**•-■ » 'sm*- :.'- ^'"%t- •, ' 7^ '"ffiWft--. ^ .««■ ■.'I.**l 3&i ££&*"■ '*# "XgL- 'ill PtvAJUf*- $-n^t\ 1R0.^\kO. of the chest were very severely burned. When ad- mitted -she complained of no pain, answered ques- tions that were put to her, but could not give any clear account how the accident happened. She had a slight shivering, her pulse was imperceptible, and her extremities cold. Rags dipped in warm spirits of turpentine were applied to the excoriated parts; thirty minims of tincture of opium were given to her, and she was ordered to take half an ounce of brandy in a cup of warm gruel every two hours. In the evening she somewhat revived, answered questions correctly, and the extremities were becoming warmer. Still no pulse could be felt. She became restless in the night, and took a draught containing twenty mi- nims of tincture of opium. Jan. 20th. She vomited twice during the night, after having taken the brandy and gruel. She was now lying in a state of stupor, could not be urged to speak or answer any question, and was totally uncon- scious of a severe pinch of the sound skin of the leg between the fingers. She remained in the same state of stupor, with stertorous breathing, till about one o'clock on the Tuesday morning, when she expired. case. A lad carrying a pail of hot soup upon his head, fell and scalded the right arm, face, neck, and side of the chest, as low as the margin of the ribs. The accident happened at about ten o'clock, a. m. The cuticle was destroyed, but the cutis appeared sound. The lime water and milk liniment was ap- plied, and a drachm of laudanum given to him. In an hour afterwards his pulse was 104, and sharp. He complained of excessive thirst, and was constantly shivering, as from cold. Half past one, p. m.: shi- vering continues. Pulse 112, smaller and feeble, INJURIES AND OPERATIONS. £9 Ordered some warm drink, and the oil.of turpentine to be substituted for the lime water liniment. Ten, p. m.: makes no complaint, but is restless and thirsty, and although not actually in a state of delirium, ap- proaches near to it; upon being asked questions, makes no reply. The shivering has nearly subsided, and the surface is recovering warmth. Pulse 136, thrilling feebly. Ordered an ounce of castor oil, and immediately after its operation, to take sixty drops of laudanum. The surface is kept moist with tur- pentine. Second day, ten, a. m.: was restless and delirious the greater part of the night, but has been for some hours in a dosing, half comatose state, from which it is difficult to rouse him. The oil had ope- rated as desired. He appears inattentive to ques- tions, expresses no pain, breathing rather hurried, temperature natural, pulse small and feeble, so as to be scarcely perceptible at the wrist,—rather creep- ing under the finger than distinctly pulsating—about 150 in the minute. The cutis has lost its florid co- lour, and seems hard and insensible, with little sur- rounding inflammation. At ten, p. m., he expired, having remained much in the same state as last re- ported, and survived the injury about forty-eight hours. To these disastrous cases, which unhappily form but a part of my collection, I subjoin two which oc- curred in February of last year, within two days of each other. I give them in the words of my hospital register, with the treatment adopted, which it will be seen was successful in the latter, the symptoms of which were as imminent as several of those that I have here recorded, and of others that I have watch- ed to a fatal termination. -(j INJURIES AND OPERATIONS. case. Anne's ward, No. 20.—Feb. 20, 1823, four o'clock, p. m.—Esther Knowles, aged six years. A severe burn caused by the clothes taking fire, ex- tending over the arms and face, with two small patches upon the chest; the cuticle abraded and de- tached ; pulse small and quick; shivers, but does not feel cold; complains of much pain. Sum. syr. papav. 3iij statim :—01. lini : liq. calcis : M. p. aeq. pro linim. Nine, p. m. She now complains very little, and appears almost in a state of stupor; pulse hardly perceptible; answers when spoken to. The feet. were cold about an hour since, but warmth is restor- ed by bottles of hot water. 21, two o'clock, p. m. Still in a state of stupor, but answers rationally to questions. Pupils rather dilated; no pulse at the wrist, but the pulsations counted at the groin, 160 in the minute. The heart is fluttering, and only half acting. She has had two stools since her admission, and has dosed continually. An enema, spir. terebinth. 1 ss. in D. avenae § iv. was injected, but almost immediately returned. A tea- spoonful of brandy was then given in three of gruel, and a leech applied to the nape of the neck, which removed about an ounce of blood. In ten minutes, another dose of brandy was given; both were re- jected by vomiting. When the first dose was given, the pulse was felt at the wrist for a few minutes, and then became imperceptible. After the bleeding, and the second dose, it again became evident, and re- mained pretty full and distinct, although very rapid. The child however was very little roused. Ordered to give the brandy every hour. Nine, p. m. The pulse evident at the wrist. None of the brandy has been retained upon the stomach. INJURIES AND OPERATIONS. 71 Half a pint of oxygen was now inhaled, and ap- peared to rouse her considerably; the pulse be- came rather more distinct. Ordered to continue the brandy. 22, nine o'clock, a m. Has been rather more live- ly during the night, and has several times spoken without being first addressed. Pulse just percepti- ble at the wrist, and very rapid. There is occasional subsultus, and grinding of the teeth. The brandy has been given three times since last night, but has never been retained. Two o'clock, p. m. Appears rather more lively; the eyes being open. Pulse just perceptible at the wrist. Breathing become laborious, with frequent sighing. Respirations forty-seven in the minute. Constant vomiting. Subsultus tendinum, with grind- ing of the teeth. A blister to be applied to the scro- biculus cordis, and an injection, T. opii Ri xxx in D. avenae f iv. to be administered. Five, p. m. Has retained several doses of bran- dy ; a tea-spoonful of a mixture of three tea-spoon- fuls of gruel and one of brandy having been given every half hour. Breathing less difficult. Extremi- ties warm. Ten, p. m, Breathings laborious, and thirty-six in the minute. Still retains the brandy. Pulse per- ceptible at the wrist, and 160. Insensible for the last hour. 23, two o'clock, a. m. Died. Examination. The vessels of the brain were not parti- cularly turgid, but there was fluid effused between the tunica arachnoides and pia mater, over the hemi- spheres and at the base. The membrane covering the pineal gland contained half a drachm of water. The plexus choroides was dropsical, but the water ^.> INJURIES AND OPERATIONS. in the ventricles was not in unusual quantity. There was some serous effusion under the mucous coat ot the larynx, which was rather more vascular than usual. No other morbid appearance. case. Mary's ward, No. 17.—Feb. 22, 1823, eight, a. m.—Ann King, aged eleven years. A severe burn from the clothes catching fire. It extends over the arms, the lower part of the abdomen, pubes, and thighs, and the neck, under the jaw on the left side. The cuticle is destroyed on these parts, and the cu- tis is very red and inflamed. She was burnt two years ago in the neck and arm by a similar accident. The pulse is quick, and pretty full; much pain and tremor. To apply spir. terebinth, to the parts, and to take T. opii gtt. xv. Three, p. m. Pulse 125. Does not complain of much pain. Sum. 01. ricini 1 ss. statim.l Five, p. m. Attacked with convulsions. Lower extremities very cold. To apply bottles of warm water to the feet, and to take a tea-spoonful of brandy in three of gruel. In half an hour the convulsions returned, and another dose of brandy was given. To take the brandy every hour. Seven, p. m. Two doses of castor oil having been given without effect, a common enema was thrown up, which procured a full motion. Ten, p. m. She is now in a state of stupor, occa- sionally convulsed. Pulse weak and frequent. Breath- ing not much affected. Pupils rather dilated. To continue the brandy every two hours. 23, ten o'clock, a. m. Not so much stupified as she was; complains of much nausea, though she takes nourishment readily. Pulse hardly percep- tible. INJURIES AND OPERATIONS. 73 Two, p. m. Stupor. Pulse imperceptible at the wrist. Six, p. m. Pulse at the wrist felt occasionally, but as slender as a thread; feet cold; breathing natural; sensible, but unwilling to answer questions; dosing constantly. To continue the brandy, and apply bot- tles of hot water to the feet. Half past eight, p. m. Pulse returned, quick, and pretty full. Tongue dry and white, with a red streak in the middle. She is more lively now% and the extremities are warmer. To continue the! brandy. \ 24, nine o'clock, a. m. Symptoms much relieved; no stupor; pulse 130 and fuller; extremities warm; t face flushed, and a general glow over the body. Has had two stools during the night, and is now more sen- sible to pain. Tongue white and moist. Two, p.m. Much the same. Pulse 128. Com- plains of pain in the belly. The turpentine having excoriated the sound parts adjacent, ordered to ap- ply simple dressing. Brandy discontinued. Haust. salin. 4tis. horis. sum. Ten, p. m. Has had two stools since two o'clock. Pulse 130. Body warm. 25, two o'clock, p. m. Pulse 110; not much flush- ed, and much better; has had several stools; tongue white and moist. Nine o'clock, p. m. Much the same. 26. Bowels regular; no fever; some appetite. 27, one o'clock, p. m. Pulse very rapid, 140, and small; feet cold; some difficulty of breathing. Five, p.m. Pulse 130, and full. The feet have been warmed by bottles of hot water. Face flushed, and hot; breathing regular; tongue white; bowels JO 74 INJURIES AND OPERATIONS. insufficiently open. Ordered, Pulv. Scammon. c. Cal gr. xij. statim. Milk diet. 28. Much better; pulse regular; no fever. March 4. Sores all improving ; health good. 10. A disposition in the elbow-joints to contract, which was prevented by the application of splints. Sores are healing kindly. She was soon afterwards discharged well. ff Remarks It may be inferred from these histories, of which scarcely a day passes in the winter season, without presenting parallel instances, as the newspa- pers of this metropolis abundantly testify, that the first three days include a period of imminent danger in these casualties. When this period is passed, re- action may be considered as established, and, speak- ing generally, the injury has nothing more in its cha- racter peculiar. Infants are sometimes suddenly attacked, and carried off by convulsions, as late as the fifth day after re-action is fully established; but this is rare. If, on the contrary, very aged, or from any cause infirm, the patient may fall a victim to the process of sphacelus, a week or ten days subsequent - to the injury, of which I have lately seen an instance, in the person of an old lady who set fire to her nec- kerchief with the candle she carried in her hand; or, after the separation of considerable portions of disorganized cutis, the patient may sink exhausted by the drain of a very extensive suppurating surface; or, from the same cause, become the subject of a confirmed hectic, terminating in pulmonary consump- tion, of which I have also seen an example. This was in a distiller's servant, who had by accident im- mersed his legs in a boiling liquid, and in whom the cutis separated completely, from the knees down- INJURIES AND OPERATIONS. 75 ward. In a case of scald, in which the superficial extent of the injury was almost equal to that of the body, and the cuticle, though raised into vesicles, was very partially removed, I have seen a sudden gangrene take possession of the injured surface on the sixth day, and carry off the patient, an adult, who had escaped the severer symptoms of direct ir- ritation. I could, of course, adduce many cases, in them- selves sufficiently interesting, of the successful treat- ment of severe burns and scalds; in which, by favor of youth and constitutional power, and assiduous at- tention, critical dangers were surmounted. But this would not aid my purpose, because they did not pre- sent the symptoms above described of primary irri- tation, amounting to a suspension of re-action. This is the broad line of distinction between the cases of death and recovery; and not so much the severity in which these symptoms exist, as their existence or otherwise. constitution? What then is the cause of this distinc- tion ? Is it constitution ? I answer generally, no; because in this first conflict, the apparently robust do not fare better in my experience than the feeble. But the opportunity of knowing the stamina of indi- viduals thus brought under our notice, is very rare, and it is a point quite impossible to be ascertained in such circumstances. It is important chiefly as regards predisposition, for the state of shock once established, whatever be the species of injury which has occasioned it, reduces all constitutions to a level. Age? Is it the period of life ? I think it probable that the greater physical irritability, and the feebler powers of resistance in infancy and childhood, may ^6 INJURIES AND OPERATIONS. be accompanied by a greater susceptibility to shock, and thus tend to swell the fatal catalogue, which, it should however be recollected, includes a larger pro- portion of young subjects from their greater liability to such injuries. The unfavorable influence of mind in adults, opposed to this, is scarcely worth appreci- ating, for in no form of severe shock is the mind capa- ble of sufficient collectedness and abstraction to be alive to its natural impulses. circumstances * Is it the extent or other local circum- stances of the injury ? These points, like strength of constitution, have more weight in regard to the after-stages than the first. Where the cutis is charred and killed, the constitutional sympathy is less than where the cuticle, ravelled up into rolls like wetted paper, leaves the living cutis bare; and, for a similar' reason, vesications however large or numerous, ex- cite less irritation than the state last mentioned. The unqualified statement that constitutional irritation is in proportion to the extent of surface destroyed, or the depth to which the destroying agent has pene- trated, would be incorrect; such a statement would apply generally, if not universally, after the lapse of three or four days from the injury, or, in other words, to the after-stages of the process; but it is unques- tionable that the situation of the injury is, as regards the first days, of greater importance,—burns upon the neck, chest, and abdomen, exclusively, proving oftener fatal by direct irritation. For this reason it is that the most destructive form of injury by fire is that in which the body-clothes are burned. Indeed burns of the extremities, exclusively, are dangerous chiefly from the extent of reparation required, over- whelming the powers of the constitution. INJURIES AND OPERATIONS. 77 rexmre? Is it on account of the texture, the seat of one of the most important functions of the animal body and the sudden arrest of this function ? if in part only by disorganization, of the remainder, it may be presumed, by continuous sympathy. If we con- sider the texture injured, as the organ of exhalation, vicarious with the pulmonary and alimentary excre- tories, or as an expansion of the sentient extremities of nerves, the destruction of which must propagate an instant shock to their source and centre, the brain —does this view offer any better solution of the phe- nomena ? The ordinary relief of the circulation, if the skin be obstructed or destroyed, may be recipro- cally afforded by the lungs and kidneys, as we see in aggravated cases of altered cutaneous texture affect- ing the entire surface ; and though the time occupied by morbid changes makes the analogy less pertinent, (as we see persons living upon a very reduced por- tion of lung, or even brain if gradually reduced,) yet we know that the organic function of the skin is more important to health than to life ; and that the lungs afford a substitute sufficient to meet the exigency, at least for a season. But the brain can offer no substi- tute for the sentient apparatus of the skin. The principal seat of tangible impressions is the surface of the body, and the involuntary sympathies con- nected with it by the medium of the brain, necessary to the due execution of the vital functions, regulating circulation, respiration, temperature, secretion, are so numerous, that the simple arrest of these sympa- thies would be sufficient to throw the system into a state of universal tumult. But, perhaps, the instant conversion of natural into morbid sensations, or irri- tants, may best explain the fatal shock which such accidents communicate to the brain, the organ to 78 INJURIES AND OPERATION>. which all sensitive impressions are first transmit- ted, whether healthy or morbid, and from which they are reflected upon the subservient organs of the system. But however these suggestions may contribute to explain the origin of these fearful symptoms, they leave us at a loss to understand why, in some in- stances, they appear, and not in others; and the question recurs, why they are occasionally fatal in less adverse, and absent in more threatening circum- stances. It is probable that the true answer to this inquiry, and which, more or less, suggests itself to the mind of the observer in every species of injury, consists in this, that all the circumstances above ad- verted to are capable of an injurious operation, either in the way of predisposition or aggravation, and that it is chiefly to their combined agency, that the unfa- vorable complexion of the case is attributable, and vice versa. Thus age, sex, constitution, the mode, extent, and situation of the injury, and the texture, may severally participate, though in unequal degrees, in determining the immediate result. To speak can- didly, treatment, both in a positive and negative sense, may, we know not how often, have a share. In some instances, pain may be added to the list of ag- gravants, but this is not a description of injury in which pain extinguishes life. On the contrary, 1 should say that in burns it is a good symptom ; the complaint of pain in the fatal cases is remarkably disproportionate to the mischief, or, at least, it dis- appears early; and it is a favorable sign, where the continuance of it seems to demand the use of opiates. The early subsidence of complaint, unwillingness to be disturbed, apathy approaching to stupor, as if the «cale of sensibility had shrunk below the point of INJURIES AND OPERATIONS. 79 pain, is invariably a fatal symptom. Continued shi- vering is an ill omen. The failure of the pulse and consequent coldness of the extremities, with a livid hue of the transparent skin of the cheeks and lips from congestion in the capillaries, drowsiness, with occasional muscular catchings, are sure prognostics of death. The disposition to coma is characteristic, and invariably occurs in a marked degree, even if no opium be given. The respiration is light, scarce- ly audible until, the pulmonary circulation failing from the diminished power of the heart, congestion takes place in the capillaries of the lungs; but this does not happen until long after the same state has pervaded the system. Finally, laborious breathing and stertor ensue, and the patient expires in an apo- plectic coma, with or without convulsions. It is remarkable to how late a period the faculties of the mind are preserved, although somewhat be- numbed, so that to rouse them a strong external im- pression is often required. A patient in a case of fa- tal burn, after the first expressions of anguish have subsided, nearly resembles a person stunned by a fall, or as much as possible stupified with liquor, without suffering an actual suspension of his senses. Inspection demonstrates fullness of the veins of the brain and its membranes, and effusion beneath the arachnoid membrane, confirming the symptoms which occur in the latter stage. But these appearances are too slight, and too frequently seen in the bodies of persons who die rapidly, to be much dwelt upon. The proximate cause of death appears to me to be a species of concussion, functional, not organic, by which the brain is deprived of its influence over the organ of circulation; for the symptoms of cerebral disorder are first manifested; secondly, a diminution 80 INJURIES AND OPERATIONS. of the power of the heart; thirdly, the respiratory function becomes impeded, as a necessary conse- quence of the two first. An inflammatory blush and oedematous tumefaction of the fauces and pharynx have sometimes been ob- served in inspections of these cases after death, but I do not know that they have been noticed in any case in which the throat and neck have been unin- jured. I shall reserve the observations I have to make on the treatment of these cases, until their pa- thology has been further illustrated by analogy. I shall now offer other miscellaneous examples of com- plicated injuries of parts not essential to life, in which the extreme state of direct irritation ensued, - which was in some destitute of re-action, in others accompanied by excitement, and in all, within a very short period, fatal. FRACTURES, CONTUSIONS, LACERATIONS, ETC. case. About six o'clock in the evening of the 2nd of July, 1819, I was called to a fine lad of thirteen years of age, who had received the charge of a mus- ket, consisting of slugs, in his thigh, from the acci- dental firing of the piece as he was standing within six feet from the muzzle. The charge entered about two inches from the trochanter major, and passed obliquely across the limb. The external wounds were small. The comminution of the bone was plainly to be perceived. There had been no exter- nal hemorrhage, but the pulse could not be felt at the wrist. His countenance was pallid; the surface cold; and the pupils as fully dilated as if under the influence of belladonna. He was perfectly rational when roused, but strongly disposed to stupor; made INJURIES AND OPERATIONS. gj no complaint of pain, but was troubled with insatia- ble thirst. Hot cloths were applied to the pit of the stomach and extremities, and warm cordial drinks freely given. He died, without any material altera- tion, except an increase of stupor, at the expiration of nine hours from the injury. Examination. The hip-joint was uninjured; the tro- chanter and upper part of the body of the femur were shattered to fragments; the surrounding mus- cles extensively lacerated; and the artery torn across. The effusion of blood was inconsiderable, the torn ends of the vessel having contracted, and receded to a distance of nearly two inches. The contents of the head, chest, and abdomen were perfectly natural, and free from any morbid appear- ance case. A waggoner, aged about fifty, fell under the wheel of his waggon, which passed obliquely across the left leg and right thigh. This happened at a vil- lage near London, at four p. m. It was ascertained upon his admission into the hospital, that both the bones of the left leg were fractured, a little above the ancle joint, and the femur of the opposite side broken transversely, a little below the trochanter. His pulse was scarcely perceptible at the wrist, and soon failed altogether; his extremities were cold; and though sensible when questioned, he lay in a state of stupor, and died within eight hours from the accident. Camphor mixture, with aether and ammonia, was repeatedly given without any obvious effect. Examination. A considerable quantity of blood par- tially coagulated was found lying around, and de- taching the muscles from the bone. The fracture extended through the cervix femoris, and obliquely 11 ^2 INJURIES AND OPERATIONS. across the root of the trochanter, so as to detach this process, and was attended with much comminution. The coats of the femoral artery presented a number of ossific patches, and a small lacerated wound was found in it, a little below the groin, from which the effused blood had escaped. My friend and colleague, Mr. Green, has obliged me with the following particulars of a case which created much interest at the time. case. « A man fell from the roof of a coach, and in the fall suffered a compound fracture of the leg. He was replaced on the coach, and brought to London, a distance of forty miles. On his arrival at the Hos- pital, he appeared as if intoxicated, but recovered from this state in the course of a few hours. On the third day, without any considerable previous inflam- mation, the leg began to assume a gangrenous appear- ance. On the fourth day he became insensible; his breathing stertorous, and the pupils of his eyes di- lated. The symptoms so much resembled apoplexy, that it was supposed some effusion of blood had ac- tually taken place in the brain. The same night, he died, and on examination no morbid appearance whatever was found in the brain or other viscera.7' For the following valuable communication, I am indebted to my friend Mr. Soden, surgeon to the Ge- neral Infirmary at Bath. case. " A girl, eighteen years of age, fractured her leg in jumping off a low wall, about one o'clock in the day. The fracture, which was a simple one, and rather below the middle of the tibia, was reduced by Mr. Hill about an hour after the accident. Cold lo- tion was used, and in the evening, the patient was conveyed home, a distance of three miles, in a boat. When her surgeon visited her at night, he found the INJURIES AJ\D OPERATIONS. g;-; bnib in a very comfortable state; the patient made »o complaint, and her pulse was only seventy-two. At midnight she appeared very restless, tossed her head and arms about, and made no reply to what was said to her. Her face was flushed, skin hot, and breathing laborious. In the morning I saw her. with Mr. Hill and Mr George Goldstone, who had also been consulted. I found her in a state of coma, with a quick and lee ble pulse, stertorous respiration, face slightly flushed, pupils contracted, and skin cold, particularly the lower extremities; but there was no difference in temperature between the sound and the injured limb. The parts about the fracture were slightly swelled and bruised, but presented no ap- pearance which could at all explain the formidable symptoms that had taken place. On examination no injury could be detected about the head About the middle of the day, the skin became hot, and thjj cir- culating system acted with greater vigor; but this state of excitement was of short duration, and at no period could she be roused so as to manifest any sign of consciousness. In the afternoon she again became cold, and the pulse weak. She expired at eight o'clock, about thirty-one hours after the ac-, cident. Examination. " About three o'clock on the following day the brain was examined by Mr. Hill, in the pre- sence of Mr. George Goldstone and myself. Our friend, Mr. George Young, was also kind enough to accompany me. The cerebrum was very firm; the ventricles were unusually dry, but a small quantity of serum was observed in the basis of the skull. The cerebellum was softer than usual, and the ves- sels throughout the brain were loaded with blood— no trRce whatever of injury was observed about the 84 INJURIES AND OPERATION ft. scalp, cranium, or brain, but it may be important to state, that the pituitary gland was unusually large and hard, and that the patient had complained, for a fort- night previous to the accident, of severe head-ache, and had talked of being bled for it." case. Between twelve and one o'clock on the morn- ing of the 27th December, 1822, a wine-porter, of robust frame, aged 54, was brought into Guy's Hos- pital, having fallen under a waggon, upon the shaft of which he was riding; and the wheel passing over his left leg, had made an extensive lacerated wound, six inches in length, on the inner side of the calf. The gastrocnemius muscle was exposed and torn, and the integuments so separated from the limb, that the fin- ger could be passed beneath them round the knee- joint. He refused to submit to amputation, which was strongly advised ; the wound was in consequence dressed with adhesive plaster and roller, and the limb placed on the outer side semi-flexed on a pillow. In the course of the day, he complained of much pain in the wound, but his countenance, manner, and pulse were natural. In the evening, the pulse be- came quick, and the patient somewhat restless, com- plaining of extreme pain in the part; his answers were quick and snappish. On the morning of the second day, it was reported that he had slept a little during the night, and had passed one stool. His countenance was sunken; pulse so thready as to be scarcely perceptible; the muscles of the counte- nance and upper extremities in a state of tremor, and he was unable to support his hand when raised from the bed. The wound seemed to have undergone no change; a poultice was directed to be applied, win^ to be taken at intervals, and a grain of opium every six hours. At three in the afternoon, he was with- INJURIES AND OPERATIONS. 