided. When the sore was healed, (the patient still con- tinuing the mercurial pills,) he was seized with difficulty of swallowing, and uneasy sensations on the upper part of the RESEMBLING SYPHILIS. 2J9 soft palate, causing him to snuffle in speaking, and to blow his nose frequently. I advised him to desist wholly from the use of mercury, that these constitutional symptoms might go on unchecked by that medicine, observing at the same time, that if they were syphilitic, and required the use of mercury, it might be used with more freedom, and perhaps effect, in consequence of this suspension. The disorder ra- pidly increased, and it was much worse in the night, when the sensations were so disturbing, that the patient could ob- tain no rest. The pain extended to the ear, and matter and blood were sometimes blown from the nose. The health of the patient was much disordered ; and as he said that no course of mercury could harass and weaken him so much as the continuance of this disease, it was agreed in consultation, that he should begin a mercurial course, and that the disease should be treated as syphilitic. The patient confined himself to his chamber, and rubbed in two drachms, by measure, of mercurial ointment every night. In the course of a week the disease was much mitigated ; in a fort- night, at which time the gums were swollen and tender, it was well. The mercury was continued (so as to keep the gums as sore as they could be, without producing that state of disease which would have obliged us to desist from the use of it) for three weeks more, when a new occurrence took place. The left tonsil became somewhat enlarged, and an ulcer was formed upon its surface. This, another surgeon who was consulted, attributed to mercurial irritation, whilst I, on the contrary, felt assured that it was the effect of the disease breaking out anew under the full effect of mercury. As the course of mercury was deemed perfectly adequate to the cure of syphilis, it was now discontinued. The ulcer however continued to spread, nor did it cease till it had en- tirely destroyed the tonsil, when it healed. About three weeks afterward, and six weeks after the disuse of mercury, a similar ulcer formed on the opposite tonsil, which pursued exactly the same course, and ended in the same manner. After about three weeks more an ulcer appeared to hav*; J10 ON DISEASES formed upon the upper surface of the velum pendulum palati, in a situation corresponding to the first, but on the oppo- site side. It was attended with the same difficulty of deglu- tition, alteration in the voice, occasional discharge of pus and blood from the nose, and tormenting pain extending to the eustachian trumpet. It seemed in vain to use mercury, and I felt great apprehension that this ulcer might destroy the soft palate. It fortunately happened otherwise; for (after continuing for about a fortnight to spread, so that its edge could be distinctly seen on the margin of the velum palati, and left side of the uvula,) it healed, leaving no greater im- perfection than what was produced by an adhesion of the left side of the uvula to the soft palate, which took place during the healing of the ulcer. After this complaint was well, various eruptions appeared on different parts of the body, many took place on the head, forming sores which were slow in healing, and many sores, which were formed in like manner on the trunk of the body, became herpetic, healing in one part and spreading in another. An inflamma- tion and induration of the coverings of the lower part of the right tibia also took place, which subsided, so as to leave but little appearance of any disorder having existed. During these occurrences the patient took the decoct, sarsae, and Lisbon diet-drink, nitric acid, cicuta and bitters, and was as attentive as possible to keep his bowels regular, which was difficult, as his digestive organs were throughout the whole of the complaint disordered. He had also lived a good deal in the country, and made occasional excursions to the sea- side, and used the tepid salt water bath. Upon his return from one of these, about six months after the discontinuance of mercury, he felt himself so perfectly well, that he indulged himself in dining with his friends, and undertook a journey into the country on business. The exertion attending this undertaking seemed to have operated in reinducing disease, for he was soon laid up with a rheumatic affection of the right foot, and one of the testes became enlarged to a con- siderable degree, but it was indolent. Nodes also appeared RESEMBLING SYPHILIS. 241 on the middle of either tibia, which regularly increased. The enlargement of the testis subsided, when the other became affected in the same manner. For between two and three months after the patient's return to town he consulted various surgeons, who knew nothing of the history of his case, and they so uniformly concurred in affirming it to be syphilitic, that the patient was even anxious to use mercury again. As the nodes did not abate as the other symptoms had, and as they did not yield to the application of leeches, evaporating lotions, or bandages, I thought an alterative course of mer- cury at this period even advisable, to see if it would control this local affection. The nodes were not like venereal nodes. They were elevated and bony, and there was a small quantity of fluid beneath the periosteum. I would have divided the periosteum at first, but I was restrained by the apprehension of the wounds becoming sores, and of exfoliation taking place, and augmenting the patient's already distressful situa- tion. He now rubbed in small quantities of mercurial oint- ment, without confining himself. This course was attended with manifest benefit; insomuch as to impress his mind with an opinion that a more liberal use of mercury would now cure him. In this opinion he was confirmed by some sur- geons whom he had consulted, and he therefore resolved to stay at home and rub in every night till his constitution was affected by mercury. By the accomplishment of this object, however, he was made materially worse. His pains were tor- menting, the nodes inflamed, and threatened to ulcerate. The mercury was left off, and I divided the periosteum to the extent of an inch and a half on the surface of one node, and let out some serum mixed with pus. The knife in pass- ing down grated against different portions of bone which were heaped up to a considerable height above the level of the tibia. The node was no longer painful. The wound healed, and pain occurred again in a slight degree and gra- dually increased. The same treatment was pursued with respect to the node on the other shin, and the consequences were the tame. After the wounds had healed the pain Vol. I. 31 2i2 ON DISEASES gradually returned, and in about a month he found himself nearly in the same state as before his confinement. Under these circumstances he again began to take diet drink, with some mild mercurial pills, which never perceptibly affected his constitution, and under the use of which he became mus- cular and fat, and by this treatment the pains left him, and in the course of three months he was well.* CASE XVI. A gentleman between twenty and thirty years of age, re- siding in the country, had an ulcer in the prepuce, which, to use the words of his surgeon, had more the appearance of excoriation than chancre ; it was succeeded by a bubo and ulcerated throat. For each of these diseases he used mer- cury so freely as to convince some of his medical attendants that the disease could not be syphilitic; his surgeon said enough to cure twenty syphilitic patients. The ulcers in his throat were sometimes better and sometimes worse, both during the continuance and after the cessation of the mercu- rial course. After about a year and a half from the com- mencement of the disease I first saw the patient, and informed his surgeon, that in my opinion pseudo-syphilitic diseases generally gave way to an alterative course of mercury con- joined to decoction of sarsaparilla. * The principal circumstances worthy of remark in this case are, that the pri- mary sore, though resembling syphilis in many respects, differed in others. It was aggravated by the free use of mercury, and it healed on one side whilst it spread on the other. The constitutional symptoms were speedily cured by a slight mercurial affection, but they broke out again under a severe course of mercury. Many constitutional symptoms got well without the use of mercury, and when at last it was employed again on account of the stubborn nature of the nodes, these diseases yielded to a slight, and were aggravated by a severe course of mercury. The disease lastly yielded to an alterative course of mer- cury, so slight as not manifestly to affect the constitution, and during which the patient got muscular, fat, and healthy. The subject of this case was a remarkably healthy man, and had before contracted syphilitic diseases, which were regular in their progress and cure. Mercury also affected his constitu- tion in $e mou>e which is considered most desirable for the cure of pvphilis: RESEMBLING SYPHILIS. 243 About nine months afterward the patient came again to town ; his throat was not ulcerated, but his nose was greatly diseased. Some affection of that part had taken place when I first saw him, which had increased to such a degree, that he was almost constantly blowing from his nose tough mucus and pus, mixed with blood. The skin covering the ossa nasi was also very red, so as to threaten the giving way of the arch of the nose. He was much emaciated and feeble, and had a chlorotic appearance. Under these circumstances, I desired him to drink a pint of decoction of sarsaparilla daily, to keep his bowels strictly regular, and to take five grains of the pilul. hydrarg. every night, desiring to see him at the expiration of a week. After that time, when he called on me, he said he could perceive no difference whatever in his disease. Thinking that perhaps in another wreek the mercurial effect would be increased, so as to affect the constitution and control the disease, I made no alteration in the quantity of the medicine ; but when at the expiration of that time, I found the disease undiminished, I recommended him to take five grains of the pilul. hydrarg. night and morning. After the expiration of another week, when he called upon me, he said that the disease of his nose seemed gone, though when he blew it some purulent dis- charge still took place. The mercury had no effect upon his gums, and he looked more healthy and felt stronger than he had done before he began the mercurial course. Finding the disorder so completely subdued by this quantity of mercury, and wishing above all other considerations, that the patient should acquire some muscular strength and vigour of consti- tution, I advised to take but one pill daily for the future, and to observe whether the symptoms subsided or increased under its use. In one week more there was no discharge from his nose, even when the air was forcibly driven through it. And after three weeks had elapsed, or at the end of six weeks, he had become so muscular, fat, and healthy looking, as to produce the greatest astonishment in all who had seen him before, and saw him after that short interval of time. .'44 ON DI.sEASLS This surprising recovery must be ascribed to the youth ami strength of his constitution relieved from disorder. I men- tion it particularly, to show that the quantity of mercury that controlled the disease did not weaken the constitution. When the patient returned into the country, I recommended the continuance of the pills every other night for some time, to prevent any relapse ; but I was informed that he soon left them off, and has since had no disorder.* CASE XVII. A gentleman had a trivial sore upon the prepuce, and being engaged to marry^n the course of a few months, he under- went what was considered as a more than adequate course of mercury, for the cure of the disease. After he had married, however, his throat ulcerated. His surgeon hesitated in pronouncing it to be syphilitic, and its progress contra-indi- cated that supposition, for one sore healed and another broke out, or ulceration again ensued in the same place. One of the testis afterward became considerably enlarged without pain, and sores broke out upon the scrotum, which was much thickened, and in the perinaeum. Six or more months passed during the progress of the disease to this state, when I was first consulted on the case. It was in the spring of the year, and we agreed that he should spend the summer at the sea- side. During this summer the sores on the scrotum healed, and it regained its natural state. The swelling of the testis subsided. His throat occasionally ulcerated and healed; but a kind of disease seemed to spread along the alveolary pro- * When a disease resembling syphilis attacks the nostrils, we are almost com- pelled to use mercury, since we cannot see the character, extent, and progress of the ulcer ; yet extensive experience demonstrates in a manner horrible to observe, how many such diseases pursue a most destructive course uncontrolled, nay, often aggravated by the most powerful effects of mercury. The cases above recited, I therefore deem worthy attention, as they show that diseases resembling syphilis may occur in the nose as well as elsewhere ; and that our practice should be regulated by the same principles in treating these, as in other symp- toms of venereal diseases. 11ESEMBLING SYPHILIS. 24b cess from behind, for the teeth loosened and came out, and in some parts the gums ulcerated. This happened on the left side of the mouth, and it advanced as far forward as the first small grinder, which still remained firm. In November he remarked, that whenever his stomach and bowels were dis- ordered, his complaints were aggravated ; and by the means which were suggested for regulating those organs, he passed through the winter without any increase of disorder. In the succeeding summer sores broke out again on the perinaeum, and by the side of the rectum, which healed under dressings of red praecipitate ointment. He had also a slight enlarge- ment of the testis, which soon got well. In the succeeding autumn the disease in the alveolary processes seemed to trouble him, and there was a slight discharge from the nose. I had recommended him to abstain from the use of mercury while his disorders were stationary ; but fearing that there might be an increase of disease in this part, I advised him to take the compound decoction of sarsaparilla and one of Plummer's pills night and morning. Under this treatment he soon recovered, without any perceptible effect of mercury on his constitution, and has remained well since. Though I feel pretty confident, for the reasons stated in the preliminary observations, as well as those contained in the third section, that many diseases which resemble sy- philis do not originate from that poison, I am by no means equally certain, that none of the cases which I am now pro- miscuously relating, might not have arisen from that source. Such an assertion would be to deny the possibility of the effects of syphilitic poison being modified by the diseased propensities of the constitution. It would be also to affirm that there is only one kind of syphilitic chancre, and one kind of constitutional syphilitic disease, which is far from being my intention. I merely state, that when the primary sores differ materially from the ordinary characters and progress of syphilitic chancres, that they may fairly be suspected to be of a different nature ; and that in general the constitutional symptoms will be found equally to deviate from the progress 246 ON DISEASES of syphilis, and, consequently, to require a different mode of treatment. I proceed to relate some cases of this description, and to give an account of the constitutional symptoms subsequent to these kinds of sores, in a few cases, that the reader may judge of them for himself. CASE XVIII. On burrowing Sores. A gentleman, forty years of age, who had lived very freely, in the month of July, 1806, contracted a sore between the prepuce and glans penis, near the fraBnum, which he believed to have originated from some acrimony in the secretions. This probably was the opinion of his surgeon, as he merely recommended cleanliness, and a poultice, until the spreading of the sore induced him to use mercury. A considerable swelling of the prepuce was occasioned by the irritability of the sore, which continued to spread by ulceration forward, so as to extend over the whole of the lower half of the glans, to within the eighth of an inch of the urethra, and backward between the integuments and lower half of the body of the penis for more than half way to the scrotum. It did not prevent him from denuding the glans, and cleansing away the discharge in some degree, but the extent of the sore backward could not be seen. It had continued to spread gradually for more than two months, although the mouth was affected by the use of a great deal of mercury. His con- stitution was much enfeebled, in a great measure owing to the mercury he had used. In this state he came to London, and consulted me. Fearing that the sore might continue to spread if the mercury was laid aside, I desired him to rub in every second night so as still to keep his constitution under the influence of that medicine, while I endeavoured to cor- rect the sore by local means. Various washes were tried ; for instance, weak solutions of sulphate of zinc, and nitrate RESEMBLING SYPHILIS. 247 of silver, calomel, and muriate of mercury in lime water. In less than a month the sore was nearly healed, except in that part which covered the urethra about half-way below the penis ; and here the ulceration seemed kept up by the escape of some urine from the canal, and he had at this time a fre- quent propensity to void his urine. It appeared probable, that the urethra had not been in a sound state prior to his contracting this complaint, and that it had derived additional irritation from the proximity of the sore to the mouth of the canal, as well as from that part where its ulceration had oc- casioned an opening. At this time an indolent enlargement of the right testis took place, and so large a hydrocele was formed, that I was much inclined to puncture it, to relieve him from the inconvenience occasioned by its weight. The patient, however, was anxious to return into the country, where he was directed to continue the same mild mercurial course. In January, 1807, he returned to town, and during the interval the hydrocele disappeared, though some enlarge- ment -of the testis still continued. The aperture of the urethra had inflamed and ulcerated, leaving an external sore. The other part of the penis, which had been ulcerated, con- tinued firmly healed. His health, however, was much dis- ordered. He had a rheumatic swelling of the finger, and a node upon one shin, with rheumatic pains in various parts of his body. Finding constitutional symptoms apparently ori- ginating from a sore, for which from. its commencement mercury had been used unremittingly, I advised him to dis- continue rubbing in, and he went to Bath in pursuance of the recommendations of some of his friends. I previously, however, introduced a bougie, and found several strictures in the urethra, which had probably existed before he had contracted the other complaint. As a bougie of a moderate size passed through the urethra, I merely advised local warm bathing. During a month's residence at Bath, he suffered much from pains in the tibia, but the nodes had not increased during that period. An ulcer larger than the surface of a shilling, with thickened inflamed and spreading edaes, deep 248 ON DISEASES in the middle, and without granulations, had formed near the outer angle of the orbit of the eye. Some sores of the same nature, but less in degree, took place also on the arms. Wish- ing to know if these symptoms were truly syphilitic, I deter- mined to try if they would get well without mercury. A poultice of bread and water was applied to the sore on the face at night, and a dressing of simple cerate in the day. The edges of it were occasionally touched with argent, nitrat. to control their fretful disposition, and under this treatment the ulcer healed. The patient was anxious to return into the country; and as I thought that his health might be better than in town, he returned to his own house, with an injunc- tion not to use mercury if it could be avoided, and there his pains in a measure subsided. After some time, however, the nodes on the shin became more prominent, though less pain- ful. The nostrils also became very much affected by the disease. He blew from them pus in a fluid form, and con- crete lumps resembling (to use his own words) "the internal parts of the nostrils ;" " but this," he continues, " gradually went off, leaving the nostrils as clear as before. My general health now improved, and encouraged by this circumstance, I was induced to make a journey to London in the month of June, where I lived more freely than before, and took fresh cold. Upon my return home, I had a recurrence of the pain and swelling in my shin bones, and the pain of the legs to so great a degree, that it was esteemed prudent to consult a physician, who recommended nitrous acid, two mercurial and an opiate pill at night. Milk diet was also recommended, which constituted my principal food. The acid was conti- nued a fortnight, the pills about a month, but little relief from pain was experienced. The nodes gradually lessened, but the pains were unabated, and occupied my knees and ankles as well as shins ; they continued during the night, and re- mitted in the morning." On the weather becoming very cold, he was recommended to pass the winter in some warm- er place than the situation in which he resided. He came 'o town and consulted Dr. Baillie as well as me. He was RESEMBLING SYi'HILla. 241J advised to take the decoction of sarsaparilla, with a small quantity of hydrarg. muriat., and to control the night pains with extract of henbane. This plan answered very well, and he returned into the country, where he said his stomach was so much nauseated by the medicine, that he was obliged to leave it off. He came to town again in the beginning of January, 1808, in a very emaciated and crippled state, owing to rheu- matism. His nights were passed in great pain, and thus ter- minated in profuse perspiration in the morning, so that he seldom rose till past noon on the following day. He was scarcely able to walk, and dreaded the least exposure to the air, which considerably aggravated his pains. Some sores had again broken out upon his face, and one of the largest was situated on the front of the ear, extending over the tra- gus, the discharge from which generally filled the concha, and this obstruction, together with the irritation, made him very deaf. I had often expressed to the patient my convic- tion that an alterative and undebilitating mercurial course would temporarily cure his disease, but wished to see him when that medicine was employed, that I might observe its effects. He now took a pint of decoction of sarsap. daily, and five grains of the pill, hydrarg. every night, and in about a fortnight he was so much recovered that he was able to ride out, which he did as often as the weather permitted. At the end of the third week, he went into the country, a short distance from town, to spend a week, from whence he rode at the expiration of that time, eighteen miles without stopping. His rheumatic pains had nearly left him, and the sores on his face were healed. In short the cessation of the disease was as striking and as rapid as in almost any case that I had seen, but he was not restored to perfect health. Though comparatively muscular and strong, he did not ac- quire that strength which he had possessed prior to the oc- currence of the disease, nor did he look healthy. He con- tinued in town taking the same medicine a fortnight longer, during which time he committed, in consequence of the liber- ty he had acquired, some little irregularities, such a^ sitting- OT.. I. *>2 » 25U ON DISEASES up late, and eating and drinking too much. The effect of this alterative course of mercury, which did not produce any evident mercurial action in the constitution, and under which the patient acquired a surprising degree of strength and appa- rent health, fully equalled and even surpassed my expecta- tion. Inferring the probability of a relapse, and that half the dose of the medicine was not likely to be in any degree prejudicial to the constitution, I recommended him to return into the country, and to continue the same medicines, taking the mercurial pill every second night only. The patient, however, did not prosecute the plan laid down, and his health has continued greatly disordered ever since this period. He has been subject to various local diseases ; but their na- ture was such, that I believe no unprejudiced person could consider them as syphilitic. He has had severe rheu- matism, but it never produced a local attack on a bone, so as to resemble a syphilitic node. He has had gout, to which he had formerly been subject. He had a great degree of inflammation and induration of both his legs. He had violent pain about the first joint of the great toe, and matter seemed to have formed beneath the periosteum, for, upon the abscess breaking, the bone was denuded. He has a redness, thickening, and tendency to ulceration, of the integuments of the alas nasi. The patient had formerly lived very freely, and the altera- tion in his ordinary modes of life, with the effect of mercury on his constitution when employed freely, at first, for the cure of the primary sore, seem conjointly to have produced this deplorable derangement of his constitution. Under these circumstances, he sometimes took the com- pound calomel pill in the dose of one grain of calomel each night, and it generally appeared to be of service to him. Sometimes he took no mercury. His local diseases did not seem to be much affected either by the use of mercury in this degree, or by its discontinuance. When once, without my knowledge, he took the compound calomel pill more freely, it evidently was injurious both to his health in general, and to his local diseases. HESEMBLING SYJ'HILIs Jo I CASE XIX. A gentleman had a sore between the prepuce and corona glandis, which was treated as a syphilitic chancre. After a time it began to spread in the cellular substance, between the integuments and body of the penis towards the pubes. In proportion as the sore became worse, the quantity of the mercury administered for its cure was increased ; so that he had gone through a very considerable course of mercury, which had made his mouth very sore, and had greatly im- paired his strength. The sore, however, was not amended, but when I first saw him was extending itself still nearer to the pubes, and more round the penis. I directed him to clean away the discharge by frequently injecting a warm decoction of poppy heads, and to keep a bread and water poultice round the penis. After some time the skin of the dorsum penis ulcerated, and gave an outlet to the discharge in this direction. The degree of disease which took place seemed to have been prejudicial to the front of the prepuce, for it became very oedematous, and the ulceration spread rapidly forwards so as to divide it, leaving the glans and body of the penis projecting above the separated and tumid sides of the prepuce. The sore gradually got well without any other medical treatment than what appeared necessary to regulate the actions of thebowels. He took indeed occasionally some decoction of sarsaparilla and some nitric acid. The patient had no subsequent constitutional disease. Respecting these sores, which I have called burrowing sores, I may observe, that only a few of them begin to burrow in the first instance. It is generally an after process, and may be considered in the greater number of cases as the effect of a new action taking place in the sore. It is, how- ever, so discordant to the progress of true syphilis, that I cannot believe it to be an effect of that disease. If we have any doubt we must look to the constitutional symptoms which succeed to them, and these we find to partake more 2.32 ON DISEASES of the nature of pseudo-syphilis than of true syphilis. Some burrowing sores do not so affect the constitution as to pro- duce secondary diseases, whilst others do. I have recorded a specimen of each, and think it unnecessary to cite more ; though I could bring forward a considerable number. The secondary symptoms in the first case were very obstinate, and those surgeons, who were inclined to believe all these diseases syphilitic, may probably think the symptoms in this instance were so. To me, however, it appears that the most potent mercurial course was inadequate to the cure of the primary symptoms, and would have been so to those of a secondary nature, while the latter were readily controllable by an alterative course, and in some instances got well spontaneously. It is also my opinion, that their continuance depended much upon the disordered state of the constitution produced by former irregularities of living, by the irritation of disease, and the debilitating effects of the too free use of mercury for the cure of the primary sore. I could produce many instances in which the secondary symptoms were more slight and more clearly pseudo-syphilitic, than in the one which has been related. The present case I brought forward because it made a stronger, impression on my mind, than those which were less vexatious, and because I do not wish to, represent the subject of the secondary diseases in pseudo-syphilis as less obstinate and severe than, they will often be found to be. CASE XX. On sloughing Sores. A gentleman, about thirty years of age, applied to me on account of a sloughing sore about the size of a shilling on the dorsum penis. I desired him to dress it with a watery solution of opium, covered with spermaceti cerate, spread on linen, and to surround the penis with linen kept constantly wet with water. His bowels were obstinately costive, his RESEMBLING SYPHILIS. 