8,3 out a pulse at the wrist, except for a few seconds af- ter taking his wine. His respirations were short and quick, forty-eight in the minute. The motions of the heart were thrillings rather than distinct pul- sations, the features distorted by frequent playing of the muscles, and the hands in continual involuntary motion. His manner was irritable and inconsistent; for example, taking his night-cap from his head and spitting vehemently into it. He made no complaint of pain in the limb, was rational, though short in his answers, and affected to make light of his case; was strongly disposed to doze, but quickly roused up af- ter each attempt in great agitation. In the evening he fell into a raving delirium, but though his manner \yas resolute and determined, he was easily control- led, being altogether powerless. This state continu- ed with very little intermission during the night; to- wards morning he became comatose, and expired at eleven o'clock, a. m., on the 29th, having survived the injury about sixty hours. Remarks on the foregoing cases. The first tWO of the CaSCS above related of complicated injury accompanied by an effusion of blood, bear a considerable resemblance to each other. It is probable that the loss of blood, though not in either case sufficient of itself to be a cause of death, may have influenced the period of survival, if not the symptoms consequent upon the injury. But of this I am doubtful, as the intensity of the shock would not be from this cause augmented, and the comatose disposition prevails in all cases in which re-action fails. I have heard Sir Astley Coop- er mention a case in all respects analogous to these, which occurred many years ago in Guy's Hospital. The injury was a crush of the knee-joint. The pa- «6 INJURIES AND OPERATIONS. tient pale, cold, and pulseless, but without loss ot consciousness, died comatose, within a few hours of his admission. I have seen several cases of ruptured intestine and urinary bladder, in Avhich the symptoms bore a strong affinity to these, excepting only that pain acted as an excitant, and that the progress of the cases to their termination, was slower, so much so as to admit of an abundant inflammatory secretion. I mean only to observe, that the mortal symptoms of the injury sustained, manifested themselves by similar characters from the commencement. Of the third case, which was admitted under the care of my la- mented colleague, Mr. Henry Cline, and of which I regret that so few particulars are preserved, I have to observe that it does not admit of being classed with cases of cerebral concussion, in the common acceptation of the term, that is, in a physical sense. The spontaneous recovery from the state of stupor existing on the man's admission, and the supervention of symptoms resembling those of apoplexy on the fourth day from the injury, seem to prove that he had never recovered the functional shock received at the moment of the injury, a conclusion which is support- ed by the absence of all morbid appearances on dis- section. The case of simple fracture, transmitted to me by Mr. Soden, a gentleman eminent for information and ability in his profession, is one of extraordinary in- terest and importance. For a period of several hours the patient's state was natural, and at the time when some febrile action might naturally be expected, symptoms of high nervous excitement presented themselves. This was in a few hours followed by coma and insensibility, and at the expiration of twen- ty-four hours from the injury, a slight but very tran- INJURIES AND OPERATIONS. JJ7 sitory re-action occurred; the relapse was fatal in a few hours. With the exception of vascular tumes- cence, I am of opinion that neither of the observa- tions made on inspection are entitled to notice as il- lustrative of the symptoms. Can the previous com- plaint of severe head-ache be regarded as indicative of a predisposition to shock ? The slightness of the injury, in respect of danger, and its frequency with- out any marked constitutional sympathy, almost com- pel the belief of some predisposing condition or idio- syncracy. The last of these cases was of a description the most formidable, viz. extensive laceration and de- tachment of the integument from the subjacent mus- cles and fascia. Mr. Key, who was at the time as- sistant surgeon to Guy's Hospital, and received the accident, was aware of this, and very strenuously urged the removal of the limb. Until the evening of the first day, the man was in all respects as well as could be wished, and even then the only change ob- servable was a little pettishness of manner in an- swering questions, for which continued and extreme pain throughout the day sufficiently accounted. The morning of the second day discovered a fatal altera- tion. The powers of life as evinced in the imper- fect and irregular actions of the muscles from the heart downwards, were failing rapidly. The excite- ment produced by wine and opium, with which he was plied freely throughout that day, terminated in a paroxysm of frenzy, and this in exhaustion. From the direct effects of such an injury the soundest con- stitution has but slender chances of escape. The subject of this accident was a hard drinker, to which his calling invited, a circumstance by which I appre- hend his chance wa<< further diminished. I watcher! gg INJURIES AND OPERATIONS. ed him narrowly during the state of agitation describ- ed on the afternoon of the second day ; every mus- cle was in motion, not a vigorous spasmodic contrac- tion, but like the tremulous and transient twitching produced by slight and often repeated galvanic shocks. It is to be regretted, chiefly for form's sake, that no opportunity was afforded of examination af- ter death. / OPERATIONS FOR RECENT INJURIES. ' I shall now present the reader with one or two histories of operations performed for recent injuries, exhibiting symptoms of extreme direct irritation, nearly allied in character, and as I believe in their origin to the foregoing, with some not unimportant varieties. case. Bryan, a stout lad of fifteen, whose employ- ment was to feed a wool-carding machine, had his wrist and hand literally smashed to pieces, by being drawn into a part of the apparatus. There was lit- tle or no hemorrhage, and he bore the amputation at the middle of the fore-arm, which was performed im- mediately on my arrival at St. Thomas's Hospital, at nine in the evening of the 29th June, 1818, almost without complaint. 30th, nine a. m. A quiet night, makes no complaint of pain or spasm of the stump. Pulse rather quick and full. Cap. 01. Ricin. 1 ss. statim. One p. m. Three copious evacuations of a bright green color. Since the last he has complained of nausea, rejected all diluents given to relieve the thirst, which has been distressingly urgent for the last two hours. Pulse very quick, and the beats not quite distinct. The upper part of his body, particu- INJURIES AND OPERATIONS. #9 larly the breast and forehead, are covered with a co- pious cold perspiration. Complains only of thirst and sickness. Five, p. m. The effervescing saline draught giv- en since the last report is not retained. Five drops of tincture of opium to be added to each draught. Ten, p. m. The vomiting is the same. Every thing is rejected with violent retching. The extre- mities are cold, partial sweats profuse; the beat of the heart is quick and sharp, but the pulse does not reach the wrist. Respiration much oppressed, with great anxiety of countenance, and distress about the praecordia. Occasionally drops into, a doze, and sud- denly wakes powerfully agitated. July 1st, seven, a. m. Has passed the night in the state last described. A pill of five grains of calomel and one of opium has been twice given at an interval of two hours, and instantly thrown up. I directed cupping-glasses to be applied to the scrobiculus cor- dis, and after drawing a few ounces of blood, a large mustard poultice to be laid upon the same part. Twelve at noon. No favorable change; extreme anxiety, cold clammy surface. Countenance livid, and extremities purple from venous congestion. Re- spiration goes on by the intercostals only, and with great labor. Two, p. m. Alcohol in the form of wine and bran- dy has been given ; of the latter, some was retained, and the vomiting was evidently abated for about an hour and a half after the cupping and application made to the stomach, though without the smallest effect upon the circulation. An enema containing three grains of opium was administered. The anx- iety and labor of breathing continued till his death, 12 90 INJURIES AND OPERATIONS. which happened at five, p. in., about eight-and-forty hours from the accident; and till within half an hour of dissolution his senses remained perfect. Esamination. The examination was made with great care the following morning. All the organs were re- markably sound and healthy, nor was any morbid ap- pearance discoverable in any part of the body, ex- cept a slight erythematous blush upon the villous coat of the stomach—an effect, I considered, of the incessant inverted action of that viscus. I may observe, by the way, that this is one of four cases of amputation of the hand in healthy lads, two at the wrist-joint and two above it, which I have been called upon to perform for the same accident. The other cases were unattended with any extraordinary symptom and did perfectly well. My friend Mr. Brodie favored me with the inter- esting case which follows : case. " Richard Dodd, a patrole, 50 years of age, was admitted into St. George's Hospital about one o'clock on the morning of Sunday, the 5th of Feb- ruary, 1815. He had had a pistol in his belt loaded with slugs and nails. While he was sitting down the pistol was by accident discharged, and the contents of it went through the upper part of the thigh. This happened about an hour and a half previous to his being brought into the hospital. " On examination, I found a very large longitudinal wound on the fore-part of the thigh, extending as high as the crural arch, where the slugs had enter- ed ; and an extensive lacerated wound of the skin and muscles on the outer and posterior part of the thigh where the slugs had passed out. The thigh- INJURIES AND OPERATIONS. 9 J bone close to the hip-joint was broken in several pieces. There had been bleeding, but to what ex- tent could not be ascertained. The trunk of the fe- moral artery had escaped injury, the wound being situated about an inch and a half on the outside of this vessel. On his first admission into the hospital, the man complained but little of pain, but in about half an hour the pain became excruciating. His pulse was regular, full and strong, beating from 84 to 90 in a minute. " As nothing short of the removal of the limb at the hip-joint seemed to afford any chance of recove- ry, and as the man consented immediately to the operation, I proceeded to perform it at a quarter be- fore two o'clock. The operation was accomplished without much difficulty, the trunk of the artery hav- ing been previously secured underneath the crural arch, to prevent the loss of blood as much as possi- ble ; and a large flap of skin and muscles was form- ed on the inside of the thigh, the soft parts on the outside having been too much injured to be useful for this purpose. " The patient having been replaced in bed at half past two, a. m., was very faint and the pulse scarcely perceptible. At three, a. m., the faintness less. At four, pulse 141, weak and irregular; a little blood has oozed through the bandages. At six, a.m., pulse nearly the same. He had been sick and vomited; he complained of a little pain in the stump. At se- ven, a. m., he was nearly in the same state; the sick- ness and vomiting continued; when he attempted to swallow any thing, it was immediately rejected from the stomach. The oozing of blood had ceased. At eleven, a. m., the nausea and vomiting continued; he had taken cordials, but they were always rejected 92 INJURIES AND OPERATIONS. from the stomach. He was perfectly sensible ; had no disposition to sleep. Pulse 160 in a minute, and stronger. At two, p. m., he was nearly in the same state. I prescribed him an enema, with forty drops of tincture of opium. Previous to the administra- tion of the enema he had an evacuation from the bowels, and after he had the enema he dozed for nearly two hours, but he was not refreshed by it. At four, p. m., his stomach continued to reject whatever was given him to swallow. Pulse 164 and feeble. At eight, p. m., the sickness and disposition to vomit were relieved, so that he was able to take brandy in small quantities. He became very restless and un- easy. At nine, p. m., he was in a state of low deli- rium ; pulse scarcely perceptible. A quarter before ten he was insensible to external objects, breathing with difficulty; pulse not perceptible, but the heart could be felt acting irregularly and feebly. At ten, p. m., he was seized with convulsions and died, hav- ing survived the operation about twenty hours." Remarks. The period of the accession and duration of the disorder constitutes the chief difference be- tween these cases. This difference is, I apprehend, to be attributed to the greater severity of the injury and operation, and the unavoidably larger loss of blood in the latter. No interval transpired before the commencement of the symptoms; the prostra- tion was rapid and uninterrupted, and life could not be maintained beyond twenty hours. In the case of Bryan, on the contrary, the system, which was not ab- solutely exhausted in less than forty-eight hours, pre- served a comparative tranquillity for the first twelve, and the symptoms of irritation then presented them- selves, as in the case of the girl, page 82, in lieu ©f INJURIES AND OPERATIONS. 93 lever. These were an excessive velocity and fee- bleness of the pulse, increasing to indistinctness, then a total failure of the pulse, with cold sweats, while the beat of the heart was quick and vibratory; the unceasing struggle of respiration seemed to be an ef- fect of spasm. The predominant symptom in which these cases coincided is characteristic of the most intense degree of shock, viz. the early and unap- peasable irritability of the stomach. Does the pro- longed or re-iterated aggravation of the injury, by the operation which succeeds it, at an interval of one or more hours, tend to the production of this symptom ? In neither of the cases last related did it occur. I subjoin a case of that less frequent form of di- rect irritation which I have denominated " prostra- tion with excitement," and which occurred very shortly after that of Bryan, above related. It will I trust be read with interest, and not the less that its termination was fortunate. case. Pike, a stout lad of fourteen, on the evening of the 20th of August, 1818, had his leg jammed by a piece of timber falling upon it. The tibia was comminuted rather above its middle. The integu- ments on the fore and outer part of the leg were se- parated from the bone and muscles, from a little be- low the tubercle nearly to the outer malleolus, and the extensor muscles considerably lacerated. He was pale and sleepy from a free hemorrhage. The bleeding had ceased on his admission, but returned in a few minutes, and a tourniquet was applied. He was received into the hospital about eleven o'clock, and at midnight I amputated the leg an inch below the tubercle. The incision through the integuments g^ INJURIES AND OPERATIONS. was carried obliquely downwards as it extended backwards, so that a semi-oval flap was formed, the verge of which corresponded to the centre of the gastrocnemius muscle. The superior part of the wound was unavoidably included in the formation of the stump, but as there was not much contusion, this was not considered of importance. It was united by suture, and the flap being brought up from below, the edges were approximated, a roller having been pre- viously applied so as to bring the integuments as much as possible forwards from the thigh. One lig- ature only was employed. During the operation he was very faint; the pulse extremely quick, and some- times almost imperceptible. A small quantity of wine, and twenty drops of laudanum were given, but rejected before he was carried to bed. 21st, five, a. m. H:is been restless, and slightly de- lirious ; frequent muscular catchings. Seven, a. m. Has vomited again, but has since taken a cup of gruel, which he retains; is disturbed by the convul- sive action of the muscles. Ordered to take twenty- five minims of tincture of opium. In ten minutes he fell into a tranquil sleep; the pulse sunk to 94, and increased proportionably in fulness. Two, p. m. Disposition to coma; rather incoherent, but can give a rational answer when roused; pulse 120, and full; tongue white; no evacuation from the bowels since last night. Ordered to take an ounce of castor oil. A cloth dipped in cold water to be kept constantly upon the stump, which oozes a good deal. Five, p. m. The lips parched; skin hot and dry; pulse in- creasing in fulness and frequency; no motion from the oil. Six, p. m. Since last report has had a con- vulsive attack, which, from the description given of it. was epileptic. The pulse is now very rapid, the INJURIES AND OPERATIONS. 95 eyes are fixed, and the body covered by a profuse perspiration. Breathing quick and laborious. Ha- beat enema domest. statim. Nine, p. m. Still no al- vine evacuation, but the more violent symptoms have subsided. He is now comatose, does not answer questions, and seems impatient of being disturbed. Pulse 100, and soft; skin moist: rep. ol. ricin. Ele- ven, p. m. Bowels not relieved ; constitutional disor- der increasing. After sleeping ten or fifteen minutes he suddenly starts up, bawls vehemently, and then falls back upon his pillow. Six ounces of house phy- sic were administered in the form of an enema. 22d, nine, a. m. Continued very restless until six o'clock, when his bowels were relieved, and he be- came composed. Ordered, Castor :gr. x. Opii gr. J M. f. bolus. 4,is horis sum. Two, p. m. Has been to- lerably quiet since taking the medicine, but when awake is some time before he can give a rational answer. Three copious pale evacuations. Ten, p. m. Evidently better, sleeps soundly for half an hour together, and answers readily. Pulse 110, and soft; skin hot and dry ; face flushed, tongue white, but not thickly coated ; but little muscular catching. 23d, eight, a. m. Has passed comparatively a good night, is perfectly sensible, makes no complaint; pulse 100; tongue less coated ; no evacuation since yesterday afternoon; subsultus has entirely ceased. Two, p. m. The enema domest. was again adminis- tered, which in the course of the afternoon produced two copious evacuations. He has at intervals slept soundly during the day. Pulse 100, full and soft; skin still hot and dry; tongue much cleaner; no anxiety of countenance. 24th, eight, a. m. Has slept soundly from three o'clock. Tongue perfectly clean; skin and pulse as 96 INJURIES AND OPERATIONS. before. Ten, p. m. Has had a natural motion, and passed the day comfortably. 25th, seven, a. m. Complains of a beating sensa- tion at the extremity of the stump. Catap. lini. Two, p. m. Dressings removed. No adhesion about any part of the stump, but suppuration profuse and foetid; the edges of the wound, particularly toward the inner part, sloughing; the flap supported by adhesive plaster. 26th. Discharge less, and more purulent; bowels regular; countenance tranquil; poultice to the face of the stump. 27th. Suture supporting the flap has given way: surface cleaner, and disposed to granulate. 28th. Ligature separated ; sloughs throwing off' kindly: discharge purulent, and not in excessive quantity; about one inch of the extremity of the tibia denuded of periosteum; the granulating edges above drawn as much as possible downwards, and the flap still supported by a strap of adhesive plaster. Sept. 2d. Health improving; appetite good ; slough all separated, and the entire surface granu- lating kindly. 9th. The shell of bone not yet detached; health good; granulations exuberant. 16th. The angles of the flap cicatrized; the sore much contracted, and health continuing good. Oct. 7th. The flake of bone broken off by forceps, leaving a healthy surface exposed. From this time the wound healed quickly, and he was shortly after- wards discharged in good condition. INJURIES AND OPERATIONS. 97 OPERATIONS TOR CHRONIC DISEASES. The next cases in the order of my subject are those of operations for chronic states of disease, proving fatal by direct irritation. I shall confine my illustrations to some remarkable cases of lithotomy in children. case. A child, three years old, was the subject of lithotomy at St. Thomas's Hospital, in the summer of 1805. The operation was admirably performed, and did not exceed one minute by the watch. A slight shivering came over the patient on being replaced in bed; and the natural temperature of the surface was not restored. He was inclined to doze, and a little convulsed, and at two o'clock the following morning died. Although this child suffered considerably from the disease, he was otherwise healthy, and his death, which excited much surprise, was attributed to fright. case. On the same day, a boy of five years old was cut by the same gentleman, and though some minutes elapsed before the stone was extracted, he recovered without an unfavorable symptom. case. In December, 1807, a child, aged three years and a half, underwent the same operation under as favorable circumstances. An hour after being put to bed, he also chilled; a stupor came over him, but without convulsion; and he gradually sunk into a state of deliquium, and died before ten o'clock the same night. rise. About the same time, a lad of sixteen was cut at St. Thomas's. Every thing went on well in the theatre; the same chilliness and torpor ensued, 13 98 INJURIES AND OPERATIONS. he sunk rapidly, and died at nine o'clock the saim evening. In each of these cases, the unfavorable symp- toms shewed themselves about an hour after the ope- ration ; all of them watered, but not so abundantly as usual. In neither of the preceding cases was the calculus remarkably large, nor had any unusual hemorrhage or other untoward circumstance occurred during the operation. So many unfavorable results within a short com- pass of time, led to minute inquiries, on the part of the surgeons, as to the previous habits and nourish- ment of these patients; and the conclusions formed from the information thus obtained, led to the mode of treatment so successfully adopted in the case which follows. case. A child, six years old, became restless with- in an hour after the operation, which had been in all respects favorable. Between five and six o'clock, the operation having been done at noon, he was cold, faint, without a pulse at the wrist, and apparently dying. In this state, gin and aether diluted with bar- ley water were got into the stomach, and repeated at intervals, until the pulse acquired a steady beat, and the surface its natural warmth. Its effect was immediate, and as salutary as could be desired. In diminished quantities the cordial was occasionally administered during his convalescence, which was from this time uninterrupted. It was in fact ascertained that the parents of these children had been in the habit of giving them gin, to allay the severity of the paroxysm in micturition. The same treatment has been since resorted to in cases where similar symptoms have presented them- INJURIES AND OPERATIONS. 99 selves. A man from the neighbourhood of Maid- stone declared that he could not survive the opera- tion, if deprived of his ordinary beverage. I introduce the following case in the words of my friend Mr. Young, as strikingly illustrative of the same principle. case. " A livery-stable keeper in Moor Fields fell with his horse and broke his leg; I saw him soon af- ter the accident; he was cold, pale, with a thready pulse; yet he was calm and self-possessed, and took a part in directing those who removed him to his bed, and who afterwards assisted me in placing his limb properly. On the following morning, I was inform- ed that he had taken little or no notice of any thing; that he had refused whatever was offered to him, and that he had not moved, but lain as if in sleep, as I then saw him; breathing very gently, with a pale, cold surface; a thready and rather quick pulse. I could rouse him by speaking firmly; he answered rationally, put out his tongue, said he had no sort of pain in the limb, which was cool, and not in the least swollen. I urged the necessity of his taking nourish- ment, and as he preferred porter, I gave him by spoonfuls, a pint, and directed that he should take beer caudle freely. He gradually recovered, but se- veral days passed before he felt quite restored, or complained of pain, or that any swelling was percei- vable in the broken leg. " Precisely the same train of symptoms, ending however in the gradual extinction of life, followed a the removal of a large fatty tumor from the fore part of the thigh of a middle-aged woman. The opera- tion was quickly over, and had been borne with ex- emplary self-possession." case. In January, 1808, a young and delicate child was cut for the stone, at Guy's Hospital. The opera- jqq INJURIES AND OPERATION'S. tion was favorable, but symptoms of irritation, and ultimately, a state of stupor succeeded, and the child died on the morning of the third day, in strong con- vulsions. case. In 1822, a fine boy of eighteen months, from Essex, was the subject of a private operation for li- thotomy. The stone, which was oblong, was easily extracted. A somewhat freer hemorrhage than or- dinary occurred at the moment of the incision, but it was immediately restrained after the removal of the stone, and was too inconsiderable to create anxiety. The child, though somewhat languid and drowsy dur- ing the remainder of the day, wetted freely, and passed the night without complaint; but early on the following morning was attacked with convulsions, and died suddenly. In the afternoon of the same day, the body was minutely and carefully examined; the incision of the prostate was clean and smooth, the bladder healthy, and no morbid appearance whatever presented itself. Remarks. The preceding cases speak for themselves. The youth of the patients, the debility induced by previous suffering, the influence of terror or of pain, the loss of blood, and in some the privation of an habitual stimulus, when really needed, may have been one or all accessary to these untoward results. When a degree of vacancy and stupor comes over the child shortly after replacing him in bed, and the countenance and general surface assume the paleness and coldness of death; the pulse, small, rapid, and * indistinct, soon ceases, and the patient becomes in a few hours comatose, and in that state expires. This is the extreme state of prostration from shock. There is no essential difference, or rather there is INJURIES AND OPERATIONS. 101 a close analogy in the symptoms and general state of these children, and of the subjects of the severest burns and complicated injuries. It will be observed, that in the two cases last re- lated, the patients died in convulsions. The una- voidable effusion of blood in operations, though in- sufficient to create alarm for the patient's safety on that score, obviously predisposes to the convulsions which sometimes prove fatal, especially to children. I have known an infant die of convulsions on the day after the removal of a naevus from the scalp, of no extraordinary size and without any after-hemor- rhage. convulsions. The phenomenon of convulsions is inva- riably coupled with the state of cerebral irritation. This irritation may have been propagated to the brain from any suffering organ, as from a wounded muscle or nerve; from worms, or sordes in the primae viae, suppressed catamenia, or tension of the gums in dentition; or it may arise from the pressure of bony spicula on the brain; laesions, vascular congestion, or effusion in that organ. In either case, convulsions are symptomatic of disturbance, amounting to an in- terruption or temporary suspension of the cerebral influence, whatever that may be. We see these spasms arise in apparently opposite states of the system—in the plethoric and the ex-san- guine—in the robust and the debilitated—in conges- tion and in effusion—in acute inflammation and in de- structive ulceration. Severe local irritation will occasion vascular con- gestion, and ultimately effusion in the brain, and hence gives rise to convulsions. Inflammation, being a frequent cause of local irri- tation, also operates to produce convulsions. When jQ2 INJURIES AND OPERATIONS. the irritating cause is in its nature such as to admit of removal, the convulsions cease upon its removal. Thus I have seen them cease after removing a spi- culum of bone by the operation of the trephine; also after the discharge of confined matter; by blood-let- ting in parturient women; by the same and the opera- tion of purgatives in recent acute inflammation, as in hydrocephalus, prior to effusion. The tendency of a local irritant to produce convulsions is augmented by any sudden depression of power, as for example by shock, by hemorrhage. When the system is thus exhausted, convulsions are often abrupt in their ap- pearance, and overwhelming in their effects, as in the cases last related. This occurs most frequently in infants, and is chiefly owing to the powerless and unresisting condition of the body; for the irritation acting singly, i. e. unaccompanied by such depression, gives a more permanent character to the convul- sions. In short, there is an active and a passive form of convulsions, and to the proper treatment of the dis- ease upon which they are symptomatic attendants, the understanding of this distinction is of the last importance. In one case we look for relief to cor- dials and tonics, in another to venesection and pur- gatives. In the commencement of inflammatory diseases, whether affecting the brain or other organs, convul- sions, if present, are of the sthenic kind, and sub- side by the free use of the lancet; but if this treat- ment be pushed too far, or the inflammation should terminate in effusion or disorganization, the powers of life yield, and they become asthenic or passive, i. e. symptomatic of exhaustion. Such are the con- vulsions which appear after hemorrhage or any other INJURIES AND OPERATIONS. 103 rapid depression of the system, and in the last stage of acute diseases. The smallest direct reduction of strength will, in such cases, extinguish life. It can only be maintained by the timely administration of such aliment and medicine as support without excit- ing, and therefore tranquillize the system. It is with this form of convulsions that we have to do in most cases of prostration following injuries and operations, but not in all, as is shewn in the case of prostration with excitement, Pike, p. 93. With every sign of high cerebral irritation, this symptom presented itself in an alarming shape, viz. a fit re- sembling epilepsy. The relief obtained in this case by exciting the action of the bowels was most mark- ed, but there was insufficient vital power to have warranted even the most temperate use of the lan- cet, and on the other hand, stimulants of any kind were totally inadmissible. When convulsions sud- denly extinguish life, or, in the common phrase, a pa- tient expires in convulsions, as in the state of pros- tration indicated by the previous signs of cerebral torpor (Cases pp. 99, 100), they most probably de- stroy by arresting the muscle of respiration, and perhaps the heart, and the external affection is con- sentaneous, or even secondary. In a limited sense, life is always terminated in convulsions. SECTION III. INFLAMMATION FOLLOWING INJURIES AND OPERATIONS. I proceed to exemplify the phenomena of direct irri- tation arising from the inflammation ensuing upon in- juries and operations. 104 INFLAMMATION FOLLOWING case Mosely, aet. forty, was admitted into Guy's Hospital on the morning of Jan. 1, 1823, for a super- ficial collection of matter in the palm, with an exces- sive inflammatory oedema of the whole hand and fore- arm. He stated that he had bruised the back of his hand with an iron hook, five days before, and had since poulticed the part. The original wound was now nearly healed. The abcess in the palm was freely opened and two ounces of sanious unhealthy matter discharged; it was again poulticed. In the evening three gangrenous vesicles appeared on the back of the hand ; the man was in a state of severe irritation, as was indicated by his countenance and manner. His eyes looked glassy, and their pupils contracted; his pulse was very small and quick, and his tongue much furred. During the night all the symptoms of disorder were aggravated; his restless- ness became delirium, and on the next day (the seventh from the injury) which closed his existence, the whole arm was found to be in a state of gangrene. / case. Woodcock, aet. sixty-six, a muscular strong / featured woman, washing a gown in pearlash, in No- ' vember, 1808, pricked the ball of her left thumb with a concealed pin. Next day the finger became much swelled and painful, and on the morning of the third day the swelling affected the whole hand and wrist, while the inflammation was spreading alarmingly upon the fore-arm; the swelling and redness were equally diffused, and not confined to tj^e track of the absorbents. The pain was excruciating, and the constitutional disorder extreme; viz. a quick, small, jerking or vibrating pulse ; dry foul tongue; precor- dial oppression; total failure of appetite; thirst; great restlessness and anxiety. After repeated and copious leech bleedings, continual fomentations, free INJURIES AND OPERATIONS. 105 purging with calomel, and the exhibition of antimoni- al opiates, the swelling and redness subsided, and the inflammation was arrested in its course, midway be- tween the shoulder and elbow, on the eighth day from the accident. But the hand now assumed a livid cast; large phlyctenous vesications appeared, both on the palm and dorsum; the pulse was very small and feeble; the tongue covered with a dry and dark crust; she was exceedingly depressed, and refused both wine and nourishment. In the evening andduring the following night, she was violently delirious, and with difficulty kept in bed; in the morning she ap- peared exhausted; stupor succeeded, and she died in that state on the ninth day from the injury, at one p. m., the hand and arm presenting a state of sphace- lus. case Laurisson, aet. seventeen, a healthy lad, on the 29th of November, 1819, received a severe wound from a piece of timber, in endeavouring to defend his boat from being run down by a barge. On his admission into Guy's Hospital, it was ascertained that the integuments in front of the knee-joint were lacera- ted, so as to expose the insertions of the vasti and rectus muscles; there was besides an aperture in the hollow of the ham, into which the little finger might be passed. There was no considerable hemorrhage, nor any escape of synovia, so that the joint was thought to be uninjured. The edges of the wound were approximated with strips of adhesive plaster, and the limb placed in a relaxed position. In the evening he complained of cold and numbness in the injured limb; his whole system seemed much depres- sed, and he was strongly disposed to sleep. His bowels had been once relieved; his pulse was 120 and small. He was ordered the camphor mixture 14 106 INFLAMMATION FOLLOWING and julep, ammoniae acetatis, with twenty drops of laudanum, every four hours. The next day there was much pain and tension in the knee and calf of the leg: the plaster was removed, and the knee en- veloped in a poultice. Symptoms of irritation were present and increasing. On the third morning the boy was much changed, the constitution sympathis- ing deeply, and great general debility very manifest. The leg was cold, clammy, and senseless, on the verge of gangrene. The surgeons in consultation declined amputating. On the twro following days, mortification spread rapidly over the whole limb. On the fifth day, at noon, he died. Examination. On examination neither the popliteal aptery nor nerve, nor any principal branch, appeared to have been injured. The popliteus muscle was torn across, and a small orifice was discovered in the capsule of the joint, behind the external lateral ligament. The edges of this wound, and the synovi- al membrane lining the external half of the joint, pre- sented an appearance of very high inflammation; while the fossa for the reception of the internal con- dyle, and its membrane, were in a perfectly healthy condition. Much blood was extravasated in the muscles and cellular membrane surrounding the joint. case. Fretter, aet. thirty, 21 st Dec. 1822, was thrown from a horse upon the stones, and the animal falling upon the patient's left leg, produced a compound fracture of the tibia at the inner malleolus, and a frac- ture of the fibula three inches above the joint. The man was immediately carried to Guy's Hospital- The joint had been opened, but not extensively, by the accident. A small splinter of bone, which pro- truded, was removed, and as the external wound INJURIES AND OPERATIONS. JO/ was small, with little surrounding injury, a dossil of lint was applied to it, and the limb placed in the half-bent position on its outer side, upon a splint resting on a pillow; the whole of it covered with linen, moistened with spirit wash. Five grains of calomel, and one of opium, were given at bed time. Next day, the pulse being quick and hard, the patient was blooded to ten ounces, and the pill re- peated at bedtime. On the third day it was reported, that the patient had passed a restless night. The pulse was 120, and hard; the bowels were moved, three times by a dose of castor oil, and the patient was ordered the julep, ammon. acetatis every fourth hour. A poul- tice was laid on the wound, without disturbing the lint. Fourth day. The limb was considerably inflamed, and the fever had rather increased. Fifth day. The patient had passed a very restless night. The entire limb was much swollen, and the foot put on a gangrenous appearance. The pulse less frequent, and small, occasionally irregular. Twenty drops of tincture of opium were added to the saline draught every fourth hour. Sixth day. The patient was much sunk, and the opium was discontinued, as it seemed to affect his head. The foot and leg were evidently gangrenous, and the discoloration was rapidly extending to the, thigh. The pulse was so small as scarcely to be felt and fluttering; the countenance sharp and hollow. Short fits of delirium, and a floccitation with subsul- tus tendinum, were the symptoms preceding his dis^ solution, which took place at 9 o'clock, p. m. Examination. On examination of the limb, the leg and thigh were found to be in a highly putrescent state : jqq INFLAMMATION FOLLOWING the anterior and deltoid ligaments were entire, so that no dislocation had occurred. The fractured bones had undergone no change, but all the muscles, even to the psoas and iliacus, were so completely softened in texture as to admit of easy laceration with. the finger. case. Fuller, aet. forty-two, was brought into St. Thomas's Hospital with a compound fracture of the leg four inches below the knee, from the falling of a plank upon it on the morning of the 3d of September 1819. This wound was two inches long, and appear- ed as if incised. The fracture was oblique, and the lower fragment protruded at the wound. A small portion of this was removed with Hey's saw, and the reduction easily effected. The limb was then placed in a straight position on a pillow, the wound dressed as a simple wound., with adhesive straps, and the long splint applied. In the evening it became neces- sary to change the dressings, owing to the free ooz- ing of blood. The limb was but little swollen. Pulse 70. Second day. Had passed a restless night. The limb exceedingly painful. A slight shivering, fol- lowed by heat. Tongue white; pulse 96, full and soft. In the evening, complained of intense pain at the seat of the fracture. The bandages were loosen- ed, and short splints substituted for the long; his bowels had been relieved in the course of the day ; pulse 120, with some hardness; skin hot and dry. He was blooded to sixteen ounces. Third day. Had had a better night; limb but little swollen; wound looked favorable. Fourth day. Had slept well, and but little pain. The limb was more swollen and tense: and a blush INJURIES AND OPERATIONS. jq£. of inflammation extended along the outer side of the leg, and inner side of the thigh. Pulse 120. * Fifth day. Had passed a quiet night, with some sleep. The leg was more swollen and discolored, and the blush of color extended upon both sides of the thigh as far as the trochanters. A thin dark co- lored fluid issued from the wound ; complained little of pain; bowels gently open; pulse 100. A poul- tice ordered to the wound and a spirit wash to the rest of the limb. He was to take saline draughts, with a few drops of opium tincture in each. Sixth day. In all respects the same as yesterday. Seventh day. Had had no sleep, owing to ex- treme pain in the leg; two or three vesicles appeared on the outer side of the leg, and one large vesicle on the foot. The tension and discoloration bf the limb were reduced, and the wound discharged good pus; bowels open; pulse 100; little fever. Eighth day. Had passed a very restless night. The whole leg was more discolored. Complained of se- vere pain in the outer ankle, which had a worse as- pect than the rest of the leg. Wound discharged scantily; pulse more frequent and small. Ordered bark, with opium and porter. Ninth day. State of the limb the same; that of the system much altered for the worse. His counte- nance pallid and sunk, and his strength evidently declining rapidly. Ordered wine ad libitum. Tenth day. Leg covered with dark colored vesi- cles, and a few appeared upon the surface of the thigh, near to the groin ; no complaint of pain; symp- toms of exhaustion. Eleventh day. At six in the evening, he expired. Examination. The tibia was extensively fractured ; two; portions of bone were completely detached, and thc j jq INFLAMMATION FOLLOWING upper fragment of the tibia had a longitudinal fissure,. The fibula was also much comminuted; there was a partial laceration of the tibialis anticus muscle, and a lar^e collection of matter found in the breach of it. The viscera were all sound and healthy. Remarks. Moseiy. woodcock. These cases exemplify the rapid and fatal termination of acute inflammation of the tela cellulosa, consequent upon slight wounds, in extraordinary constitutional irritation. This is by no means, however, a legitimate consequence of the mischief inflicted. When such eases have been per- mitted by the patient's neglect, or slight appreciation of an injury apparently trifling, to reach a certain point, the efforts of art are often ineffectual to preserve life. The patient in this class of life seldom applies for proper assistance until, to use his own phrase, he "feels ill all over." Then we find him labouring under the established symptoms of constitutional ir- ritation. A contracted and quick pulse, foul and en- crusted tongue, rigors and flushes, great anxiety, be^ wildered expression, constant vigilance, diffused pain, &c. Then follow increased rapidity and inter- mission of the pulse, cold clammy surface, hiccup*, subsultus, muttering, or paroxysms of frenzy, stupor, and death. This is a description of case which happens, yet" more frequently in the lower limbs. An old leg ulcer, a slight recent injury, as an abraded instep^ ancle, or shin—a diseased toe-nail, an inflamed corn, or gang- lion, irritated to acute diffused inflammation of the cellular membrane of the limb, gives origin tea con- stitutional state over which medicine has little con- trol. Unquestionably the susceptibility to such a state is greater in the aged, the dram-drinker, the INJURIES AND OPERATIONS. HJ man of broken constitution; but in these the aggra- vation is less because the constitution sooner takes alarm. The robust and healthy, relying on the sound- ness of constitution, quickly reach the same pe- rilous crisis by braving the evil. " This ought not to have been," is the instant impression which the sight of the case conveys. This the patient always feels, and'often expresses; but to look back is as little con- solatory as the prospect. I have known eminent practitioners prescribe calomel and jalap every six hours; ^within two days of the patient's decease, in the belief that so vitiated a condition of the visceral secretions as of course and consequence exists, is yet the gravamen of the mischief. At the same time wine and strong nourishment have been proscribed. This is the ultraism of faith in certain doctrines un- impugnable when unabused, but capable, like every thing excellent, of being injured by a blind devoted- ness. The most important practical indications which these cases convey are, 1st, early and free venesection to the relief of pain ,l 2nd. early and free openings of abscesses. If these are overlooked, the effective aid of medicine is questionable; if they are fulfilled, it is capable of affording most essential bene- fit, both in the stage of excitement and collapse. The common error is reliance upon topical blood- letting, till general blood-letting is interdicted. This was the point lost in both these cases. Under a pru- dent restriction, pain may be taken for a director to the use of the lancet, even in incipient gangrene. It is not the process of mortification which des- troys in these cases; it is the irritation of the ner- vous system by the inflammation, and the acutely- agonizing pain which accompanies it. When the powers of life are well nigh exhausted, the part, the ]22 INFLAMMATION FOLLOWING texture of which has been broken up by the disease, presents the phenomena of gangrene; but this is an effect, not a cause of the constitutional malady. The general impression which the appearance of gangrene on the eve of dissolution has given, is erroneous. The part is disorganized, and no longer retains the principle of resistance to decomposition, but the mis- chief is done before the discoloration and bloody vesicles appear; nay, it as often happens before the part has so lost its organization as to part with its vitality. How many instances do we see in which with very moderate constitutional disturbance, gan- grene passes on to sphacelus, and limbs are separated, to use Mr. Hunter's phrase, by 4 the natural surgeon.' But the power required for the process of separa- tion depends upon a less disturbed state of the sys- tem, a state comparatively tranquil, and opposed, in all respects, to that of direct irritation. Laurisson The gangrene in the case of Laurisson was an obvious result of the irritation communicated to the system by the acute inflammation, following a penetrating wound, of the knee-joint. With the joints the sympathy of the brain is most active ; even the instant effects are severe, indicated by a peculiar depressing pain, nausea, faintness, cold chills and tremors pervading the entire frame. The acute in- flammation of the synovial membrane, however ca- pable of producing irritation under any circum- stances, would not have given rise to such extreme universal disorder as was indicated by the state of the patient, and of his limbs, on the third day, unless combined with the shock of severe injury An in- flammation from sprain or contusion without a pene- trating wound, and still less, from cold, or- constitu- tional causes, would either not have assumed the INJURIES AND OPERATIONS. 113 same degree of intensity in the interval of time, or would have obtained relief at once by the natural events of effusion or of suppuration; but the sudden and remarkable depression of the nervous system determined the arrest of the inflammation in its first stage; and the disorganization of the limb ensued, not from mechanical interruption of the vessels or nerves, for this did not exist, but from the prostration of vital power. Already, i. e. on the third day, the patient was too much sunk to make the removal of the limb a justifiable proceeding. Inflammation of the stomach would scarcely have destroyed life more rapidly, it would have destroyed it however on the same prin- ciple. Fitter cuiier In Fretter's case we see the symptoms of irritation consequent upon one of the severest forms of reparable injury, increasing with the inflam- mation up to the fifth day, and terminating in those of dissolution on the sixth. Fuller was a country labor- er, of a spare frame, a sound and inirritable consti- tution. In his case the same career of symptoms was only a little more protracted. The mischief in both cases was sufficient to excite the highest inflam- matory action. This could neither be prevented nor repressed by the adoption of measures which might have been effectual for one or other of these purposes, in the absence of extensive disorganization. These are the cases involving the important question of an immediate operation as a preventive of the constitu- tional irritation so much to be apprehended. Here was no second opportunity, as sometimes happens, viz. when the symptoms of primary irritation sub- side, and the constitution rights (if I may use the ex- pression) so as for a time at least to struggle with its burden. Aware of the uncertainty of this issue, I 15 JH INFLAMMATION FOLLOWING earnestly and repeatedly urged upon Fuller to sub- mit to immediate amputation, but to no purpose—he obstinately refused the alternative. The case which follows shews that this is not always to be relied on. OPERATIONS. case. Haggar, a drayman, aet. forty-four, was ad- mitted into St. Thomas's Hospital, at seven o'clock on the evening of the 24th, of November 1823, with a compound fracture of his left leg occasioned by the wheel of his dray having passed over the limb about two hours before. The tibia was fractured to com- minution in three or four places, and the fibula was also broken above the inner ankle. The belly of the gastrocnemius muscle projected through the upper half of the laceration, and the lower was filled by coagula of blood. The man had bled freely before his admission, and but little since that period. He felt considerable pain in the limb, his countenance was pale and anxious, his manner indicative of extreme distress. His pulse 96 and full. At half past eight o'clock the limb was amputated below the knee, a flap being formed of the integument on the outer side of the leg. The patient was very faint during the operation, but recovered on taking a cordial. After he was put to bed the cordial was once or twice re- peated, by which his circulation and warmth were restored; and forty drops of laudanum were given in an ounce of camphor mixture. 25th. Had not slept during the night, but was free from pain, except in his back. Had complained of sickness at the stomach between twelve and two, but it soon passed off At six in the morning, jumping and starting of the limb came on, which continued, INJURIES AND OPERATIONS. jjf«j and prevented his sleeping. His tongue was white and dry, except at the edges. Respiration oppressed, pulse 120, full and rather hard. Coughed a little and complained of thirst, and of slight tenderness in the epigastrium on pressure. 26th. Had slept pretty well: the limb was quiet; tongue white and dry; not so thirsty as yesterday; pulse 144, full and quick, but softer; respiration freer, and the tenderness in the epigastrium diminished No stool since his admission. Ordered to take half a scruple of compound scammony and calomel pow- der in two pills. 27th. Had slept well till about one o'clock this morning, when shooting and starting of the limb came on, which continued till six o'clock and was succeed- ed by heat. At ten o'clock some bleeding occurred, but it was stopped by cold effusion, and the wound was afterwards dressed. He lost, as was supposed, about half a pint of blood. His countenance became more pale and anxious; he was faint and chilly ; re- spiration laborious; tongue parched; pulse 120 tre- mulous, and rather small. The bowels had been twice relieved by the medicine. The limb was till dis- posed to start. He had taken a little brandy and water during his fairttness, and was now ordered the effervescing draught, with five minims of tincture of opium, every six hours, and four ounces of Port wine in sago in the course of the day. 28th. Had passed a very restless night, and was at times delirious; pulse 126; tongue dry and brown; thirsty; frequent hiccough; pain in the epigastrium on pressure; bowels open twice during the night. A discoloration of the thigh, which had been first no- ticed yesterday, was deeper and more extended. He had vomited repeatedly since the last report. This af- 116 INFLAMMATION FOLLOWING ternoon the dressings were removed from the stump. which was covered with a purulent sanies; it was well washed, and two or three strips only of adhe- sive plaster were applied. He was ordered half a scruple of castor in a bolus, with a draught of cam- phor mixture and ether every four hours. Wine to be continued, and porter, for which he felt inclined, ad libitum. 30th. Great restlessness at night with occasional mutterings and short dosings; has continued drowsy with his eyes and mouth half open; nearly insensi- ble when roused. His countenance had become contracted and death-like; pulse about 130, but ir- regular ; very thirsty ; respiration sonorous, and fre- quent hiccough. His bowels had not been open since the night before the last. His adomen was a little swollen, but not hard. The stump and thigh had assumed a blackish hue ; it was ordered to be of- ten bathed with warm spirit wash. At four in the af- ternoon his pulse began to fail, and at half past six he died. Examination. Several ounces of a dark-colored fluid were contained in each of the pleural sacs. The lungs were preternaturally loaded with blood, and the bronchia with mucus. The internal coat of the stomach erythematous. Liver, large yellow, and in- durated. Integument of the stump livid and deprav- ed. A copious purulent secretion in the loosened cellular membrane of the limb, corresponded to the gangrenous discoloration of the integument noticed "before death. case. Anne Pearson a native of Gibraltar, aet. thir- ty-six, was admitted a patient of St. Thomas' Hospi- tal for a tumor situated on the inner side of the tibia INJURIES AND OPERATIONS. j jf of the left leg, near its lower extremity, on Thursday. the 28th June, 1821. She perceived the tumor about four or five months ago, after a day's hard labor at the washing-tub. The enlargement of the tumor was marked by se- vere lancinating pains, increased upon stooping or walking. The tumor had a knotty and uneven sur- face, discolored from a number of superficial vessels contorted and diffused thereon. No distention of the larger veins was apparent. It felt, as its appearance bespoke, irregularly hard and soft, containing slight depressions and elevations in its substance. Its great- est length was about four inches, its breadth three inches. Its size was sensibly increased and dimi- nished on an alternate application and removal of pressure upon the popliteal blood-vessels. Friday, 27th July, 1821. After having ineffectual- ly employed pressure with a view to the absorption of the tumor, it was cut out this day. So strong and intimate were its adhesions to the skin above, that they could scarcely be separated, while its attach- ment to the subjacent strong fascia near the bone, covering the muscles of the leg, was but slight and easily broken through. Its consistence was hard, tough, and granulated, being composed chiefly of molecules of fat, connect- ed by numerous vessels and reticular membrane. From these vessels during the operation there was a pretty free bleeding. 28th. Symptomatic fever with an inflammatory redness extending up the leg and thigh along the ab- sorbents. Pulse 110; bowels open. Applic. lotio spirituosa. 