253 tongue much furred, and he had so much fever and head- ach, that the use of mercury seemed to be prohibited by the disordered state of his constitution. The sore spread so as nearly to encircle the penis, and to occupy its whole length. Various dressings were employed until the surface of the sore was no longer sloughy, but the edges were thickened and very fretful. These were touched every day with argent, nitrat. which seemed to counteract their fretful state: they afterward became healthy, and the sore healed in the space of two months from its commencement. Before the sore healed, symptoms of constitutional disorder appeared. The throat became sore, but did not ulcerate in any material degree. Spots came out on the skin and breast. He had afterward a rheumatic affection of the knee and foot. All these symptoms disappeared successively without the use of mercury, to which medicine he had so strong an aversion, that it would have been difficult to persuade him to take it: he soon recovered from the effect of his disorder, and felt as well as before he had contracted it. The medicines which were taken in this case, were sarsaparilla, nitric acid, bark, and aperients. Secondary symptoms do not succeed to every sloughing sore, and these symptoms occasionally ap- proach more to the nature of syphilis than in the preceding case; yet I have known no instance in which, either from the irregularity of the progress of the symptoms, and their insusceptibility of cure by the powerful action of mercury, they could not be distinctly recognised as pseudo-syphilitic. CASE XXI. A gentleman had a sloughing sore, which spread round the prepuce, without extending backwards to the integu- ments covering the body of the penis, yet its breadth was so considerable as to involve the whole of the prepuce, which it eventually destroyed. The surgeon who first saw the pa- tient had given him mercury, but, doubting the propriety of its continuance, I was consulted, and immediately opposed 254 ON DISEASES its further use. Fumigations with cinnabar were found to be more efficacious than any other applications which wen- tried to this sore; these quickly arrested the sloughing pro- cess, but an ulcerative one continued till the prepuce was eaten away. After two months from the commencement of the sore, when it was nearly healed, the constitution of the patient became much disturbed, and secondary symp- toms appeared. These were spots and blotches of rather a livid aspect, the latter of which in many parts of the body spread out into extensive sores which had a sloughing ap- pearance. One on the outside of one foot and ankle was as large as the palm of the hand. The original sore was also irritated by the disturbance of the constitution, and began to ulcerate again very rapidly, insomuch that the glans penis, and a considerable part of the corpora cavernosa, were de- stroyed. Neither fumigations nor any other of a great va- riety of applications appeared to retard the destructive pro- gress of this sore, and mercury was employed. The patient was ordered to rub in two drachms, by measure, of mercu- rial ointment every night for five weeks, when his gums be- came tender and swollen, and his constitution considerably influenced by the mercury, yet no material alteration took place in the disease. The unavailing effect of mercury being proved, the patient went into the country where all these complaints gradually disappeared. His health, howr- ever, was still disordered, and new symptoms came on. His nose became slightly affected, and he had pains in his bones He now removed to the sea-side, and after conti- nuing there for a considerable time, he wrote to me, saying, that ulceration had taken place in his nose, which had de- stroyed the septum narium, and that the integuments, cover- ing a kind of node on one shin, had formed into a foul and fretful sore. I now recommended an alterative mercurial course. He took five grains of pil. hydrarg. at night, and a pint of the decoct, sarsae daily; and in the course of four or five weeks he was apparently well, having acquired health and strength at the same time. In a second letter he ex- RESEMBLING SYfHILIS. 255 pressed his great surprise at his amendment, and wished for my further directions. I then desired he would take the pil. hydrarg. every second night, if the state of the biliary secre- tion required it; but as that was not the case he took no more of that medicine, and has since remained perfectly well. CASE XXII. A gentleman had a very irritable sore on the prepuce, just behind the corona glandis, which was covered with slough : this having been thrown off was succeeded by another slough, and the sore spread laterally to the right and left; but it neither extended backwards so as to affect the skin covering the body of the penis, nor forwards so as to touch the glans; neither did it eat deeply into the part so as to af- fect the corpus cavernosum. I tried various dressings, but none seemed to do much good. I touched the surface of the sore with argentum nitratum, but that did harm. I therefore was obliged to sooth this sore, since I could not correct it. A salve made of spermaceti cerate, with as much aq. litharg. acet. and tinct. opii as could be incorporated with it, seemed to answer best; and the parts were kept cool by enveloping them in linen moistened with the decoction of poppies. The most perfect quietude was enjoined, and the part laid upon a pillow with the extremity rather raised above a hori- zontal line. I had given the patient some pilulae hydrargyri in the first instance, but his constitution was so deranged by the irritation of the sore that it would have been absurd to persevere in the use of mercury. The sore continued to slough, and to extend in a circular direction nearly all round the prepuce, the lower part of which became extremely swollen. This took up nearly two months: about five weeks after the commencement of the disease, a spot appear- ed more than an inch from the corner of the mouth. It was soon covered over with a scab, which rose far above the surface. It had increased to the size of a sixpence, when I thought right to dress it, that I might distinguish the sur- 256 ON, DISEASES face of the sore. I found that the ulcer was very deep, but I could not see the surface for a very viscid discharge, which adhered to it like mucus. Poultices and various dressings were employed, but the appearance of the sore was unchanged, and it gradually became of the size of a shil- ling. At length a kind of fungus shot from that edge of the sore farthest from the mouth. A similar spot had made its appearance on the ear, and was also increasing. The ac- tivity in the disease of the prepuce had gradually declined, and I began again to try some medicated application :—the sore seemed much benefited by touching it daily with argen- tum nitratum ; but when this was omitted the sloughy ap- pearance of the sore again took place, and it increased in dimensions. It was now agreed at a consultation that this patient should use mercury, and he rubbed in two drachms, by measure, every night for six weeks. As the mercury took effect, it seemed to operate beneficially on the spot on the ear, which gradually died away; and on the sore of the penis, which also gradually acquired a healthy appearance, and the parts became sound, except at one part where tbe prepuce was not quite destroyed, and which still retained an unhealthy appearance. The mercury, however, did not af- fect the sore on the cheek ; the fungus which I mentioned seemed to increase, and, after a time, skin formed over it, so that the sore healed in an unhealthy manner at the edge far- thest from the mouth. But it still spread in the other direc- tion till it reached the angle of the mouth, and it afterward extended itself along each lip. On the upper lip it had spread to the extent of one-third of an inch, and still retained the same diseased appearance which characterized it at the beginning. It was deep, and its surface could not well be seen on account of a viscid matter which adhered to it. It was now agreed in consultation to leave off mercury, lest the irritated state of the mouth should increase the de- struction which the ulcer was committing on the lips. The sore now no longer spread ; it very slowly lost its diseased state, and healed. This also happened in the remaining dis- eased part of the sore on the prepuce. RESEMBLING SYPHILIS. 257 CASE XXIII. Of Sores which become indurated in their Circumference. A medical man contracted a sore on the prepuce, which, while it was healing, became indurated in its circumference, and when healed, it became soft and apparently healthy in the middle. The patient had taken and rubbed in mercury from the commencement of the complaint; in short, he treat- ed it strictly as syphilitic. When it assumed the appearance and character which I have described, he showed it to me. 1 advised him to continue the mercury, in such small quantity as not to affect his health, until the induration subsided, lest from want of this precaution it should fret into a sore. Under this plan of treatment, however, constitutional symp- toms occurred. The throat became ulcerated, and numer- ous small spots came out all over the body. His health was also much disordered, and he could only take such small quantities of mercury as could have no influence on true sy- philis. He took at the same time the decoct, sarsae. All the symptoms gradually disappeared, and he got perfectly well in the course of a few months. CASE XXIV. A gentleman who had just left London on a visit to some friends in the country, perceived a sore on the prepuce, which he undertook to manage for himself. He dressed it simply, and took from ten to fifteen grains of the pil. hydrarg. daily. After a month he came to town with the sore much enlarged, having diseased indurated edges, but with a healthy surface. As his mouth was affected, I desired him to conti- nue the mercury in less quantity, so as not materially to dis- turb his constitution. The sore healed under this treatment, in the course of another month, but it exhibited the appear- ances which characterize those ulcers of which I am now Vol. f. 33 25S ON DISEASES speaking. It was soft in the middle, but had a circular hard rim, of the extent of a shilling. At this time his health was much disordered, and his throat ulcerated. Deep and foul ulcers also took place in his cheeks opposite to the grinding teeth, and some sores appeared on his tongue. His gums were spongy, and loosened from his teeth, like those of a person having scurvy. I now recommended him entirely to discontinue the mercury, and to take the nitric acid, which he did, in the dose of from 60 to 90 drops daily. Under this treatment, both the constitutional symptoms, and the remaining induration of the primary sore got well in the course of six weeks. Nearly a year afterward he had a se- vere and intractable ophthalmy, attended with nervous symp- toms, and disorder of his constitution. After a time, spots again appeared on his skin, and he then applied again to me. By taking decoction of sarsaparilla daily, and five grains of pil. hydrarg. every second night, at the same time paying at- tention to keeping his bowels regular, his health was re- stored, and all these complaints totally disappeared in about five weeks. These circumstances occurred in the spring of the year, and in the autumn the pituitary membrane of his nose began to ulcerate, and it continued to do so more or less during the whole winter, and even some discharge continued for the space of a year. The ulceration destroyed a great part of the cartilaginous part of the septum narium, so that the ala? nasi being less supported, sunk a little, and made the termi- nation of the bones apparent beneath the skin. The de- formity was, however, too trivial to attract the notice of an indifferent or inattentive spectator. For this disease the al- terative plan of treatment which had been so successful on the former occasion was again instituted, though with little advantage. At first when the patient's apprehensions were considerable, as the alterative course of mercury failed to do good, the dose was increased even so as to affect the niauth, but the disease was so evidently aggravated by it, that rhe medicine was for a time left off, and with manifest advan- RESEMBLING SYPHILIS. 25H tage. In the autumn of the succeeding year a new disease occurred. A large deep ulcer formed in the throat, which had all the characters of syphilis. It, however, very sud- denly acquired its largest dimensions, being about an inch in length and half an inch in breadth. It was situated obliquely between the top of the tonsil and the front of the velum palati. It was very deep. As so little success had attended the alterative course of mercury in the ulcerative disease of the nose, and as the progress of the present ulcer could be noted, no mercury was employed, and in about a month this ulcer was well, and the patient has not since had any relapse ; and, from the length of time which has since elapsed, it is highly probable that he never will have any. I have already said, that sores which indurate in their cir- cumference do not in every instance produce constitutional symptoms. Apprized of their nature, I generally order for the patient that dose of mercury which may be taken without affecting the constitution, as a discutient of the hardness, and I have known nearly six months elapse before it has been completely dispersed. This kind of partial induration is so different from the progress of true syphilis, that I think it must be readily granted not to be of that nature. It must however be also remembered, that sores which indurate in all parts are not always syphilitic. As I have already related two instances, I think it unnecessary to add more. Having thus endeavoured to represent the constitutional effects resulting from sores, which differ materially in their characters and' progress from syphilitic chancres, I wish to subjoin another case, though I am doubtful whether the dis- ease originated from infection, or was the product of con- stitutional disorder. I think it deserves to be recorded on account of its duration. In the year 1793, a gentleman aged twenty-six, who had been married two years, had a paralytic affection of the whole of the left side, from which he gradually but not com- pletely recovered in about nine months, the latter of which he spent in the country, and he attributed much benefit to 260 ON DISEASE* the country air. About four months from the commence- ment of the paralysis, he had an indolent enlargement of the testis as .big as a large fist, which did not subside, but in 1796 suppurated, broke, and very slowly got well. In 1797, he had an ulcerated sore throat, for which he went through a very regular and severe course of mercury. He was con- fined from July to November, and the mouth was in a greater or less degree affected during the greater part of that time. The throat soon got well. The year 1798 he spent in the country, and regained his health and strength in a very con- siderable degree. In 1802, a node appeared about the mid- dle of the right shin, which was removed by a blister kept open for some time. He had at the same time a pimple on the nose which formed a scabby ulcer, but slowly got well from the application of a solution of the hydrarg. muriat. He had subsequently several eruptions, forming scabs upon the trunk of the body and arms which did not ulcerate, and got well without medicine. In 1804, there was a thickening about the os calois and tendo achillis, which threatened to suppurate. In 1805, I first saw the patient; his tongue was furred, the secretion of bile irregular, with a great degree of nervous irritation. He was also subject to rheumatic pains which particularly affected his knee. I recommended a strict attention to the state of the bowels, and soothing ap- plications, with pressure to the heel. Under this treatment, the heel gradually got well, and the spots disappeared. In the spring of 1806 some nodes appeared on different parts of the skull, when I told the patient to prosecute the same plan of treatment, and if they got better to disregard them, but if worse, to let me see them. In the autumn of this year, he called upon me with the nodes on his head considerably aug- mented ; one on the right side of the forehead was as big as a large walnut, and threatening to break, and two on the left parietal bone, but of less size, had broken and healed. There was also a very considerable node near the top of the left tibia, which had been opened by caustic, and had left a foul ulcer. I then recommended the decoct, sarsae with a RESEMBLING SYPHILIS. ->D[ compound calomel pill, night and morning. This plan was continued from November to the end of May, when the de- coction was left off, though the pill was continued in a smaller dose for some time longer. Under this course, which never produced the slightest mercurial effect on the constitution, all these complaints got well, and the patient became healthy and fat, and, as he says, better than he has been from the commencement of his disorders, which is fourteen years ago. This case appears to me to be very similar to that related at page 227. In neither do I believe that the symptoms were the efleets of poison imbibed, but, on the contrary, of a disordered state of health. While I was attending this patient, his wife's throat ulce- rated to a considerable degree. Both tonsils were ulcerated, and the ulcer continued from one along the edge of the velum palati to the extremity of the uvula. The ulcers were hol- lowed, covered by viscid matter, and surrounded by inflam- mation. I should without hesitation have pronounced these sores syphilitic had they succeeded to a chancre. Another surgeon had no doubt of their nature. The patient's bowels were disordered, and she felt generally unwell. I directed her to take some decoction of sarsaparilla, and small doses of rhubarb, whilst I attentively watched the progress of the ulcer. In the course of a week it was so decidedly amended that I had no doubt of its not being syphilitic. Where it ran down the side of the uvula, it had granulated, and was in a great measure healed. As the discharges from the bowels were blackish, I directed five grains of the pilul. hydrarg. to be taken every night for a fortnight, which gradually corrected the biliary secretion, and in that time the ulcers were per- fectly healed. The patient took the pills every second night for another fortnight, when the bowels being in all respects right, and the constitution in general relieved from all disor- der, they were discontinued. About six months afterward, this patient being in the coun- try, thought she had caught a cold in her head, as she had V&Z ON DISEASE* frequent occasion to blow her nose, and as she snuffled in sneaking: this complaint gradually increased ; and after a fort- night had elapsed, she perceived a difficulty of deglutition, which alarmed her, because it reminded her of her former indisposition. She was at this time also very unwell, and felt in the same manner as when her throat had ulcerated. These symptoms gradually increasing, after another fortnight she came to town. There was no doubt but in this second attack ulceration had taken place in the upper surface of the vtlum palati, for the ulcer had eaten through the soft palate at a small distance from the termination of the bone, there presenting a circular aperture, about as large in circumfer- ence as a pea. This complaint was made perfectly well in three weeks, by the same treatment as was instituted in the former. The health in general, and the digestive organs particularly, were disordered in the second attack as they were in the former one, and both were set right by the measures that were pursued. I have known many ulcerated throats, which could not, by inspection, be distinguished from syphilitic diseases, and which were even supposed to be so on account of the diffi- culty of curing them, arise from an irritable state of the stomach, and they have readily got well by the treatment above described. The foregoing case might have been one of this de- scription. Might it not, however, have arisen from con- tagion, and have been caught from her husband ? I have re- corded it chiefly on this account; for I am desirous of mentioning, that I have seen several instances of pseudo- syphilitic diseases communicated from husbands to wives, where there were no sores, nor apparently any morbid dis- charges from the genitals. If this supposition be true, it would probably be considered as a very curious fact, and I mention it to excite general observation, by which alone it can be confirmed or confuted. I shall briefly relate another case, suggesting the same opinion. RESEMBLING SYPHILIS. 263 A gentleman had been my patient on account of a chancre, for which he regularly took mercury so as slightly to affect his mouth. He had afterward an ulcerated throat, which got well without the use of any medicine. Shortly afterward he married a very healthy woman, who in about three months became very unwell, and had pseudo-syphilitic diseases, for which a mercurial course was instituted without benefit. As I had attended the husband, I was once consulted on her case. She had then a deep and foul ulcer between the ala nasi and upper lip. Her diseases afterward got slowly well under a plan of treatment calculated to restore her general health. I am aware that the cases which I have related by no means represent all that deserves to be displayed, in order to convey to the reader that extensive knowledge of the subject which a surgeon living in this metropolis may and ought to possess. For example, I have not related any case to show that the primary sores, in many instances, are subject to paroxysms of disorder; that they will amend and seem inclined to heal, and when, from their appearance, the greatest hopes are en- tertained, on a sudden, a renovation of disorder takes place, and more parts become diseased or destroyed. This cir- cumstance happens whether mercury be employed or not, and under an equal operation of mercury on the patient's consti- tution. Also in syphilitic and pseudo-syphilitic affections, sometimes diseases occur which are the effect of derangement of the consitution at large, such as unhealthy abscesses and sores ; and while mercury, if employed, acts beneficially on the symptoms for which it was administered, it often has a prejudicial effect on these accessory diseases. I have now lying before me the written records of many cases similar to the foregoing, each of which exhibits some interesting variety observable in these diseases. I forbear, however, to adduce more instances, from a conviction that recorded cases will n^ver make a forcible impression on the 2M ON DISEASES minds of practitioners, and that they merely serve to induce attention to the occurrences which are met with in practice, so as to lead each person, by observing circumstances to which he had perhaps before been too little attentive, to ac- quire practical information and knowledge from his own experience. RESEMBLING SYPHILIS, 265 SECTION V. On the Treatment of Pseudo-Syphilitic Diseases. The impropriety of putting patients under a full mercurial course, such as is necessary for the cure of syphilis, without taking into consideration the nature of the primary sore, or watching, even for a short time, the progress of the consti- tutional symptoms, must, I think, be to every one sufficiently evident. If the constitutional symptoms proceed in the manner detailed in the second section, and get well sponta- neously, it would be absurd to use mercury ; but if they are progressive, and threaten to destroy parts of importance, even though we may have great reason to believe that they are not truly syphilitic, an alterative course of mercury, with the addition of decoction of sarsaparilla, seems to be, in ge- neral, the most efficacious means of effecting a temporary cure. In the second section, I stated, that after having waited till I was assured that the constitutional symptoms were not truly syphilitic, and, consequently, did not require for their cure a strong mercurial course, I generally gave the compound ca- lomel pill with a view to shorten the duration of those symp- toms. This practice has been said to be ridiculous. I only wish to show that, in general, it is the most successful that can be pursued. The cases which have been related attest, that an alterative course of mercury will cure diseases which a potent one will aggravate; and that neither course can be considered only as producing the temporary effect of curing the present symptoms without eradicating the constitutional disease. In proof of this point, I could adduce the most abundant and clearest evidence. I take the liberty to men- tion, that some eminent surgeons of this metropolis, who concur with me in opinion respecting the nature of these diseases, are averse to employing mercury for (heir cure; Vol. I 3! 266 ON DISEASES. and as such sentiments and practice may become very gene- ral among those who clearly perceive that the most powerful mercurial courses will not radically cure these diseases, and that they will get well without that medicine, I feel it neces- sary to discuss the subject a little more at large. I have found a compound calomel pill, or five grains of the pilul. hydrarg. taken every second night, sufficient in many cases to heal sores more rapidly than I wished, while in others, the same pill taken every night has been insufficient, and the disease has been controlled and cured when the pill was taken night and morning. The dose which has been most successful has been one that has not perceptibly affected the mouth nor weakened the constitution; during its use, on the contrary, patients have acquired muscular strength and increase of bulk. The constitutional symptoms in these cases frequently occur when the patient's health is much disordered ; and it may be feared that any course of mercury, however trivial, may increase the weakness and irritability of the constitution. However, it will be found, on the contrary, that an alterative course of mercury, by controlling the disease, will produce a diminution of irritability, and increase the strength of the pa- tient. All persons who are not familiarly acquainted with the fact are extremely surprised at the wonderful acquisition of bodily strength and vigour obtained by the patient during the use of a medicine which they have always considered as likely to debilitate. The difficulty is to ascertain the precise dose that shall cure the local diseases, without apparently producing any mercurial effect on the constitution in general. This dose must necessarily be various, as the susceptibility of being acted on by mercury varies greatly in different persons. Respecting doubtful cases, and of this description must many be, which are presented to the notice of a surgeon who has had no opportunity of- observing the characters of the primary sore, &c, I wish to ask the following question. If a disease that may be suspected to be syphilitic gets well, when the patient takes only five grains of the pilul. hydrarg. RESEMBLING SYPHILIS. 267 <;ach night, (taking also the decoction of sarsaparilla in the day,) without the mercury apparently disturbing his consti- tution, but, on the contrary, contributing to the increase of his strength, ought such a disease to be regarded as syphilitic, and requiring a persevering course of mercury for its cure ? Were I to answer this question agreeably to the dictates of my own experience, I should reply in the negative, because I have seen many such instances, wherein it was evident that the disease was of the kind which I have termed pseudo-sy- philitic. Within these few months three cases have come under my observation, in which the throat was deeply and very badly ulcerated, and the general health greatly impaired; and yet all the patients got well in about a month by such a course of medicine as I have described, increasing in health as the local disease amended, and without any mercurial ef- fect on their constitution being manifest. This is a point of practical conduct, much deserving of consideration, and requiring to be established. It would ap- pear wrong to use more force for effecting a purpose than is requisite. In syphilis the cure of the diseases for which mercury is administered is a proof of the sufficiency of the mercurial course. Syphilitic symptoms will not, however, as far as my experience enables me to determine, give way to so trivial a quantity of mercury. Therefore the mode of cure of these diseases may serve as a test of their nature, and as a guide for our conduct on a recurrence of symptoms, in cases where no other evidence can be obtained. Were this question determined, were it decided, that truly syphilitic symptoms would not yield to an alterative course of mercury, which produced no apparently mercurial effect on the patient's constitution, but under which it acquired a natural degree both of tranquillity and strength, another in- quiry would yet remain. Are we warranted in continuing or augmenting the mercurial course, in order to prevent a return of the same or similar symptoms ? Were my own experience to direct me in my reply to this question also, I should again answer in the negative ; because I have frequently, in such 268 uN DISEA;>ES dubious cases, put patients under a full mercurial course, in order to prove, that if any relapse should occur, the disease could not be syphilitic, or curable by such a course of mer- cury. The cases to which I allude were those of officers and persons of strong constitutions, in which it seemed ne- cessary to establish this fact, with a view to the subsequent treatment of any symptoms that might occur. Yet in these cases new symptoms were manifested. I have also been frequently consulted with respect to the degree to which a mercurial course should be carried, and the time it should be continued, that had been instituted for the cure of pseudo- syphilitic symptoms, which had been mistaken for those of true syphilis; and I have recommended that it should be continued, to that degree and for that duration, that should render a repetition of it unnecessary, by proving it to be un- availing, should a recurrence of symptoms ensue. Yet in these cases also, either the same symptoms returned or simi- lar diseases took place, and in most instances these returning symptoms have got well without the use of mercury. The cases also, which I have detailed, show how unavailing the most potent courses of mercury are, in effecting the radical cure of these disorders. It seems therefore better to desist from the use of medicine, when the local diseases are well; and should they recur, to cure them again by an alterative course of mercury, which appears, from its effects, to be not only innocent, but even salutary. In some cases which I have attended, after having cured the local symptoms by an alterative course of mercury, with the addition of the decoc- tion of sarsaparilla, without producing the slightest apparent mercurial effect on the patient's constitution, I have recom- mended the continuance of half this innocent quantity of mercury for a considerable time, in order to prevent a relapse, and in many instances this plan of treatment has seemed to succeed, whilst in others it has failed. In some cases of pseudo-syphilis, one set of symptoms will disappear without the use of mercury, yet new symp- toms occurring, they will be progressive and destructive so RESEMBLING SYPHILIS. 2U0 as to require mercury for their cure. The reverse of this also happens : one set of symptoms seemed to require, and to have been cured by an alterative course of mercury; yet others subsequently arising, may disappear without its admi- nistration. Even an innocent and alterative course of mercu- ry should not, in my opinion, be hastily resorted to. The object which we are to keep in view, throughout the whole treatment of the disease, is to tranquillize and invigorate the constitution, and only to check or cure destructive or very distressing symptoms by an adequate quantity of mercury. Though an alterative course of mercury is so generally bene- ficial, yet in some instances it aggravates these diseases. There are persons of so peculiar a constitution, that the smallest doses of mercury cannot be given without pro- ducing irritation and disorder. Mercury also may fail to be beneficial, when administered at one period of these diseases, and yet have the most desirable effect at another. It may, for instance, fail to do good at an early period of the disease, when it is in a state of considerable activity, and yet may counteract and subdue it, when its vigour is on the decline. The cases furnish examples of these facts. Though in general the decoction of sarsaparilla appears to be the best medicine that can be given in addition to alterative doses of mercury, yet, when the constitution of the patient is weak, it is useful to give medicines of a tonic and cordial kind. This practice is peculiarly proper, when it requires a more powerful operation of mercury than I have in general described, to control and cure urgent symptoms.