29th. Inflammation of the superficial absorbents 118 INFLAMATION FOLLOWING clearly marked. Pulse 110. Ordered aperient and saline medicine. Contin. lot. spirituos. 30th. There was extension of the inflammation along the absorbents as high as the groin, where the inguinal glands were enlarged. No disposition in the wound to heal; a slip of lint spread with the ung. cerae was* applied to it, and a linseed meal poultice laid over the whole. She had no inclination for food, but rather nauseated it, and frequently could not retain her drink. Pulse from 100 to 110; bow- els open; tongue much furred. To the leg and thigh were ordered leeches and fomentations, fy Hydr. submur. gr. iij. Pulv. rhei gr. x. M. 6ti9 horis sumend. 31st. The inflammation has subsided a good deal; there is less nausea and sickness; pulse 100; skin hot and dry; tongue much cleaner. Four or five motions have been produced by the calomel and rhubarb, and she feels better. She drinks tea, le- monade, &c. Rep. Hirud. xij. et fotus. 1st. August. Inflammation much diminished; she feels considerably relieved. 2d. During the greater part of this morning she was very anxious and restless, notwithstanding she had passed a quiet night. Towards evening this an- xiety increased. She complained of violent pains, particularly in her right arm and down the right side and leg. On looking at the arm, a patch of redness appeared a little above the elbow, and during the night the redness diffused itself over the whole arm, and upwards to the shoulder. 3d. At four o'clock this morning, the attendant found that the arm had changed its color from red to black, in large irregular patches. The patient was delirious, and could not be restrained from talking INJURIES AND OPERATIONS. 119 incessantly. She was very thirsty, and drank much tea, water, &c. At eleven o'clock there seemed to be every sign of approaching death. The blackness or lividity had diffused itself entirely over the arm, reaching to the right mamma, and extending over the shoulder to the scapula. The same disposition to discoloration appeared on both legs, and spread rapidly over the whole body. No pulse could be felt in the wrists, nor could the beating of the carotid artery be per- ceived ; scarcely that of the heart itself. Excessive prostration of strength; cold clammy perspirations; anxiety; nausea; with a tongue black, dry, and fur- red. The wound on the leg clean. Camphor mix- ture with aromatic confection was ordered, and as much wine as the patient coitfd take. The extremities recovered somewhat of their usual warmth, although no pulse was to be felt. In this slightly altered condition she remained till about three o'clock in the afternoon, when a large vesicle containing sanious fluid appeared on her right arm, more decidedly marking the supervention of gan- grene ; a short time subsequent to this appearance she died. Examination. The only morbid appearance upon a care- ful inspection of the body after death, was a chronic and firm adhesion between the costal and pulmonary pleurae, on both sides of the chest. case. Gillard, aet. twenty-three, baker, a sober healthy young man, underwent amputation of the ring finger, at the metacarpal bone, on the 1st October, 1817, in consequence of its having become useless and stiff by a chronic inflammation from injury. The integuments were at the time in an unfavorable state. 120 INFLAMMATION FOLLOWING adhesion did not take place, and the wound turned sloughy. Some secondary hemorrhage took place upon the separation of the ligature, which was re- appi: 1. Although '!." I*--* of blood was not consi- derable, the man was evidently rendered irritable by it, and the appearance of the wound was farther alter- ed for the worse. No alarming constitutional symp- toms however ensued till the 11th, when he was at- tacked by a severe rigor, and became feverish, rest- less, and excessively irritable. He was ordered pills of calomel and antimony every six hours, but with- out relief. 14th. The rigors recurred, the pulse was fre- quent and jerking; he was much debilitated, watch- ful, and extremely irritable; his countenance anx- ious, and his skin covered with a clammy moisture. Ordered a draught of ammonia and bark, with a few drops of laudanum, and two ounces of red wine, eve- ry four hours. 15th. A considerable alteration for the worse. The eye languid, countenance sunk, pulse depressed and rapid; in short, he was moribund. The arm was now observed to be much swollen, and upon di- lating the wound freely, a large quantity of purulent matter escaped from beneath the palmar fascia. At half past past seven, p. m., he died, being the fourth day from the attack of rigor. case. Elsden, a footman, aet. twenty-eight, was af- flicted with a caries of the first phalanx and metatar- sal bone of the great toe. It had existed five months; several fistulous openings had formed both on the upper and under side of the toe, and having tried various applications without relief, he consented to have it removed on the 16th of August, 1822. A INJURIES AND OPERATIONS. \2\ double flap was made of the sound integument, and the metatarsal bone having been sawn through in the middle, the edges of the integument were brought to- gether by adhesive plaster. 17th. Complains of pain in the wound and has passed a restless night; bowels have been relieved three times. 18th. Has passed a better night; is free from pain; bowels open. 19th, twelve o'clock, a. m. About two o'clock this morning was seized with rigor, which was followed by delirium. The dressings have been removed, and the wound looks sloughy; lint dipped in a solution of opium to be applied to the wound, and a poultice over it. Pulse 90, full and soft. A very wild expres- sion of countenance, and incoherent speech. As he obstinately refused to take medicine, two drachms of laudanum were given in an enema. Ten o'clock, p. m. Is now in a profuse perspiration; has had a se- cond severe rigor since last report; continues deliri- ous. The enema opiatum to be repeated. 20th, ten o'clock, a. m. Had two hours' sleep in the night, and has been quiet since twelve o'clock; appears to be recovering sense; wound looks clean- er. Ordered a turpentine glyster, a spirit wash to be constantly applied to the shaved scalp, and a large blister to the nape of the neck. Six o'clock, p. m. Is perfectly sensible, and has asked for drink. Ten o'clock, p. m. The glyster has not returned; he has slept for an hour and a half, and remains tranquil. The wound is beginning to suppurate. 21st, ten, a. m. Slept two hours during the night, but awoke in fright. Tongue moist, and covered with a white fur; pulse weak and quick. Has had no motion: an ounce of castor oil to be given, arid 16 122 INFLAMMATION FOLLOWING repeated in four hours if required. Six, p. m. Ha- slept two hours; bowels still confined; pulse and tongue as before. Oil to be repeated. 22nd, ten, a. m. Has passed a good night, had five motions, and appears composed; wound discharges freely, and looks cleaner; complains of his head feeling light. Nine o'clock, p. m. Expresses himself as quite easy; two stools since morning; has taken broth and sago. 23rd. Much improved in every respect. 24th. Has passed a comfortable night; and had a healthy motion from a dose of castor oil. 26th. Continues convalescent; wound healing; to be dressed with the emplastrum adhesivum. 27th. Complains of a bad cough; pulse soft, and no pain in the chest. Ordered a linctus, and blister to the chest. September 4th. Cough relieved by the blister; pulse natural; wound healthy. 9th. Pulse quick; is much pinched in counte- nance, and altered in manner; seems in danger of phthisis. 12th. Cough very troublesome; pulse quick and small; appetite gone ; rambles in his sleep. 15th. Expired, having sunk within a month from the operation under symptoms of hectic. Examination. Extensive but not recent adhesions be- tween the pleurae on both sides of the chest. Sub- stance of the lungs healthy. The ventricles of the brain somewhat fuller of fluid than usual, and some effusion between the membranes. A large collection of pus was found beneath the flexor tendons in the sole of the foot. This was not suspected during life. the wound being clean, and nearly healed. INJURIES AND OPERATIONS. 123 uemarks. Haggar. The ciicurnslances attending Hag- gar's case rendered the operation unavoidable, but were far from being propitious to its success. He was the subject of a chronic disease of the liver, result- ing probably from the habitual abuse of fermented liquor. He had the aspect of an unhealthy man, had evidently lost much blood at the moment of the in- jury, and was irrecoverably sunk by the secondary hemorrhage on the morning of the fourth day, though it did not exceed eight ounces. The stump, which is generally a faithful index of the state of the sys- tem, fell at once into gangrene; and the extension of this morbid condition to the cellular membrane of the thigh a day or two preceding his death, indicated that it was not so much a result of the local injury as of the exhausted state of the system. Pearson. The operation in Pearson's case was per- formed for a chronic disease. It was undertaken at the solicitation of the patient, partly on account of the inconvenience it occasioned her, and in part from apprehension of its increase and intractableness. Up to the seventh day, the case presented nothing un- usual. Absorbent inflammation and its accompany- ing fever excited no surprise ; it was not out of the ordinary course; it yielded to the ordinary treat- ment. The concluding part of this history resem- bles thc action of a subtle poison absorbed into the system. Having felt and expressed considerable re- lief from the means successfully employed durino- the preceding days, to reduce the inflammation, and after passing a quiet night, the patient on a sudden becomes restless, very anxious, and complains of acute diffused pain in the limbs of the opposite side to that which had been the subject of the operation. An erythematous blush appears above the elbow 124 1N FLAMMATION FOLLOWIN 0 and quickly spreads over the whole arm, breast, and r iioulder; and its florid hue, resembling scarlatina, in a few hours assumes a dark livid cast. The disco- loration is not confined to the inflamed parts, but ap- pears upon the lower limbs, and becomes quickly diffused over the entire surface. Talkative and wild delirium, and parching thirst, are succeeded by the extreme state of prostration, in which the heart is incapable from diminished power of performing its function, and in six and thirty hours from the attack, she dies. Was not this erythema, tending directly to gan- grene ? Its color, appearance in patches, rapid dif- fusion and discoloration, and the formation of a vesi- cle filled with sanies, contribute to this impression. I should say it was a sympathetic inflammation of the reticular texture of the skin, exciting the nervous system to such a pitch as at once to prostrate the vi- tal powers. I shall bring forward, in another section, abundant evidence of the fatal excitement of the nervous system attending upon acute erythema. The existence, for some days preceding, of absorbent and glandular inflammation with severe sympathetic fe- ver, had perhaps predisposed the patient to fall an easy victim to the attack. How it should happen that at the moment when the inflammation of the operated limb and the attendant fever were to all appearance subsiding, the remote morbid action should spring up, is a mystery which 1 do not pretend to fathom. This case reminds me of another, so extraordina- ry, of acute diffused erythema following the applica- tion of leeches to the mamma of a young lady appa- rently in high health, that I take the liberty of intro- ducing it here. I am obliged to Dr. Ramsbotham, INJURIES AND OPERA I IONS. 1 2.J at whose request I visited the patient, for the follow- ing particulars. case. Miss----, aet. 17, well grown and healthy, was the subject of a cutaneous affection, resembling scabies, which a child had brought into the family from school, and who, there was reason to believe, had contracted the disease from another recently ar- rived from India. It was attended with inveterate itching. For this complaint, the warm bath and simple sulphur ointment were prescribed. After pursuing these remedies for two days, the patient complained of an acute pain beneath the right mam- ma, for the relief of which leeches were applied to the pained part for two successive days, viz. Wed- nesday and Thursday. A blush of redness was ap- parent after each application of the leeches, which on the following day (Friday) assumed the aspect of erythema. On the Saturday, the inflammation had extended, the leech bites had ulcerated, and the young lady complained of an increase of pain. On Sunday (the day on which I first saw her,) the in- flammation had taken on a decidedly gangrenous character, and considerable sloughs had formed in the vicinity of the leech bites. The symptoms of irritation were at this time alarming. The pulse was very rapid and feeble, the countenance anxious and sunk, the mind wavering, and every indication pre- sent of excessive debility. Next day almost the en- tire surface of the skin appeared to be inflamed, the discoloration had extended down the side, and was attended with an emphysematous sensation to the touch. The patient had passed a very restless night with frequent wanderings. The symptoms of dis- |2ft INFLAMMATION FOLLOWING IN JURIES, ETC. order increased until her death, which took place ai an early hour on Wednesday morning. Gniard and Eisden. The cases of Gillard and Elsden pointedly illustrate the effect of a latent and unsus- pected accumulation of matter within a theca, fascial sheath, or aponeurosis, after a wound communicating with such parts, to excite the destructive irritation of the system. In Gillard's case no external sign of this shewed itself until the morning of his dissolu- tion, and in Elsden's it was not discovered until after death. When with an indolent and not otherwise unhealthy condition of the wound symptoms of irri- tation, ushered in by rigor, arise on the third or fourth day or later after an injury or operation, the vicinity of the wound should be most carefully ex- plored, all adhesive dressings be laid aside, and any sinus that can be detected be fairly dilated. The tendency to form sinuses is an argument for the early and easy dressing, au plat, as the French term it, of stumps and deep wounds of all kinds. A perseve- rance in the attempt at union in defiance of unfavor- able appearances, has been often, I suspect, instru- mental in creating these mischiefs. Rigors, irregu- lar spasmodic action of the muscles, even to con- firmed tetanus; delirium, stupor, and sinking, are consequences of which this confinement of secretion is productive. HEMORRHAGE, ETC. 12? SECTION IV. HEMORRHAGE AXD COLLIQUATIVE SUPPURATION. Effusion of wood. The state of direct irritation is often produced by exhaustion from loss of blood, concomi- tant with, or consequent upon injury, and from what I shall term, colliquative suppuration. A hemorrhage which does not prove directly fatal, as from a wound- ed artery, sometimes leaves the patient in a state of exhaustion so great that he is incapable of sustain- ing the shock of an operation. In lacerated, espe- cially gun-shot wounds, complicated with fracture, a person is occasionally reduced to such extremity of weakness by loss of blood, that it becomes a question very difficult to decide, whether he will survive the removal of the injured part, if that measure be ne- cessary. The following is an example. case A man was sent up to me from a distance of ten miles in the country, with a shattered arm, owing to the bursting of a gun. The surgeon had secured the tourniquet upon the limb, but his wife, who ac- companied him, apprehending from his faintness that he was bleeding, in attempting to tighten, unfortu- nately relaxed the screw, so that he arrived at the hospital in a state of collapse from hemorrhage. I waited for a couple of hours to ascertain his condi- tion before proceeding to amputation, which from the extent of the mischief, was indispensable. His pulse was then, viz. at the expiration of two hours from his arrival, beating 60 in a minute, and neither thready nor intermitting, as before; his faculties were per- fect ; his limbs warm; and his complexion much re- covered. In the operation, which was performed above the elbow, scarcely an ounce of blood was 128 HEMORRHAGE AND suffered to escape. He supported himself with re- markable firmness until the limb was separated, when he suddenly swooned, as if from the effort. From this he soon recovered ; but although closely watched, and well plied with cordials, swoonings re- turned at intervals, and he expired on the evening of the following day. Very analogous to this appears to have been the case of Grainge, the constable of Shenley, who was shot in the arm by Mr. Conolly on the 31st of De- cember, 1823, in the execution of his duty. The am- putation was deferred only on account of the very alarming state of exhaustion from loss of blood. When somewhat revived it was performed, but he lived only a few hours. A considerable loss of blood either during an operation, or consequent upon it, is most commonly attended with serious consequences of another kind. It so prostrates the vital powers as to expose the parts to imminent hazard of erysipelas and gan- grene. case A stout middle-aged gentleman was cut for a deep fistula, and some hours afterwards bled from the wound, to the extent, it was conjectured, of two pints or more. On the fifth day following the opera- tion, the nates, scrotum, and top of the thigh on thc same side, were attacked with acute erysipelas, which threw up phlyctenous vesications, and ran ra- pidly into gangrene. To this he speedily fell a vic- tim, in spite of every effort to support him by diet and medicine. case. I have known a case of the excision of he- morrhoids, from which a considerable quantity of blood had been for some time previous discharged at the daily stool, terminate in erysipelatous inflamma- COLLIQUATIVE SUPPURATION. 129 tion of the mucous membrane of the rectum, which in a few days destroyed the patient. A similar re- sult where the patient has been much debilitated, has been known to follow the operation of tying a por- tion of the gut in prolapsus ani; and in one remark- able instance a copious secretion of pus was found upon the interior membrane of the bowel, and also in the hemorrhoidal veins; but this patient was, at the time of the operation, the subject of scrofulous tubercles in the liver. When the system has been rendered irritable, but is recovering, either from hemorrhage, or from an in- jury or inflammation unattended by hemorrhage, a secondary bleeding, even though it be inconsidera- ble, often extinguishes life. This is the case in wounded arteries which have been unadvisedly trust- ed to the compress and bandage; and in deep sup- purations, where a vein is opened by ulceration. I have seen persons really recovering from severe injuries, thus suddenly carried off The symptoms in these cases are those of sinking, or pure pros- tration. The loss of blood by injury, when insufficient to destroy life by syncope, induces that state of the ar- terial system which prevails in gangrene; in other words it converts healthy inflammatory, or sympathe- tic fever into the asthenic excitement which accom- panies prostration: and the inflammation of healing (granulation) into that of destruction (sloughing.) Debility is the basis of morbid irritation, and those causes of debility which operate with the greatest force and directness, most invariably aggravate the state of irritation. These I call examples of death by irritation as- suming the character of prostration, because, how- 17 130 HEMORRHAGE AND ever the cause by which direct debility is induced may differ from that which operates in shock, where lit- tle or no blood escapes, the symptoms bear a close resemblance, and are equally to be referred to a great and sudden reduction of power with a local irritant. The loss of blood is not fatal in cases in which the circulation, although feeble in the extreme, recovers and maintains its regularity, and no excitement remains, as in uterine flooding after delivery; but where an extra burthen lies, or is im- posed, upon the system, whether the unrelieved ute- rus, the unrecovered shock, the mutilated limb, or the removal of it, the vital powers succumb. It is very questionable whether the administration of stimulants is not more frequently injurious in these circumstances than beneficial. Excitement to in- creased action where the power is so much reduced as to be scarce able to maintain that which is neces- sary to life, only the more rapidly exhausts it. Hence it has been a good turn of fortune for many persons to have been left for dead, as it is called, on the field of battle. Sleep will restore where alcohol destroys. And whether life thus reduced in power can be main- tained artificially in any case, i. e. where the patient being left to himself, the relief of natural sleep comes not to his aid, or comes in such a shape as not to refresh,may well be doubted. I am sure I have seen cases in which the remnant has been more quickly consumed by the incessant appliance of sti- mulus, than would have been the case had nature been left to her own economy. On the other hand, it must be admitted, in cases of such extreme pros- tration as is indicated by the entire relaxation of the sphincters, that the very sparing, but frequent sup- ply of a nutrient liquid, a tea-spoonful at a time, or COLLIQUATIVE SUPPURATION. Jg] of a stimulus so diluted as not sensibly to swell the pulse, has sometimes succeeded in preserving the life ' of him that was ready to perish.' Excessive suppuration. A rapid and profuse suppuration so sinks the vital powers as to induce the state of direct constitutional irritation in an extreme degree. In many cases, this result is due to the excess of the se- cretion alone, in others, to the excess coupled with the situation of the secreted fluid. In the former case, the symptoms are those of prostration without excitement; in the latter, they are mixed, or the ex- citement is even preponderant. Thus the confine- ment of matter within a theca or fascia, as in the cases of Gillard and Elsden, related in the preced- ing section, and others that will be found among the examples of reflected irritation, is competent to the production of violent delirium or tetanus. The cases which follow, shew the effect of colli- quative suppuration ensuing upon different forms of injury, and the fact which renders them important and interesting to a painful degree, is this—that at a certain period subsequent to the primary disturbance of the system, both were in a condition of tranquillity approaching to convalescence. case. Friday, May 30th, 1823. Gurton, a robust man, aged thirty-seven, by trade a fisherman, while cleaning some periwinkles, rubbed a piece of skin off the back part of the hand, on Monday, May 26th, four days previous to his admission into St. Thomas's Hospital. Poultices had been applied, and an inci- sion made above the wrist, but matter had not then formed. The arm was excessively swollen, being nearly twice the natural size, very painful, the skin red and shining, and tense, with large vesications on 132 HEMORRHAGE AND the fore arm. The redness extended as high as the axilla. The pulse was full and quick, tongue white, bowels confined.—The poppy fomentation poultice was applied. Aperient pills of calomel and colo- cynth were administered immediately, and a mixture of sulphate of magnesia and infusion of roses direct- ed to be taken three times a day;- an anodyne draught containing sixty drops of tincture of opium was gi- ven at night. Saturday, May 31st. Had been restless in the early part of the night, but had slept a few hours towards morning. Mixture repeated, and a pill con- taining a grain of opium given every six hours. June 1st. Had passed a better night, the arm rather less swelled, a small portion of the integu- ments above the elbow sphacelating. Bowels open, evacuations healthy, tongue moist. Pulse frequent and full. June 2nd. The sphacelus extending; the arm swelled below the elbow, forming a little pouch, into which an opening was made, but no fluid escaped. Erysipelatous inflammation appearing upon the side and upper part of the back. Medicines continued. A pint of porter to be taken daily. Poultices and fomentations as before. June 4th. A large portion of the integuments of the upper arm sphacelated; arm less swelled; pulse quick; tongue and skin dry; bowels regular. De- coction with tincture of bark, to be given three times a day. Anodyne pills continued, and to take a pint of port wine daily. 8th. The integument of the fore-arm sphacelated. Scarifications made to facilitate the separation of the parts. Medicines and applications continued. 10th. A fluctuation felt below the elbow. A punc- COLLIQUATIVE SUPPURATION. 133 ture was made, and twelve ounces of matter esca- ped. The integuments separating above the elbow, the surface underneath very healthy. Medicines continued. 13th. Discharge considerable from the arm. Por- ter to be increased to two pints daily. Poultice, about a week before, for a wound in his finger. This insidious introduction of the poison should put dis- sectors on their guard, and rouse instant attention to a wound however apparently trifling. In Mr. Dease's case, the source of mischief presumed by others was not admitted by himself. If it be possible for the enemy to approach without the signal of acute local % poisons. 191 pain—and the history of these cases shews some va- riety in this respect—the danger becomes formidable indeed. It is probable that lives have been lost in this way under a total ignorance of the mischief. A lamentable case not long since occurred in the French schools, which furnishes a reasonable ground for this painful suspicion. air. Newby's case. I do not consider that Mr. Newby re- ceived any disease from the subject of his dissection, and he certainly was not affected with erysipelas of any sort. He had absorbed the poison of decompo- sed animal matter from the body which he examined on the Sunday. All the symptoms conform to this theory, both local and constitutional. The pustule in all probability was formed upon the site of a slight and superficial abrasion or puncture,* and was characteristic of the poison. Languor, headache, nausea, and other symptoms of fever preceded the appearance of pustule, and this, without any affection of the absorbents of the arm, was followed by sore- ness and the erythematous swelling and inflammation of the breast, pain, excessive irritability, delirium, and death. There is much reason certainly to be- lieve, that the indisposition greater or less of the five persons employed in nursing or attending upon Mr. N. was referable to a morbid effluvium. Vigilance and anxiety, however, were also present, and in the case of the nurse, who was most under the influence of these predisposing circumstances, the disease went a fatal length; but the others appear to have been either differently or very slightly affected, which * The circumstance of its being the left thumb, adds strongly t© the probability of its being occasioned by puncture. 192 POISONS'. would scarcely have been the case had any specific contagion been generated. Heginbothamscase Of the nature of Heginbotham'scase no doubt can, I think, be reasonably entertained. An abraded surface imbued with decomposed animal matter is followed by shivering, pain of the head and limbs, and vomiting, with flushed face, and pulse of 120. By the operation of medicine these symptoms are abated, but on the fourth day there is soreness in the top of the shoulder, and fulness in the axilla, and on the day following, the breast becomes swollen and efflorescent. The fever returns, the symptoms are those of general increased excitement, with an augmentation of the local pain, swelling, and red- ness. To this succeeds delirium, which is followed by prostration and coma, and death on the tenth day. Let it be remarked that in the short interval between the attack and his dissolution, the scratch suppurated, and that the absorbents of the limb were unaffected throughout. The former circumstance shews that the scratch had been irritated, and in an active state ; the latter that the track of the poison may escape observation. air. Graves's case. Mr. Graves's case, faithfully detailed by an intimate friend and fellow-student who never quit- ted him, presents some remarkable features. No mention is made of inflammation of the wound or absorbents of the arm. On the third day he is at- tacked with smart fever, and soreness of the breast and axilla, incoherence and increasing irritation on the fifth, and on the seventh, raving delirium. Vo- miting and hiccough, almost incessant, now add to his sufferings, with increasing pain of the breast and poisons. 193 arm-pit, and on the ninth, great soreness is complain- ed of along the opposite arm and leg. The symp- toms continuing with every indication of excessive debility, on the twelfth day a blush attended with soreness appeared on the right fore-arm, and on the thirteenth he died, exhausted. After death the absorbents of both extremities are found to have undergone an inflammatory thickening, and some purulent secretion is discovered in their track. It is difficult to reconcile with these appear- ances, the late and very slight and partial appear- ance of absorbent inflammation. From the diffusion of inflammation through the absorbents of both limbs it follows that the entire lymphatic system was affect- ed, a change which must be ascribed to the morbid state of the circulating fluids, like the farcy of the horse. Mr. Archer's case. The case of Mr. Archer I well re- member, having attended him with Sir A. Cooper. Neither the wound nor the arm were inflamed, though the former, insignificant as it appeared, was painful. The pain in the axilla, which was much swollen, was excruciating on the evening of the third day. The pectoral fulness appeared on the fourth; and on the fifth, there was a mental confusion approaching to low delirium. On the seventh, delirium and insensibility alternated ; then followed the chilliness and hectic irritation attending obscure suppuration. On the twelfth, deep and fixed pain in the left side was in- creased by cough and full inspiration; and on the sixteenth the system was additionally sunk by pro- fuse diarrhaea. A copious purulent discharge was obtained on the seventeenth, by an incision made at a venture, without any relief to the symptoms; and 25 194 poisons. on the nineteenth another discharge, as copious as the former, followed a puncture at some little dis- tance from the first. It was only by the aid of much support from wine and opium that the system held out till suppuration had taken place. The diarrhaea was a symptom of breaking up, it was never after- wards controlled, and at length purulent matter was discharged from the bowels. Cases of Messrs Delph and Smartt. The CaSCS of MeSSrS. Delph and Smartt, originating at the same time from the same source, are deeply interesting. Mr. Delph's wounds with the point of the scalpel did not inflame; Mr. Smartt's wound, which was a deep puncture with the needle, inflamed, and formed a small circumscrib- ed abscess, which ran its course in about three weeks. In both the fever assumed the typhoid type, and the local action showed itself upon different and remote parts of the body on the same side with the wound- ed limb, in extensively diffused suppuration of the cellular membrane. All these cases exhibit strong excitement in the commencement, and early and rapid prostration. In none is any marked or permanent affection of the ab- sorbent vessels apparent during life, yet the pain, fulness, and other signs of cutaneous or cellular in- flammation of the arm, axilla or pectoral region, are one or all present. In all the brain and nervous system sympathise quickly and deeply; in some the stomach and diaphragm are affected, and not in others. In one case the local inflammatory disposition is stronger than in another. It is by no means to be supposed that the causes which act in aggravation of common inflammation are suspended in cases of poison, when inflammation is once set up. There poisons. 195 may be therefore more or less of acuteness and strength in the local action, according to the habit of the subject and the circumstances of the injury, as the nervous excitement may be more or less rapid and considerable in different individuals, under similar degrees of intensity of the poison. In draw- ing the line, therefore, between the simple and the specific action, we must bear in mind that to a cer- tain extent they necessarily co-exist, and this adds considerably to the difficulty of the distinction. In- flammation, by whatever cause excited, is still the same in its natural history, though it may affect dif- ferent textures and assume different appearances under the various circumstances of its origin ; and the rate of its progress may be subject to as much diversity. It can only be by ascertaining some pecu- liar and determinate character, resulting from the association of the local with the constitutional action, that we can hope to arrive at a diagnosis of these cases sufficiently accurate to open up the important question of treatment. The following case, for which I am indebted to Dr. Spurgin of Guildford Street, displays well the minor degrees of irritation, local and constitutional, to which coOks and others, in handling putrid animal matters with chapped and scratched fingers, are exposed. The inflammation, which is attended by occasional exacerbations to intensity, of throbbing pain, is of the erythematous species, appears in patches, and though subject to shift its position, does not quit the vicinity of the wound. It seldom advances to sup- puration. The health and spirits suffer a material temporary depression. " On the 4th of December, 1823, a cook-maid aet. 35, of an unhealthy appearance, though free from in- 196 POISONS. disposition, was practising herself on a stale hare, for the purpose of learning the mode of boning them, in spite of being strongly cautioned against it. A few- days afterwards, two slight scratches, which she remembers to have received at that time, and to which she paid no attention, began to inflame; one was situated on the back part of the fore-finger, be- tween the second and third joints, and the other over the middle joint of the ring-finger of the left hand. This inflammation was accompanied with a dull pain and feeling of numbness, and an occasional darting pain, along the inside of the fore-arm; this induced her to apply a poultice, and to take some aperient medicine, and a warm drink at night, by which she was so much relieved as to discontinue the poultice the following morning; but in the course of two days the same symptoms recurred, and as it was mentioned to me in a cursory manner, I advised her to foment as well as poultice, and to take ten grains of com- pound extract of colocynth, with five grains of extract of hyoscyamus, at bed-time. "The next day (the 11th) I prescribed two scruples of cinchona and one of dried subcarbonate of soda three times a day, with a view to allay or counteract that constitutional irritation or peculiar state of body, which seems to render one person more liable to suffer a diseased action from the cause above mentioned than another; but this wished-for effect was not obtained, for in the evening of the 12th she was attacked with most severe pain at the point of the fore-finger, which throbbed so violently, as to give her the sensation of its being about to burst at every pulsation, and she shortly afterwards came to request me to cut open the part. I could not per- ceive any pulsation, nor indeed any enlargement of poisons. 197 that part, but I made an incision lengthways of the finger, about three quarters of an inch: the blood which came away had more the appearance of sanies than any thing else. The relief she experienced was almost immediate, and after taking ten drops of laud- anum, and renewing the poultice, she passed a com- fortable night. " The next morning she was free from pain, but had no appetite; her tongue, presented two brown- ish streaks on a white ground, and was more dry than natural; there was great dejection of spirits and lan- guor, with a weak and unsteady pulse; I therefore ordered her to take a tea-cupful of the compound decoction of sarsaparilla every four hours; this caus- ing nausea, however, and loathing of stomach, was soon discontinued. " 13th. The pain returned; it was of a more prick- ing kind, deeper seated, and shooting through the second joint of the ring, and third of the fore-finger; the inflamed parts were much darker than common, and the inflammation was becoming more extensive. Five leeches were applied directly upon the inflam- ed points, and the subsequent bleeding was encour- aged : this was followed by a complete cessation of the pain, inflammation, and immobility of the fingers; the arm, likewise, which was previously swelled and painful, more especially along the course of the ab- sorbents and veins (symptomatic;) on its inner side, became free. In the mean time, the liq. ammon. acet. with camphor mixture, tinct. hyoscyam. and tinct. calumb. was prescribed. " I 1th. The pain and inflammation returned as before, and several leeches were applied in the course of the day, wherever the pain seemed to be concentrated; a small pustule with a hardened base appeared just above the wrist, but was not painful. 198 POISONS. " Fomentations and poultices were employed con- stantly during the 15th. " 16th. She had but little rest the two preceding nights; last night she took twelve drops of laudanum; in the forenoon a throbbing pain attacked the palm of her hand, near to the ring-finger, and a pricking sensation extended through the joint to the back of the hand. Four leeches were applied to the latter place, whilst an incision was made through the hard skin of the former: by these means the inflammation was again removed. Her constitutional derangement and general debility seemed, however, on the whole increased, more especially the depression of spirits and anxiety. The mixture was continued, as, to use her own expression,4 it comforted her,' In the after- noon, the inflammation returned, but was removed by leeches. " 17th. The repetition of leeches was required this morning, but having an opportunity of sending her into the country a few miles, she set off at noon, with an injunction to have recourse to leeches as before, and to take twelve or fifteen drops ofdiluted sulphu- ric acid every five hours in some water. " 22d. All affection of the hand has disappeared, and her appetite and strength are improving rapidly." Remarks. This narrative brings several parallel in- stances to my remembrance. That these cases have the specific character I think there can be no doubt. The circumscribed sphere of the morbid action may be due to the very super- ficial injury inflicted, and consequently the imper- fect exposure of an absorbing surface ; or to the mere application of the matter to such surface in place of its introduction by inoculation; from either POISONS. 199 of which causes it might result, that the quantity of matter absorbed was so minute, or its virule^-'e so modified, as to expend itself upon the parts contigu- ous to the wound, thus operating as a strictly local poison. It is conformable to observation that the action of many poisons upon the living body is potent in proportion to their concentration and quantity. Finally, its circumscribed operation might be refer- red to the action of putrescent matter as an irritant exclusively, and not by absorption. It is possible that a specific irritant may produce upon the part, effects similar in character to those which follow upon its absorption into the circulation. The cases which I shall next adduce are a class of more frequent occurrence, and, on the whole, of less alarming severity. Although presenting very diverse phenomena, they are, I believe, generally but not universally considered to owe their origin to a similar cause with the foregoing. It is of importance to examine and decide this question. Dr. Gordon, ofFinsbury Square, obligingly presented me with the following valuable and interesting case. Case 0." Mr. Clifton, surgeon, of Islington. "Mr. Clifton, of Islington, aged 37, scratched his thumb with a needle whilst engaged in sewing up a body he had examined. The patient, a female, had died of peritoneal disease under ordinary circumstances, and the scratch was too slight to attract attention or indicate the application of any remedy: nor did Mr. C. experience any effect from it throughout the evening, during which he was actively engaged in speaking in a large assembly. " He was awakened at three o'clock the next morning, September 12th, with excruciating pain in the thumb, extending along the fore-arm and shoot- ing into the axilla. Although accustomed to pain, 200 POISONS. and enabled by constitution to endure it, he descri- bed the agony he experienced as surpassing any idea he had previously formed of suffering. I first saw him at one o'clock in the afternoon of the same day, and found the local symptoms much aggravated; the thumb and fore-arm tense and swollen; there was hardness perceptible in the course of the absorbents, but no redness. The hand and arm communicated a burning heat to the touch, while the rest of the body was rather below the average temperature. The constitutional symptoms were very striking. On entering the room, having no previous knowledge of the case, the first view of the patient brought to my recollection the symptoms of hydrophobia. Al- though naturally a man of a very firm and calm dis- position (and in the present instance perfectly col- lected and even cheerful,) his whole appearance was that of extraordinary anxiety. He seemed sensible of the least noise, and disturbed by even the breath- ing of surrounding persons. The countenance, which in health is full and dark, was shrunk, hag- gard, and cadaverous. He complained of much headache and sensibility to light, with an intolerable sense of oppression on his chest. The tongue was loaded ; there was nausea but no vomiting. He sat in bed supporting the arm, and whilst conversing calmly he occasionally sprang out of bed, apparent- ly unconscious of what he did. (Mr. C. has since explained that this was the result of pain, and of a resolution to suppress complaint as much as possi- ble.) The skin was contracted and shrunk; but there was neither shivering nor rigor. The pulse was in an extraordinary degree full and hard, and about 120 in the minute. His constitution was ge- nerally speaking good, and he had enjoyed as much poisons. 201 health as is compatible with the discharge of exten- sive professional duties. He had taken a large dose of calomel in the morning, by which the bowels had been freely opened. He was immediately bled to 3 xxx ; some febrifuge and aperient medicine was given, and cooling lotions were applied to the arm, with a poultice to the thumb. He was much relieved by the bleeding, and the pulse fell to 80, although after the faintness had subsided it had not lost any of its volume or hardness. The blood was not buffy and the crassamentum was very soft. " 13th. He had passed a sleepless night, and suf- fered dreadfully from pain, but the constitutional symptoms were much mitigated, the pulse being 90 and softer. The hand and arm were much swollen; red lines were perceptible in the course of the ab- sorbents, and there was some pain in the axilla, but it did not extend to the pectoral muscle, nor was there any erysipelatous blush on the skin. He appeared much sunk in every respect, and complained greatly of his head. The cold applications had somewhat relieved the tension, but as they produced a sense of chilliness, warm fomentations were substituted, and when the heat excited by these became disa- greeable, the cold applications were renewed. Leeches and cold applications were directed to be applied to the temples, and the other medicines were continued. " 14th. The appearance of the patient was consi- derably improved. He had lost much of that cada- verous look alluded to, but he had suffered dread- fully from pain and want of sleep. The pain in the axilla had decreased, and the red lines had become fainter, but the hand and arm were more swelled. He described the pain as deep-seated, and convey- 26 202 POISONS. ing to him the impression of a tight and very painful bandage compressing the internal muscles ; arising, probably, from the highly inflamed state of the fascia of the fore-arm. The pulse was hard and full, 100 in a minute. He was bled to I xij, and leeches were applied in great number to the arm. The blood was much buffed. The leeches afforded temporary relief to the local as the bleeding did to the consti- tutional symptoms, but he became much worse in the evening, when there was a return of the worst con- stitutional symptoms. The pulse not so full, but J 30, hard and wiry, and he complained of overwhelming oppression in the chest and head. He was bled to |xvi; leeches and purgatives were continued. This bleeding immediately relieved the oppression of the chest, as well as the extreme irritability, which per- vaded the whole system, and which the patient des- cribed as more intolerable than even the pain. " On the 15th, we considered him in a very preca- rious state. His head was relieved, but with the exception of this one symptom, he was much worse. He had again passed the night without sleep, and in the greatest agony. The pulse was 120, hard, wiry, and hurried. A very careful examination of the hand was now made, but not the slightest trace of deep- seated matter could be felt. Neither had there been any thing like rigor or shivering. At the consulta- tion, however, the presence of matter in the thumb was inferred from the following circumstances : 1st, from the great probability that the part where diseas- ed action was first assumed would be most likely to yield such a result, seeing that in the introduction of most animal poisons, Nature seems to make an effort to resist it; 2d, from the continuance of violent fever after the progress of the local disease towards the POISONS. 203 axilla had been arrested; 3d. from the peculiar na- ture of the fever itself, assuming no fixed type, being easily subdued by active treatment for a short pe- riod, and then again rapidly resuming its virulent form. In pursuance of these views an incision was made along the hand, but only blood issued. The thumb was then laid open to the bone along its whole extent, and about a tea-spoonful of matter flowed from the point originally punctured. The matter was quite healthy, and the relief was instantaneous. The hand was buried in a poultice, and shortly after- wards he fell asleep. But in a few hours he was dis- turbed by hemorrhage from the hand, and he lost upwards of |xxx before it could be stopped, which was effected by means of compression. After the faintness occasioned by the loss of blood had subsi- ded, the pulse rose to 120, became full and hard, and the deep-seated pain in the arm returned. Leeches were applied along the affected parts as often as the paroxysms of pain returned, and they were the only application that gave relief. In this way about 140 were applied from Sunday to Tuesday. Putting a few on at a time and quickly renewing them seemed to afford more benefit than the simultaneous applica- tion of a great number. In the intervals various ap- plications were tried for the arm. The vapour of warm water and hops, &c. gave momentary ease, but we could only depend on the leeches. " On the evening of Tuesday, the 16th, a sudden alteration took place. I was with him at the mo- ment, and nothing could be more striking. The countenance became cold and cadaverous, and he threw himself back on his bed, abandoning the sit- ting posture, which was the only one he had hitherto been able to bear. He sighed frequently, tossed his y 204 poisons. arms about the bed, and rolled from side to side. The pulse rose to 110, became soft and compressi- ble, but there was no diminution of pain. The symptoms appearing to me now more those of irri- tation than inflammation, I gave him twenty-five drops of Battley's solution of opium, and subsequently fif- teen more. I may here observe that he had not been able to take opium in any form, and even hyoscyamus disagreed violently with him, for on the second day, his pulse having been reduced by the bleeding, and suffering much from pain, I gave him five grains, which instantly affected his head and increased his restless- ness. In the present instance, given just at the mo- ment its exhibition was indicated, it was attended with the happiest effect, and he enjoyed some hours of refreshing sleep. The application of leeches was only necessary once or twice more, for though some pain remained, and the hand continued swelled, he gradually improved in health and strength. The pulse continued steadily at 100 for some time, but it was gradually reduced, and the pufliness and swel- ling of the arm were diminished by active purging. As soon as this was effected, friction and bandaging were employed with great benefit, and he slowly but effectually recovered the use of his hand. The wound healed very readily by the first intention, and although the fibres of the muscles forming the ball of the thumb, were transversely and completely di- vided, the flexor and other muscles, in the course of some months, recovered their wonted action. The nerve w hich supplies the middle finger having been divided, the finger remained for a time benumbed, but this also completely regained its nervous power. It is right to mention that during the whole of this af- POISONS. 205 flicting malady, the patient retained his consciousness and self-possession." SM^Jte' "Mr.N.R. Brayne,* aet. 22, in the course of his professional studies during the summer of 1820 became, from dissecting in hot weather, the subject of severe diarrhaea and an eruption on the face. The latter occupied the seat, and possessed the characteristics rather of sycosis menti than a proper pustular disease. Medicine being of little or no service to him during his residence in London, a trial of the sea was deemed necessary, from which he returned after eleven days, much improved in his general health, with the eruption nearly well. On the 7th of November he resumed his occupations in the dissecting-room, in which he spent most of his time. About a month subsequent to this (December 9th,) he was pricked by a pair of common forceps in the fore-finger of his right hand, while examining the body of a man who died the day before in St. Thomas's Hospital, from extensive psoas abscess, and diseased dorsal vertebrae, which succeeded to an accident. On the evening of the same day the finger was considerably inflamed, for which leeches, fomentations, and poultices were applied. " On the following day (December 10th) the ax- illary glands of the same side became enlarged, but no affection of the absorbents was perceptible. His nights were tolerable, but considerable fever and ir- ritation came on, together with vertigo and headache. Brisk purgatives, numerous leeches to the finger and axilla, with fomentations and poultices were directed. It was sometimes thought that the headache was in- * Now surgeon of Banbury, Oxon. 206 POISONS. creased when the purgatives operated most. After a week passed in this manner, the finger appeared quite well, but the axillary glands were slowly advanc- ing towards suppuration. The pulse was generally about 100, and somewhat sharp; the headache, at one time better, and at an another worse, had now concentrated itself at the upper part of the left trans- verse ridge of the occipital bone, and sometimes ex- tended along the basis cranii towards the orbits. It was occasionally very intense, and more particular- ly on attempts at motion, which were performed in the most slow and cautious manner, the hands being generally applied to steady the part affected. Under these circumstances, having been hitherto confined to his room, and feeling much debilitated, he put himself into a stage coach on the 1 Ith day after the accident, and went into the country a distance of seventy-five miles, supposing better air and diet most essential to his recovery. " For the first few days after his arrival at home he seemed to be gaining ground. Pulse about 100, rather small. Tongue white, but yet some inclina- tion to food. Bowels open. Urine very high color- ed, with a slight dysuria. Sleep a good deal disturb- ed by dreaming. The axilla was pouliiced, and dis- charged considerably, a thick and healthy pus. It is worthy of remark that he had become exceedingly irritable and impatient, manifestations directly oppo- site to his natural temper and manners. On the 8th day after his journey he found his head so much bet- ter, though the axilla continued inflamed and dis- charging, that he partook with his friends of a more liberal diet than had been heretofore allowed him, and in the evening exerted himself much in conver- sation. This was followed by a restless night, and poisons. 207 on the next day the pain of the occiput was worse than ever. It was for the most part aggravated by the erect, and alleviated by the recumbent posture. There was not much pain in the axilla, except when the arm was raised, or the integuments covering the surrounding muscles were too roughly handled. The pulse now rose to 104, and he began to perspire pro- fusely in the night. The bowels were kept open by moderate aperients, and little else was done in the way of medicine. He had frequent calls to void urine, particularly in the night, the few last drops of which escaped him involuntarily. He had scarcely complained of any thing like chilliness or shivering during his illness. The skin during the day was near- ly of a natural temperature ; in the early part of the night it was hot and dry. He seldom complained of thirst. " On the 22d day from the accident, after a bad night, in which he had been occasionally incoherent, great stupor and insensibility to external impressions were added to his other symptoms, and continued to increase during the day. In the evening, therefore, the scalp being observed to be much hotter than na- tural, the pulse 110, with throbbing of the temporal arteries, a more foul tongue, and urine exceedingly high colored, the head was shaved, and a dozen and a half of leeches applied to the left temple, and af- terwards an evaporating lotion to the scalp. These measures somewhat relieved the state of oppression, but on the succeeding day the pain of the occiput sometimes rose to such a degree as, to use his own expression, »■ seemed to threaten the wreck of his intellect." During the two subsequent days he took several doses of calomel and opium, but the pain of the head continued much as usual, and as the dis- 208 POISONS. charge from the axilla seemed to be augmented by it, it was discontinued. He was rapidly losing flesh, and, almost despairing of relief, began to be very dejected. " The formidable nature of these symptoms seem- ed to render it not improbable that some organic change was going on within the cranium, and there- fore saline medicines with calomel and antimony were chiefly prescribed, with the occasional use of a seda- tive dose of tinct. of hyoscyamus. A strict antiphlo- gistic diet was observed. " On the 26th day of the disease, the other symp- toms being nearly as before, he complained of great tenderness and pain about the circumference of both patellae, much increased by motion or the slightest pressure. It was chiefly seated on the outer edge, over which was discovered a slight blush of inflam- mation. This new symptom not being found after twenty-four hours to be productive of any alleviation of the affection of the head, some leeches were ap- plied to each knee, and on the following afternoon all trace of disorder in these parts was gone, and the joints had recovered their usual power of easy motion. " On the night of the 28th day after the injury, he took a pill composed of two grains of calomel, five of Dover's powder, and five of rhubarb. He slept better after it, and complained less of his head than usual, but was the next day very drowsy. It moved the bowels freely, and for the first time the urine passed in the night was less high colored, though it had several times before been perfectly natural in the day. The pill was not repeated until bed-time, and though he did not sleep so well, he was more ca- pable of moving, and with less apprehension. The poisons. 