* * It may be thought by some, that I have relied too much, in the treatment of the foregoing diseases, upon the internal administration of mercury, and have not sufficiently tried its effects by inunction. I therefore think it right to ex- plain, that it seems to me immaterial, whether a mild oxyde of mercury, such as should be contained in mercurial ointment, and quicksilver pills, is absorbed from the skin or the alimentary canal. I generally find that as much of the quicksilver pill can be taken internally as is necessary to produce the degree of mercurial affection of the system, which is requisite for the cure of pseudo- syphilitic symptoms, without in the least disordering the functions of the di- 270 ON DISEASES Such is the result of the observations I have made on the treatment of these most vexatious diseases;—diseases which must, I believe, perplex all surgeons, whatever opi- nions they may entertain respecting them, and whatever con- duct they may pursue with a view to their cure. They, who believe them aH to be syphilitic, and regard mercury as the only remedy, must be perplexed by discerning its inefficacy. They who abstain from it must be perplexed by observing the pertinacious nature of the disease, and the frequent re- currence of new and distressing symptoms. They who steer a middle course, as I have done, will not avoid difficul- ties. Without any particular investigation of the nature of venereal diseases, two different modes of treatment seem to have been adopted by the profession. One party has used mercury liberally for evident reasons. It seemed necessary for the cure of syphilis, and it has been successful in cases of that disease. Believing all venereal diseases to be of that nature, and further incited by frequent recurrence of symp- toms, one party of professional men has used mercury, as I believe, in a most injurious degree ; whilst others, from wit- nessing the beneficial effects of an alterative course of mer- cury in pseudo-syphilitic diseases, have considered such a course to be all that was necessary in every instance. No improvement in practice could possibly take place, whilst former opinions prevailed ; whilst surgeons regarded every constitutional disease that had the appearance of syphilis to be really of that nature, and treated it accordingly. This was done, whatever might have been the characters and pro- gress of the primary sore from which it originated ; and even when it was preceded by no sore, it was considered as an in- stance of syphilis long lurking in the constitution. Even gestire organs; but, on the contrary, with evident benefit by exciting and main- taining the natural and healthy actions of those organs. It is right, however, to add, that the pilul. hydrarg. which I have always em- ployed, has been procured from the Apothecaries' Hall; and that when it has been obtained from other places, its effects have by no means corresponded to what I have represented of them. RESEMBLING SYHIPLIS. tfi Mr. Hunter, who so accurately observed diseases, and so clearly distinguished, that there were many diseases resem- bling syphilis which were not of that nature, must have been exceedingly perplexed in his opinions and practice. As he believed chancres might be modified by the diseased propen- sities of the constitution, when he met with ulcers in the throat, eruptions, and nodes consequent to such chancres, which, not even his accurate observation could, I will ven- ture to affirm, in many cases, distinguish from those of sy- philis, he must, I think, have deemed it right to treat them as if they were syphilitic. The cases to which I now allude are recorded in the second section. But in these cases, the symptoms will recur in general after the severest course of mercury. That he met with such cases, and was perplexed by them, may be inferred from bis opinions, he having accounted for such failures by saying, that mercury will cure the disease when in an active state, but will not cure the disposition to diseased actions, which certain parts may have assumed. I believe, however, it will be found that mercury cures both the actions and dispositions to act in true syphilis, and that the perplexing cases were of a different nature to that disease. How far the diseased ac- tions incited by syphilitic poison admit of considerable modi- fications from peculiarity of constitution in the primary sores or chancres, we have, I believe, yet to learn. There are, however, good reasons for supposing that when a poison is absorbed without inducing a sore, and when that sore is of a nature very discordant to those of syphilis, that the constitu- tional symptoms will be found equally to differ from those of syphilis in their nature, and require a different mdde of treat- ment. Having been instructed by Mr. Hunter to believe, that there were diseases resembling the venereal disease, which were different in their origin and progress, having perceived nothing to contradict, but, on the contrary, every thing to confirm that proposition, I have in this publication avowed my opinion of their existence to a far greater extent than Mr. 272 on DISEASES RESEMBLING SYPHILIS. Hunter supposed. Knowing how much opinions influence our judgment and conduct respecting facts which come un- der our observation, I have even wished that these opinions, if they be correct, might become general and confirmed. Being conscious that they have not been hastily adopted; and that in surveying the facts upon which they are founded, I have endeavoured to keep my mind as unprejucied as pos- sible, I should think myself guilty of a culpable timidity, were I not to avow them. If the opinions be correct, it must indeed be acknowledged, that cases of true syphilis are much less frequent now than formerly, and for this I have endeavoured to assign a reason in the second section. Well aware how liable an individual is to err, in forming ge- neral conclusions from his own limited experience, and con- scious that the opinions which I entertained respecting these diseases were different from those of a great number of eminent surgeons, I at first published my observations on the subject in portions ; and the same apprehension as to the possibility of error has now induced me to republish them in a less methodical manner than I could have wished. I thought this mode would show better the rise and progress of those opinions which I cannot but entertain; inasmuch, as they appear legitimately to be deduced from facts. Had I published all I knew and thought relative to these subjects under another title; had I called the book Additional Observa- tions on Venereal Diseases, or on progressive and remittent syphilis, it might have been better received, because it might have been more accordant to the notions of others. Yet in whatever way I might have represented the subject, the difference would only have been in the manner of dis- playing it; there would have been none in the matter to which it related, as that consists of actual occurrences in practice. ON DISEASES OF THE URETHRA. Vol. I. ,55 ( 275 ) On Diseases of the Urethra ; particularly of that Part which in surrounded by the Prostate Gland. SECTION I. Every surgeon will, I believe, acknowledge, that aii ob- scurity hangs over the subject of strictures of the urethra, which prevents us from perceivingthe cause of many circum- stances which occur in daily practice. Contractions of this canal are sometimes readily enlarged to their natural diame- ter by the introduction of common bougies, and the cure thus effected is permanent. In other cases it is difficult to procure even a temporary enlargement of the contracted part; and the stricture returns, when the means by which it was relieved are discontinued. This variety in the event of dif- ferent cases may in some instances, depend on the kind and duration of the disease in the strictures themselves ; yet, in many others, I am convinced that it is owing to other cir- cumstances, which it is my design to consider in the present paper. Before my observation had been directed to these. circumstances, I was much puzzled to account for the dis- cordance in the result of cases apparently similar. I was equally unable to understand some occurrences, like those which are represented in the following case. 276 ON DISEASES CASE I. A gentleman whose life was made uncomfortable by a very frequent and very urgent propensity to void his urine, ap- plied to me for advice. Two strictures were discovered in the further part of the urethra, which did not oppose the passage of a bougie as large as a goose quill. Some difficulty was experienced when the bougie entered that part of the urethra which passes through the prostate gland ; and the patient complained of pain, which was considerably increased at the orifice of the bladder. The instrument, however, en- tered the bladder, though with difficulty ; and it seemed to be grasped by the sphincter. The prostate was enlarged to twice its natural size ; which circumstance seemed to me to explain the cause of the slight impediment which occurred to the passage of the instrument through it. The urethra was unusually long in this patient; and though bougies had been frequently introduced, I suspect that they had never been passed into the bladder. The patient was of this opinion, from the peculiar sensations which he experienced, and which he had never felt before. He called upon me four days afterward, said that he was much relieved, and request- ed to have the operation repeated. The same bougie which had been used before now passed with much greater facility. The patient still felt peculiar sensations, though much dimi- nished in degree, as the instrument went through the prostate. It entered the bladder without difficulty and without appear- ing to be grasped. I now introduced a larger bougie, which went through the strictures with less difficulty than the smaller one had done on its first introduction. This pro- duced the same uneasy sensation on entering the prostate ; it was retarded for a moment at the orifice of the bladder, and was slightly grasped at its entrance. All the symptoms were still more relieved by this second introduction. The same operation was repeated a few times; at first every fourth day, and afterward once a week, till a bougie of the OF THE URETHRA, &c. 277 largest size could be passed without occasioning any un- easiness. The patient, during the latter part of the time, did not require to void his urine more frequently than is com- mon. He was relieved from a great trouble; and though many years have elapsed, he has not experienced similar in- convenience. Such cases as the preceding induced me to suspect that a stricture might exist in the orifice of the bladder. The following case gave me new, and, as I think, just ideas rela- tive to this subject. Whether the opinions be correct or not, the cases, it must be admitted, deserve attention. CASE II. A gentleman, more than seventy years of age, had ex- perienced for about six years a difficulty in voiding his urine, which gradually increased, till the stream became very small. This was attended with a frequent propensity to dis- charge the urine, which disturbed him every second or third hour during the night. At last a complete retention took place when he was in the country ; and a surgeon attempted to introduce a small catheter, which however was prevented, by a stricture, from passing farther than six inches. The patient immediately came to London, when I directed him to take some castor oil, and to bathe the perinaeum and ad- jacent parts frequently with warm water. After some time the urine flowed again, and he was relieved from the present urgent symptoms. In two days I examined the urethra, and found a stricture at six inches, through which I could not pass even a very small bougie. I touched this with the ar- gentum nitratum ; but the application did not produce any alteration in the circumstances of the disease. On the third day the bougie passed on to a stricture, at seven inches, which was also touched with caustic; and the same treat- ment was repeated with another stricture, at the distance of half an inch from this. The bougie now passed through all the strictures, and entered the prostate, when I was obliged 278 ON DISEASES to withdraw it immediately, from a sudden attack of pain and faintness. No enlargement of the prostate was discovered by an examination per anum ; nor was it tender when compress- ed. I told the patient that 1 considered it very desirable to introduce a tubular instrument into the bladder, but that the minuteness of the stream of urine rendered it doubtful whether this could be accomplished. I requested him to call in another surgeon, that the attempt might be made by us conjointly. A flexible varnished catheter, containing a strong wire, was readily passed into the prostate, but could not be made to enter the bladder. The attempt was not long persevered in, from an apprehension of doing injury, if the instrument were not guided in the right track. No blood flowed upon withdrawing the catheter. A slight retention of urine followed this attempt; but, after a few days, the patient was in the same state as before. On examining the urethra four days afterward, I found that the smallest bougie would not pass further than six inches ; so that the contraction of the first stricture had beenre-excited by the irritation occasion- ed by our late attempt. As the application of the argentum nitratum had so suddenly and completely relieved this stric- ture in the first instance, I now repeated this application, although I knew that the stricture was merely spasmodic. In the course of a few days a small bougie was introduced into the prostate, and afterward a larger one. I now wish- ed to ascertain whether I could pass the bougie into the bladder, or learn, by means of that instrument, the cause of the obstruction. As the patient found that he could void his urine most easily when lying on the left side, it seemed proba- ble that the orifice of the urethra might be found in that direc- tion. I therefore depressed the point of the instrument, and carried the other extremity towards the right groin, when most unexpectedly it went forwards into the bladder. When the bougie was withdrawn, a considerable quantity of clot- ted blood and mucus, with some matter, oozed out of the urethra; and the patient afterward voided in a large stream about eight ounces of turbid and foetid urine mixed with mu- ')E THE URETHRA, &c. 279 cus; after which he felt as if his bladder were completely emptied. From this time he had no occasion to void his urine more frequently than is natural, and he expelled it in as large a stream, and with as much facility, as he had ever done at any period of his life. The bougie was for some time introduced every third day, and afterward once a week. It passed easily not only through the urethra, but into the blad- der, when guided in the direction which has been mentioned. At first the point was soiled with blood and matter, but after- ward these appearances were no longer observable, which led me to conclude that the circumference of the ulcerated orifice of the bladder had completely healed. Two years afterward this gentleman experienced a recurrence of his former complaints ; a small bougie only could now be intro- duced into the bladder. A larger bougie was passed through the urethra on the next attempt; but was not carried for- wards into the bladder, from an apprehension of irritating the prostate. After a few days the larger bougie was introduced into the bladder, and met with a little resistance at its orifice. From this time it passed with the same facility as when I discontinued my former attendance, and the patient found himself equally well. Two years have now elapsed, without any necessity for repeating these operations. In this case a disease took place in the prostate gland, without producing any evident enlargement or tenderness of its substance, though it had proceeded to a state of ulcera- tion. The disease seems to have operated on the continuous parts in two directions ; backwards upon the bladder, render- ing that organ irritable; and forwards upon the urethra, causing strictures, which were in some degree organic, though chiefly of a spasmodic nature. It must be allowed, however, that the obstruction of the aperture into the blad- der by the discharges from the ulcerated surface contributed in a great degree'to maintain the irritability of the organ, by impeding the discharge of the urine. This disease was also of a nature that admitted of relief, and the passage of a bou- gie seemed to effect its cure. It had, however, a tendency 280 ON DISEASES to recur, and the use of the bougie lessened the irritability of the part, and arrested the progress of the disease. The circumstances of this case do not indeed unfold the cause and precise nature of the disorder, which, however, will, in my opinion, be elucidated by those which follow. They induced me to suppose that those instances, which I had formerly met with, and which appeared so unintelligible, were of a similar nature; and they made me particularly at- tentive to the state of the urethra, where it passes through the prostate gland, as I saw the possibility of this canal being diseased, without the prostate being materially implicated in the disorder. The following case occurred soon afterward. CASE III. A gentleman, between fifty and sixty years of age, had for twenty years been subject to occasional fits of dysury. I was desired to see him in one of these, which had been very severe and long continued. He was obliged to void the urine at least every hour. The calls were sudden and ur- gent, and the pain continued for a considerable time after the urine had been discharged. He had some fever, which such irritation would naturally produce. A moderate-sized bougie stopped at two strictures, but passed through them without much difficulty: when it entered the prostate, the patient complained of burning pain ; of a strong irritation to make water ; and grew so faint that I had merely time, by a gentle pressure, to ascertain that the bougie would pass into the bladder: when I withdrew it, the point was covered with blood. The patient was directed to bathe the perinaeum with warm water frequently, if the dysury was urgent. He was much relieved by the introduction of the bougie, and did not want afterward to void his urine oftener than every se- cond or third hour. The calls were less urgent, and the sub- sequent uneasiness less in severity and duration. After two days, a bougie of the same size was introduced to the extent of eight inches, and withdrawn; no blood adhered to its OF THE URETHRA, All-. 251 surface. A smaller bougie, much curved, was now passed into the bladder ; the patient complained of the same uneasy sensation as before, when it entered the prostate; but he did not grow faint. The point w*s bloody for three quarters of an inch, but less so than on its first introduction. More relief was experienced this time. The urine was now voided only every fourth hour. Two days afterward the bougie was again introduced into the bladder, considerably curved, and with the point carried along the upper surface of the urethra, where it passes through the prostate gland. The point was soiled with a yellowish fluid, slightly tinged with blood. As the patient was getting much better the operation was not repeated till after four days, and then after the inter- val of a week ; at which time the blood and the yellow fluid had entirely disappeared. The urine was not voided more frequently than natural, nor was its expulsion attended or succeeded by any painful sensation. The strictures in this case felt firm, and not easily dilatable : I thought it ne- cessary to relieve them, lest they should contribute to re-in- duce the irritation in the prostate ; but the patient felt him- self so well, that he was averse to any thing which might renew his former sufferings, and he has had no symptoms of dysury since that period. The prostate in this patient was not enlarged nor tender. Conclusions similar to those, which were deduced from the former case, may be more fairly drawn from this ; viz. that a disease may occur in the membrane of the urethra where it passes through the pros- tate, and that it may render the bladder irritable, and produce stricture in the urethra ; for in this case there was no me- chanical obstruction to the expulsion of the urine to produce irritation in the bladder. It also appears that the disease ad- mitted of relief by the introduction of a bougie. I have lately met with another case in a younger man, who is between twenty and thirty years of age, and who was af- flicted with similar fits of dysury, the cause of which could not be ascertained. I passed a bougie for him a few times, but found no stricture in the urethra. The same painful Vol. I. 36 282 ON DIsEA&ES sensations were produced in the prostate, as in the preceding cases. The bougie did not appear at the time to relieve the dysury; but the complaint gradually ceased, and the patient left town. He has been much better since this time, and at- tributes his relief to the passage of the bougie. CASE IV. A gentleman, about sixty years of age, was affected with dysury, which increased with violence, though various means were employed during two years for his relief. He voided his urine every second hour, or oftener, with great pain and severe irritation: which continued for some time after its expulsion. He had such a sensation of heat and uneasiness in the perinseurn, that he could not bear to bring his thighs together; and he was obliged to use a cushion, with a va- cancy in the middle, when he sat down. He could not ride in a carriage, or even walk out, although his general health was good. A moderate-sized bougie halted a little at two strictures, and when it arrived at the prostate produced a vio- lent burning sensation, a vehement propensity to void the urine, and extreme pain at about two inches from the orifice of the urethra; which part was always particularly painful during the time of voiding the urine, and after its expulsion. On withdrawing the bougie, which had entered the bladder, its point was found to be covered with blood. The prostate being examined, felt rather broader than usual, but was not tender. The patient was relieved by the introduction of the bougie, which was repeated on the third day: it went more freely through the strictures, and the sensations, caused by its passage through the prostate, were diminished. The point of the bougie was bloody. I ascertained that the blood came from that part of the urethra which is situated in the prostate, by introducing a large bougie to the distance of eight inches, and then withdrawing it: the point was not in the least soiled with blood. The second introduction of 'he bougie produced considerable relief. The urine was re- Dl THE URCTHRA, fccc. 2&3 tained longer, the uneasy sensation in the perinaeum wa< diminished, and the patient could walk or sit down more comfortably. The bougie was used every third or fourth day for three weeks; and then once a week for a month longer, its size being gradually increased. The appearance of blood on the point gradually ceased : it was afterward soiled with a purulent and then with a mucous fluid, which appearances also gradually ceased. The water was now voided only at intervals of four hours, the subsequent pain being either trivial or entirely wanting; the uneasiness in the perinaeum was so inconsiderable, that the patient could walk for several hours, and sit down without pain. The seminal discharges had been attended with extreme pain, so great as almost to produce fainting, before the state of the prostate had been relieved : they afterward took place without any unusual sensation. These cases show that the urethra may become irritable and diseased, where it passes through the prostate gland, without any material disorder of the contiguous parts. They induced me to pay particular attention to the state of that part of the urethra ; which attention will, in my opinion, be found of great consequence in directing our treatment of these disorders. As it would render this paper extremely voluminous to detail the particular cases which I have met with, I shall merely relate the observations which I have made, and the inferences which I have drawn from them; that the profession in general may investigate the subject, and determine how far these observations and opinions are cor- rect. First, then, it has appeared to me that a state of in- flammation and irritation may take place in the remote part of the urethra to a greater or less extent. It may produce in the prostate that peculiar sensibility of the part which I have described ; and in the perinaeum it may cause contrac- tions of different parts of the canal. Either of these affec- tions may be more permanent than the other, even where each part has been equally affected in the beginning. This -tatr of inflammation and irritation is frequently produce'' ISi ON DISEASE* by gonorrhoea, though it may occur from other causes, ll a bougie be introduced injudiciously, when this disorder first occurs in a gonorrhoea, numerous spasmodic strictures* are met with ; the patient becomes alarmed by the difficulty of passing the instrument, and by the name of strictures, and consults a more experienced surgeon, who directs local warm bathing, and the application of leeches to the perinaeum. The disorder is cured; the patient expects that strictures remain; a full-sized bougie is introduced to satisfy him, which passes without the least difficulty. I am unable to de- termine, whether in such cases the urethra is affected in the first instance in that part which passes through the prostate, as I never made any examination under these circumstances, though I think it very probable that it is so. When a gleet becomes unusually protracted, it is frequently owing to the effects of this disorder in the remote part of the urethra, maintaining a degree of irritation in the front. Under these circumstances, it is allowable to introduce a bougie, when strictures will frequently be found in the perinaeum; and in many cases, the patients whom I have attended have experi- enced those sensations, which are characteristic of tender- ness in the membrane of the urethra^ where it passes through the prostate. If, therefore, we look to the origin of those cases, which we are called upon to attend in their advanced stages, we might expect to find the disorder of the urethra various with respect to the kind and extent of the disease. That it will be found so in practice I do not hesitate to affirm from the observations which I have already made relative to this subject. In some cases, strictures in that part of the canal, which is subject to such contractions, will be the sole disease. In others, an uneasiness, and such sensations as I have described, will be complained of as the bougie passes through the last inch of the urethra, which is contained in * I have used the term spasmodic strictures in the indiscriminate manner in which it is generally employed, though I am aware that it is objectionable: a stricture from spasm is not a stricture .« nnd a stricture may be irritable or 'cposmndfcal. or ntherv. i«e. OF THE URETHRA, &c. 283 the prostate gland. In some cases also, the strictures will be the less degree of the disease, and the irritation in the prostate the greater; and in some cases it will be found that nothing is discoverable which can fairly be denominated a stricture, and yet the tenderness which I have described exists in a most painful degree. A student of the hospital who had a slight gleet, but of long continuance, having also some pain and irritation after voiding his urine, though without any frequent desire to void it, passed a bougie, which arrived at the prostatic part of the urethra without impediment, or causing him to feel any par- ticular uneasiness ; but when it glided on through the pros- tate, it occasioned, he said, a burning pain and irritation, so peculiar, as not to admit of description, and so severe, that he could not have believed it, but on the evidence of his own senses. My observations have also led me to believe, that the in- flammation of the testis, which is so frequent an attendant on gonorrhoea, is excited by inflammation of this part of the urethra, and not by a sympathy between that gland and the urethra in general. In deducing these diseases from the inflammation which gonorrhoea excites, I mean only to trace them from a very common origin. The same disorders frequently take place without having been preceded by that complaint. An atten- tion to the circumstances, which have been mentioned, seems to me to explain the contradictory events which happen, when a similar plan of treatment is pursued for the cure of diseases of the urethra. When strictures are the sole disease, they are often readily, and generally permanent- ly, cured. When an irritation, such as I have described, exists in the prostate, it is difficult to enlarge the contracted portions of the canal ; and, when that is accomplished, the strictures recur, as a cause of irritation to the urethra still continues. In some cases, the enlargement of the strictures fails to mitigate the dysury, and in others it is augmented by the measures which have been employed to cure the stric- jao ON DISEASES tures, when the state of irritation at the neck of the bladder has been unadverted to. Many patients have applied to me un- der these circumstances, after having been under the care of other surgeons. They have stated, that small bougies only could be passed in the first instance, and that though the largest could now be introduced, the complaint was no better; nay, some have thought themselves materially worse. A bougie has passed in these cases eight inches, without meeting any considerable obstruction, or exciting much sensation; but, after this point, it caused a most acute and burning pain, with vehement desire to make water. Some have inquired if I was withdrawing the bougie, whilst it was slowly proceeding, and some have complained of great pain in the front of the urethra. Similar cases have occurred in my own practice. I have relieved strictures without materially benefiting my patients; of late years, I may venture to say, without making them worse; because I have been cautious not to hurt the canal, where it passes through the prostate. Some cases of disorders of the urinary organs are made worse by the attempt to cure strictures ; and I think I deliver an important admonition to the younger part of the pro- fession, when I caution them to beware, in their attempts to cure strictures, that they do not irritate nor injure the last inch of that canal, where there are no strictures, but in which considerable disorder may nevertheless exist. In some cases of diseased urethra, which I have not unfre- quently met with, strictures are found, through which a small bougie passes with difficulty; and it produces those sensa- tions, in passing through the prostate, which I have de- scribed, as peculiar to that part of the canal when in a dis- eased state. The patient, however, experiences relief from the introduction of the bougie ; and if it be passed again on the third day, it will meet with no obstruction from the stric- tures, and cause less uneasiness in passing through the prostate. I have then taken a bougie of a larger size, such as it would have been impossible to introduce in the first instance, and OF THE URETHRA, 6.<- >$"i this has passed through the strictures to the distance of eight inches ; but I have forborne to carry it any further, lest I should irritate the urethra near the neck of the bladder. It appears therefore to me, that you may relieve or aggravate strictures in such cases in proportion as you diminish or augment the morbid sensibility of the remote part of the urethra; and an attention to the state of this part is on this account of the greatest importance. Having thus adverted to the probable origin of the disease, which I am endeavouring to describe, and its connexion with strictures, I proceed to observe, that such a state of morbid sensibility in that portion of the urethra, which passes through the prostate, may perhaps exist as a symptom of an irritable bladder. If the lining of the bladder be inflamed and irrita- ble, it is probable that the disorder will extend into the urethra for some small distance. In the fourth case, I believe that the disease in question was complicated with an irritable state of the bladder; but whether it was to be considered as an adjunct circumstance, or in the relation of cause or effect, cannot be determined. The irritability of the bladder was diminished, but not cured, by the treatment which lessened this disease. In one gentleman, who apparently died of an irritable bladder, and who complained of the sensations which I have described, in an acute degree, on the bougie passing through the prostate, the diseased parts were examined, but very trivial morbid appearances were discovered. The lining of the bladder was not perfectly natural, and was inflamed; yet the diseased appearances were not striking; and in the urethra the deviation from the healthy structure was still less observable. It is not improbable, however, that such a morbid sensi- bility of the prostatic urethra may arise from an irritable bladder. Perhaps, also, it may occasionally arise from the irritation of the last stricture. Many patients with strictures, who complained much of the sensations at the neck of the bladder, at the commencement of the treatment of their com- plaint, have asserted, that they felt no unusual sensations 28S ON DISEASES when the bougie passed through the prostate, after the stric- tures had been cured. Yet, though I would admit that a tenderness of the canal of the urethra in the prostate may sometimes arise from its proximity and continuity with the lining of the bladder, or with the last stricture, I think it more frequently exists tfs an original and independent disease. It has been shown, that it may render the bladder irritable, and excite contractions in the urethra. Some cases have been adduced, which show that this state may exist, and yet the bladder may not be constantly irritable, but that it may be affected by fits. I have also met with a case where this sen- sibility existed in an extreme degree, and yet it seemed to have very little influence on the bladder. I have likewise known this irritable state of the urethra complicated with en- largement of the prostate. I proceed, in the next place, to relate what I have observed respecting the treatment of the disease, which I have been describing. The three first cases show, in a striking manner, the advantage derived from the introduction of bougies; and I have seen many similar ones, though I scarcely think so de- monstrative of the utility of this mode of treatment. I know some patients with occasional attacks of dysury, and who have this tenderness of the remote part of the urethra, in whom the passage of a bougie, together with warm bathing of the perinaeum and adjacent parts, very speedily relieves a dis- ease, which had proved very tedious and distressing before these measures were adopted. If a bougie be introduced, for the first time, in a case of this description, severe pain is felt, and faintness is occasioned : if this operation be repeated three days afterward, the pain perhaps is much less severe, and it may diminish at each succeeding introduction of the instrument. Should this be found to be the case, surely no- thing need be farther said in commendation of this mode of treatment. The morbid sensibility of parts is diminished by it. This happened in the three first cases in a remarkable degree, and I have known it take place in many others. Nor is there any thing in this event that should excite surprise : OP THE URETHRA, &c. 289 every surgeon is familiar with the same circumstance, with relation to strictures in the urethra. The first introductions of a bougie are very painful; the subsequent ones become to be even disregarded. Still, however, I think it may be useful to dwell a little on this subject, and to consider the probable causes of these effects, as it may tend to establish rules for our conduct in practice. It appears to me, that we diminish the morbid as well as the natural sensibility of parts by doing them a degree of violence, short of that which produces a kind of reaction in them, by which their sensibility is height- ened. This is, indeed, the consideration which guides my practice in these and in many other cases. If, even in strict- ures of the urethra, the sensibility of the canal becomes in- creased by the introduction of bougies, or, in other words, if inflammation is excited, surely it is wrong to prosecute such measures at this juncture. If the morbid sensibility be dimi- nished, we may use more freedom in the prosecution of our measures. In passing the bougie, in the cases now under consideration, it ought at first, I think, to be so small as not at all to distend the irritable urethra. I have always curved it considerably, and kept the point in contact with the upper surface of the urethra, as it passes through the gland. I re- commend warm bathing to the perinaeum, with a view to ob- viate or diminish irritation. If I find, on the second intro- duction of the bougie, the sensibility of the parts diminished, it induces me afterward to proceed more freely ; but at all times with a caution excited and regulated by the considera- tion which I have mentioned. Now, though such conduct has been successful in many instances, I am concerned to state, that it has failed in some others ; and, when 1 clearly ascertain that I am not likely to succeed, I cease to make farther attempts by the introduction of bougies, and pursue only general methods, such as warm bathing, bleeding by leeches, &c. When there are strictures, which it is right to enlarge, and when the irritation of the prostatic part of the urethra is not relieved by the measures which have been sug- gested, I pass the bougie through the last stricture, without Vol. U 3? ^90 ON DISEASE;^ carrying it on, so as to irritate the tender part of the urethra, which lies behind it. A knowledge of the nature of diseases cannot but be desirable, even though it does not enable us to cure thern all. If strictures are removed, and dysury remains, I believe it is common to consider it as arising from an irrita- ble bladder; now, though this may be generally true, there are many exceptions. I do not find that attention is paid to the description of cases, which makes the subject of the pre- sent paper: I was unacquainted with them till I met with the cases which I first mentioned ; the knowledge which I have thus obtained has enabled me to afford relief in many cases, and has prevented me from error in others. UF THE URETHRA, &c 291 SECTION II. On the constitutional Origin and Treatment of Diseases of the Urethra. Having in the preceding section pointed out one cause which renders strictures and other diseases of the urethra difficult of cure, in this I shall advert to another ; I mean, a state of irritability and disorder of that canal, produced or maintained by constitutional causes. To explain my ideas on this subject, I wish, in the first place, to excite the atten- tion of the profession to the constitutional origin of disorders of the urinary organs. That they are very liable to be disordered by the state of the health in general is very ap- parent. Indigestion becomes a cause of foul and unhealthy urine, in consequence of much unassimilated matter being conveyed into the blood with the chyle. Nervous irritation affects the kidney and impairs its functions, so that whilst under its influence, scarcely any thing but water is separated by that organ from the blood. The nervous irritation at the same time operates on the bladder, and creates a frequent and sometimes urgent desire to void this unstimulating urine. Many persons during the day, or until they have dined, are greatly incommoded by this circumstance; whilst on the contrary, after dinner, nervous irritation ceasing, and the urine becoming in consequence loaded with salts and animal matter, the bladder will retain the acrid urine, even in a large quantity, for a great number of hours. In other cases, nervous irritation takes place, and limpid urine is frequently voided after dinner ; which I merely men- tion, because it may tend to throw light on the cause and nature of the nervous irritation.* If the kidneys and bladder " The qualities of the urine are sometimes the only circumstances by which we can discover that there is general irritation of the nervous system ; they rtlso denote imperfect digestion ;. they may further indicate the state of the blood ; nnil for all these reason's they de^rve particular attention nwl invc"?1ia;it!'-"> 2i*2 ON D1SEAM.S. can thus be operated upon by nervous irritation, it is reasonable to suppose, that the urethra will participate in the affection; and I am convinced, by numerous observa- tions, that many diseases of the urethra, in both sexes, originate from a continuance of this kind of constitutional dysury. The cases of such diseases occurring in females who have passed the middle period of life, will probably be considered as affording the most unequivocal proofs of the correctness of these opinions. Under such circumstances, I have known, indifferent instances, strictures in the urethra, induration and tenderness of the whole tube, and even ulcera- tion of its orifice to ensue. Though I have seen relief obtain- ed in cases of this description by bougies and local remedies, yet I believe the treatment of such diseases ought to be con- stitutional, and that such treatment will succeed in curing the disease without local remedies. I know one instance in which the dysury had been very severe, and two considerable strictures had formed in the urethra; there was also a thickening accompanied with whiteness and hardness of the membrane of the vagina, causing a contraction in the orifice of that canal; yet all dysury ceased, and no inconvenience was experienced upon the patient's acquiring better health ; which change was affected partly by medicine, and partly by removal into the country. Women will suffer a great deal from these disorders before they reveal their distress; and when from the urgency of the symptoms, and the belief that they have a stone in the bladder, they are willing to submit to examination, the disorder maybe speedily and com- pletely relieved and cured by means which have the effect of tranquillizing nervous irritation. It may be useful to Telate a case in proof of this assertion. CASE V. A lady, between thirty and forty years of age, who had long suffered very considerably from dysury, agreed to per- mit an examination to be. made of the nature- of a disease, OF THE URF.THRA,"&c 29 o which, from the severity of its effects, she cOuld but believe to be of a very serious and alarming nature. On inquiry, I found, that though she voided her urine frequently, and with great pain, yet it flowed freely, and that she did not suffer that extreme and continued pain after- ward, which is generally the consequence of the stone. I found also, by inquiry, that her bowels were not in a proper state, and her tongue was much furred. Supposing that a state of nervous irritation might be caused or aggra- vated by disorder of the digestive organs, I objected to making any examination of the state of the urethra, &c. till the functions of those organs were put right by medicine, because I was aware that nothing but a conviction of the indispensable necessity of examination would have induced her to submit to it. In a very short time, the state of the primae viae being corrected, and her health in general amend- ed, all dysury completely ceased. Dysury of this description is liable to occur in paroxysms. I have known it alternate with disorders of the bowels, and with rheumatic affection, which, I think, shows that there is a common constitutional origin, producing such various complaints; and I repeat, that I have known such dysury lead to actual disease of the affected organs. It is very com- mon for men who have been married many years, and who, perhaps, never had gonorrhoea (or if they had in their youth, it is probable that it had left no disorder in the canal of the urethra,) gradually to acquire, as they advance in life, diseases of the urinary organs. Surely, then, the origin of such diseases must be regarded as spontaneous, and likely to be induced and maintained by whatever occasions irritation in the affected organs. There is, however, no period of life exempt from this kind of dysury. Children are frequently much affected by it, and at that age when the bodily powers are generally in the great- est vigour, if they become disordered, dysury occurs in com- mon'with other diseases. 1 have mentioned in the first par' 294 On diseam > of these observations, in speaking of the constitutional origin of local diseases, that I have known dysury of this description I subjoin another striking case of constitutional dysury occurring in a child. CASE VI. A child, about two years of age, became affected with dy- sury, for the relief of which various means were tried without benefit; on the contrary, the symptoms increased, and strikingly resembled those occasioned by a stone in the bladder. The calls to void the urine were frequent and ur- gent, and the pain afterward very severe. There was an elongation and stricture of the orifice of the prepuce which induced a surgeon who attended the child, to divide that part, as he thought it might contribute to the difficulty expe- rienced in expelling the urine. Under these circumstances, the child was examined by a surgeon of great professional eminence, who had no doubt that the symptoms were caused by a stone, which he thought he felt; yet recommended that no operation should be attempted till it had increased in size. The child continued to suffer in the same manner for two years, when I was desired to examine him. 1 could not, however, discover any stone, and upon inquiry, I found that the child complained of considerable pains in his loins, and that his digestive organs were greatly disordered in the man- ner that I have previously described in these observa- tions. Unirritating and undebilitating doses of the pilul. hydrarg. were given every second night, and strict attention was paid to keep the bowels clear, without inducing what is ordinarily called purging. The effect of this treatment was surprising ; all the symptoms were immediately relieved, and they completely ceased in a month, at which time the functions and secretions of the digestive organs appeared to be so correctly healthy, that all medicine was discontinued. After some months, a slight rdanse of dysury took place, which immediately ceased, upon resuming for a short, time l»F THE URETHRA, &c. 2Uo the same plan of treatment; and the boy has since remained perfectly well, though several years have elapsed. If, then, irritation of the urinary organs, even to a de- gree productive of local diseases in them, may occur from constitutional causes, and more apparently from a disorder of the digestive organs, I need not then urge the propriety of our endeavouring to keep the latter organs, as nearly as pos- sible, in a state of health, whilst we are endeavouring to re- lieve the diseases of the former by local measures. Of the beneficial effects of such conduct, I could relate many in- stances, but it does not seem necessary to detail cases in proof of so self-evident a proposition. I have explained, in the first volume, my ideas of the mode by which relieving dis- orders of the digestive organs relieves and cures local dis- eases ; and in local diseases of the pelvic viscera another reason may be suggested for the benefit which is obtained. It has been observed, that in disorders of the digestive or- gans, the lower part of the intestinal canal is frequently most affected. Irritation in the rectum must affect the plexus of nerves, from which not only that intestine, but the pelvic viscera in common derive their energies ; and thus it mav lead to a similar participation of disease. 29<> ON DISEASES, SECTION III. On some Effects of Diseases of the Urethra. I shall take the present opportunity of exciting the at- tention of the profession to some effects of disorders of the urethra, which have not hitherto received in my opinion a sufficient share of attention. If a violent affection of this canal can produce a corresponding degree of inflammation of the testis, as it frequently does in gonorrhoea, it may reason- ably be expected, that a less degree of disorder in the urethra may produce a milder irritation of the testis, which may ter- minate in a slow disease of that gland. Indeed it has ap- peared to me that there are two circumstances causing irritation and consequent disease of the testis : one is, disor- der of the urethra ; and the other, that derangement of the constitution at large, which 1 have described in the first part of these observations. I need not point out how inefficacious any local treatment of an irritated or diseased gland must be, whilst we leave the causes which produced it still to ope- rate in full force for its continuance. I proceed to relate a few cases, in which irritation originating in the urethra first caused, and subsequently maintained, disease of the testis. CASE. A gentleman who had been confined with a chronic dis- ease of the left testis, which had proved very refractory and irreducible by various means employed for its cure, applied to me when the gland was four times its natural size, and very hard. I recommended the application of three or four leeches once a week, a bread and water poultice at night. and aq. ammon. acetat. during the day. 01 THE IRLTHRA, N.c. 2Q7 This treatment was pursued for six weeks with very little benefit. I then changed the poultice'to one. made of linseed, over which mercurial ointment was spread. The ointment was also rubbed upon the scrotum in the morning, and a soft rag applied over it. The patient likewise took a compound calomel pill every night. This treatment was also persevered in for about six week^, but with no manifest advantage. I then put two setons"* through the scrotum, and continued the poultice at night and a dressing of spermaceti cerate during the day. Under this treatment the testis diminished very considerably in size, but at the end of two months, the setons had gradually- come out, in consequence of the ulceration which they occa- sioned. Shortly afterward, the testis became painful, and it enlarged to its former dimensions, so that no advantage was obtained from all these endeavours to reduce the disease. I had frequently inquired of this patient respecting the state of his urethra, and been as often told that he was not conscious of any disorder existing in that canal. Now, however, on repeating my inquiries, he said, that he had remarked the stream of urine to be small, and that the calls to void it were more urgent than formerly. On passing a bougie, I found two strictures considerably contracted, and a tender state of the urethra where it passes through the prostate. These diseases being relieved, all irritation in the testis ceased, and the enlargement rapidly subsided ; so that in two months it was scarcely larger than the other, and all disease had ceased. This happened without any other local appli- cation than a poultice at night, and support by a bandage. Even the poultice at night was soon discontinued. This pa- tient has had no return of disease of the testis, and many * Setons may be conveniently made and worn in the scrotum. I first em- ployed them in conformity to those general principles which regulate our con- duct in the treatment of local diseases ; and I have known several instances of diseased testis, which resisted various local modes of cure, and even considera- ble courses of mcrcuiv. vield, and get well when setons were employe) Vol. T 3* 2!>S UN DISEASES years have elapsed since the occurrences which 1 have been relating. The following case was drawn up by a medical man, of considerable information and talents, who was himself the subject of it, and who was convinced with respect to his own case of the truth of those opinions which I am now offering to the public. CASE. -----------------5 a;tat. thirty, about four years since had an uneasy sensation in both testicles, which, however, occur- red so seldom, and was so trifling, that he paid little attention to it; about a twelvemonth after, he found the left testicle harder than natural, but not enlarged ; for some time previ- ous to this, he had been obliged to void his urine very early in the morning from great irritation to do so; but not too frequently during the day ; and occasionally had a tightness and sense of constriction in the perinaeum, with frequent aching pain in the glans penis. The testicle remained in the above-mentioned state (without pain or increase) till March, 1S06, when he received a blow from an accident on horse- back : no violent pain was immediately felt, nor did any ap- parent alteration take place till about a fortnight after, when he perceived the testicle larger and much harder than it had hitherto been : and it gradually though slowly increased till the end of August, when he saw Mr. Abernethy. The testis was at this time of twice its natural size, hard and painful to the touch. Leeches were applied once a week, and the tes- ticle was kept suspended, and wrapped during the day in a cloth dipped in tinct. opii. and water, and an evaporating poultice was applied at night. By this treatment it gradually became less, but the hardness still continued. He saw Mr. A. again in September, and was then desired to rub campho- rated mercurial ointment upon the testicle, and cover it with a soap-plaster. The testicle still kept decreasing, but re- mained equally indurated till the twentieth of November, OF THE URETHRA, &x. 299 when it swelled with considerable pain and irritation, and began to adhere to the scrotum.* He again saw Mr. Aber- nethy, who introduced a small bougie, and found a stricture about six inches from the orifice of the urethra, and a second the eight of an inch from the former. The bougie passed without much pain or difficulty through the strictures, till it came to the prostate, when much pain and sensation of heat, irritation, and a strong inclination to make water were felt; the bougie, however, passed into the bladder, and was closely held by the spincter. The perinaeum was then ordered to be bathed night and morning with warm water, and a bread and water poultice to be applied to the testicle, which were done, and at the end of the week, the pain and irritation in the testicle were greatly relieved ; the same bougie was then passed, but with greater ease, and the painful sensations which had before been felt on its entering the prostate were much diminished. The warm bathing and poultices wrere continued, and the same bougie passed at the end of the following week with still greater ease and slighter sensations. At the end of the third week the strictures were touched with kali pur., which produced little irritation ; and on the week following a much larger bougie passed with ease ; the warm bathing and poultices being continued in the interval. During the three following weeks the large bougie passed with great ease : no irritation was felt after it, and the sen- sations, whilst it was going through the prostate, were slighter each successive time. The testicle at the end of this time (seven weeks) was re- duced to its natural size, and was become nearly undistin- guishable from one that had never been diseased. Shortly after the first introduction of the bougie, all the shooting pains and occasional uneasiness of the testis ceased, and it so rapidly and regularly declined as the state of the urethra amended, as to leave no doubt but that the amend- * The testis was now about three times its natural size, and at the upper part of the epidydimis, the scrotum had adhered to the subjacent part, and wa* so .-••tlnnicd as to indicate th* nrobn^ility of (he formal ion of a:. ;ib -,■<•*•■ ;il)U OM DISEASES ment of the testis is to be ascribed to the relief of disordei in the urinary canal. CASE. A gentleman, between twenty and thirty years of age, consulted me on account of a hydrocele, from which I discharged about six ounces of fluid. The testicle did not appear enlarged, but both it and the bag of the tunica va- ginalis seemed very tender to the touch. I recommended that the parts should be supported, and that Goulard's wash should be applied. In about six months the tunica vaginalis was more distended than at first, and as the part was trouble- some from its size and sensations, it was again punctured ; and the same circumstances were noted upon the evacuation of the water. The hydrocele again collected, and when it was full, which happened in about six months, the patient was desirous of having the tunica vaginalis injected, in order that he might be made radically well. As there was nothing prohibitory except the tenderness, I consented to his desire; but when the fluid was discharged this time, he complained of greater pain than formerly, and could scarcely bear me to touch the testicle, which made me dislike to perform the operation, and it was therefore postponed till the next time that the hydrocele should become full. 1 thought it right, however, to direct the application of leeches, once a wTeek, and of linen kept damp with Goulard's wash.* Under this treatment, the hydrocele filled very slowly. After four months had elapsed, the patient consulted me relative to * I have known many cases of hydrocele, the consequence of irritation and inflammation, cured by evaporating washes ; and it would be right to distinguish the kind of hydrocele, upon which such treatment may be expected to have beneficial effect. Without such discrimination, a surgeon, seeing a hydrocele cured by these means, would prosecute the same measures in an indolent, and, as I may call it, dropsical hydrocele ; or finding the means fail in many cases from their indiscriminate use, he may be induced to consider the treatment upon the whole as inefficacious ; and thus neglect it in cases in which it is likely to be boieficial. L>E THE LRETHKA, Uc. JUl sores which frequently broke out upon the prepuce ; some of which were very tardy in healing. He also was subject to a considerable collection of that substance which is secreted to moisten and lubricate the prepuce. I told him that these symptoms were the effects of irritation of the prepuce, and was led to inquire more particularly into the state of the urethra than 1 had done before, because I thought both the disorder of the testis and the prepuce might originate in the same cause, that is, disease in the urethra. On examining that canal with a bougie, I found strictures, and a tender state of it where it passes through the prostate. By local warm bathing, and the occasional and gentle use of bougies, the morbid sensibility of the canal was diminished. The strictures were touched with kali purum ; and in con- clusion, I could pass a large-sized bougie without occasion- ing any particular uneasiness in one part more than in another. The effect of this treatment was, that the remaining fluid of the hydrocele was soon dispersed, and the testis was no longer irritable or painful when compressed, so that even the suspensory bandage was laid aside, nor has any inconvenience been experienced since that time, which is more than four years ago. The sores also on the prepuce healed, and that patrt was much less irritable, but it still remains so in some degree; indeed sores have been since contracted from sexual inter- course, which circumstance may perhaps have contributed to prolong the disorders of that part. I also suspect that the urethra may again have become in some degree irritable. In the foregoing case, it is said that the habitual occur- rence of sores on the prepuce led me to suspect disorders of the urethra; and this is an effect of such disorders, which I think has been but little adverted to, and which is neverthe- less deserving of particular attention. That disorders of the urethra do in many cases, cause temporary or continual irri- tation in the external parts which are continued from its ori- fices, 1 shall prove by the recital of a few cases. 