209 discharge from the axilla had been reduced, but was again augmented since the exhibition of the calomel, and a slight blush of the surface was observed upon the inner side of the upper arm. A small blister was applied over the seat of the pain at the occiput. During the next four days the pill was continued, night and morning, and he drank a pint of decoct, sarsae. comp. during each day. Under this plan the pain of the head gradually were away, he became less irrita- ble, the pulse decreased in frequency, and his appe- tite improved. The perspirations at night were still very profuse, and of a strong and penetrating odor. At the same time the urine, except now and then, when the head was affected, gradually resumed its natural color and appearance. Two or three sinuses formed down the arm and towards the pectoral mus- cle, and therefore the poultice was exchanged for simple dressing, a compress and a roller; by means of which, in about a week, the axilla, save a slight in- duration, was quite healed. The pain of the occiput had daily diminished, as well as the perspirations, which were no longer offensive, and by the time of the complete restoration of the movements of the arm, neither were at all complained of. His health and strength rapidly returned, and by the first week of February he considered himself perfectly restored." Case of Mr. H. Slight, student of medicine. Mr. H. Slight, while dis- secting the body of a negro on the 16th of Decem- ber, accidentally wounded the second finger of the right hand with the point of the knife. A little blood escaped from the wound. Nitric acid was applied. No inconvenience was felt for some days, and Mr. S continued his dissection. 27 210 POISONS. In the afternoon of the 20th, severe pain was ex- perienced above the elbow, which increased on pres- sure. He suffered much from head-ache, attended with chills, loss of appetite, and general constitution- al disorder. On the evening of that day, the pain in the head was much increased, and during the night a severe febrile attack was experienced; the pulse was full and strong, with much heat of skin. These pa- roxysms recurred every four hours. He took a saline purgative draught every six hours, and a sudorific in the interval. By this treatment, conjoined with a low diet, the symptoms considerably abated. 22d and 23d. Although the violence of the symp- toms was much mitigated, severe pain continued in the arm attended by occasional rigors and head- ache. 24th. The constitutional symptoms returned. On examination of the finger, a collection of matter was discovered at the part punctured. A free incision was made, and a poultice applied. The arm was swelled in a trifling degree, and painful on pressure, but no inflamed absorbent could be discovered, nor any gland in the axilla enlarged. The incision afford- ed some relief to the other symptoms. On the 26th, Mr. S. left town, still experiencing much pain from the shoulder to the elbow. The arm was fomented with hot water. The pain was much increased during the following days, and the febrile commotion became very distressing, the temperature rising much above the natural standard; the pulse full and hard. This was followed, on the nights of the 4th and 5th of January, by profuse perspiration, and a feeling of extreme languor and debility. The bowels were kept open by small doses of Epsom salts. There was great irritability of the nervous POISONS. 211 system, and the temper was ruffled by the slightest occurrences. The night sweats were profuse, attend- ed by almost constant watchfulness. The sulphuric acid in bark infusion, was taken every four hours. 7th. Debility extreme. The glands in the axilla appeared somewhat enlarged, though the pain was principally referred to the arm. An oatmeal poultice was ordered to the axilla, and fomentations twice a day. A more generous diet was advised, the bark to be continued, and three or four glasses of port wine daily The exhibition of wine produced excessive irritability both of mind and body, head-ache, and a sensation of spasmodic twitchings of all the volun- tary muscles, amounting almost to a state of delirium tremens. Its use was therefore discontinued, and porter in effervescence with animal food allowed, and half a grain of opium given three times a day. As however this produced but little sleep, though it al- leviated in a great degree the excessive irritation, a full dose of laudanum (130 drops) was taken at bed- time, and with the best possible effect of lessening the head-ache without increasing perspiration. The poultice in the axilla was continued; the wound in the finger was now quite healed. The stomach be- came affected with nausea and vomiting, and the bowels, generally costive, were acted upon by the mildest medicines. 26th. By this time the debility was extreme; the patient was unable to stand, and his emaciation ren- dered it necessary to pad the shoulders and hips to prevent ulceration. The stomach still continued very irritable ; vomiting occurring frequently during the day. 30th. A suppuration in the axilla appeared fully established. An incision was made into the abscess, 212 POISONS. and a pint of highly offensive green matter was eva- cuated. The poultice was ordered to be continued twice a day, and at each dressing a large quantity of matter was discharged. The abscess shewed no in- clination to adhesive inflammation, but continued to spread in the direction of the pectoral muscle, and also across the scapula, burrowing among the mus- cles. During the succeeding fortnight, several spi- cula of bone were discharged, which were consider- ed to be exfoliations from the fourth or fifth rib, there being much pain felt in the situation of these bones. The matter gradually decreased in quantity for a fortnight, when nausea and vomiting recurred. A se- cond collection of matter was formed so low on the breast that another opening became necessary about an inch below the nipple, and from this a large quan- tity of matter was also discharged. The patient was at this time in a state of the utmost debility, although the night sweats were lessened. Much inflammation ensued on the second incision, and within forty-eight hours, the abscess, the parietes of which could not be felt by the probe, became closed by adhesive in- flammation ; and no untoward symptom supervening, Mr. S. gradually recovered his health, though the arm continued long afterwards painful. Case of Mr. Wanibrough, surgeon. On the 28th of June, 1 822, Mr. Wansbrough assisted a medical friend to examine the body of a female who died of diseased ovaria. The body was offensive from putrefaction. After the dissection he washed his ha.ius with alcohol. On the morning of the same day, when pulling a rose, a thorn had entered the inner part of the first joint of the right fore-finger. The wound was very trifling, and he took no notice of the occurrence. poisons. 213 Within thirty hours after the dissection he felt pain in the part where the thorn had entered, and on ex- amining the joint it exhibited a slight blush of inflam- mation. The pain increasing, Mr. W. extracted the thorn, which was so small that he could scarcely per- ceive it on the point of the probe. This was at six o'clock; the pain increased till eleven, when he ap- plied a poultice, and went to bed. On the morning of the 30th, Mr. W. was awaken- ed by the pain in the finger, which had now extended to the last joint, and was attended with much swell- ing. Suspecting the cause, he applied a hot poultice of bread and water over the whole hand. The pain rapidly increased, till it became excruciating. The swelling extended over the hand, the back of which was like a boxing glove, and highly inflamed; the finger was twice its natural size, and the skin distend- ed almost to bursting. The wrist and fore-arm were beginning to partake of the inflammation, and inflam- ed absorbents were clearly seen on both sides of the arm, as far as the elbow. The fingers were extend- ed to the utmost. A dozen leeches were applied to the back of the hand, and when they fell off, the arm and hand were immersed in water as hot as it could be borne. The whole hand and wrist were after- wards covered with a large poultice. During nine successive days and nights, fomentations and poul- tices were applied, and leeches every third day. There was great derangement of the nervous system; the powers of the stomach were wholly suspended; the tongue was covered with a thick white coat; and the countenance exhibited the utmost distress. Ar- row-root, tea, and tapioca were taken by table-spoon- fuls at a time. Wine disagreed at first, but after a long period of abstinence during which the patient 214 POISONS. appeared to be sinking fast, it was again had re- course to, and was fortunately retained. Medicine was rejected, except calomel. This acted on the bowels, and kept them in an open state without pro- ducing ptyalism. On the second day, an incision was made along the whole length of the fore-finger, in the hope that by lessening the tension of the integuments it would afford relief. A copious flow of blood followed the operation, but without any abatement of the pain. The constitutional irritation was increased by it. On the third day a slight fluctuation on the outer side of the fore-finger was felt; a lancet was intro- duced and a little lymph exuded, but without abate- ment of the pain. The inflammation of the ab- sorbents was relieved by the application of the liq. ammon. acet. lotion; it never extended above the elbow. On the sixth day an abscess was opened which pointed on the inside of the fore-finger; it yielded in the whole an ounce of pus. A tent was introduced, but was withdrawn on account of the irritation it oc- casioned. The wound soon closed, and on the eighth day a second abscess was opened between the joints of the fore and middle fingers, which was found to extend to the wrist. On the tenth day another large abscess was open- ed, and about six ounces of pus discharged. It com- prised almost the whole hand; the matter had insi- nuated itself beneath the palmar fascia, and a sinus existed from the tips of the fingers to the ulnar liga- ment. A considerable mitigation of suffering follow- ed the operation; the poultice was changed the next day for the saturnine lotion, applied at a tepid, and afterwards at a lower temperature. In four and twen- POISONS. 215 ty hours the powers of the stomach returned for the first time during ten days. The patient was much exhausted by pain and watchfulness, and having been very faint, a little wine was administered, which pro- cured him a refreshing sleep of some hours' duration; the first he had enjoyed since the commencement of his illness. In a few days, Mr. W. was well enough to be moved to the coast, where he speedily recover- ed his health. Mr. W. had but a very inconsiderable degree of fever throughout this attack.* Mr. W. Percivall, now veterinary surgeon to the Royal Horse Infirmary at Woolwich, favored me with the annexed report of his case. Case of Mr. Percivall, student of medicine. " About three, p. HI. of the 14th January, 1820, I punctured both thumbs, and the middle and fore fingers of my right hand, in sowing up the abdomen of a woman who had died of peri- tonitis. I washed my hands thoroughly on the spot, and again before dinner, and went to a ball in the evening. I mention this to show that I took no heed of the accident at this time. " 15th. About eight, a. m. I was awoke by an acute burning pain in the punctured parts, with my axillary glands on both sides as large as filberds, and very sore on pressure or motion. Being fully sensible of the nature of my case, but perhaps considerably overrating the danger of it, my mind took instant alarm, from which I could never afterwards divest it. I took immediately some calomel and colocynth pills; and applied a poultice to my right hand, which was the more painful of the two. Soon after I had a shi- * Abridged from the London Medical Repository for May, 1823. 216 POISONS. vering fit, followed by heat of body and acceleration of pulse, probably in part occasioned by the perturb- ed state of my mind. In the evening, with the con- sent and advice of Mr. Travers, for whom I was then dressing, 1 left town for Shooter's Hill. " 17th. Small abscesses had formed where my thumbs were pricked, and the pain and inflammation in them were much abated. All my suffering was now centered in the point (the part punctured) of the middle finger of my right hand. The finger itself was hot, tense, and swollen, and exceedingly painful; the whole hand was unnaturally hot and tender, and two or three faint waving red lines were seen upon the muscular part of the fore-arm. Mr. Travers saw me and ordered purgatives; leeches, fomentations, and poultice to the hand; and a roller wetted with liq. plumb, acet. dil. to the arm. " After a day or two the leeching was again had recourse to, in consequence of the daily progress the disease was making in the hand. As soon as any thing like fluctuation could be perceived, a lancet was directed through the injured part and thrust down to the flexor tendon; a drop or two of pus es- caped, but no very striking relief followed. " One night, a few days after, when the whole hand had become not only the seat of constant throbbing pain, but, from discoloration and extreme tumefac- tion, quite a terror to me when the poultice was re- moved, it was resolved to bandage it up with white wash, and discontinue the poultice. The next morn- ing, I felt a numbness in the point of the finger. I ex- pressed my apprehensions that it was dead, but those around me, I believe, thought otherwise. The second or third day afterwards, the nail separated, the cuti- cle peeled off, and exposed the last phalanx in a mor- poisons. 217 tified state. In about another week, the second pha- lanx commenced sloughing off at the joint. The skin of it had ulcerated through, and the ligaments were slowly undergoing the same process, when Mr. Tra- vers visited me and amputated the part. At the same time, the palm, which was under-run by pus, was laid open throughout its whole length. Nothing worth recording occurred afterwards. My hand pro- gressively amended, and my general health, which had not been greatly reduced, was speedily restored by gentle exercise in the air. For some time after the parts were healed, I had but a very imperfect use of my hand, in consequence of extensive adhe- sions among the flexor tendons in the palm. By con- tinual exercise of it, however, in a variety of ways, it has regained its functions so completely that I now feel no inconvenience." Remarks. Mr Clifton. I visited Mr. Clifton while yet con- fined to his bed, and after a full narration of the then recent circumstances of the case, I expressed, as I now do, my belief that it was a case of simple irri- tation. The disturbance of the nervous system it is true was unusually great, but the rapidity and ob- scurity of the suppuration, the unrelievable confine- ment of the matter, and the aggravation of acute in- flammation from this cause, sufficiently explain the overwhelming pain, and thence the whole train of symptoms. The case was most judiciously treated, and reflects great credit upon his medical attendants. It must be obvious to the reader that Mr. C. more than once owed his life to the lancet. Mr B.ayne. Mr. Brayne was my dresser, and previous to quitting London was under my care. I did not 28 218 poisons. then consider it a specific case, and the history, so ably reported by his brother, Mr. Thomas Brayne, confirms my opinion that the disease was one of sim- ple irritation affecting a delicate and previously dis- ordered system. The narrative in detail affords a valuable specimen of the complication and diffused- ness of the aches and pains which occasionally su- pervene upon severe local irritation, and the alarm which they excite by their utter intractableness to medicine, and their semblance of being more than functional. Mr slight. Of the same class I consider Mr. Slight's case, although, as may be said of the others, this was not the opinion generally entertained. This gentle- man prosecuted his dissection, and was not indispo- sed until the fourth day. He was then attacked with pain above the elbow, and fever symptomatic of sup- puration. At the interval of three weeks from the injury, the axillary glands were enlarged ; and at the expiration of another three weeks, they suppurated copiously. In the mean time the symptoms of irri- tation, viz. head-ache, vigilance, muscular twitch- ings, and irritability of stomach continued, and in a state of extreme hectic debility and emaciation from prolonged suffering and profuse perspiration, it is not surprising that the abscess was not circumscri- bed, but had extended itself both on the front and back of the chest. The constitutional disorder cor- responded to, and was symptomatic of the state and progress of the local irritation. Mr. wansborough. Mr. Wansborough's case differed only in this from Mr. Clifton's—that the suppuration was originally cellular and fascial, instead of being poisons. 219 within the theca of the flexor tendon. Hence the difference in severity of constitutional symptoms. Mr pPrcivaii. Mr. Percivall's case exhibits a different, but not very uncommon termination of the same spe- cies of injury. I am, at the time of writing this, at- tending a young practitioner for a sudden gangrene of the last joint of the thumb, from a slight puncture at the root of the nail received in dissection three weeks ago. The cases of Messrs. Clifton, Wansborough, and Percivall, exhibit in different degrees the simple acute irritation, those of Messrs. Brayne and Slight, the chronic, and therefore more complicated irrita- tion, attending upon suppuration. If the further consideration of this subject, the voluminous evidence which I have already adduced, and that which I have yet to offer should appear te- dious, I must plead in apology the embarrassment arising out of the mass of hitherto unarranged mate- rials which it is essential to investigate in order to form a correct judgment; the intricacy, and above all, the vital importance of the questions which they involve. H^cnr/nlTEgan. The case of Mr. Hutchinson related, with that of Mr. Dease, by Dr. Colles, in the second volume of the Dublin Hospital Reports, I consider an unequivocal example of absorption. The milky ve- sicle upon the site of the wound, the intense pain in the shoulder, the extensive erythema on the right side of the trunk, together with the extreme dejection of spirits, and constitutional suffering, are truly diagnos- tic. Mr. Egan's case, described in the same paper, 220 POISONS. I reject—not because 1 doubt that much variety may exist in the seat and character of the local action, but because neither the constitutional nor local symptoms were characteristic; they were in fact such as a simple local irritant was both competent and likely to produce, viz. erysipelatous redness of the wounded thumb, pain passing up the arm, an enlarg- ed gland at the edge Of the pectoral muscle, with the deep-seated abscess of the axilla, and symptomatic fever of suppuration. Dr. Duncan, Junr.'s cases. A large, and in some respects ve- ry valuable collection of cases has lately been given to the public by Dr. Duncan, jun., in the first volume of the Transactions of the Medico-Chirurgical Soci- ety of Edinburgh, under the title of " Cases of dif- fuse Cellular Inflammation."* I entirely coincide in the learned author's statement that this " is the most frequent form of that severe and often fatal affec- tion, which occurs from the application of the fluids of a dead human body to a wound or abraded surface." Of the cases communicated by Dr. Duncan, those of Messrs. Blyth and Young, and Mr. Hersey, ap- pear to have been well marked instances of ab- sorption.f * Dr. Duncan, I may observe by the way, appears to me to have generalized too much, and to be equally in error in his supposition that cellular inflammation, as constituting a distinct form of disease, has been altogether overlooked by practical observers, as in classing all the cases which he has narrated under the same head, as speci- mens of this affection. t The following extracts are so strikingly illustrative of the af- fection that I cannot forbear citing them. " In each," speaking of Messrs. Blyth and Young, " there was sligiit abrasion on one finger, but when accurately examined there POISONS. 221 The cases of Dr. Dewar and Mr. Cumming bear a considerable analogy to each other, especially in the was no inflammation nor any appearance indicating a poisoned wound. There was not the slightest trace of an inflamed absor- bent or vein from the finger to the axilla. In the axilla of both gentlemen was the first appearance of a morbid state. In both, the glands were enlarged, and there was exceedingly painful gene- rally diffused swelling with considerable redness from the axilla up along the neck, and for several inches downward along the side. The swollen part did not pit on pressure, but gave an obscure sense of fluctuation, which was well characterized by Mr. Lizars, by the term ' boggy.' At my request Mr. Lizars plunged a lancet into the swelling on Mr. B.'s side, about an inch and a half below the axilla, but nothing at that time was discharged from the wound but a little blood." '' An abscess was now found extending downwards as far as the os ilium, and nearly to the pubes. To allow a free exit to the pus, several punctures were made at the most depending points, and to preserve a free communication between them, a probe was occa- sionally introduced at the upper orifice and brought out at those be- low. For many days there continued a very copious discharge of purulent matter, at last accompanied by considerable flakes of a substance not unlike a skein of thread, which we considered to be disorganized cellular membrane." Mr. Young when convalescent of this malady died of a sudden attack of pleuritis : the following is taken from the notes of the ex- amination. " An incision was first made from the clavicle to the crest of the os ilium, and another crossing it to the axilla ; when the subcutaneous cellular substance appeared in some places dis- tended with serum, especially about the loins, while in others it was turgid with purulent matter which was most conspicuous over the pectoralis major. On prosecuting the.dissection the whole cellular substance of the side from the axilla down to the os ilium, and from the spine to the sternum, was more or less purulent ; the cellular sheaths of the latissimus dorsi, serratus major anticus, pectoralis ma- jor and minor muscles, were all purulent; and even the prolonga- tions of the cellular membrane, which divide the muscles into their different fasciculi, were equally purulent. Between the two pecto- ral muscles and beneath the minor, the infiltration of the cellular substance with purulent matter was very conspicuous. The carne- 222 POISONS. remarkable circumstance of inflammation commenc- ing in the left, and afterwards appearing, as by me- tastasis, in the arm of the right side, and there reach- ous fibres of these muscles had in general lost their cohesion, and were of a dirty yellow colour." " The cellular substance of the arm was every where healthy, and there was not the slightest vestige of disease in the fore arm, nor could any connexion be traced between the abrasion on thc finger and the morbid parts." In Mr. Hersey's case a pustule appeared where the puncture was made; on the 3d day the arm was much swollen and had an erysi- pelatous blush—no distinct trace of inflamed lymphatics could be perceived extending along the fore arm, nor any tumefaction or pain of the glands of the axilla. 8th day. '' Several vesicles, some of an oblong, others of a more circular shape appeared to-day on the back of the fore arm, below the elbow, and along the outer and inner side of the arm above the joint, the smallest of which is about the size of a sixpence, ele- vated, and the longest from two to three inches in length. Some are filled with transparent serum, and others with a thin fluid, but of a dark colour. The erysipelatous inflammation encircling these vesicles has assumed a dusky hue, which extends over the greater part of the arm from above the wrist, and upwards over the shoul- der, but becomes gradually fainter as it recedes from the bases of these vesicles." 9th day. " Inflammatory hue, deepening in tint, extends over the deltoid muscle, and from the breast backwards over the shoul- der. The region of the deltoid is also occupied by vesicles similar to those already described, varying in size, and filled with a dark se- rous fluid. Some of the vesicles on the arm were opened, and some have burst." 10th day. " Most of the vesicles have burst, and have dischar- ged such quantities of fluid as to penetrate the bed, and run upon the floor." Early on the 11th morning he died. This case presents an unusual combination with the other signs of the malady, of erysipelas affecting the arm, owing in part pro- bably to position, the patient having continued in business when he was very unfit to be out of his bed, even until the 5th day. The pustule on the wound and the existence of vesicles encircled by an POISONS. 223 ing its greatest degree of severity.* The suppura- tion appears to have been secondary upon the con- stitutional disorder. Whether a consequence of fe- ver, or the result of a poison absorbed, is a question which I do not feel competent to decide. Notwith- standing the probability from the circumstances of their origin that they were genuine instances of ab- sorption, the details do not furnish to my mind satis- factory evidence of the fact. The spontaneous at- tack of deep-seated suppurative inflammation on the right arm, at an interval of about six days from the injury, real or supposed, was marked in both cases by a retrocession of the primary affection in the left. In the first of the cases communicated to Dr. Dun- can by Dr. Barlow of Bath, the characteristic signs of absorption are wanting, and the existence of ge- neral tumefaction of the arm, with inflammation of the lymphatics and cellular substance, and deep- seated suppuration, render its specific character very questionable. The second of these cases, so far as the paucity of detail permits of an opinion, appears to have been genuine. Mr. Whitelaw's case (10.) resembles that of Mr. Slight, page 209 of this Essay, but was undoubtedly more severe. Dr. Hennen, jun.'s case of axillary abscess from dissecting the same subject with Mr. Hersey. Mrs. Edie's from a pin-scratch in washing a towel employed in the dissection in which Mr. Cum- ming met with his fatal accident, cases 16 and 17, erysipelatous blush, which became fainter as it receded from their bases, are characteristic, together with the constitutional disorder, of specific irritation. * See case of Mr. Graves, p. 217. 221 POISONS. 18, 19 and 20, which are the remaining cases ot wounds in dissection given by Dr. Duncan, and case 21, "from a prick with a fleshhook," are neither of them in my opinion cases of absorption* All these I consider as properly classing in this respect with the last five cases which I laid before the reader. But. it may be asked by those who incline to a contrary opinion, may not a difference in the quality of the poison, or in the susceptibility of the individual, ac- count for the difference in the phenomena which en- sue ? DS*S^ I believe that the difference in quality may explain the greater or less severity, but not the difference of phenomena. If of two individu- als injured in dissecting the same subject, the case of one present the symptoms of absorption, and the other not—as for example, Mr. Dease and Mr. Egan, Mr. Hersey and Dr Hennen—I infer that the one ab- sorbs the poison, and the other escapes it. The cases of Mr. Blyth and Mr. Young, Mr. Delph and Mr. Smartt dissecting the same subjects, were affect- ed with symptoms precisely similar, each to the other* The absorption or non-absorption may be determin- ed by accident, the clean or the foul instrument, &c. or it may be referred to the second head of the ques- * Mrs. Edie's was a true paronychia or suppuration within the flexor theca. Messrs. W. D. and A. B. students of medicine, were cases of ordinary absorbent and glandular inflammation. Mr. Burton's was a suppurative erysipelas of the arm artificially in. duced, viz. by the ligature. Mr. Lizars's pupils were affected with fascial inflammation and abscess of the hand. Mrs. Hodge's case was an acute cellular and absorbent inflammation of the arm and axilla, such as has been often known to follow a lacerated wound of the finger or thumb. POISONS. 