30:2 ON DISEASED CASE. A gentleman, between forty and fifty years of age, had for fifteen years been subject to sores about the prepuce and glans, so as to oblige him to pay constant attention to pre- vent and control them. He had consulted many eminent surgeons, who recommended various washes and modes of treatment. A new application had generally the effect of healing the sores, but when persisted in for some time, gra- dually lost its effect. When the patient consulted me, the whole of the skin covering the glans, and lining the prepuce, was thickened and white, and the prepuce was so thickened that though it was naturally large and loose, it was difficult to unfold it. There were numerous sores of an oblong form in the transverse direction, appearing like chops, covered by adhering pus. I told the patient that it was necessary to in- quire whether there were any cause maintaining this irritable state of the prepuce, and mentioned that I had observed it very frequently to depend upon strictures of the urethra. The patient had no suspicion that he had such disorder, for he voided his urine readily, and not much more frequently than is common. Upon examining with a bougie, however, several much contracted and very firm strictures were dis- covered ; and these being relieved, the sores on the prepuce healed without any further attention, than what cleanliness required. The foreskin became soft and pliant, as did also the skin which lined it, and is extended over the glans. This case occurred many years ago ; and as I have not seen the patient since, I conclude that the relief which he thus ob- tained was permanent. To show that strictures may exist in the urethra, and may perhaps prove the cause of more vexatious disorders, though the original exciting cause escapes observation, I may men- tion an instance which occurred to a medical man. i»F THE URETHRA, &c 303 CASE. This gentleman had been subject to sores which frequently broke out on the prepuce without any evident cause. There was not, however, any striking evidence of general irritation in that part, as in the former instance. Sometimes the sores which occurred put on the appearance of chancres ; and in consequence of the advice of his friends, he underwent a sa- livation. The sores for which the mercury was employed healed under the use of that medicine, but broke out upon its discontinuance. He then consulted me, and upon my mentioning my suspicions of strictures existing in the urethra, he smiled at the opinion, and said that it might be given to patients in general, but not to those of the medical profession. I told him that nothing would convince me that I was in error, but his permitting me to examine by means of a bougie. Two considerable strictures were found, and these being re- lieved, the sores healed under simple dressings. The gen- tleman, however, did not reside in London, and I know not the further history of the case, which I mention merely for the purposes that have been stated in the beginning. I have also seen a very troublesome phymosis, in which the prepuce could not be retracted without great difficulty and pain, depending upon the same cause, in a case in which the patient had been long accustomed to the daily use of bougies;* * As strictures of the urethra depend on a disordered state of parts of the canal, so whe'n the introduction of simple bougies fails to cure them, the too fre- quent use of those instruments sometimes keeps up and aggravates an irritation, which might otherwise, perhaps, subside. This is a subject foreign to my present purpose ; but I mention it to introduce the following case, which de- serves publication. A gentleman, more than fifty years of age, had for more than twenty years been in the habit of introducing bougies for himself, which he generally kept in for an hour daily. At length his urethra became so irritable, that he could scarcely void his urine, which he was frequently called upon to attempt. Apprehensive of caustic bougies being employed, he consulted me, and I found I could introduce a small k>uc;ie without much difficulty: it halted at several strictures, but with very 304 ON DISEASES but after the strictures had been touched with kali, and the constant use of bougie desisted from, the phymosis relaxed, and the prepuce could be retracted without the least difficulty or uneasiness. I have also known many cases of warts yield to the same treatment. These cases are related to show, that irritation and dis- eases may be induced in parts which have a sympathetic con- nexion with the urethra, even where the original affection may have been too trivial to attract attention. It appears to me to be of the utmost importance to investigate, as far as pos- sible, the causes of diseases; for how can we expect to cure the effect, while the producing cause continues to operate ? The secondary disease may also become even of an esta- blished or malignant nature, if there be diseased propensities in the constitution or affected part. Diseases in the canal of the urethra may not only cause such effects as I have represented, by producing a state of irritation on the continued surface of the glans and prepuce, but they may also cause sores contracted from sexual inter- course to be very irritable, peculiar, and slow in getting well. I have seen many such instances; but none in which the fact was more strikingly apparent than in the following case. gentle pressure it passed through them. I recommended him to bathe the pe- rinaeum and contiguous parts with warm water, by means of a sponge, night and morning, and told him I wished to introduce the bougie again after three days had elapsed. He was extremely apprehensive that the passage would com- pletely close during the interval,and strongly remonstrated against such inefficient practice. On the third day he acknowledged that he passed his urine more freely, and the bougie which I had first introduced went through the urethra without impediment. I took one of a little larger size, and passed it with the same sort of resistance which the first had met with. The warm bathing was continued, and by pursuing these measures for three weeks, I passed a bougie one-third larger than he had been able at the best of times to do for many years. The patient now voided his urine in a large stream, and not more frequently than is common ; in short he felt himself perfectly well. Since that time, no bougie has been introduced, except once, annually by myself, that he might bo assured that the stricture had in no degree contracted. OF THE URETHRA, &.c. 303 CASE. A gentleman, who had just arrived in this country, had con- nexion with a female, which was followed by general irrita- tion of the prepuce, and surface of the glans. Shortly after- ward six sores formed, three of which became of considera- ble size. I desired him to wash the parts three times a day with the poppy-fomentation, and to encircle the penis by linen kept damp with it, in order to lessen the heat of the part. He at the same time took five grains of the quicksilver pill night and morning. After some days, he could no longer retract the prepuce, so that he was obliged to cleanse the part by means of a sy- ringe. After a little time, a weak solution of zincum vitriol- atum was tried, but the pain it occasioned was too severe to permit its continuance. It was therefore left off, but after four days tried a second time, when the pain which it occa- sioned was very tolerable, and as it diminished daily, it allowed us to increase the strength of the wash. After a few days he was able to retract the foreskin, when the smaller sores were healed and the principal ones had granulated, so that a fungus bulged forth above their surface ; they appeared of a tawny colour, and their edges were slightly thickened. I slightly touched these sores every third day with argentum nitratum, which appeared to do them much good. The vitriolic wash was continued. In about five weeks from the commencement of the disorder the patient was quite well. The mercury had occasionally affected the bowels, which obliged the patient frequently to omit his pill in the morning. It never affected the gums, nor did I urge the continuance of it, after his sores were healed, because I did not believe them to be syphilitic. About three weeks afterward, being in company with some jdissolute females, he had his passions much excited, and one of them forcibly compressed the penis with her hand. The irritable state of the foreskin again 'ook place, and a great Voi . I. ?° 306 ON DISEASES number of sores broke out, particularly behind the glans, which appeared like chops, being long, and not wide, and the matter which they discharged adhered to the surface. After a few days he could not retract the prepuce, so that I can give no distinct account of these numerous sores. It appeared that they were very fretful, for the external skin be- came inflamed opposite to them; and they gave much pain when pressure was made on the inflamed part. The external inflammation and tenderness on pressure changed their situation, showing, that a sore which was most fretful at one time, became less so at another. The sores were, however, so painful as to prevent the pa- tient from sleeping; and as no amendment of the complaint took place in three weeks, though various local measures were employed during that period, the patient wished to use mercury, and I acquiesced in his desire. As this medicine formerly affected the bowels, I desired him to rub in two drachms by measure every night, which was done for one week, without any amendment in the. sores, or indeed any perceptible effect on the constitution. The patient now complained of a pain in the perinaeum, when he voided his urine ; and I directed him to bathe that and the contiguous parts for seven or eight minutes, with comfortably warm water by means of a large sponge, three times a day. This produced a most evident diminution in the irritability of the sores, and convinced me that there was a stricture ; I there- fore introduced a bougie, and found two strictures, the front one of which was so tight and tough, as to admit but a small bougie to pass through it, which it grasped and indented. The warm bathing was continued. 1 touched the stricture with kali, as Mr. Whately has recommended. From the time that the stricture became an object of attention, the sores had so rapidly amended, that in a few days the patient was enabled to retract the prepuce ; when it was found, that though the sores had been numerous and extensive, thev had been merely superficial, and had not destroyed any part. From the time that I first passed the bougie and ascertained a OF THE IRETHRA, &c. 307 stricture, the mercury was discontinued ; nevertheless the sores healed so rapidly, that in ten days they were prefectly well. After the sensibility of the stricture had been heightened by the touch of the kali, the patient complained of acute pain in the sores when he made water ; and once, when I touch- ed some of the sores with argentum nitratum, he complained of equally sharp pain in the perinaeum. I lately attended a married man, who had been for many years tormented by occasional sores forming about the pre- puce, which were so irritable, as to be prohibitory of sexual intercourse. In the last attack they were considered by several surgeons as syphilitic, but as they had not the cha- racters of that disease, I dissuaded the patient from the use of mercury otherwise than as an alterative. This patient, upon taking food, had the pain and inflammation of his sores so aggravated, that he was obliged to rise from table, and bathe the affected parts with warm water. These sores im- mediately lost their irritability, and even rapidly got well, upon a stricture in the urethra being relieved by local warm bathing and the use of bougies. I have still further to observe, with respect to the occa- sional consequences of diseases of the urethra, that many dis- eases of the glands in the groin originate from them. I shall not, however, detail any cases in evidence of this fact. It will be sufficient to say, that I have seen several cases of enlarged inguinal glands dispersed by relieving disorders in the urethra; and I have seen instances of foul and irritable sores, losing their diseased characters, and healing from the same cause. The latter event is not, indeed, likely to be a frequent occurrence. In a gonorrhoea, the glands in the groin are commonly irritated, and sometimes slightly swollen ; the swelling rarely increases and suppurates, except in cases where there is a predisposition to disease in those glands. If, then, irrita- tionjnthe urethra, occurring from gonorrhoea, can thus affect the inguinal glands, it may be rationally inferred, that other 308 0 V DISEASES OF THE URETHRA, tec, causes of irritation of the urethra may produce similar con- sequences. Nocturnal emissions are also commonly the effect of morbid irritability or disease of the urethra; and it seems, therefore, irrational to attempt to cure them by tonic medicines or sedatives without adverting to the state of the urethra. Indeed in many of the persons who are subject to these discharges, the morbid sensibility of the urethra is con- nected with a disordered condition of the digestive organs; which is of itself a sufficient cause of great weakness and hypochondriac feelings. After thus adverting to such causes, we cannot wonder at the terrors felt and described in cases of tabes dorsalis. That diseases of the urethra may exist, without producing the consequent diseases which I have been describing, is very manfest; that such diseases may arise, independently of the causes to which I have at- tributed them, is also evident. My object, therefore, is merely to announce, that I have very frequently observed the diseases which make the subject of this section to arise from a disordered state of the urethra, leaving it to the ex- perience of the public to determine, how far such cases may be regarded as frequent occurrences in general practice. ON INJURIES OF THE HEAD; AND ON MISCELLANEOUS SUBJECTS. r ON INJURIES OF THE HEAD. SECTION I. When the Members of the Academy of Surgery in France, and Mr. Pott in England, severally inculcated to the surgeons of their respective countries the propriety and necessity of trephining the cranium under various circumstances con- sequent upon injuries of the head, they probably recommended a too free and frequent performance of that operation. Such appears to be the opinion of many respectable writers who have published since their time ; particularly of M. Desault of Paris, Mr. Dease of Dublin, and Mr. John Bell of Edin- burgh. But although these writers unite in censuring the frequency of the practice, they are very far from being agreed in other respects ; and many material points seem to me to require still further elucidation. Believing that the observations which I have had an op- portunity of making at St. Bartholomew's Hospital enabled me to throw some light on this important and intricate sub- ject, I am induced to submit to the public a short account of several cases that occurred there, and the inferences which I drew from them: The difficulties connected with this part of surgery are sufficiently proved by this circumstance, that, notwithstanding it has at all times excited the attention of surgeons of the 312 ON INJURIES OF THE HEAD. greatest talents, and possessing the most extensive field for observation, much difference of opinion still subsists, and the practice that ought to be followed in particular cases yet remains a matter of dispute. It is not, indeed, probable, that any part of medical science can in a short time receive all the improvement of which it is capable ; for, in propor- tion as we advance in knowledge, we are led to remark many circumstances in the progress of a disorder, which had before passed without notice, but which, if known and duly attended to, would clearly point out to us the nature and remedy of the complaint. Hence the records of former cases are of much less value, as the symptoms about which we are now anxious to inquire have in them been entirely overlooked. I was led to this remark by reading the Works of Hildanus, Wepfer, Du Quesnay, and others, wherein are to be found a number of interesting cases, which I have been precluded from mentioning, as the nature of them cannot be exactly ascertained in consequence of this deficiency. Although I have been for many years attentive to the treatment of persons who had suffered injuries of the head, and also to the examination of the parts after death, where the case has terminated fatally; I still perceive so many circumstances which require investigation, that I entertain no hope of ever being able to obtain, from my own expe- rience, all the information which is wanted. I hope, however, that the hints offered in this Essay may have the effect of inducing surgeons to pay a closer attention to cases of this kind, and that thus, by their united observations, the public may at length become possessed of that knowledge which the labours of an individual could never supply. In the accounts which we have of the former practice in France, it is related, that surgeons made numerous perfora- tions along the whole track of a fracture of the cranium ; '>.\ IN.JfftlES OF THE head. 313 ;md, as far as I am able to judge, without any very clear design. Mr. Pott also advises such an operation, even with a view to prevent the inflammation and suppuration of the dura mater, which he so much apprehended. But many cases have occurred of late, where, even in fractures with depression, the patients have done well without an operation. To con- firm the accounts that have been given of such cases, and by this means to counteract, in some degree, the bias which long- accustomed modes of thinking and acting are apt to impress on the minds of practitioners, I shall relate the histories of five cases, that occurred at St. Bartholomew's Hospital in the space of twelve months ; and afterward offer a few remarks upon the subject. The principal circumstances only of each case are related; for, as many examples of the same kind are to be found in various surgical books, a minute detail of particulars seems to be unnecessary. Cases of Fracture of the Cranium with Depression, which terminated favourably, although no Operation was per- formed. CASE I. A woman, about forty years of age, was admitted into the hospital for a wound on her head. About a week before she applied for advice, her husband had knocked her down with a brass candlestick. She was stunned by the blow, and lay for some time senseless; but, on recovering, she felt no other inconvenience than the soreness occasioned by the wounded integuments. She had suffered some slight indisposition since the accident. On examining the head, the right parietal bone was found denuded about two inches in extent; a fracture of the same length was also to be felt; and the bone on one side of the fracture was depressed about the eighth of an inch.—She Vol. I. 40 oil h.N LNJLR1ES OF Tli'E HEAD. remained in the hospital a fortnight, without any bad symplonv occurring, and was then, at her own desire, discharged, although the wound was not perfectly healed. CASE II. A boy, about twelve years old, received a kick from a horse in Smithfield, which stunned him; and he was imme-* diately brought to the hospital. The integuments of the forehead were divided by the injury, and the lower part of the os frontis and superciliary ridge of the frontal bone depressed at least a quarter of an inch below its original level ; the de- pressed portion measuring, about an inch and a half in length It is obvious that the bone could not be thus depressed without a fracture of some part of the basis of the skull occur- ring at the same time, on which account the case might be considered as more dangerous.—In less than two hours he had recovered from the immediate effect of the blow, being at that time perfectly sensible. Fourteen ounces of blood were taken from his arm ; his bowels were emptied by a purge ; and saline medicines, with antimonials, were directed to be given. He went on tolerably well for two days, at the end of which time evident symptoms of considerable irritation of the brain took place. He now complained of pain in his head; slept little; and, when dozing, often started, or was convulsed in a slight degree. To remove these symptoms, he was bled twice, took opening medicines occasionally, was kept quiet, and without light, and' was allowed only a spare diet. By continuing this plan for about three weeks, he per- fectly recovered. CASE III A man, between thirty and forty years of age, received a blow on the forehead from a brick thrown at him, by which the frontal bone was fractured about half an inch above the orbit: the fracture measured two inches in length, and the ->. INJURIES OF THE HF.Alt. Jl.» upper portion of the bone was depressed about the eighth of an inch. He was not even stunned by the blow, and walked to the hospital without assistance, complaining only of sore- ness in the wounded integuments. Sixteen ounces of blood were immediately taken from his arm; he was confined (much against his inclination) to a scanty and liquid diet, and was purged every second day.—This patient did not experience any illness; and the wound soon healed. CASE IV. A boy, about thirteen years old, had a fracture, with de- pression, of part of the temporal and parietal bones. By similar treatment, he also escaped without any material ill consequences ; but in this case part of the injured bone ex- foliated. CASE V. A girl, thirteen years old, had a considerable fracture, with depression, of the left parietal bone. She was not brought to the hospital until ten days after the accident. When admitted, she was feverish, had pain in her head, and the little sleep she got was very much disturbed: but, by the use of bleeding, with antiphlogistic medicines and regimen, she soon got per- fectly well. The cases above related are not offered to notice on ac- count of any striking peculiarity attending them, but merely to show that such are not unfrequent, as they all occurred within the course of a year. From among a great number of similar cases, I shall select the two following, as the symp- toms attending them were more violent than ordinary. CASE VI. A lad, seventeen years of age, had his head pressed between ■i cart-wheel and a post; by which accident the tiN INJURIES OF THE HEAD. sides was turned downward, so as to expose the lower half of the parietal bones, the squamous part of the temporal, and also part of the frontal and occipital bones ; about a quarter of the cranium being thus completely denuded. The perios- teum was in several places stript off from the skull, the scalp much bruised, and the posterior and inferior angle of the left parietal bone was beaten in. The visible part of the depressed portion was an inch in length, and more than an eighth of an inch below the level of the cranium; but the fracture extended along the squamous part of the temporal bone toward the basis of the skull: it could not, however, be traced, as the temporal muscle had not been removed from that part by the injury.— The scalp, being cleansed, was replaced, retained in its situa- tion by slips of sticking-plaster, and a slight pressure by band- age was applied. The boy was perfectly sensible, his pulse regular, and not quickened. He had bled considerably from the temporal artery, which had been divided by the accident: eight ounces of blood were, however, taken from his arm; and some purging medicine was administered next morning, which procured three or four stools.—The next day (Friday,) his pulse beat nearly 120 in a minute ; his skin was hot and dry; and he complained of pain in his forehead. Twelve ounces of blood were taken away, and four grains of pulvis antimonialis ordered to be given three times a day. On Saturday, the former symptoms still continued, and were rather increased. The antimonial powder made him sick, or at least increased his disposition to be so. Fourteen ounces more of blood were taken from him ; the vibratory feel of his pulse not being altered until that quantity was taken away: the blood, on standing, appeared very buffy. His skin, notwithstanding all this, still remained extremely dry; some antimonial wine was given, which produced vomiting. On Sunday, his pulse was evidently lowered by the evacuations he had undergone, but it was still quick, and sufficiently strong. The pain of the head remained as before. Having a sufficient number of stools, and the sickness still continuing, the antimonial powder was omitted. He was ON INJURIES OF THE HEAD. .J17 bled, however, in the vena saphena, and his feet and legs were afterward immersed in warm water; during which, he, for the first time, perspired copiously. A blister was also ap- plied to his neck.—The scalp united, with only a trifling sup- puration over the fractured part of the bone ; and to this ready union, the lowering plan, by preventing inflammation, seems very materially to have contributed. The matter col- lected over the fracture was discharged by a puncture, and the boy got well. CASE VII. A lad, eighteen years of age, had the squamous part of the temporal bone beaten in; the fracture ran horizontally, about a quarter of an inch above the zygoma, and could be dis- tinctly traced with the finger, introduced through the torn scalp and temporal muscle, for two inches. The upper part of the bone was depressed about one-eighth of an inch ; and it was impossible to trephine below the fracture in order to elevate the depressed portion. The lad had recovered from the immediate stunning occasioned by the injury ; nor was there any symptom that indicated material derangement of the functions of the brain from the pressure which it sustained. He was bled largely, and took a purging medicine, and was moderately well on the following day. On the second morn- ing he was again purged ; and when I saw him at noon no- thing materially wrong appeared ; but when I came to the hospital, at eight in the evening, I found he had gradually be- come delirious, and that he then could scarcely be kept in bed. His skin was hot, and his pulse frequent and strong. These symptoms could be attributed to nothing but inflam- mation of the brain ; he was therefore immediately and largely bled. He now became quiet and manageable; but the next morning his replies to all questions were incoherent, his pulse frequent, his skin hot, and his tongue dry. The bleeding and purging were repeated, and at night a blister was applied to his neck. On the following morning he was JlvS >>N INJURIES OF THE HEAD. sleeping and feeble, but his answers were rational; as the frequency and fulness of his pulse increased in the evening, he was again bled. The inflammation of the brain was now subdued, and the patient gradually recovered. The wound healed without any exfoliation of the bone, and when he was discharged from the hospital there was not the most trivial circumstance which could induce us to suspect that the brain had sustained any injury from the accident. His sleep was sound and undisturbed, and the sudden motion of his head in any direction occasioned no giddiness or inconvenience. It appears very clearly, I think, from these cases, as well as from a great number of others to be found in books, that a slight degree of pressure does not derange the functions of the brain, for a limited time after its application. That it does not do so at first is very obvious ; as persons are often perfectly sensible, and free from headach and giddiness im- mediately after the injury. Whether it may not produce such an effect at some remote period, is not so easily deter- mined, since this cannot be ascertained but by a continued acquaintance with the persons who had received the injuries. All, however, whom I have had an opportunity of kuowing for any length of time after the accident, continued as well as if nothing of the kind had ever happened to them. In Mr. Hill's Cases in Surgery, two instances of this sort are related ; and Mr. Hill knew both the patients for many years afterward, yet did not perceive any inconvenience to arise. It deserves to be mentioned, too, that one of the patients was a sailor, and therefore, probably, led a life of irregularity as well as of exertion. The result of cases of this kind, which I have met with in authors, does not lead to the apprehen- sion of any future mischief; nor is it easy to conceive that the pressure, which caused no ill effects at a time when the contents of the cranium filled its cavity completely, should afterward prove injurious when they have adapted themselves to its altered size and shape. Severe illness, indeed, does often intervene between the receipt of the injury and the US INJURIES OF THE Hi.All. J1(J patient's recovery ; and many surgeons might be inclined to attribute this to pressure ; but it equally occurs where the de- pressed portion is elevated ; several instances of which I shall have occasion to relate, and many others are to be met with in authors. This is a circumstance which nothing but very extensive experience can show in a true light. If, for instance, a surgeon who was prepossessed with the opinion that elevation of the bone is necessary in every instance of depressed cranium, should have acted upon this opinion in the first, third, fourth, and fifth cases, and afterward have employed proper evacuations, his patients might, perhaps, have had no bad symptoms, and he would naturally have attri- buted their well-doing to the mode of treatment which he had pursued : yet these cases did equally well without an opera- tion. If the same surgeon had been witness to the disturb- ance which arose in the second, sixth, and seventh cases, he would, without doubt, have attributed them to the continuance of pressure made by the bone ; yet these cases also did well by medical treatment only : and when the symptoms which come on thus are of the inflammatory kind, they may gene- rally be removed by the same means. Many cases also are to be met with in books, and some are related in the subse- quent part of this Essay, where not only great but even fatal mischief ensued, notwithstanding the brain had been relieved from pressure at an early period. Another surgeon, preju- diced against the use of the trephine, might, with equal injustice, consider the mischief, which ensues in certain cases, as entirely owing to the operation. The degree of pressure which the brain can sustain with- out great injury to the system, may probably vary according to the disposition of that organ to be affected by it, the sud- denness of its application, and the direction in which it is made; and although it must be very difficult to obtain any precise knowledge on this subject, yet there is great reason to believe that the brain can bear more pressure without in- jury to it than was formerly supposed. The first of these circumstances seems evident; for in some persons a slight ;J0 ON INJIE1ES OF THE HEAD. pressure produces severe symptoms ; whilst, in others, a much greater degree is borne without inconvenience. We can rarely judge of the effects of pressure when any part of the cranium is beaten in by a blow ; for in that case the shock generally occasions stupefaction. Internal haemor- rhages, perhaps, afford us the best criterion whereby to deter- mine the effects of pressure on the brain. The eighth case will serve' as an illustration of this remark, where it appears that a considerable haemorrhage must have taken place before it deprived the patient of his faculties ; for he walked home, undressed himself, and went to bed, after the trunk of the middle artery of the dura mater had been ruptured. In cases of apoplexy, also, the haemorrhage is generally very large before it produces those consequences which destroy life. The authorities quoted by Morgagni, as well as his own observations, show that people may recover from apoplexy even after a considerable effusion of blood has taken place. But as the records of such cases are not common, and as it appears to me that further confirmation of them would be highly useful, I have obtained permission of Mr. Wilson to mention a remarkable case of this kind, which occurred to his notice.—A gentleman fell down suddenly, and remained for some time in that lethargic state which is usual in apo- plectic cases ; but afterward gradually recovered his faculties both of mind and body, and continued to exercise them very perfectly for two years, when a second attack of the same kind took place, and destroyed him. Upon opening the head, the cause of his death became evident; for a large quantity of blood was found in the ventricles, and at the basis of the cranium. But what seemed particularly worthy of attention, was a cavity in the right hemisphere of the brain, extending from the front to the back part of the cerebrum, being more than four inches in length, and more than an inch in breadth. Within this cavity were contained flakes of coagulated lymph, and a bloody-coloured fluid, which Mr. Wilson, whose abili- ties and accuracy of observation entitle his opinion to the ON INJURIES OF THE HEAD. ;J21 fullest credit, was convinced were the remains of the blood extravasated at the first attack. I also examined the brain of a gentleman, with whom, for the last five years of his life, I was intimately acquainted. When I first knew him, he was slowly recovering from a severe fit of apoplexy, which had paralyzed the left side of his body. Though he could not raise his left arm to his head, nor move his left thigh and leg with freedom, yet he walked about moderately well, and could work in his garden. Every winter he was subject to fits of the gout, and every summer to such a plethoric and inflammatory state of the vessels of the head as to threaten another apoplexy. He was once immediately and most completely relieved from very distressing feelings from the latter cause, by the ab- straction of ten ounces of blood from the temporal artery. The last fit of apoplexy, which I have mentioned, was the third, with which he had been afflicted. The first affected his speech, the second hie right arm, and the third produced the effects which I have related. His bodily and mental powers remained however very vigorous, even during the five last years of his life. On dissection, three apoplectic cells were found. One was situated superficially in the left lobe of the cerebellum, one in the left hemisphere of the cere- brum, and one, which had probably been the cause of the last and greatest degree of paralysis, in the middle of the right hemisphere of the brain. Nothing but the membranes, which immediately invest the brain, covered the effused sub- stance, which had become of a gelatinous nature. I do not exaggerate, when I say, that this cavity was large enough to have held six ounces of blood. Though a slight degree of pressure does not immediately affect the functions of the brain, yet it may act in another way j—it may excite inflammation of that organ, as it does of other parts of the body. Its power in this respect, however, will probably lessen by the part becoming accus- tomed to it; and the cases on record, where fractures with depression have done well, as well as those of recovery from Vol. I. -H 322 ON INJURIES OF THE HEAD. apoplexy, are proofs that the cause which in the first instance was injurious by its pressure, may continue to exist without inconvenience. Such cases ought surely to deter surgeons, from elevating the bone in every instance of slight depression, since, by the operation they must inflict a further injury upon their patients, the consequence of which it is impossi- ble to estimate.