225 tion, viz. the difference in susceptibility. The fret quent exposure of some individuals to this and other poisons with perfect impunity is a matter of notoriety, and this may explain why the specific disease is no- set up, when that which results from simple irritation is—and in truth the greater susceptibility of local ir- ritation and inflammation may be a condition coupled with insusceptibility of absorption, and afford in some measure a safeguard to the constitution. Thus, if the poison operate as a chemical irritant upon the part, and this inflame, whatever mischief extends to the system is referable to symptomatic irritation; but if it find a quiet and ready entrance into the system as by an open door, the system is alarmed first, and the local consequences are displayed at a distance from the seat of injury. To what causes this susceptibility is to be referred, or to what extent it operates we are ignorant, and whether the nature of the wound afford- ing a facility for absorption in the one case, and not in the other, be the real explanation; however the fact is undeniable. But this theory of susceptibility supposes no difference in the phenomena character- istic of absorption, but refers the difference in symp- toms to the fact of non-absorption. In severity the symptoms of both specific and simple wounds undoubt- edly vary; those however of the former less than of the latter. The appearance of vesicles or pustules, or the contrary; the affection of the opposite limb or side of the body, or the definitive boundary of the action by the median line; the rapidity and vehe- mence with which the symptoms of pain and cere- bral disorder are manifested, or the reverse, indicate different degrees of severity. Compare the cases of Dr. Pett and Mr. Dease with those of Messrs. Delph and Smartt. Whether it be to local circumstances 29 226 POISONS. or constitutional peculiarity that some individuals owe their security in situations of exposure, I ima- gine that if the poison be once admitted into the cir- culating system, none are exempt from its effects. Different species or poison ? But it may be further asked—since we admit that the poison absorbed from dead animal bodies varies in degree—may it not also vary, like the morbid poisons, in kind, and hence the difference in phenomena attending upon wounds in dissection be explained ? For example, in some cases only, are pustules, pimples, or vesicles found in one or more parts. In some the absorbent glandular system is chiefly affected, in others the cellular; in some the wound inflames, and inflammation spreads along the limb from the wound; in others the wound can scarcely be said to inflame, but the inflammation is acute at the opposite extremity of the limb, or cour- ses over the trunk of the body ; in some the primary inflammation is altogether insignificant, the pain and general disorder of the system enduring and most severe, and after a continuance of many weeks of extreme debility and emaciation a deep chronic ab- scess presents, and proves critical of the malady. Lastly, in other cases the inflammation subsiding favorably in the injured extremity, appears within a few hours in that of the opposite side, and terminates in deep and extensive suppuration, or gangrenous erysipelas. It would appear on the above hypothe- sis, that one form of the poison irritated upon contact and provoked resistance to its admission, that is, in- flammation in all the parts through which it passed ; and that another, by its silent and uninterrupted en- trance, and instant admixture with the mass of blood, POISONS. 227 exhibited on the contrary its characteristic effects at other and remote parts of the system. ,nsuffio[ePttem\pnaindiffercnce The following objection to ad- mitting the cases in question to be instances of ab- sorption appears to me to be decisive; they differ in no important respect from simple injuries with clean instruments; from abrasion and bruise, or in- flammation of the cutis even without laesion. From such causes inflamed absorbents and their glands, and continuous cellular inflammation and suppura- tion are constantly arising, and there is no evidence to prove that continuous inflammation ever arises from the passage of poisons into the mass of blood. On the other hand, distant, diffuse and superficial cellular inflammation is certainly not an effect of simple injury, but this is the prevailing characteris- tic of the local action in the most urgent and fatal cases. Now although it is in the highest degree pro- bable that the poison varying in intensity should oc- casion a more or less severe disease, as we see in the cases related, it is as improbable that the character of the specific action should be subject to variety: in a word, it is improbable that the effects of the poison, quasi poison, should be at one time such as we have described, and at another such as are liable to be produced and frequently are produced by simple causes of irritation. m^££E?&£$£F Are the cases then of non-ab- sorption to be regarded simply as results of mechani- cal injury, and would the subjects of them have been liable to be affected by similar consequences from similar injuries inflicted with clean instruments, in pure air and wholesome occupations ? 228 POISOAS. I think I have drawn a line of distinction broad enough to be easily recognised, even by a superficial observer, between the cases of absorption and of non- absorption. If therefore the consequences of the wounds from dissection are more serious than such as result from ordinary clean wounds, and which I am disposed to believe they often are, the difference must be attributed to some peculiarity attending them, local or constitutional. It is not necessary that a local irritant, acting chemically, should be received into the mass of blood to produce extraordinary local excitement. The matter of gonorrhea is commonly a more severe local irritant than the matter of syphi- lis ; and various substances employed in surgery, which furnish no evidence of their absorption, exem- plify the same fact. The constitutional excitement is in these cases the legitimate consequence of the inflammation produced by the local irritant, and is either slight or severe according to the seat, nature and degree of such inflammation. The chemical, therefore, are to be regarded as operating on the same principle upon the constitution as the mechani- cal irritants, where their tendency is to produce high local inflammation; and their action being not dissimilar, it is probable that they act in concert, and that the irritation of an acrimonious substance, super- added to that of a penetrating wound, may determine the extraordinary activity and extent of the local in- flammation, and by consequence of the constitution- al disorder. I conclude that it is therefore probable that the irritation in some of these cases, though strict- ly local, is in its nature such as to act upon the con- stitution with greater severity than that of similar clean wounds. POISONS. 229 peculiar irritability. Many persons have been disposed to refer the severity of the inflammation attendant upon these wounds to a peculiar irritability of constitu- tion. This when present must have a prejudicial in- fluence, but the case too frequently occurs in the ab- sence of such predisposition. The frequency of ex- posure to such injuries in dissection must be taken into account. It is well known that a large propor- tion of the students who meet with these accidents regard them as productive of no inconvenience in their own persons, and although we have no means of estimating the number of those who escape, we have reason to believe it greatly exceeds that of the sufferers. My experience as regards these cases does not lead me to attach more weight to this opi- nion than belongs to its general application. Constitutional affection more severe. I Consider the Constitutional state in the cases of absorption to be as much more severe than that which prevails in a large proportion of the cases of simple irritation, as the local is less so. The latter present the fever symptomatic of lo- cal irritation, or the fever of suppuration, acute or chronic. It takes its form and pressure from the local inflammation. If it be more violent in the first, or more protracted and exhausting in the second stage, it is nevertheless such in character as we are accus- tomed to see in local inflammations which have a dif- ferent origin, and we treat it on the same principle. The former, if I judge rightly, is a constitutional be- fore it is, openly at least, a local disease. It may even destroy without exhibiting, if we except pain, a local sign; the local sign may be either scarcely develop- ed, or, on the contrary, may have approached a fa- vorable termination, when the system exhibits symp- 230 POISONS. toms of dissolution. There are however some cases of simple irritation, of not very rare occurrence, viz. the cases of true paronychia, or acute suppuration within the sheath of the flexor tendon, in which the general and high excitement of the nervous system is so sudden and peculiar,* that we cannot be surprised where other circumstances favor the conclusion, to find such instances recorded as cases of a poison ab- sorbed. And as respects the constitutional pheno- mena, they might merit to be so regarded ; for there is little, if any difference to be recognized between them in the acuteness of the suffering, the high ner- vous excitement, and the suddenness of the col- lapse.f Remoteness or the inflammation from the injury. In reference to the CaSCS of absorption, the question natur illy recurs.J why, if the poison is conveyed into the circulating system, the first evidence of its introduction should be fur- nished at a distance from the part injured, while that part escapes with impunity ? 1 admit the importance and difficulty of this question, and offer the following solution of it. A slight and soft fulness of one or more glands, and tenderness in the course of the absorbents is the re- sult of mere irritation, and occurs therefore as rea- dily in simple as in poisoned wounds.§ * Case of Mr. Clifton, p. 199. t The more invariable and severe attack of rigor in the cases of ahsorption deserves to be noted. In those of simple origin it is of- ten wanting. J See page 147. § The cordy hardness (adhesive inflammation of the coats) of the absorbents, which is not peculiar to the morbid poisons, is a gradual process, and only occurs after the primary irritation has been long established. poisons. 231 The fact of the intermediate part being unaffected in acute inflammation and abscess of the glands, in which the absorbents of the part irritated terminate, is seen every day in the sympathetic bubo attendant upon gonorrhea, and sores of the penis, mammae and fingers. The virulent and irritating quality of a poison not formed by a specific inflammation and secretion of the part, as the morbid poisons, but introduced, ready made, as I might say, into the system, as that of de- composed animal matter, discovers itself by the same signs, but greatly augmented in rapidity and intensity, as regards constitutional excitement and pain, and with this remarkable difference—that the seat and extent of the pain and inflammation are invariably diffused instead of the contrary.* Arrest of the poison by the axillary glands. The arrest of tile poison of animal matter in the first stage of its progress by the axillary glands, determines the original focus of the inflammation and pain : these glands irritated by the contact of the noxious fluid, become congested, and partially obstruct its transmission into the circu- lation. The cellular tissue in part forming, imbed- ding and connecting them, inflames, and the puffy swelling denoting, first, serous effusion into the cellu- lar membrane, and afterwards, by an erythematous blush, an inflammatory secretion in that texture, ex- tends from the axilla to the pectoral and sub-sca- pular regions. The pain affecting the top of the shoulder, subclavian and pectoral regions, is explain- * The tendency to diffused erythematous inflammation from the absorption of animal poisons is exhibited in the stings and bites of inserts, and the effects of certain animal substances taken into the stomach. 232 POISONS. ed by the distribution of the muscular twigs of the thoracic, supra and infra-scapular and circumflex nerves of the contiguous axillary plexus, if this theory be correct, the invariable locality of the pri- mary inflammation, as well as the mere and transient irritation (if any) of the absorbents, is explained. If the poison so insidiously entered the system and min- gled with the mass of blood as to excite no primary irritation, the natural sign of resistance to its admis- sion, it would be difficult to assign a reason why its effects should have this or indeed any local manifes- tation. It is well known that a ligature on the limb will prevent the effect of the viper's poison on the system, and that violent erysipelatous inflammation ensues, as in the case of Mr. Butler, related by Dr. Duncan. The lymphatic glands act as a natural but unfortunately ineffectual barrier to the passage of the poison; effects not very dissimilar to those of the mechanical impediment, are produced in their imme- diate vicinity, and are most conspicuously apparent in parts where the connecting membrane is disposed in greatest abundance and laxity of texture. But al- though the irritant has this local manifestation, its passage is impeded only, not prevented, and the con- stitution therefore frequently exhibits disturbance sooner than the part, which in the instance related, p. 141, proved destructive, even before any visible sign of inflammation appeared. site of secondary inflammations. The occasional determination of inflammation on the opposite side of the trunk or op- posite extremity, in the second instance, is not alto- gether peculiar to cases of specific irritation, nor common in these. It appears in some cases to be re- poisons. 233 fcrable to a casual irritation of the part,* but in others no p'-obable cause of local congestion ap- pears, nor does it admit of explanation on the ground of a proper nervous sympathy. The sympathy of continuity and that which prevails throughout the whole expansion of the same texture, as the lympha- tic and cellular, may explain the extension of a dis* eased action, but not the affections, partial and re- mote, to which I refer. Neither does the impregna- tion of the circulating blood with the matter of poi- son assist to remove the difficulty. But the insulated patches of the erratic erysipelas,the abscesses forming at the subsidence of fever, which have been called critical, nay, the local determination of inflammation in general, for which no cause appears, are points equally unintelligible, except on the hypothesis of a local irritation and congestion, not obvious to our senses. I believe, in the cases of absorption, the cel- lular texture in the immediate neighbourhood of lym- phatic glands, superficial or deep-seated, to be, on the principle above stated, the chief seat of the se- condary inflammations. Condition of remaining animalization ? of in- Tn tkp n0eaC !n niViipri flio cipient decomposition'! of putrefaction ? xu "lc tdBtB ill Wllltll UiC admission of a poison is undisputed, two or three ob- vious inquiries arise. Is the frequent fatality of these injuries to be ascribed to the condition of remaining animalization which has hitherto resisted the opera- tion of external agents ? or to such an alteration in the quality of the animal fluids by the incipient pro- cess of decomposition as merely divests them of the properties of living matter? or to a state of putre- faction so advanced, as to be actively disengaging * See page 187. 30 234 poisons. new and deleterious compounds ? Our knowledge of this subject is not sufficiently advanced to enable us to answer this question satisfactorily. The larger proportion of genuine cases of the disease have their origin from dissections of bodies recently dead under inflammation, by which an abundant secretion of morbid fluids is accumulated,* and in which the tho- racic and abdominal viscera are examined and han- dled. But a single strongly marked exception is suffi- cient to shew that no condition of the dead subject is exclusively prejudicial, and of the cases above cited, nearly as many had their origin from the dis- section of stale bodies, i. e. such as had been buried, as of recent subjects. We have the vesicle or the pustule ensuing in both cases, viz. from protracted dissection for demonstration (Mr. Dease, Mr. Hutch- inson ;) and from recent examination (Mr. New by, Mr. Hersey.) If, as is probable, at the moment of expiring vital influence, or of de-animalization, new combinations give birth to a specific matter of con- tagion, it is to be presumed that the ultimate state of dissolution and decay, which we term putrefaction, so alters its quality, as to neutralize and render it inert. And it is in conformity with observation that actual putrescency is in some degree a security from the effects of this species of injury. Putrid matters act as a strictly local poison: they irritate and in- flame the part wounded and its immediate vicinity, and the constitution is in proportion protected. * If the dissection be performed before the body has entirely parted with its warmth, a faint and peculiarly oppressive odor id emitted, which is disagreeable, not to say revolting, even to per- sons habituated to dissection, and which not unfrequently creates nausea. poisons. 235 We know that vegetables undergo certain chemi- cal changes, or form new compounds at the expira- tion of life, prior to those which take place in their state of ultimate decay. Luminous animals cease to emit light when putrefaction commences and not before, and on the other hand there are animal and vegetable matters which become luminous in a state of rottenness. Chemical observation and analysis directed to the subject would, and probably one day will throw light upon the fact, that the first changes which take place in the animal body, after the utter extinction of the vital influence, produce a fluid more deleterious in its effects upon the living body, than any which succeed it, and will also determine whether the fluids generated by disease when under- going these changes possess more or less of this pro- perty. Pathologists in the mean time may be well employed in determining the importance due to the habit of the individual affected, to the nature of the wound, the fatal disease, acute or chronic, of the subject, and the varying rate of decomposition in the interval which has elapsed since death, from circum- stances operating before as well as after death.* Hitherto observations are not sufficiently multiplied to warrant more than the general conclusion that the disease bearing a specific character may be derived from absorption of the fluids of both fresh ^and stale bodies. ^afid^Ztrn9uebTerctcr- Another inquiry is, if any spe- cific contagious disease be capable of being commu- nicated after death, as erysipelas, with which Mr. * " Faith, if he be not rotten before he die (as we have many pocky corses now-a-days that will scarce hold the laying in) he will last you some eight year>" &c—Clown in Hamlet. 236 POISONS. Newby was supposed to be affected, small-pox, or lues? Although I assent to the opinion that erysi- pelas is in some circumstances contagious ;* a ques- tion so subtle as to be still coram judice, as regards the living subject, is not likely to be decided by an appeal to the much more limited experience of the profession in its properties after death. It is proba- ble, indeed scarcely doubtful, that a pustular or ve- sicular disease like small or cow-pox, retains forsome time after death the property of communicating the local poison, by reason of the favorable circum- stances in which for a given time the virus is pre- served. Students dissecting small-pox subjects have had variolous pustules of a spurious description form upon their wounded fingers. This is common; but I never knew an instance in which the constitutional disease was communicated. The effectiveness of the living poison, preserved for many months by ex- clusion of the atmosphere, is obviously a distinct fact, and in no degree bears upon this question. A specific morbid secretion, as that of lues, is ca- pable of transmitting the constitutional disease from one living system to another. I was acquainted with an accoucheur who, while troubled with a sore finger, delivered a woman affected with a venereal ulcer of the vagina, and in consequence became the subject of ulcer, eruptions and nodes, bearing the characters of syphilis, and which were only cured by a full course of mercury. Bodies used Moracuvsftcyrtn02eat°h.e their *°r dissection are, with few ex- ceptions, in a morbid condition, and although I have known instances of wounds re- * See Dr. Wells's observations in the Transactions of a Society for the Improvement of Medical and Chirurgical Knowledge.— Vol. ii. art. 17. POISONS. 237 ceived in the dissection of poxed and cancerous subjects in the stage of ulceration, I never knew nor heard of a case in which venereal or carcinomatous symptoms succeeded to such casualties. If the sim- ple morbid secretions of living bodies were capable of acting as poisons, surgeons would be occasionally subject to peculiar diseases from this source as well as from dissection; and if the morbid poisons were transferable as such from the dead to the living, the fact could not have escaped observation. Poi=on of glanders retains its properties Vptprinnrv Qlirv Experimental Enquirv. WITHOUT RE-ACTION. 397 I have called this state < prostration,' because the term is descriptive without involving an hypothesis to explain it. It is a state not actually amounting to, but threatening or nearly approaching a cessation of vital action. Whether it be the direct result of the shock, or of an exhaustive effort of nature to meet the emergency—as those persons may suppose who look instinctively for a final cause, and resolve every action into a salutiferous or restorative operation—I will not presume to decide; but it would be utterly subversive of my notion of the case to suppose that nature is in a condition to make any arrangement for her own relief. What are the means by which we can hope to rally the flagging power, and restore the natural harmo- nies of the system ? The state of the circulation inferred from the pulse, 'Complexion, breathing, and temperature, is our chief, if not our only guide. If the shock be unattended by hemorrhage, and as the argument supposes, by lesion of any vital organ, im- mediate or accessary, cordial drinks, as spirituous and vinous liquors and compounds, and what are called diffusible stimuli, as ammonia, aether, camphor, &c. with the aromatic distilled waters, and warm and gentle stimulating enemas are the most obvious inter- nal remedies. Externally, the stimulus of artificial heat applied to the pit of the stomach and extremi- ties, as by fomentations ; and camphorated and spi- rituous embrocations, or gentle frictions where the state of parts permits, are the usual means resorted to of exciting the sentient extremities of nerves, and inviting the capillary circulation. If any advantage be gained by these means, it be- comes necessary to substitute some light aliment for the dram, as gruel, yolk of egg, arrow-root or sago, 308 0F THE STATE OF PROSTRATION or to join them, as in jelly, or either of thc above sub- stances, with wine or brandy. indication twofold. We have two points especially to bear in mind, first, maintaining action, secondly, not forc- ing action. The first requires the incessant observation of the surgeon. No nurse can be qualified to superintend, or at least to direct the administration of the stimu- lus. It is the devotion of a few hours to the life of a fellow-creature. The duty may be divided. The happy effects resulting in numerous instances from perseverance in the process of recovering a drowned person, although a shorter and less delicate process, hold out strong encouragement in these cases. When syncope is overcome, the system, it is true, rights of itself: the phenomena, however, of syncope and shock, allowing for the difference of duration, bear a considerable analogy; it is in their causes that they differ, as I shall presently shew. Purgative medicine ought not, in my judgment, to be given until the circulation is restored and pretty steady—then a spoonful of castor oil may suffice. It is idly premature to talk about the secre- tions. Medicines directed to this object cannot act beneficially in such a state of the nervous system, if, as I much doubt, they act at all. It is besides of im- portance to avoid putting any thing into the stomach but what is essential to support the faultering action of the heart and diaphragm. Since it is upon the stomach we place our chief reliance, we should en- deavour by every means to keep it in temper. If we neglect to supply stimulus, when called for, the spark of life goes out. The signs of its indica- tion must therefore be vigilantly observed. We are WITHOUT RE-ACTION. :jo9 maintaining action upon inadequate power, in the hope that the natural resources may come to our relief, and that we may gradually diminish stimulus and increase nutriment, which is our only method ot raising power to a balance with action. 2d. The respondence of the circulating forces to an increased supply of stimulus, must serve as a caution against over-supply. Since power is defi- cient, we must carefully husband our only resource, and not waste it in inordinate action. When the signs of re-action are manifested, its excess is much to be apprehended, if such re-action has been obtained by over-stimulation. Excessive re-action, so induced, is 'prostration with excitement' in its most perilous form. When such a state is the original form of the malady, it is probably less dangerous, because in this case the in- equality between power and action is less. cerebral influence in prostration. The degree of cerebral affection, independent of any direct injury of the brain, varies so much as to influence materially the symptoms of prostration. The mental faculties are more clouded and stupified, the respiration is more difficult, and the. temperature of the surface sinks in proportion as the cerebral influence is diminished. The muscles are subject to spasmodic and convulsive actions, and the pulse to irregularity and intermissions, in proportion as the cerebrum is, or becomes affected. The * fris- sonement,' which ordinarily accompanies shock is distinct from rigor.