—From all, therefore, that I have learned from books, as well as from the observations I have made in practice, and from reasoning upon the subject, I am disposed to join in opinion with those surgeons who are against tre- phining in slight depressions of the skull, or small extrava- sations on the dura matter. In the latter, it is probable the compressing cause will soon be removed by absorption; and in the former, according to the observations of Mr. Hill* and Mr. Latta,f the bone will regain its natural level if the subject be young. In adults, however, and especially in persons of advanced life, this circumstance cannot be ex- pected ; so that in them the accommodation of the parts to each other, necessary for preventing future mischief, must be effected by a corresponding alteration in the form of the brain. A circumstance, however, frequently occurs, that may render the surgeon doubtful as to what course he ought to pursue ; this happens when, at the same time that the skull is slightly depressed, the patient labours under the effects of concussion. The circumstances, which generally serve to distinguish those two injuries, will be noticed hereafter. At present it is only necessary to observe, that, as the effects of the latter gradually abate, a little delay will enable the sur- geon to decide upon the nature of the mischief, and take his measures accordingly. Where the patient retains his facul- ties, nothing farther is necessary than a continuance of the antiphlogistic plan; and should any inflammation afterward take place, the same means, employed in a degree propor- tioned to the urgency of the symptoms, will in most instances * Casein Surgery, p. 113. + Pract. Sy.«f. of Snrgerv, vol. ii. p. 17>N INJURIES OF THE HEAD. ,m surface ; which appearance seemed owing to coagulated blood which adhered to its surface, as the part had bled so much, that one half the cap which the man had worn was rendered quite stiff by it. In raising the top of the skull to inspect the contained parts, the tumour was in some degree torn from its basis. The pia mater was in general much inflamed, and, as well as the dura mater, was deficient at the place where the tumour protruded. Apart of this tumour being cut off where it was lacerated, appeared to consist of coagulated blood of a fibrous texture. The brain was now taken out, and the tumour carefully examined, when it was found to be of the same nature throughout, and to have originated within the substance of the brain, about an inch below the surface ; but I could not discover the open vessel from which the haemorrhage had proceeded. The appearances, on dissection, clearly explained the cause of the symptoms which had taken place, and rendered it evi- dent, that the disease under which this man had chiefly laboured was inflammation of the pia mater. The nature of the tumour, also, was not less satisfactorily pointed out. It was plain, that, in consequence of the brain being injured to some depth beneath the surface, disease of the vessels, and consequent effusion of blood, had ensued ; that the effusion was for a time restrained by the superincumbent brain and its membranes ; but these gradually yielded to the expansive force exerted from within, and at last giving way altogether, the fluid blood oozed out and congealed upon the surface of the tumour. It appears very probable, that the disease frequently described by the term hernia cerebri, consists, as in this instance, of a tumour formed by coagulated blood ; for an organized fungus could hardly be produced in so short a time as that in which these tumours are usually formed. CASE XVI. A carpenter, while at work in a newly-built house, was crushed by a part of the wall falling in upon him. His 34U O.N INJURIES OF THE HEAli. abdomen was bruised, his clavicle broken, and his head wounded. Beneath the wounded scalp the right parietal bone was found fractured and depressed. He was slightly comatose for many hours after being brought to the hospital, yet answered rationally to those questions that were put to him. As the coma, however, remained, and his pulse did not beat with the freedom that is usual, the surgeon, under whose care he was admittied thought it right to trephine him. Accordingly, one perforation beingmade, the depressed bone was elevated. No blood was found upon the dura mater, nor did any thing indicate the propriety of using the trephine a second time. The patient was largely bled ; and saline medicines, with antimony and opium, were given. As he complained much of pain in his belly, fomentations were ap- plied to this part, and clysters administered occasionally. He was again bled on the second and fourth days after the operation. At the end of a week the antimony was omitted, on account of his weakness ; and he seemed to get rather better, until December 7, twelve days after the accident, when a hernia cerebri appeared, rising through an aperture in the dura mater, opposite to the perforation in the skull. It increased rapidly in size, and exhibited the same appear- ance described in the foregoing case.—Two days after this the patient died; On examining the head, the dura mater was found every where adherent to the skull; but on its inner layer there was a secretion of pus. The hernia cerebri, which had pushed up through an ulcerated opening in the dura mater, Was of a fibrous texture, and evidently formed of congealed blood deposited in the medullary part of the cerebrum ; the containing cavity being about an inch diameter, and its pa- rietes appearing to be the substance of the brain condensed by pressure. I was equally unsuccessful here in my search after the vessel whence the blood had issued. The ven- tricles of the brain were full of a serous fluid mixed with blood, and a large abscess was also found in the spleen.— In this case the mental faculties were not deranged as in the ON INJURIES OF THE HEAD. 3il former. Both the symptoms and dissection show the disease to have consisted in the effects of concussion, with inflam- mation of the dura mater, and subsequent effusion into the ventricles of the brain. The opinion I had formed respecting the nature of hernia cerebri was now confirmed; and I think it received addi- tional illustration from the following case, although the dis- ease was in a different part of the body.—A patient in the hospital had a disease in the head of the tibia, from whence there arose an unhealthy fungus, which Mr. Blicke removed ; and afterward the bone was kept bare by caustic applica- tions, in hopes that a separation of the diseased parts would take place. The patient, however, became feverish, and his health was much impaired. On the cessation of the fever, there suddenly arose, within the wound, a fungus-like sub- stance, about the size of a large apple, which seemed to sprout from the bone ; it was of a livid colour, and its sur- face appeared as if covered with sloughs. I took off the tumour, which was nothing but coagulated blood, with the knife ; and some blood oozed from its basis, but the haemor- rhage was stopped by the application of lint. In a few hours, however, a similar fungus-like tumour arose. As both the size and situation of the open vessel were unknown, and as the patient could neither support the loss of much blood, nor the irritation which an extensive wound, made in search of the artery, together with that arising from the dis- eased bone, would infallibly produce, it was judged best to remove the limb. This was accordingly done; and upon injecting water into the popliteal artery, it was found to be a branch of that vessel which had given way. It seems that Pare, and the surgeons who lived about hi> time, often mistook the tumours that arose out of the cra- nium, for aneurisms, on account of their pulsatory motion. M. Louis, in the .mem. de VAcad. de Chirurgie, torn. V. has well distinguished the nature and treatment of those proceed- ing from diseases of the dura mater or bone. There may. 342 ON INJURIES OF THE HEAD. perhaps, be tumours of various kinds arising from the pia mater and brain ; but if there are such, I believe they have not been discriminated ; and the accounts given of many of them by authors* are similar to those just recited. They have generally been treated of under the name of fungus, or hernia cerebri: and if the effused blood of which they con- sist ever acquired vascularity, they might then deserve that title: but none of those that I have just noticed were of an organized structure.—Their formation seems to proceed from an injury done to a part of the brain by concussion or con- tusion, which has terminated in a diseased state of the ves- sels, similar to what occurs in apoplexy. The morbid state increasing, one or more vessels give way, and an effusion of blood into the substance of the brain ensues, which, if the skull were entire, would probably occasion apoplexy, but, where there is a deficiency of bone that allows it to expand, presses the surface of the brain and its meninges through the vacant space. The dura mater soon ulcerates, and the tumour, pushing through the openings, now increases with a rapidity proportioned to that with which the haemorrhage takes place within. At last, the pia mater, and the stratum of the brain, which cover the effused blood, are so extended as to give way, and the blood oozes out and coagulates.— Thus, the quick growth, and all the other phenomena ob- servable in these tumours, are satisfactorily accounted for. The plan of treatment to be adopted with tumours of the kind which I have described, is next to be considered ; but as I have had no opportunities of acquiring knowledge as to the treatment of these diseases, since I became acquainted with the nature of them, I can only offer a few general re- marks on this subject. Where no bad symptoms precede the appearance of the tumour, or where they go entirely away upon its being freed from the confinement of the dura mater, it may, perhaps, be most prudent not to interfere in the treatment of the com- plaint : for probably the haemorrhage will cease, and the ON INJURIES OF THE HEAD. 343 coagulum will drop off in pieces,* or gradually waste away, and be no more renewed.f All that appears necessary, then, under such circumstances, is to cover the tumour and sore with some mild dressing, carefully avoiding all pressure, which both reason and experience show is likely to be at- tended with bad consequences. Should the bulk of the tu- mour, however, become inconvenient, or render pressure from the dressings unavoidable, the practice which present experience has shown to be most successful, consists in occa- sionally paring off the tumour with a knife. In this manner Mr. Hill treated several cases with success. But if the tumour continues to increase, and if the patient suffers a train of bad symptoms, apparently arising from irri- tation and pressure made on the brain, some further attempt to relieve him seems to be required. Under these circum- stances, we have reason to suspect that the coagulum, from want of room to protrude, is enlarged internally ; or that by plugging up the orifice in the bone, it prevents the escape of some fluid collected within the cranium.}: The obvious mode of relief here appears to be, to enlarge the opening in the bone in proportion to the extent and increase of the tu- * See a case iu the Edinburgh Medical Commentaries, vol. i. p. 93., where the tumour continued to increase for fourteen days, and had squired the size of a goose's egg, when it.dropped off in pretty large pieces. A similar case is re- lated in the Medical Museum, vol. iv. p. 463. | Fabricius Hildanus relates a case in his fifteenth Observation, where the tumour arising from the brain became, in 24 hours, as large as a hen's egg, and afterward gradually disappeared. t Mr. Hill, in relating a case of this kind, says, that he " was obliged to shave away the tumour, and push a lancet into its root as often as the stupor and other symptoms showed that matter was lodged there, by which the pa- tient was uniformly relieved, and afterward recovered."—(See his cases in Surgery, p. 91, 92.) But very different was the event in two similar cases (one is recorded by Scultetus, in his Armamentarium Chirurgicum, Obs. XIX.; the other in the Lond. Med. Journal, vol.;*. p. 277.,) in which repeated attempts were made to prevent the growth of the tumour by compression : one patient died at the end of a month ; the other not until nearly six months after the ac- cident. In the brain of each there was found, upon dissection, a large cavity, which had been formed by the accumulation of a fluid that could not escape, on account of the aperture in the bone being closed by the tumour. 34 1 ON INJURIES OF THE HEAD. mour. Many surgeons have objected to the removal of much of the cranium, lest protrusions of this kind should ensue ; but it is evident that these tumours arise from an injury and consequent disease of a part of the brain, the event of which must be more fatal if the bone were entire. A large removal of bone was formerly a frequent event; but a protrusion of this kind very seldom took place. But although, by thus allowing a free escape to the effused blood, we may prevent the injurious effects of its pressure on the brain, yet the degree of haemorrhage may endanger the life of the patient. The quantity of blood effused will depend on the magni- tude of the vessels, or on their dispositions to bleed. As the disease is generally situated not far beneath the surface of the brain, there is less risk of its proceeding from the former cause. If it arises from the latter, it is very likely that the distention caused by the confinement of the effused blood would irritate the vessels, and keep up their disposition to haemorrhage ; therefore the treatment already recommended is likely to diminish it. But should the quantity of the hae- morrhage seem to threaten the life of the patient, I should think it most proper to take away the coagulum, and to ex- pose the cavity in the brain, in order to learn whether suffer- ing some sudden loss of blood to take place, together with the exposure of the bleeding vessels, might not produce a beneficial change, and a cessation of the haemorrhage. I am induced to propose this mode of conduct, from reasoning' founded on analogy : for in other parts of the body a haemor- rhage will sometimes continue, notwithstanding a considera- ble pressure made by a large quantity of coagulum, together with that which the resistance arising from the closure of the external opening, and that which is occasioned by the dress- ings, conjointly produce. Yet, upon exposing the bleeding surface, the haemorrhage will cease, and never afterward be renewed. I am still further induced to propose this plan of treatment, because I do not perceive any other which carries with it ON INJURIES OF THE HEAD. ,J4j a probability of success. The impropriety of attempting to restrain the haemorrhage by pressure has been shown; ligatures cannot be applied, and styptics are known, by ex- perience, to he dangerous. I shall extract one case from the first volume of the Me~ moires de VAcademie de Chirurgie,* to show that the removal of the coagulum is not likely to be attended with any alarm- ing consequences.—A young man received a blow on the right parietal bone, which occasioned a fracture ; some hone was removed, and a hernia cerebri was afterward produced, which was repeatedly pared down with the knife. On the thirty-fifth day from the accident, the patient having intoxi- cated himself, while in this state, slipt his hand under the dressings, and laying hold of the protruding coagulum, tore it away with violence. The next day the surgeon found, that almost the whole of what he considered as corrupted brain, was removed, and a vacancy left, so deep, that he could see nearly to the corpus callosum. From this time forward the parts went on healing, until they got quite well; but the patient continued to labour under a paralysis of the left sidej which had supervened the day after he received the blow. It is obvious, from the nature of the substance of which the tumour is composed, that styptic remedies applied to its surface can have scarcely any effect in lessening its bulk, and none at all in putting a stop to its growth; and experience shows, that the more active of them are not only ineffectual, but highly dangerous. Hildanus, in his Fourteenth Obs. re- lates the case of a man who died in consequence of an em- piric having dressed a tumour of this kind with alum and calcined vitriol. And Mr. Hill tells us, (p. 198.) that, after shaving off the protruding part, he once sprinkled the basis with some blue vitriol, and another time with red precipitate; but found that " his patient had a very bad day after each of these ;" no doubt in consequence of their being dissolved by * See the Memoire of Mr. Du Quesnay, 10th Observation, Vol. I. '14 .J4(i ON INJURIES OF THE HEAD. the discharge, and insinuating themselves between the tumour and the edges of the skull, so as to get into contact with the sensible parts within ; for, that it was not owing to their effect upon the tumour, is evident from its indolence when he had removed it with the knife.* * In most cases in which the brain becomes protruded from an augmentation of the contents of the cranium, in consequence of effusion or extravasation, the protruding part becomes crushed, and what comes out is a mixture of brain and different kinds of secreted matters, or effused blood. The foregoing cases explain a particular kind of protrusion, which seems to me to have been fre- quently described by authors, and of which they serve as specimens. Such occurrences cannot be observed without surprise ; the suddenness of the pro- trusion scarcely admits the supposition of the protruded part being organized. It was never meant by the recital of these cases to deny, that the surface of the brain, when exposed and irritated, would throw out a vascular fungus ; it was only intended to describe a species of those appearances which had been de- nominated fungus or hernia cerebri. In all the cases of true fungusc erebri which I had seen when I first wrote the foregoing account, the fungus grew so slowly that it could not be mistaken or confounded with the appearances which took place in the cases I have cited. Since that period, I have seen cases in which the fungus grew1 much more rapidly, yet none in that degree which would make it liable to be confounded with the appearances described in the presenS section. The curative indications in the true fungus cerebri seem to be, to di- minish those causes which occasion the brain to be thrust upwards against the bone, and to apply gentle pressure from without, so as to give that degree of support which the part ought naturally to receive from the dura mater and l>one, •v INJURIES OF THE HEAD. ■ U~i SECTION" IV. Concussion of the Brain. As I am of opinion that the effects of concussion have not been justly described by authors, and as the symptoms related by them are not, according to my experience, those which usually occur, I* have therefore selected two cases out of a great number that I have seen, in order to show what have appeared to me the common consequences of this injury ; and I shall afterward offer some remarks respecting the. treatment of this affection. CASE XVII. Harriet Silverthorn, aged twenty-three years, slipped down stairs, and struck her occiput against some of the lower steps, by which the integuments were divided about half an inch in length, but the wound was not deep, nor were the surrounding parts much bruised. She was taken up sense- less, was bled, and the next morning conveyed to St. Bartholomew's Hospital. When brought in, she was comatose; could not be made to answer any questions ; yet she drew back her arm when pinched, and seemed very uneasy when the wounded parts were pressed upon. Her breathing was without stertor, but performed at some inter- val, as if she did not wish to inspire until obliged by necessi- ty. The pulse, which was full, and labouring, intermitted every fourth or fifth stroke,—Eight ounces of blood were immediately taken away, and an opening medicine given, which procured three stools, after which she was ordered a mixture, containing aqua ammoniae acetatae, and antimonial wine.—The next day, (Friday,) she was rational, put out her tongue when desired, and said she had no pain in her head ; her breathing was more regular, and her pulse free from in- termission.—(Saturday,) she was still more sensible, and 34b ON INJURIES OP THE HEAD gave some account of herself; complaining now of head- ach, and general uneasiness. The mixture was continued, the purging medicine given again, and a blister laid on between her shoulders.—(Sunday,) her pulse was harder ; she was sensible, but restless ; complained of pain in her forehead, sat up in bed, and wanted to go home. Six or eight ounces of blood were taken from her temples, and the mixture ordered to be continued as before.—(Monday,) she was much more composed ; but as she had still some pain in her head, a blister was applied to it.—(Tuesday,) she had slept quietly during the night, answered rationally, but with quickness, and eagerly desired to go home. As the blisters appeared to have been serviceable, that on her neck was renewed.— (Wednesday,) she was perfectly quiet, and in every respect better; nor had she, after this, any complaint worth mentioning. CASE XVIII. A Frenchman, twenty-seven years of age, who had been many years in England, and (as it afterward appeared) spoke our language perfectly, had met with some accident, (but in what manner, I know not,) in consequence of which he was brought to the hospital. He was then very comatose, and expressed much uneasiness at being roused from that state ; yet he put out his tongue when bid, but did not give ration- al answers to questions put to him, and his replies were made in his native language. His pulse was regular, strong, and about 96 in a minute. Ten ounces of blood were taken from his arm; and after being purged, the common saline mixture, with antimonial powder, was ordered to be given. In the night he grew delirious, got out of bed, and tore the bandage from his arm ; in consequence of which he lost a good deal of blood before it was perceived. This, however, seemed of use to him ; for he became more tranquil after it, and lay quietly dozing till morning. Next day, he was more rational, and complained of pain in his head, When I told ON INJU1MES OF THE HEAD. 349 him that if he kept quiet, he would soon be well, he said, he hoped so ; and appeared solicitous to know what should be done to him. His pulse was only 80, and not strong. A gentle laxative was given, and a blister applied to his head, —On the third day, he was much more sensible, spoke with clearness, and mentioned the pain being in the fore-part of his head ; yet, when I asked his age, he told me he was but sixteen years old.—Tuesday, (fourth day,) he appeared more excited and wild; his tongue was dry, but his pulse only 75. Nine ounces of blood were taken from the temporal artery. —Fifth day, his pulse was only 70, and perfectly natural ; yet he had pulled off the dressing from his blisters, and seemed to be very irritable.—Sixth day, still pain in his fore- head, pulse rather quicker, but tongue not furred. After this he gradually recovered, without any particular symptom occurring, and without any other medical treatment. It is not likely that, in either of these cases, extravasation, at least to any considerable degree, had taken place within the head, since in neither of them was there stertor, dila- tation of the pupils, or insensibility. They may therefore, 1 think, be considered as exhibiting the symptoms which attend simple concussion. The foregoing cases were indeed in- stances of but slight concussion to what the brain sometimes suffers, and which proves fatal. To display the symptoms which occur in the worst cases, I relate the following in- stance. CASE XIX. W. Thomas, about thirty years of age, fell from the top of a brewhouse, a height of at least 80 feet. His hand being stretched out, first sustained the shock, by which the carpal bones were separated, and driven upwards, some before, and others behind the ends of the radius and ulna, the articular surfaces and periosteum being at the same time forced off the latter bones. I mention these particulars to show the great violence of the fall. The man's head afterward struck Jjy • >N INJURIES OF THE HEAD. the ground as appeared by a bruise on his face ; but the cra- nium was not injured. When brought to the hospital he ap- peared almost deprived of life, his body being cold, and his pulse scarcely to be felt. The gentlemen then attending put his feet into warm water, and gave him an opiate. After this he gradually became warmer, and it was ob- served that there was not much dilatation of the pupils, and but little stertor in respiration. I saw the patient next morning, at which time his skin was very hot, and he perspired co- piously. His breathing was repeated at regular intervals, but the expirations were made with unusual force. The pulse was extremely irregular, both in frequency and in strength; generally about 140 in a minute. His pupils were moderately contracted, his eyebrows drawn into a frown as if he suf- fered pain. When I spoke to him softly, he did not answer. I pinched his hand slightly, but he did not move : but when I repeated this a little harder, he drew it away with seeming vexation. He disliked that his eyes should be examined. When by speaking loud, I roused him, and inquired if his head ached, he answered, "Yes." I got him to swallow some opening medicine, which emptied his bowels; and four leeches were applied to his temples; but they extracted very little blood, and I thought his pulse countermanded any further evacuations. In the afternoon he appeared better. His pulse was more regular, and his skin of a more natural temperature ; his pupils, however, were more contracted, and his sensibility in- creased. I tried the effect of giving him forty drops of tinct. opii. Thinking it might diminish sensibility, and keep him quiet for some time, during which the vascular system (which seemed to be particularly deranged) might perhaps regain its powers. The opiate increased his disposition to sleep, and he appeared to suffer less pain; but in the evening his pulse was more feeble and frequent, and his skin hotter, and quite wet with perspiration. Wine was now given to him, but without any apparent benefit; the powers and actions of life gradually diminished, and before morning he died. ON INJURIES OF THE HEAD. Jol Un dissection there appeared every mark denoting violent inflammation of the brain and pia mater, of short duration. The minute arteries of the pia mater were turgid with blood ; in many places there was the appearance called blood-shot, which was also to be seen in the lining of the ventricles. Dark-coloured, and, in some places, bloody, coagulable lymph filled all the recesses between the tunica arachnoidea and pia mater. On dividing the substance of the brain all its vessels appeared as if injected with blood. I am inclined to believe that the medical treatment of this patient did him neithermuch good nor harm. The means em- ployed seem to have acted on him as on a person in health. The opening medicine rendered him cooler, and quieted a little the disturbed actions of the system. The opiate made him more still, and disposed him to sleep. I leave it to practitioners to consider, whether cordials would have been of any service in this case. Would they not rather, by stimulating the nervous system, have increased the disturbance of the sensorium, and, by exciting the heart and arteries, have tended to aggravate the inflammation of the brain. I add another case, because it is remarkable for the violence of the subsequent inflammatory symptoms. The case was attended by Mr. Sheppard of Chew Magna, who was at the time it happened, dressing pupil to Sir Charles Blicke, at St. Bartholemew's Hospital. To his judicious and unremitting attention I cannot but attribute, in a great degree, the ultimate welfare of the patient. The account which I have drawn up, is taken from Mr. Sheppard's notes. CASE XX. David Davis* a robust man, thirty-five years of age, was admitted into St. Bartholemew's Hospital on the 21st of No- vember, 1799. He had fallen from a considerable height on his head, and had bruised and wounded the scalp, but with- out fracturing the bone. He was, when brought to the ho*- So2 ON INJURIES OF THE HEAD. pital, so far insensible, as not to be affected by slight impres- sions, and his extremities were cold. His feet were put into hot water, and, after some time, he became warm and more sensible, and the pupils of his eyes contracted as in common. Twelve ounces of blood were taken from the temporal artery* and a purging medicine given. On the following day, the pulse being full and hard, sixteen ounces more of blood were taken away, and the purging medicine repeated, which pro- cured several stools, and a blister was also applied to the nape of the neck. Notwithstanding these measures, however, he became delirious, and his skin felt hot, and he complained of pain in his head. Twelve ounces more of blood were therefore taken, and three grains of pulvis antimonialis given every fourth hour. November 24. The delirium still continued, but the pa- tient lay more quiet: his pulse was 120, and full: therefore twelve ounces of blood were taken ; and as the delirium and strength of the pulse still continued, in the evening, the bleeding was repeated to the extent of twelve ounces. His bowels were also emptied by magnesia vitriolata and senna. Afterward he had thirty drops of tinct. opii given him at night. He slept some hours in the night, and next morning his pulse was less hard and only 96 in a minute ; his answers to ques- tions were also muchimore rational, and deliveredin a less loud and quick tone of voice than before. For during the greater part of the delirium he had been very unmanageable, rolling about in bed, and endeavouring to get up, and speaking in a loud and fierce manner. Toward the evening the symptoms again increased ; his pulse was 120, and harder and fuller than in the morning; his skin was hot, and he complained of thirst. He had taken purging medicine in the morning, which had operated. Three grains of antimonial powder were now given every fourth hour, and his feet put into warm water, in hopes of procuring perspiration: ten ounces of blood were taken from the temporal artery, and the opiate repeated at night. 25th. The patient had slept during great part of the night •' ON INJURIES OF THE HEAD. his pulse 100: he complained of cold, though his skin was hot; and of great pain in his head. More stools were pro- cured, and twelve ounces of blood were taken from the tem- poral artery. He now took six grains of pulv. ipecac, comp. every four hours. 26th. He had been delirious during the former part of the night, but had slept toward the morning ; in other respects he was much as before. In the evening, as his pulse would bear it, twelve ounces of blood were again taken away. 27th. Pulse softer and frequent. He had three stools from medicine in the evening. The delirium seemed to have a little subsided, and he was much inclined to sleep, so that is was difficult to obtain an answer from him. 28th. A blister was applied to his head, and in the eve- ning, his pulse becoming full, ten ounces of blood were taken from him. Two grains of opium were given him at night. 29th. He had slept well, but complained of his head, and of difficulty in swallowing, and in the evening had hemiphle- gia of the right side of his body. 30th. He had slept but little, the bowels lax, the pulse small and frequent, the hemiphlegia continues. We had thus far been endeavouring, by the most powerful means, to subdue a violent inflammation of the brain, and could scarcely be said to have accomplished our design, when a new affection called for attention. I think it can scarcely be doubted, that the hemiphlegia was the effect of pressure made by an effusion of fluids, in consequence of inflammation, operating probably chiefly on the left hemis- phere of the brain, so as to paralyze the opposite side of the body. Under this persuasion, and without expectation of success, I directed that two drachms, by measure, of strong mercurial ointment should be rubbed in on his arms and legs night and morning, and that five grains of the pil. hydrarg. with one grain of opium should be given three times a day. These means were continued for three days without any striking amendment being perceived, but on the fourth (Dec. 4.) he stretched out his right arm when required, and he wa? Vol. I, 45 \ol "N INJURIES OF THE HEAD. able to swallow without difficulty. Ashe was getting better, the same plan was persevered in till the 9th, when the mer- cury had affected his mouth, and produced a diarrhoea. He now knew all those persons who attended him, and his state was surprisingly altered. During the inflammation of the brain he had been very unmanageable, and his replies and ex- pressions were fierce and loud. Now he was extremely tractable, and wept whenever he was spoken to. His pulse was very feeble, and beat but 90 in a minute. It seems right to mention, that a few days afterward, when he was slowly recovering, one of the wounds of the temporal artery gave way, and he lost perhaps fourteen ounces of blood before it was perceived. This circumstance of course made him weaker, and increased the frequency of his pulse, but it did not much impede his recovery, which, though very slow, was very perfect. Extensive sloughing of the integuments of the nates had taken place, which it does not seem requisite to mention, but inasmuch as it tends to show the reduced state to which he had been brought. Indeed, if this patient had not possessed a vigorous constitution, it seemed scarcely possible that he could have survived the debility which this disease and the treatment conjointly produced. The extent of the evacuations, that surgeons are obliged to make in inflammations of vital organs, is such, as would deter the inexperienced from pursuing them, and must asto- nish those who have employed them with success, that they could be borne with so little apparent injury. It can only be accounted for by considering the disease as the stimulus which keeps up the actions of the constitution under such exhausting measures, as would occasion them to sink but for this excitement. The opinions that prevail among surgeons respecting the treatment of concussion, are very different. Many late writers advise stimulating cordials, such as wine, and volatile alkali, to be given ; while others pursue a directly opposite conduct. Nor do they agree in the account of the symp- toms, which they consider as depending on this species of '»> INJURIES OF THE HEAD. 3.")o injury. Most writers represent the subject, as if the deranged state of the brain, which is the immediate consequence of the shock, continued to the termination of the patient's ill- ness or of life; while, in the cases given by Mr. Pott, the symptoms appear to proceed more from the inflammation which ensues, than from the concussion. The whole train of symptoms following a concussion of the brain, may, I think, be properly divided into three stages. The first is that state of insensibility and derangement of the bodily powers, which immediately succeed the accident. While it lasts, the patient scarcely feels any injury that may be inflicted on him. His breathing is difficult, but in general without stertor; his pulse intermitting, and his extremities cold. But such a state cannot last long ; it goes off gradu- ally, and is succeeded by another, which I consider as the second stage of concussion. In this, the pulse and respira- tion become better, and though not regularly performed, are sufficient to maintain life, and to diffuse warmth ovrr the ex- treme parts of the body. The feeling of the patient is now so far restored, that he is sensible if his skin be pinched; but he lies stupid, and inattentive to slight external impres- sions. As the effects of concussion diminish, he becomes capable of replying to questions put to him in a loud tone of voice, especially when they refer to his chief suffering at the time, as pain in the head, &c.; otherwise, he answers inco- herently, and as if his attention could not be excited, or was occupied by something else ; he is, in short, like a man in a heavy sleep. The concussion of the brain, lastly, produces a state of inflammation of the organ, and this constitutes the third stage, which is the most important of the series of ef- fects proceeding from this cause. These several stages vary considerably in their degree and duration ; but more or less of each will be found to take place in every instance where the brain has jbeen violently shaken. Whether they bear any certain proportion to each other or not, I do not know. Indeed this will depend upon such a varietv of circumstances in the constitution, the iiu 356 ON INJURIES OF THE HEAD. jury, and the after-treatment, that it must be difficult to de- termine. With regard to the treatment of concussion, it would ap- pear, that in the first stage very little can be done. From a loose, and, I think, a fallacious analogy between the insensi- bility in fainting, and that which occurs in concussion, the more powerful stimulants, such as wine, brandy, and volatile alkali, are commonly had recourse to, as soon as the patient can be made to swallow. The same reasoning which led to the employment of these remedies in the first stage, in order to recall sensibility, has given a kind of sanction to their re- petition in the second, with a view to continue and increase it. But here the practice becomes more evidently pernicious. The circumstance of the brain having so far recovered its powers, as to carry on the animal functions in a degree suf- ficient to maintain life, is surely a strong argument that it will continue to do so, without the aid of such means; which tend to exhaust parts already weakened, by the violent action they induce. It seems probable that these stimulating liquors will aggra- vate that inflammation which must ensue sooner or later. The access of it, in the cases which I have related, is suffi- ciently evident; and its cure is to be effected by the common methods. The great benefit of evacuations was, in those cases, very evident. Indeed, it appears to me, that there is no complaint which requires such means to be more rigo- rously prosecuted, than an inflammation of the brain or its membranes. In addition to the reasoning which I have offered here, I would observe, that surgical books abound with cases in which suitable evacuations have been freely employed in concus- sion, with the best effects ; while the advocates for a con- trary practice have rested their arguments upon vague theory, and communicate no particulars of their success. If the foregoing cases exhibit the genuine marks of con- cussion, the administration of cordial medicines, which has ON INJURIES OF THE HEAD. 35"; been so much recommended, appears to be very ill adapted to the relief of such an injury. I have seen so many additional cases of concussion, so exactly corresponding to those formerly related, that I am more fully satisfied of the truth of the representation which has been given of them. I have in consequence been led more and more to wonder, that a contrary plan of treatment to that which has been so uniformly successful, could ever have been recommended, and to conjecture what cases could have occurred, in which such opposite practice must not have been strikingly prejudicial. Probably I may point out such cases ; and as I do not find them described in books of surgery, because they have not been deemed sufficiently im- portant, it may not be improper briefly to mention them. A young lady was stooping in a closet, and rising up sud- denly and forcibly, she struck her head against a shelf. The blow occasioned extreme pain, but did not stun her. She went down stairs without mentioning the accident, and, after sitting with her friends for a short time, she fainted. As it was in the evening, she went to bed, but could not sleep for pain in her head, and the next day her pulse was very languid, and her extremities cold ; she complained of great pain when the scalp was slightly touched, and said there was a sensation as if cold water was dropping on it. She took some gentle opening medicine, which relieved these symp- toms, but she could not sit up for many days, and it was a considerable time before she recovered from the languor, which the blow had occasioned : but neither fever, nor fail- ure of sensation, or of intellect, took place in the slightest degree. I have seen many similar cases, and in one the pa- tient said his sensations were such as would induce him to be- lieve that his brain was loose, and moving on the inside of the skull. All these cases were relieved by slight evacuations, as gently opening medicines, leeches, or cupping, though I am inclined to believe that a contrary plan of treatment, which has been recommended in concussion, might have been pur- sued without material detriment. Cases of this description 3-5S ON INJURIES OF THE HEAD. are to be considered as arising from nervous symptoms, at- tendant upon slight injuries, rather than as effects of serious concussion. In nervous patients, cases of actual concussion, to a de- gree that occasions insensibility, are frequently followed by nervous pains in the head, which evacuations from the sys- tem do not relieve, or but for a short time ; and the permanent feebleness which they induce greatly aggravates the disor- dered state of health which existed prior to the accident. Of this I shall also mention one instance, in order to excite the reader's attention to the subject. A young lady went out of London for the improvement of her health. She being unable to walk from a kind of rheumatic affection of her ankle, when in the country she was accustomed to take ex- ercise by riding out in a gig, which was one day upset, and the "'patient was thrown out with a force that completely stunned her. When the insensibility had subsided, an intelli- gent surgeon in the neighbourhood bled the patient, and pre- scribed aperient medicines. While the disposition to coma still remained, the patient complained of tormenting pains in the head, for which she was repeatedly bled, and with tem- porary relief to her sufferings. On the fifth day after the accident she was unable to distinguish objects, and shortly afterward declared that she was totally blind. This occur- rence induced her friends to request me to visit her; and as it appeared that the paralysis of the optic nerves was not the result of any immediate injury produced by the accident, as it occurred after a series of depletion, which was likely to prevent any effusion from taking place, I recommended that the case should be treated as one of nervous blindness, by paying the strictest attention to those means which are cal- culated to ensure the performance of the respective functions of all the organs concerned in the digestive processes, ac- cording to the plan suggested in the first part of these obser- vations, and by the use of medicines which have a stimula- ting effect upon the stomach, and which are known from experience beneficially to excite the nervous system. Under ON INJURIES OF THE HEAD, 353 this treatment the patient gradually, and even speedily regained her sight and health. It seems proper further to add, that every violent concussion of the brain is followed by a state of weakness or disorder of the nervous functions of that organ, which, as in all other cases, occasions a corresponding dis- order of the digestive organs, which latter malady must main- tain, and may aggravate the former. Mr. Pott, in speaking of concussion, says, that he never knew patients recover from the immediate consequences of it, without an imperfection in some sense, or part of the body, remaining. The result of my own experience has been very different; and yet I am ready to believe that such events may not unfrequently take place, as I know from examination, that the substance of the brain is sometimes lacerated and disorganized in violent concussions. I have, however, ex- amined other cases of fatal concussions, without observing any such lesion of the substance of the brain. It has hitherto been considered as a desirable object, to point out any marks by which we might distinguish between compression and concussion of the brain; but I believe no such criteria have yet been communicated to the public. If we judge of the symptoms of compression from what occurs in cases of apoplexy, or from cases like those which have been related of the rupture of the middle artery of the dura mater, (in one of which cases it was evident, that concussions had no share in producing the symptoms,) we must, I think, be of opinion, that pressure on the brain occasions insensi- bility, partially, or generally, and in a degree proportionate to its quantity. In extreme cases, such as I have cited, the insensibility is manifested by every circumstance. The pupil of the eye is dilated, and cannot be made to contract even by a strong light. The respiration is slow and stertorous, and the pulse proportionately slow and labouring. There is no vomiting, which would indeed indicate sensibility of sto- mach. The limbs are relaxed, as in a person just dead. No struggles take place, nor signs of sensation appear during the operation ; hut on the pressure being removed, sensation 360 ON INJURIES OF THE HEAD. and intelligence are immediately restored. In concussion, the insensible state is of short duration, and during its con- tinuance the body is generally cold, and the pulse feeble and intermitting. Afterward the skin is hotter than usual, the pulse and respiration more frequent; the former often inter- mits, and the latter has not the stertor of apoplexy.* The pupil of the eye is not dilated, but rather contracted. The countenance expresses pain or uneasiness ; and vomiting oc- casionally takes place. The state of the patient is like that of a heavy and uncomfortable sleep; yet, being roused, signs of intelligence appear. In fractures of the basis of the skull, however, it must be acknowledged, that the symptoms are often deceptive. In general the symptoms resemble those of concussion, yet sometimes a degree of insensibility may be observed like that produced by pressure, when no pressure has really taken place. I cannot better represent to the reader what I concieve of the value of the distinctions which I have made, between the symptoms of compression and concussion of the brain, in ordinary cases, than by relating briefly some of the particu- lars of a case sent me by Mr. Davies, surgeon of Tetbury, who was formerly an industrious and intelligent student at St. Bartholomew's hospital. The case, also, in my opinion, de- serves to be recorded for other reasons, which I shall after- ward mention. A young woman was knocked down by a blow on her head, and the place where the blow had been received was denoted by a soft swelling of the scalp. She lay in a state of apoplexy, and appeared like a corpse. The pupils of her eyes could not be made to contract by the approach of a strong light; her olfactory nerves were unaffected by the * But the absence of stertor must not be relied on as a proof that there is no compression; for Morgagni relates dissections of apoplectic persons, where the effusion was considerable, yet no stertor had occurred ; and I have seen cases where it took place only in a very slight degree. ■UN INJURIES OF THE HEAD. 361 most pungent odour; her ears were equally insensible to sound ; she manifested no uneasiness upon being sharply pinched ; her pulse was small and intermitting, and her breathing scarcely perceptible; and a cold and clammy moisture covered her skin. Mr. Davies immediately divided the scalp, and finding the bone fractured, he trephined it. There was no blood upon the dura mater, but that membrane was thrust up into the aperture made by the trephine. The dura mater being di- vided, about five ounces of blood was suddenly discharged, and the patient rose up in bed, as if waking with affright. Her pulse and respiration were soon relieved, and became natural. A plan of treatment calculated to prevent and subdue inflammation was strictly pursued, and the patient did well without any remarkable occurrence taking place. From what has been already said it may be inferred, that I do not consider the division of the dura mater as a slight evil. It is, doubtless, the duty of a surgeon, when he has been urged to trephine, on account of strong symptoms of pressure, to divide that membrane, if it be thrust upward into the aperture which he has made. I have said that frequently the blood is coagulated, or so thickly grumous, that the whole of it cannot be discharged. In the present case, however, the promptitude of the surgeon's conduct enabled him hap- pily to discharge the effused blood while it remained fluid. V..i.. J ■ !(• <.-N INJURIES OF THE HEAD. SECTION V Inflammation of the Pia Mater.* The inflammation of the dura mater, which occasionally succeeds to injuries of the head, has been well described by Mr. Pott. Patients labouring under this complaint are fever- ish, have a constrictive pain in the head, but continue ration- al, and give a clear account of their symptoms, until matter forms, or inflammation of the internal parts ensues. This is what we might naturally expect from the structure of the dura mater, the manner in which it is supplied with blood, and its vessels having little connexion with the brain. When the pia mater becomes inflamed, as the brain derives a considera- ble portion of its blood through the vessels of that mem- brane, the disease is instantly communicated to the cere- brum, and deranges its functions. This derangement varies in its nature and degree, accordingly as the inflammation of the pia mater is more or less violent; as it is confined to the surface, or extends to the internal parts ; as it produces a greater or smaller secretion of fluid which compresses the brain; or as it is more or less blended with the effects of concussion. The state of the patient will vary considerably under these different circumstances. If the inflammation be violent and general, the patient will be irrational and dis- turbed, having his mind strongly affected by wrong ideas, * In the first edition, I related in this section cases of inflammation of the pia mater, in which this disease occurred distinctly, and terminated fatally, in order to authenticate the specific symptoms attendant on it. As many of the forego- ing cases, however, are instances of this disease coming on after concussion or fracture, and yet occurring as a distinct disease, and uncombined with symp- toms arising from the peculiar nature of the injury, I think a further narrative of cases superfluous. ON INJURIES OF THE HEAD. 363 and endeavouring to act in consoquence of them. If the in- flammation be moderate, and affect the surface only, he will be irrational, uneasy, restless, and perhaps endeavour to get out of bed, but without the violence of mania. Should a mode- rate inflammation be blended with the effects of concussion, he will have less appearance of irrationality, will lie pretty quiet, and inattentive to slight impressions, as appeared in some of the cases related.—I am not able to particularize every variety that may occur in the symptoms ; but in all, there roust be more or less derangement of the powers, both mental and corporeal, depending upon the degree of inflam- mation, &c.*—The symptoms, which chiefly characterize the complaint, are those of an increase of sensibility ; the pu- pils of the eyes are contracted ; the patient often withdraws his arm on being touched, and his pulse and tongue denote general as well as local inflammation. It seems of the ut- most importance, that those means which in general cure in- flammation, should be prosecuted very vigorously at the commencement of this complaint; since otherwise, although they may check, they will not overcome it. Large blood- lettings, brisk purging, and extensive counter-irritation by blisters, ought to be employed at the very commencement; for, if omitted, the disease will then become established, and the powers of the body will soon be too much sunk to ad- mit of the same active treatment at a later period. I have here represented the general effects of inflamma- tion of the pia mater when it arises from external violence. In other cases, indeed, where it comes on, as it were, spon- taneously, or without any powerfully exciting cause, (in which case it generally falls under the care of the physician,) it has appeared to have affected the brain but little, and to have been very slow in its progress, and inactive in its na- * An unusual infirmity of the bodily powers is sometimes observed, accom- panied with tremors, low delirium, and exceedingly rapid pulse ; yet, on dissec- tion, a slight inflammatory appearance of the pia mater and brain is all that can be discovered. Such a state «n,„Him..s occurs after an abscess has formed ... N INJURIES OF THE HEAD. 3G7 SECTION VI. Cases of Disease of the Bone and Dura Mater. The diseases of the cranium, and consequent affections of the dura mater, have been well described by some French and German surgeons.* But as they have not, I believe, been explained by English writers, I shall confirm the ac- counts which we have received of them by additional cases; and afterward shall offer some remarks on this subject* CASE XXII. A man, between thirty and forty years of age, was salivated for complaints in his head, supposed to be venereal. There were two tumours of the scalp; one a little before the coronal suture, and the other a little above the posterior superior angle of the left parietal bone. The man's health was greatly reduced by the course of medicine he had undergone, as well as by the disease, which had con- siderably increased during the use of mercury. The integu- ments covering the posterior tumour had ulcerated ; and a probe could be passed under them, so as to discover a con- siderable extent of bare and carious bone. The surgeon, under whose care he was admitted into the hospital, divided the integuments, and perforated the diseased bone, which was found separated from the dura mater. That membrane also had a very morbid appearance, being covered with a soft substance of a dirty reddish colour. On pressing down the ' Vide Mons. Louis's Mcmoire, in the fifth volume of the Mem. de 1' Acad; ■le Uhirurgic, and Hafler's Disputationes Chirurgicar. 26* ON INJURIES OF THE HEAD. dura mater with a probe, to see if it was detached to any extent, nearly a table-spoonful of healthy pus issued from beneath the bone, about an inch behind the part perforated. The surgeon thought this might be sufficient to relieve, and therefore deferred making another perforation. But the man, who had lain stupid, though not irrational, and had subsultus tendinum accompanied with great debility, grew shortly after delirious ; in which state he continued about two days, when he became convulsed, and died. On dissection, purulent matter was found on the dura mater, beneath both the carious portions of bone. The membrane also, which was detached, was much thickened, so as in some degree to indent the surface of the brain. The pia mater was generally inflamed; and a larger quantity of fluid than usual was found in the ventricles. CASE XXIII. An old man was admitted into the hospital for a complaint of giddiness and pain in his head. Upon examination, a tumour was perceived over the left parietal bone, into which an incision was made, and a good deal of matter discharged. The pericranium was found to be detached for three inches in length, and two in breadth. In the middle of the bare bone, which seemed to be dead, and really was so, granula- tions of a healthy appearance had sprouted out. These arose from the dura mater, and had made their way through the bone. The patient's health, which was moderately good at the time of his admission into the hospital, gradually declined; and, after about six weeks, the pain in his head became par- ticularly severe. From this time he became gradually coma- tose, took no food, and soon died. On dissection, the dura mater, beneath the carious bone, was found detached, and had granulated. Much pus lay between the left hemisphere of the brain and the falx; and the whole of the dura mater covering the right hemisphere • »N INJURIES OF THE HEAD. 369 Was lined with healthy pus, which adhered to its surface, and appeared to have been secreted by that membrane. The cases of diseased bone, which require perforation of the cranium, have not been sufficiently treated of by any English writer. Mr. Pott has, indeed, noticed the disease and death of portions of the skull, that succeed to contusions; but he has not sufficiently explained the affections of the membranes of the brain, which even these diseases sometimes occasion. The circumstance, which seems particularly to have attracted his attention, is the inflammation and suppura- tion in the diploe, which proceed from injury done to the bone. The existence of that complaint, however, is easily known; for while there is a fixed pain in that part of the bone, there is no general inflammation, or but very little, of the dura mater. The disease continues, too, a much longer time without producing any seriously bad symptoms, than any disorder of the internal parts could do. When matter is formed in the diploe, the pericranium will certainly separate from the bone, and the external table of the skull will un- doubtedly perish. In a case so clearly marked, the conduct to be pursued is obvious, which is, to remove a portion of the external table with the trephine, so as to discharge the matter collected in the diploe, without which no relief can be obtained. I have seen in several cases where the opera- tion was performed early, that the external table came away within the circle of the trephine, the matter was discharged from the medullary part of the bone, and the internal table remained sound and entire, covering the dura mater. Granu- lations soon arose, and the patients got well, with the ex- foliation only of a portion of the outer table. The mis- chievous consequences of delaying the operation, when once the disease is known, must be evident; for the matter col- lected within the bone, having no natural outlet, will press on every side, first gradually destroying the diploe, some- times extending itself over almost the whole of the cranium, and at last occasioning the partial absorption of both tables. Vol. I. 47 370 «'N IN JURIES 01' THE HEAD. so that the skull after death sha'il be found perforated with ff number of holes, like a piece of worm-eaten wood. These holes afford a discharge to the matter, which not only oozes out beneath the pericranium, but also insinuates itself between the skull and dura mater ; till at length the patient sinksr worn out by the irritation and fever which this painful and extensive disease creates ; unless, as it sometimes happens, he is previously destroyed by inflammation attacking the membranes of the brain. Suppuration of the diploe, and the death of a portion of the bone, are the common effects of injury done to the cra- nium ; and such a morbid state may indeed occur at some distance of time from the receipt of the injury. But the disease, which the cases represent, generally arises without an obvious cause. An affection of the dura mater is almost the necessary consequence of such a disease in the bone. In syphilis it probably takes place later than in any other instance ; for that disorder attacks the outside of the skull, which it gradually destroys ; the inner table and the dura mater remain sound until the last. But when, as in the com- plaint I am now considering, the whole bone is involved in disease, we can no more expect that the dura mater should remain unaffected within, than that the pericranium should continue sound and attached without; for that membrane may be regarded as the periosteum to the internal table of the skull. It is well known that, in general, the dura mater separates, and becomes thickened from a deposition and subsequent organization of coagulable lymph between its layers. This thickening is sometimes considerable, so as to form a tumour which causes an indentation in the cerebrum ; as happened in a very remarkable degree in the case of the Sieur le Gallois, related by M. Louis.* Sometimes the dura mater secretes pus, which being confined within the cranium, produces inflammation of the brain, &c. At others, granula- * Sec Mem. de 1' Acad. deChirurg. torn. v. It also took place more slightly 5» one of the ca->cs whice I have related. uN l.NJUUES OF THE HEAD. 371 lions arise from the irritated membrane, and, making their way through the bone, form those tumours so well described in the Memoir just referred to. This took place in one of the cases I have related ; and is a remarkable instance of the power which granulations possess of removing bone. The disease, however, does not confine itself to the part first at- tacked ; for if the irritated state of the dura mater be not ap- peased, thickenings will take place in other parts of that mem- brane ; or the inflammation becoming more extended, sup- puration may be produced even over the opposite hemisphere of the brain, as happened in both the cases which I have re- lated. I do not mean to say, that in every case of diseased cra- nium, even where both tables of the skull are equally affect- ed, the perforation of the bone is indispensably required. 1 know it often happens that the bone exfoliates, without any bad effects having been produced. But surely no surgeon, who perceives the danger of delay, would hesitate to remove all the dead portion of bone, if symptoms denoting general irritation of the dura mater take place. The best event that can be expected, is, that the bone will at length exfoliate without much pain to the patient, or injury to his constitution. By removing the dead bone, and giving an early and free discharge to any matter collected beneath it, the irritation which it occasioned will be taken away, the diseased state of the dura mater will gradually subside, and healthy granulations arise from its surface ; nor will any further disease occur in other parts of that membrane. M. Louis tells us, at the conclusion of the Memoir already quoted, in what manner experience had taught him to treat fungi of the dura mater. He says that " the whole of the tumour should be exposed, which cannot happen till the bony circle, which conceals its basis, is re- moved ; and that afterward means should be employed to destroy the fleshy excrescence."* Although the destruction * The excellent advantages of such bold but judicious practice are well shown m a case related in ihe Pth Paper of Hallit'< Disputaliones Chirurgira'. vol. i 372 ON INJURIES- OF THE HEAD. of the fungus might be proper for the sake of expedition, and although it can perhaps be attended with no harm, by whatever means effected, yet it may not be necessary. Like other animal fungi, it will probably cease to grow, and soon disappear, when the irritation which occasioned it has been removed. In cases of tumours rising from within the skull, it is of consequence to determine from what part they proceed. In general, they will be found to spring from the dura mater, and to be the effect of disease in that membrane, induced and kept up by irritation. Surgeons have endeavoured either to reduce them by caustic, to restrain them by pressure, or to take them off by a ligature or the knife ; and the excres- cences have either ceased or continued to grow, according as the irritation which gave rise to them has been removed or not. If the former happened, the surgeon has sometimes attributed undeserved merit to the means he had employed for the cure. Those tumours which come from within the dura mater may possibly differ in their kind in different diseases ; and of these I have spoken in a former part of this Essay. What I have written must appear very defective, if it be considered as regarding the effects of injuries of the head in general. But my intention has been only to endeavour to illustrate particular points of practice, by a relation of cases selected from a considerable number of each kind. I shall next relate a case, in which, though the brain was not the immediate subject of the injury, yet it became affect- ed in consequence of it, and I think the case deserves to be recorded, not only on account of several useful facts and hints relative to practice which it affords, but also because jt may eventually tend to throw light on the economy and diseases of the brain. jn which a piece of di,sensr ON THE OCCASIONAL ILL and effects. I need not insist on the necessity of discrimi- nation in these complaints: those who have described the symptoms resulting from an injured nerve have repre- sented them as at all times imminently hazardous, and fre- quently fatal. An operation is here demanded; from it we have reason to expect immediate mitigation of the patient's sufferings, and his future perfect restoration. Yet this ope- ration in any other of the complaints * before treated of would be unnecessary, and perhaps detrimental. I shall arrange what I have to say on this subject in the following manner: First, I shall explain what nerves arc subject to injury ; secondly, I shall investigate what are the effects likely to be produced by such an accident; and third- ly, I shall inquire what means are most likely to afford relief. First, the two cutaneous nerves are those which are ex«< posed to injury. I dissected them in several subjects with attention, and found some irregularity in their distribution ; most frequently all their branches pass beneath the veins, at the bend of the arm ; but sometimes, although the principle rami still go beneath these vessels, many small filaments are detached before them, which it is impossible to avoid wounding in phlebotomy. As I believe many surgeons retain but an indistinct remembrance of these nerves, and as I have never seen them accurately depicted in any anatomical book, I thought I 6hould do an acceptable service by giving an en- graving of them. I therefore made two drawings of them; one exhibiting their most simple course ; the. other, their most complicated distribution. These, I conclude, are the only nerves liable to injury. It may be suspected that the me- dian nerve might occasionally be wounded; but its situation, I think, makes this opinion improbable. If, however, a doubt should be entertained on this subject, an attention to symp- toms will soon dispel it; when a nerve is irritated at any part between its origin and termination, a sensation is felt as if some injury were done to the parts which it supplies. If, therefore, the cutaneous nerves were injured, the integu- CONSEQUENCES OF VENISECTION. 397 ments of the fore-arm would seem to suffer pain : but'if the median nerve was wounded, the thumb and two next fin- gers would be affected with pain. By referring to the plate it will be seen, that if the patient be bled in the vena mediana basilica, the branches of the in- ternal cutaneous nerve are exposed to injury; or, if the vena mediana cephalica be opened, the branches of the external cutaneous nerve may be wounded. Secondly, I wish to inquire what are the ills likely to arise from a wounded nerve.—Whoever reflects on the wonderful minuteness of the nervous fibrils, and considers their perfect distinctness from each other, although connected by a com- mon covering of cellular substance, will scarcely imagine a partial division of a nervous fibril. If I sought to express myself strictly on this subject, I should speak of a partial division of a packet of nerves. But I shall use the common- ly adopted language, and call those chords nerves, which are really composed of multitudes of separate nerves. I first beg leave to examine the opinion which has prevailed, of a nerve being partially divided. Admitting that a nerve be partially divided, would it not, like a tendon, or any other substance, unite ? I think there can be no doubt but that it would : I am induced to this opinion by considering that nerves of equal size with the cutaneous nerves of the arm are distributed in considerable numbers throughout the body. In the many operations performed, and in the wounds daily occurring, I think it would be strange if a partial division of a nerve should not happen ; yet no peculiar symptoms are observed usually to ensue. The pain which some people suffer from bleeding, in my opinion, indicates an injury done to a nerve. If the reader refers to the plate, he will perceive that, in some cases, it is impossible to avoid dividing branch- es of nerves in phlebotomy, as sometimes they pass before the vein. These branches are so exposed, that I should be surprised if they did not many times suffer a partial division. Surely, however, a half-divided nerve would unite without causing a general derangement of the nervous system. Yet 398 ON THE OCCASIONAL ILL it is possible that an inflammation of the nerve may acci- dentally ensue, which would be aggravated if it were kept tense, in consequence of imperfect division. In the cases related by Mr. Pott, and Dr. Monro, I believe that some days elapsed after the infliction of the injury, before any alarming derangement of the nervous system ensued. In- flammation of the surrounding parts also appeared. These observations make it evident to me that the disease consists in inflammation of the injured nerve, in common with the other wounded parts ; and this inflammation I can conceive to happen with or without a total division of the nervous chord. I should consider a case of inflamed nerve, as an object of great curiosity: every one, I think, will admit, that it is likely to communicate dreadful irritation to the senso- rium : and every one will perceive that a cure will probably arise from intercepting its communication with that import- ant part. Thirdly, I proceed to inquire what is the most probable method of relieving the effects arising from an inflamed nerve.—The general opinion is, that the nerve is only partially divided, and that a total division would free the pa- tient from a continuance of his sufferings. Mr. Pott sup- posed that the wounded nerve was situated at one or the other extremity of the wound which had been made in the vein ; he therefore proposed to divide it totally, by enlarging a little the original orifice. It is, however, possible that the point of the lancet might injure a nerve lying beneath the vein. This will be easily understood by referring to the plate. Mr. Bell directs an extensive transverse incision to be made through the original wound ; but if the injured nerve be situated at the upper extremity of the orifice, it will remain unaffected by this operation. Mr. Bell also advises the incision to be continued to the bone ; but this appears to me dangerous and unnecessary. If the injured nerve be inflamed, I think it doubtful, whether even a total division of it, at the inflamed part, would effectually relieve the general nervous irritation which the CONSEQUENCES OF VENISECTION. 399 disease has occasioned. To intercept the communication of the inflamed nerve with the sensorium does, however, promise perfect relief. This intention can only be accom- plished by making a transverse incision above the orifice in the vein. The incision need not be very extensive, for the injured nerve must lie within the limits of the original orifice, and it need only descend as low as the fascia of the fore- arm ; for all the filaments of the cutaneous nerves lie above this fascia. The vein which had been opened, and some filaments of the cutaneous nerves,* are all the parts of conse- qnence which will be divided in this operation. The proxi- mity of the division of the nerve to the vein must be regu- lated by the supposed extent of the disease. However, as the extent of the inflammation of the nerve is uncertain, I submit it to the consideration of surgeons, whether it may not be advisable, in some cases, to divide either of the cutaneous nerves, still more remotely from the injured nerve. I find little difficulty in detecting the trunk of these nerves in the dead subject; and I should suppose but little would occur in the living state; for the compression of the tour- niquet would prevent any obscurity which haemorrhage might cause. Explanation of the Plate. A Vena basilica. B Vena cephalica. C Vena mediana. D Vena radialis. E Vena cubitalis. F Vena mediana basilica. G Vena mediana cephalica. H Nervus cutaneus internus. I Nervus cutaneus externus, ( [ CONSEQUENCES OF VENISECTION 401 General Observations on the ill Consequences sometimes succeeding to Venisection. I think it very probable that these diseases would less fre- quently happen, did not the situation of the veins usually opened contribute to their occurrence. The common offices of life so constantly demand the employment of the arm, that its motion becomes almost inevitable. Unless the orifice made by the lancet has been attentively closed, the effect of this motion will be to separate the edges of the wound from each other, and to prevent their union by the first intention. Some slight degree of inflammation will ensue ; the continu- ance of motion of the arm causes a friction of the inflamed surfaces against each other, and thus the disease is increased. Under these circumstances, if the constitution of the patient be irritable, the inflammation will extend itself, although ir: may still be confined to the cellular substance and integu- ments ; or, perhaps, it may be transmitted to that part which has sustained most injury in the operation. The vein, the absorbents, the fascia, or the nerve may, in that case, suffer peculiar disorder. Although the injury done by a bad lancet may contribute to the production of disease, yet I think it probable that a patient, improperly bled, would sustain no injury if the treatment of the wound was judicious; whilst another, on whom the operation had been dexterously and well performed, would be liable to these ill consequences, it the proper attention to unite the wound was neglected. In the account given of these diseases, they have been re- presented as they occurred, separately; doubtless, in some cases, they may be combined. The principal curative indications appear to be, to miti- gate the inflammation about the orifice, and to preserve the arm supported in a motionless state. I need not enlarge this account by describing the modes of appeasing inflam- mation and irritation, as they are well known to every srv- s-eon. VOT. I *1 ON EMPHYSEMA. i ON EMPHYSEMA. Much praise is, in my opinion, due to Mr. John Bell, for the clear and spirited description which he has given of the state of the lungs in one kind of emphysema. The follow- ing case is related to corroborate his remarks, and also to lead to others which I am desirous of offering to the public on the subject of emphysema in general. CASE. A poor woman, about forty years of age, was run over by a mail-coach, one of the wheels of which passed lengthwise over her back, and fractured several of her ribs on the right side. When brought to the hospital she breathed with much difficulty, and an emphysema of the integuments had taken place. An opening was made through the skin to let out the air; and the emphysema did not afterward spread. The pa- tient was bled largely; but the difficulty of breathing had in- creased to the third day, at which time I first saw her, in company with Mr. Harvey, under whose care she was. She had passed the preceding night without the least sleep, and breathed at this time with extreme difficulty; indeed it seemed as if she could not long continue the labour of such imper- fect and distressful respiration. It was supposed that one side of the thorax was filled with air ; and as it was sus- pected that the opposite lung might be oppressed by this cause, it was agreed to extract the air from the right side of the chest. With this view, Mr, Harvey, made an opening into the thorax, in the following manner: He first made an incision about two inches in length through the integuments, iyt, ON EMPHYSEMA. near the middle of the seventh rib, and opposite to its IoWcl edge. He then drew the skin upwards, so as to expose the. intercostal muscles which connect the upper edge of this rib to the one above it. These he cautiously divided, as he next did the pleura. At the time this was effected, I believe the patient was in the act of expiration ; for a blast of air evidently issued from the thorax ; and afterward, whilst the integuments were kept retracted, and the aperture in the pleura consequently uncovered, the external air continue d to rush in during the enlargement of the thorax, and to be forced out again during its contraction. But when the divided skin was allowed to descend to its natural situation, and thus the opening of the pleura was covered, no farther passage of air took place, and all that could then be perceived was a depres- sion of the integuments opposite to the aperture in the thorax, occasioned by the pressure of the atmosphere during the en- largement of that cavity. I had got ready a large injecting syringe, and, introducing the pipe into the cavity of the chest, I drew up the piston, and thus exhausted the air, till 1 found I was stopped from proceeding by the lung, which had risen up and applied itself to the mouth of the syringe. The skin was then immediately brought down over the aperture in the thorax, and served, like a valve, to prevent the further ingress of air into that cavity. About ten ounces' measure of air might probably have been extracted by the syringe. As this quantity of air could have occupied but a small space when compared with the size of the thorax, it was probable that the back part of that cavity was filled with fluids.— Nothing further, however, was done at this time; and shortly after the poor woman fell asleep, and breathed with compar- ative ease for nearly six hours. But the difficulty of breath- ing again increased during the night, and at noon on the fol- lowing day was nearly as great as ever. Mr. Harvey and I agreed, however, that it would not be wrong to inspect the thorax, to see if the lung had collapsed, or if we could by any means afford relief to the patient. Upon separating the rwmesion which had formed between the skin and subjacent ON EMPHYSEMA. 407 parts, and introducing a finger through the aperture in the pleura, we found the lung adhering to the inside of that mem- brane ; but, upon slightly varying the patient's posture, some turbid bloody serum flowed from beneath the lung. When we had discharged as much of this fluid as we conveniently could, the external wound was closed ; but the patient con- tinued to breathe with increasing difficulty till about mid- night, when she died. Dissection. On examining the body, no air was discovered in the cavity of the chest. The right lung was partially inflated, and the anterior part of it closely adhering to the pleura cos- talis, as far as the place where the opening had been made. About three pints of bloody fluid lay in the hollow of the ribs posteriorly, and about half filled the cavity of the chest on that side ; the surface of it being nearly on a level with the opening which had been made to exhaust the air. Upon the surface of this fluid, the half-inflated lung seemed to float.— I looked for the place where the lung had been wounded by the injury ; but cannot say that I could perceive it. It was, however, certainly healed ; for the lung bore inflation with- out letting the air escape from it. The pleura was covered with coagulated lymph. The cells of the lung contained a quantity of fluid, and the whole substance of it was of a livid colour.—The cells of the lung of the opposite side of the chest also contained more than their ordinary quantity of fluid ; its vessels were turgid, and it was hard and thick- ened in several places ; which was probably owing to for- mer disease. There was likewise more than a usual quan- tity of turbid serum in the left cavity of the thorax. It seems to me highly probable that there are two states of the lungs in emphysema, one of which, indeed, can rarely be proved by examination, since the patients in general do well. 1 have, however, met with instances in which patients effected with emphysema from a wounded lung died of other 408 ON EMPHYSEMA. injury, and thus been able to ascertain that the lung had not collapsed. I once also met with a proof of this fact in a pa- tient who survived, and I will relate the circumstances of the case. CASE. Mr. Crowther requested me to see a poor man who was brought into a work-house with fractured ribs, accompa- nied with a great degree of emphysema. The integuments covering the upper part of the left side of the thorax and neck Avere elevated to a great degree by air that seemed con- fined in one cavity, and not diffused in the interstices of the cellular substance. The integuments of the face were also considerably inflated. The pulse was very frequent and small, and respiration quick and difficult. The extremities were cold. All these circumstances had taken place so ra- pidly, and were apparently increasing with so much celerity, that I thought it right, for reasons which will be mentioned afterward, to make an opening into the cavity of the thorax, which I accordingly did, between the 7th and 8th ribs, where the digitations of the serratus anticus muscle meet those of the external oblique. The external wound was made in the manner described in the foregoing case. The lung was in contact with the sides of the chest, nor did it recede when exposed. Should such an occurrence ever take place, a surgeon has the means of preventing its happening to any in- jurious degree, by instantly closing the wound. We next made a puncture through the distended integuments on the front of the chest, about opposite to the coflar-bofle. A blast of air escaped, and they subsided to their original level. The diffused air was expressed, in some degree, from the in- teguments of the face and neck through the same wound. A bandage was now applied round the walls of the chest, so as to prevent their motion, and the escape of air into the cellular substance, and the patient was afterward bled. No more emphysema occurred, and the patient 'lid as wel! ON EMPHYbEMA. 400 as in a case where the ribs are merely broken, and the lungs uninjured. I cannot satisfactorily account for the great quickness and difficulty of respiration that took place in this case, except by attributing it to the agitation of the patient's mind, alarmed by the inflation of his neck and face. I have seen so many cases of emphysema, attended with very little difficulty of breathing, or other inconvenience, in- deed, proceeding in a manner so like cases of fractured ribs unaccompanied with wounds of the lungs, that I cannot sup- pose patients were in these cases reduced to the necessity of breathing with one lung only. These patients, indeed, were all treated in the manner recommended and practised by Sir William Blizard. Observing the great pain and irritation which the constant motion of the fractured ribs occasioned, he was induced to disregard the emphysema, and to confine the motion of the ribs by a tight bandage, in the same man- ner as when the lungs are uninjured : afterward the patients were largely bled, and other evacuations were freely made. This practice he has since continued with general success. The pressure of the bandage, in general, prevents the air from escaping out of the wounded lung, and pervading the cellular substance. It will, perhaps, appear probable to many sur- geons, that, for this very reason, the air will be likely to in- sinuate itself between the two pleura?, and thus occasion a collapse of the lung. I do not, however see any good reason for such a supposition. The two pleurae remain in their natu- ral state of contact; and there is no space for theVir to pass between them. So frequently also are there adhesions be- tween the surface of the lung and the sides of the thorax, that / I think, in some of the cases of emphysema which I have seen, this circumstance must have occurred, and that if the ! lungs had receded from the sides of the thorax, the symptoms would have indicated the laceration or stretching of these ad- hesions. 410 ON EMPHYSEMA. An idea has generally prevailed among surgeons, that it tin. pleura costalis were divided in the living subject, the lung would immediately collapse, as it is usually found to do in the dead one. But M. Bremond* has shown by experiments, that not only when an opening is made into the cavity of the thorax, but even when some of the riSs are removed, the lungs still oc- cupy their natural situation, and are even thrust up into the opening during expiration. Mr. Norris has also lately shown by experiments undertaken for this purpose, as well as by observations on the effects of accidents, that frequently the lungs do not collapse when the cavity of the chest is exposed in the living animal ;f and I have also had occasion to ob- serve, on dividing the pleura costalis in a case of supposed hy- drothorax (in which, however, no water was found,) that the exposed lung did not collapse; a circumstance which, I think, ought to encourage us to a more frequent performance of such an operation. In other experiments, however, the lungs have been known to collapse ; and the circumstances on which either of these effects depends are not perhaps well understood. For these reasons, I believe that in most cases of emphy- sema succeeding to broken ribs, pressure by bandage not only hinders the air from diffusing itself through the cellular sub- stance, but serves to prevent it from escaping out of the wound. ed lung, and of course facilitates the healing of the wound, which would be prevented by the constant transmission of air. Its early application, therefore, will often prevent a very troublesome symptom, whilst, at the same time, by keeping the fractured bones from motion, it greatly lessens the suf- ferings #of the patient. In some cases where the lungs are wounded by the ribs, the air does undoubtedly get into the cavity of the thorax, as happened in the case of the poor woman already mentioned, and as I have seen in other instances. When the air passes from the wounded lung into the cavity of the chest, and the * Memoirs tie I'Acad. ties Science?, 1739- Memoirs of the Medical Society of London, vol. iv. p. 440. ON EMTHYSEM v ill lung becomes in consequence collapsed ; still the symptoms and progress of the complaint will differ from the effect of circumstances which have not been much attended to. When the wound in the sides of the thorax allows of the expulsion of air from that cavity during expiration, and does not admit air during inspiration, it is not to be supposed that the wound of the lung can heal; for the cavity of the thorax must, under these circumstances, be filled from the wounded lung every time that it is enlarged during inspiration. But this state of circumstances, which is so particularly in- jurious, and which usually takes place when the lung has collapsed in the manner described, it is the business of the surgeon to remedy; and it may be accomplished in two ways: First, by preventing the escape of the air from the cavity of the chest, in which case the necessity of its being filled from the wounded lung will, in a great measure, be done away. And as I know surgeons have apprehended, that if an outlet was not given to air from the cavity of the chest, the opposite lung might become oppressed, I beg them to re- flect a little on the state of respiration under these circum- stances. To examine this subject, let us suppose the thorax ex- panded, and one of its cavities filled with air, at which time the patient attempts to make an expiration; what will be the effect ? The air cannot return through the wound in the lungs; and we have supposed that it cannot escape through that in the pleura costalis. The muscles of respiration are unable then to produce any considerable change in the dimensions of the cavity without an exertion productive of pain, which it is not probable that they will make ; the inactive diaphragm will not be thrust up into the hypochondrium as in natural expiration, and the ribs will remain nearly stationary; but in proportion to the degree of the expiratory effort that is made, the air may be condensed, and the mediastinum thrust to the opposite side of the chest. But no injury will arise from this pressure, neither can it happen in any great degree ; for* hoth sides of the chest being dimmi^d at the same time, a 4liJ ON EMfHYSEMA. slight compression of the opposite lung cannot be detrimen- tal, since it helps to express the air from it,—the very effect which is now required; and as that lung is pressed inwards by the sides,of the thorax, it will counteract any great pressure made on the mediastinum. Upon inspiration taking place, the condensed air will expand and fill the enlarged cavity, and the mediastinum will regain its natural situation ; so that the function of the sound lung is scarcely, if at all, impeded by the compression which takes place on the opposite side of the chest. In whatever state the lungs happen to be when they are wounded, a bandage, if it can be borne, seems therefore to me extremely useful. By means of it, the pain and irritation, which the motion of the fractured ribs must otherwise occa- sion, are, in a great measure, or entirely, prevented. In that state of the lungs which I have first described, the pres- sure of a bandage prevents emphysema, and does no harm; in the other, it not only prevents emphysema, but does good, by keeping the collapsed lung at rest, and thereby free from the necessity of constantly transmitting air. Patients, how- ever, will not always be able to wear a bandage when one lung is collapsed (particularly if any previous disease has existed in the other,) as it equally confines the motion of the ribs on both sides, and as every possible enlargement of the chest becomes necessary for the due admission of air into the lung which still executes its functions. Under these circum- stances, if the emphysema continues (and its continuance must always denote that the wound in the lung is not closed,) I should esteem it the best practice to make a small opening into the chest, so that the external air might have free com- munication with that cavity; and then the injured lung must remain motionless till its wound is healed, and the medias- tinum will, in every state of the thorax, preserve its natural situation. As almost all the circulating blood must, in such cases, be transmitted through the vessels of one lung, if the quantity of that fluid be not greatly diminished, the pulmonary vessels ON EMPHYSEMA, 413 will become turgid ; a larger effusion of fluids will therefore take place into the air-cells and cavity of the chest, and thus the function of the acting lung will be materially im- paired. This reasoning illustrates what experience has al- ready determined, viz. that the preservation of life in these cases depends on the most copious blood-letting. The case which I have related clearly shows that the col- lapsed state of the lung affords an opportunity for the wound of its surface to heal; and when this desirable event is ac- complished, the air which is at that time in the cavity of the thorax, will be speedily absorbed, and the luug will again acquire its former size and situation. But should the func- tion of i* be more immediately necessary, from a diseased state of that on the opposite side, or from other circum- stances, it may be more quickly restored by exhausting the Air, in the manner described. If the cavity of the chest contain a quantity of fluids, and it is thought right to extract them, it cannot well be done by varying the posture of the patient so as to let them run out of the opening that has been made : the difficulty with which respiration is performed will render such an attempt almost insupportable to the pa- tient. It would therefore be better to introduce a hollow bougie, or some such instrument, into the posterior part of the thorax, there connect it to the syringe, and thus extract the contained fluids. I need scarcely add, that the same method may be employed with advantage for the extraction of water from the cavity of the chest in hydrothorax. The great advantage of retaining the lung in a collapsed state is, if possible, more strikingly shown when those bodies , have suffered a greater degree of injury than can occur to \ them from the fracture of a rib. I have seen cases in which bullets have passed through the lungs, near the root of those < bodies, and where many of the large vessels were consequently ( torn, in which the blood has been poured into the cavity of 1 the chest, has condensed the lung by its pressure, and thus suppressed the haemorrhage. The injured vessels might, under these circumstances, unite ; and the blood being hi 414 ON EMPHYSEMA. out of the thorax, the lung might gradually be restored to its former function. Yet in the cases which I was a witness to, the patients died of inflammation and fever; but the particular nature of the circumstances was unknown during the life of the patient; and of course the conduct appro- priated to them was not pursued. The fluid contained in the cavity of the thorax had in these cases undergone a de- gree of putrefaction previous to the patient's death ; which state required its discharge. But should this be attempted in other cases, it becomes very essential to keep the thorax filled with air, lest the lungs should become prematurely inflated, the newly healed part lacerated, the haemorrhage renewed, or inflammation in- duced ; and the surgeon would be able, I believe, without much contrivance, to regulate the inflation of the lungs as circumstances seemed to indicate. Surgeons used formerly to keep canulae in the thorax in these cases, with a design to give an outlet to fluids ; but such means might have been beneficial, by preserving the lungs collapsed; and they might have been continued from being found serviceable, though the manner in which they became so was unknown. NLM041391826