* It is a cerebral affection like * The distinct origin of tremor from mental and physical im- pressions is familiarly known. " You tremble, Sir," said a bye- stander tauntingly to one of the unfortunate victims of the Resolu- tion, on his way to the guillotine. "True friend," he replied. '' hut it is from cold, not, fear." 310 OF THE STATE O* PROSTRATION the shudder produced by certain acutely painful im- pressions of the mind or organs of sense. It is not always present, and sometimes wanting where the temperature, to which it seems to have no reference is to our sensations reduced. On the other hand, I have often seen it without any sensible coldness of surface. It is only at the moment of its occurrence that the direct injury of the brain is liable to assume the com- mon characters of prostration, which are in no wise to be regarded as proper and legitimate signs of ce- rebral mischief. The stupor, convulsions, and deliri- um, which characterise injuries of the head by their appearance after an interval in which re-action has been fully established, assume a pathological charac- ter very different from those identical symptoms oc- curring at the moment of injury. But if after an injury unattended by hemorrhage, in which the head has suffered no direct mischief, the surface retain its natural warmth, and the pulse and the breathing be oppressed, and there be present stupor, convulsion, and inaction of the pupil; blood should be taken in such quantity as to relieve congestion, and its effect upon the symptoms duly noticed. If on the other hand stupor and convulsion be accompanied by a contracted and cold surface, and a thready or inter- mitting pulse,—I have repeatedly seen both states— the cordial is the proper remedy. Greater freedom of circulation, and a consequent diminution of the stupor and convulsion will be found to follow both one and the other practice, as it is judiciously resort- ed to. BiyxMetting upon injuries The custom of letting blood indis- criminately after accidents is so irrational, that the WITHOUT RE-ACTION 311 authority of long-established custom forms no excuse for it. Prophylactic blood-lettings may be proper in certain cases, as in threatened apoplexy, or where a hemorrhagic disposition prevails in parturient women, &c.; but they are seldom admissible where injuries have been inflicted. I have seen a practitioner tie up the arm of a person to bleed him after a fall, in a pale cold stun, in which the pulse could scarcely be felt at the wrist. I have known operators permit a large artery to bleed before tying it, in amputations unexpectedly performed on very robust subjects. It is easy to see the motive of such operators, but it is an erroneous pathology, and a dangerous practice: the effects attending upon loss of blood are peculiar, and the reduction of strength by these means has no analogy whatever to that which is brought about by chronic disease, and renders the effects of operations less formidable. Whether the congestion of the cerebral circula- tion in prostration proceeds from deficient action or determination, the tendency of opium is to increase the congestion; opium, therefore, appears to me to be inadmissible. In the above observations I have referred to the state of prostration without re-action, from whatever cause proceeding, for in such a case it were frivolous to refine upon the diversities of treatment which in a more advanced stage, as when re-action is establish- ed, a reference to the circumstances of the injury or operation might suggest.* *' The cases of prostration without re-action are those under tlio liead of' Burns,' except the two last; of Bryan, p. 121, and Dodd, p. 121 : of Lithotomy, p. 135, et seq. '212 OF THE STATE OF PROSTRATION Treatment or burns. Burns and scalds are unattended with hemorrhage. No species of injury exhibits the symp- toms of prostration in a more marked degree than these, when of a severe description. The remedy upon which I rely in burns inducing this state, is brandy in gruel, in the proportion of one part of the former to two of the latter. This is administered in doses of a table-spoonful or two at short intervals, until we obtain a sufficient distinctness and fulness of the pulse at the wrist, with a corresponding improve- ment of complexion and temperature of the surface. The bowels should be simply kept unloaded by means of castor oil or common injections. If there be much stupor, and the bowels have been previously costive, I prefer to give ten or fifteen grains of the compound calomel and scammony powder. The use of opium, a remedy still generally employed on account of the patient's sufferings, 1 have abandoned, being convinced by experience, that in small doses it is inefficacious, and in large ones injurious. I have before observed, that pain is a good symptom in burns. I need scarcely observe that the exhibition of the stimulus requires unceasing and judicious attention; it must be intermitted, if the pulse become bounding, and the patient flush. Nevertheless in deep and very extensive burns gf adult subjects, I have frequent- ly found it necessary to persevere in its use for a week or ten days at lengthening intervals; occasion- ally intermitting, and always gradually withdrawing it. Not only has the partial remission of this plan been in some instances imperative, when re-action was permanently established, but symptoms of the head or chest have made their appearance which re- quired blood-letting, either topical or general; and a WITHOUT RE-ACTION. 313 smart purge of calomel and scammony I have found on such occasions very useful. In deep burns the external remedy which I prefer is the turpentine and olive-oil liniment, or turpentine and cetaceous oint- ment, upon the principle, though not exactly the plan, recommended by Dr. Kentish of Newcastle, and subject, after suppuration commences, to such changes as the state of the surface may require. This appears to me to coincide advantageously with the internal use of the stimulant. The lime-water and milk liniment, and when suppuration has become abundant, the calamine or chalk powder lightly strewed over the whole surface, and defended by the same or simple ointment thinly spread on linen, is the local treatment which I adopt in superficial burns. Upon the whole, the results of the stimulant treat- ment of burns, which I have more strictly pursued since my attention has been directed to the subject of this Essay, have proved highly satisfactory. Epitome of shock. A fit of syncope and the recovery from it present an epitome of the phenomena of shock; the representation, it is true, appears exaggerated, its access being more abrupt, its progress more ra- pid, and its events altogether crowded and con- densed into a shorter interval of time. The heart is affected with tremor, and although it does not cease to act, acts so unavailingly that the cerebral circulation is nearly arrested, and the current of life seems at its last ebb. As the heart and vessels of circulation recover their action, and the mental fa- culties begin to be restored, a momentary hallucina- tion or delirium comes over the patient, not unfre- quently accompanied with violence, to which suc- ceeds a subdued rigor, and this is followed by a 40 314 OF THE STATE OF PROSTRATION warm glow, then a gentle moisture of the surface, and a calm but somewhat oppressive languor. The causes which lead to this are not more different from each other in various cases, than from those which give origin to the state of prostration; and circum- stances are not wanting to explain the suspension more or less of the senses and intellectual faculties and voluntary powers in the fainting fit, and its non- occurrence in ordinary instances of shock, without injury to the stated analogy between the cases. If we would allow to a sudden and artificial irritation, the gradations between the extreme states of excite- ment and depression which we allow to that which is the result of inflammatory and other diseased actions, it would not be difficult to explain all the varieties of sensorial and nervous affection, from a slight stupor to a profound coma, from simple incoherence to ac- tive delirium, from a momentary sinking to the fatal syncope which sometimes succeeds to injury. To pursue the illustration.—It is upon the brain in both cases that the first impression is made, and to its influence upon the organs of circulation and re- spiration, that the phenomena which differ in degree and duration more than in kind, are to be ascribed. Syncope following a slight injury is very common and very unimportant; syncope following a severe inju- ry, not attended by hemorrhage, is rare, and in the highest degree dangerous. In the first instance the shock is partial, slight and evanescent; in the latter it is extended, deep, and permanent. The order of the train of symptoms in the two cases being similar, and the rapidity of the crisis in the syncope, the main distinction; are we to infer that the same principles of treatment are applicable, and that similar means may be employed with a like WITHOUT RE-ACTION. 315 prospect of success ? The principles will be the same, and the means not essentially different, but the probable results admit of no parallel or comparison. This is to be explained by the difference of circum- stances which have operated to produce the two states, and not the difference in kind of the effects produced ; for as I have stated, shock sometimes as- sumes the form of syncope, and when it does so, generally proves fatal; whereas from a slight cause, a fainting fit is not attended with danger. symptoms analyzed. I shall now shortly analyze the symp- toms of prostration. Nausea.—The stomach is affected with nausea and loathing of food by any sudden depression of nervous energy. We see this effect continually in health from sudden affliction, &c. The effect is too instantane- ous to be attributed to a deficiency of secretion, even where hunger had not previously existed. I believe it is such a direct loss of tone, I would say of erethism, in the sentient extremities of the mucous surface, as we see a sick stomach, and other causes, ». produce upon those of the cutaneous surface. The want, that is, disappointment of food, palls and often destroys appetite. Taking food frequently creates it.* Suppressed or depraved sensation is one of the most immediate and remarkable effects of irritation. It is probable that a similar morbid sympathy to that which suddenly unfits the mind for thought, or the body for exertion, is the cause of that disgust in the stomach which constitutes nausea. Nausea is not only an ordinary consequence, but * «• L'appetit vient en mangeant." 31 ti OF HIE STATE OF PROSTRATION a never-failing cause of nervous depression. The universal sympathy is in no organ more strongly ex- emplified than in the stomach, as is proved by the instant nausea preceding faintness from remote and transitory causes. The effects of its disorder are more rapidly and sensibly diffused over the system than those produced by the disorder of any other organ, as is seen in the direct debility of the nervous, vascular, and muscular systems ensuing upon sea qualms, and the introduction into the stomach of nau- seating medicine and indigestible food. Hence the stomach has been named the centre of sympathy. While the state of nausea continues urgent, no effec- tive re-action can take place. Vomiting is its relief, and is to the oppressed stomach what rigor is to the oppressed heart. The system, after one full vomit- ing, experiences a lithesomeness as after the removal of an intolerable burthen; but if the unnatural ac- tion he renewed, and become habitual, it is as much a sign as a cause of exhaustion. Vomiting.—In muscular organs morbid sympathy- shews itself in extraordinary action. Thus we ex- plain palpitation, hiccup, vomiting, dysphagia, dysu- ria, cramp, and spasm. The change which a great and sudden depression of nervous energy works in the quantity and quality of the secretions, has undoubted- ly a share in provoking the act of vomiting. It would appear that a regurgitation of bile, and its overflow upon the stomach, takes place in these cases as a consequence of the first debilitated, and afterwards deranged or inverted muscular action of the stomach and intestines. Vomiting may be concomitant with a constipated or a lax state of bowels. If it should be attended with constipation, stimulant drastic ene- WITHOUT RE-ACTION. 3 j 7 mas should be exhibited. If with a free state ap- proaching to looseness, a full opiate enema should be given; and in most cases five or ten grains of calomel with one or more of opium prove advantageous in this state, if retained. A spoonful only of fluid, as brandy and water, or strong tea, or coffee, should be taken by the mouth, and that seldom. A bladder of hot water, a mustard cataplasm, or a blister, should be applied to the pit of the stomach. The more im- mediate operation of the two former renders them preferable in urgent cases. I have known the calo- mel and opium pill, and the injection, both cathartic and opiate, selected according to circumstances, stop urgent vomiting, where effervescent saline draughts, acids, alkalies, antispasmodics, cordials, and in short, every liquid had been rejected from the stomach. Hiccup.—Hiccup, a more advanced and decided symptom of prostration, is a spasmodic affection of the diaphragm, probably from a contiguous sympathy with the stomach. We see it generally, but not al- ways connected with the irritability which gives rise to vomiting, and both symptoms with a flatulent state of the small intestines, I believe, invariably. Intes- tinal obstruction, of which vomiting and hiccup are symptomatic when arising from a mechanical cause, operates, though in a different manner and degree, to produce these symptoms in prostration, whether di- rectly induced by shock, or indirectly by gangrene, or typhus fever. These enfeeble almost to paralysis the proper muscular motion of the intestines, and thus give rise to excessive flatulent distention. Hic- cup is a symptom very variable in its occurrence: sometime*, though not frequently, appearing early, 3]# OF TH1: STATE OF PROSTRATION. and occasioning great distress from its violence, sha- king the whole frame, its sonorousness, such that it may be heard on another floor of the house, and its unintermission, preventing the patient's slumber. When of this aggravated character, I have not known it arrested, scarcely alleviated, by any remedy. Its continuance seems to depend, like that of vomiting, on the absolute exhaustion of nervous energy, the presence of which, be it remembered, is as neces- sary to repose as to action—to control as to incite. Rigor.—Rigor is the most uniform announcement of re-action, though by no means peculiar to this state. It is attendant upon local irritation under a great variety of forms, and is the first sign of com- mon febrile excitement. It is a sympathy of the cir- culating with the sensorial organ—of the heart with the brain. The propelling power of the heart is so languid that the venous trunks become loaded to con- gestion, while the capillary circulation seems to be at a stand-still. Cold air, cold and moisture especi- ally, induce rigor, acting from the surface upon the interior. Whatever depresses the nervous energy so much as to affect the equal and uniform distribution of the blood, may be said to act from the interior, as fever, fear, or shock. Rigor therefore, is a symptom of more or less importance in exact proportion to the cause operating to produce it. Arising from a local inflammatory action, as that of suppuration, it is more important than from a temporary exposure to cold or moisture, which does not go the length of produ- cing fever. Arising from a direct nervous impression as syncope, or the prostration which is characteristic of severe irritation, it is most important as the har- binger of returning animation and action, if it do not OF RE-ACTION. 319 by its violence and duration, destroy re-action, or render it in turn excessive and exhaustive. Where no previous sign of constitutional indisposition has been manifested, it is commonly the forerunner of a permanent morbid action of the constitution sympa- thetic with some, perhaps concealed, local irritation. But although rigor has its origin in the enfeebled action of the heart, and the unequal distribution of the blood, I believe that the phenomenon would not take place if the heart were not instinctively roused to an inordinate activity, in order to overcome the gradually accumulated obstacles opposed to the cir- culation. The struggle between the heart and the capillaries constitutes the rigor. As the former over- comes the latter, and the balance of circulation is restored, the rigor subsides. Its temporary existence, severity, and periodic return in ague, give it the ap- pearance of a spasmodic condition. It is partially relieved or abridged by external warmth, and inter- nal stimuli. In fever and inflammatory diseases, the duration and intensity of the rigor augurs a probable correspondence of severity in the ensuing stage; but in irritation a hot stage is either very transient or im- perfectly formed, or altogether passed over, flushes and partial sweats succeeding to the rigor. («•• I'HOSTKATIO. WITH .EXdTEMEST. AND EXCESSIVE KE-AljXIO\. Rc-actiun may be gradual, and restorative of a tranquil and natural state of the system, as exempli- tied in an ordinary fainting fit; or it may be irregular and violent; in fact an action unsupported by suffi- cient power to maintain and carry it through; and in this case the state of exhaustion into which the patient lapses, quickly terminates life. Symptoms of excite- 320 PROSTRATION W ITU EXCITEMENT, ment are intermingled with those of an opposite des- cription, an effect sometimes attributable to the over stimulation of the system. The sudden accession, the imperfect developement, not less than the abrupt termination of the symptoms, broadly distinguish this ephemeral excitement from that of continued irrita- tion, and evince that the former, like the lighting up which often precedes natural dissolution, is a genuine feature of that state of universal atony of the nervous system, subject to preternatural excitation, which I have termed ' prostration with excitement'.* This partial re-action is distinguished by its short lived- ness and the non-attainment of a permanent condi- tion, from that in which re-action being complete, the more determined and durable character of the symp- toms which supervene implies, that it is the result of a positive and continued irritation,t either in itself or in its effects. In the former case (i. e. in itself) the irritation is direct, as after a wound, fracture, or op- eration, active hemorrhage, or acute poison; in the second (i. e. in its effects) reflected, as in the healing or actually cicatrized state of a wound, or a cachexia ensuing upon a local injury, a passive, or small and frequently recurring hemorrhage, or a chronic poison, which has entered or has been generated in the system. Treatment of prostration with excitement. The Iiame whidl I have given to this state sufficiently conveys my opinion that it is based in debility. The energies of the system are diminished in proportion as the actions * Of this kind were the cases communicated by Mr. Soden, pages 64 and 82. t See cases, pages 63 and 93, and the cases generally under thf head " Inflammation following Injuries and Operations.'' AND EXCESSIVE RE-ACTION. 321 are increased in cases of excessive re-action. It is a question worthy of our most serious and undivided attention, whether we are in possession of any means of moderating excessive, that is, exhaustive re-action, and of tranquillizing the nervous system, at a time when the greatest disparity exists between power and action. The heart is rather thrilling than fairly pulsating; its semi-contractions are innumerably rapid; the expression is by turns excited and oppress- ed, wild and comatose; the breathing short, and wanting the relief of sighs. A continued exertion of reason cannot be maintained, and after a correct reply or remark, the patient wanders into irrationality. The confusion arising from the rapid alternation of symptoms usually denoting contrary states of the system, and the urgent conviction that death must speedily ensue if this tempest be not assuaged, per- plex the judgment of the practitioner. After repeat- edly witnessing the total inadequacy of remedies em- ployed under the sanction, and in deference to the axioms of schools and school authorities, I must be permitted to remark that in such a crisis, experimental measures supported by any fair hypothesis should be encouraged rather than met by special objections. If re-action become excessive, and the case assume the character of high excitement, the shaved scalp should be frequently bathed with a cold spirit lotion, a large blister should be applied to the nape of the neck, and the bowels should be cleared with pills of calomel and jalap, or scammony, or, if medicine be rejected from the stomach, by stimulant and purga- tive injections. The propriety of following up this practice, should it be productive of temporary bene- fit, is a question of the last importance, for such a 41 322 PROSTRATION WITH EXCITEMENT, state is extremely precarious, and often shifts sud- denly into that of sinking. For the most part medicine taken into the stomach. if it be not rejected, appears to me to be inert. This organ is not in a state to act upon its contents. Pills are thrown up unaltered an hour or more after they have been swallowed. I prefer in such a case to leave the stomach to itself, and give medicine in the way of lavement. The main question is—should opium be administered in this state ? I have seen the high- est degree of symptomatic delirium yield to an injec- tion containing three drachms of tincture of opium, repeated after four hours ; and by a solution of three grains of the extract in a quarter of a pint of gruel, so exhibited and repeated in the state of incoherent wandering, the mind rendered permanently clear and calm, with a corresponding improvement of other symptoms. In whatever way administered, it is only in full doses that this remedy is admissible in the high excitement of irritation; for larger will be re- quired in such a state to affect, much less to control the nervous system. If it succeed in doing this, its employment is attended with the happiest effects. In the low muttering delirium which accompanies sink- ing, the frequent repetition of a small dose of opium, as a pill containing a quarter of a grain every second hour, is decidedly beneficial, as I have seen in many instances. The virtues of other sedatives are in my observa- tion pretty correctly appreciated. There is, how- ever, one deserving of particular mention, both as an adjunct to opium, and the best substitute when this is inadmissible. I mean the extract of henbane.* As * In the ruffled states of the system generally, but especially in the over-active state of the vascular system, there is a charm in the AND EXCESSIVE RE-ACTION. 323 an anti-irritant it should be given in doses of three to five grains every third or second hour. SECTION II. OP CONSTITUTIONAL IRRITATION FROM INJURIES AND OPERATIONS. Mr. Hunter observes,—" the constitutional symptoms arising from local complaint may be divided into three, the immediate, indefinite and remote." The immediate is the symptomatic or sympathetic fever, the second are nervous affections, and the third is the hectic. " The secondary are not so determined as to time. I have called them nervous, though not strictly so in every case, because more variety of af- fections are produced than from any cause I know; yet these affections seem all to have more connection with the nervous than the vascular system, and are generally excited by the particular tendency or sus- ceptibility of different constitutions."t Mr. Abernethy, eminent alike for the sagacity, soundness and clearness of his views as a pathologist, to whom the profession and the public are indebted for the improvement, I might almost say for the intro- duction, of medical surgery, distinguishes the fever which attends upon injuries into the sympathetic in- operation of henbane, altogether peculiar. It is feeble as an anodyne, feebler as a soporfic ; but not " poppy nor mandragora" soothe and still so unexceptionably as henbane. f " A man shall have a very bad compound fracture of his leg ; the first constitutional symptoms shall have been violent, but all shall appear to have been got the better of, and there shall be hopes 324 0F CONSTITUTIONAL IRRITATION flammatory, the hectic, and the sympathetic typhoid, or irritative fever. " The fevers," he says, " produ- ced by local disease, are the very identical fevers which physicians meet with where there is no exter- nal injury." " Local disease, injury, or irritation may induce, as its immediate consequence, pain, sickness? fainting, rigor, convulsions, delirium, and tetanus. These nervous affections have the natural priority." "It may be a fit subject for inquiry," says Mr. Ab- ernethy, " whether it be possible for particular organs to become affected otherwise than through the medi- um of the nervous system in general. Though some instances of sympathy are strange and perhaps inex- plicable, there are strong reasons for believing that the inflammatory fever, the state of vigilance and de- lirium, convulsions and tetanus, which arise in con- sequence of injuries of the limbs, are produced by ir- ritation 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 dis- of recovery ; when suddenly he shall be attacked with a shivering fit, which shall not perform all its actions : viz. shall not produce the hot fit and sweat, but shall continue a kind of irregular hot fit, attended with loss of appetite, quick, low pulse, eyes sunk, and the person shall die in a few days. Or he shall go into the common diseased symptoms of the second stage, viz. the nervous, with many of its effects as the tetanus, and dissolution shall also be a conse- quence. Or if the local disease docs not and cannot heal, and is such as to affect the constitution, it then brings on the hectic, and sooner or later dissolution takes place ; for the hectic is an action of disease, and of a particular kind ; but dissolution is giving way to disease of every kind, therefore has no determined form arising from the nature of the preceding disease."—Treatise on the Blood and Inflammation. FROM INJURIES AND OPERATIONS. 325 ease."—"It is most probably the disorders of the brain which affect the stomach; but the re-action of the latter affection is liable to increase and maintain the former, by which it had itself been produced."* The irritative fever Mr. Abernetby regards as a necessary consequence of the local disease ; so that unless this can be altered, we can have no hope of amending the constitutional symptoms. Attention to the regulation of the bowels, cordials, medicines which impart strength, and opium to allay the prevailing excitement, constitute the treatment which he recommends. Of drastic and forcing purga- tives he disapproves, and expresses a doubt, to my mind very natural, whether purgative medicines in this disease act beneficially; whether the return of the secretions to a healthy state is not owing to a change in the action of the nervous system. Sir Astley Cooper's first lecture contains several valuable examples of the phenomena of irritation. He observes, " Injuries producing fatal consequences destroy life in three different modes. 1. When slight, by keeping up a continued constitutional irritation, they gradually wear out the system. 2. When more severe, they destroy by occasioning excess of action. 3. The most severe, by shock to the nervous system, cause death without re-action." The rationale and the treatment of irritation as given by Sir Astley Cooper, are precisely the same as of inflammation— both being considered as directly co-operating in the restorative process.f * Surgical Works, Vol. I. ' On the Constitutional Origin and Treatment of Local Diseases.' t'' When a part of the body receives an injury, the nerves convey n knowledge of it to the important, organs, as the spinal marrow, 326 OF CONSTITUTIONAL IRRITATION lnbS3££* I am far from presuming to gainsay these authorities—but I am disposed to consider apart from fever or constitutional inflammation the nervous affections,* to regard them as a distinct order of mor- bid actions occasionally ensuing upon injuries, upon inflammation, upon the exhaustion attending loss of blood, and upon the admission of noxious matters into the circulation. I do not mean to say that such actions originate exclusively from these sources, but I select these as presenting prominent examples. Neither would I say that they may not be combined with febrile action: but if this be the case, they so far pervert or suppress the symptoms of fever, as to present a very striking exception to Mr. Abernethy's observation,that sympathetic fevers are indistinguish- able from those not depending on injury. It will not, I think, be denied by experienced surgeons, that there is a large, and very important class of cases, in which neither the assemblage of symptoms nor brain, heart, stomach, &c.; nature immediately commences the restorative process by stopping all the customary secretions; the various outlets being thus closed, the blood collects in quantities in the heart and large vessels, which propel it with unusual force to the injured part; giving rise to inflammation in whatever form can best accomplish the desired effect. This is an illustration of the man- ner in which nature contends for a cure, &c."—" There are two means of reducing irritation : first, by restoring the secretions of the different organs, and by thus opening the outlets, lessen fever." —" The second mode of relieving irritation is by allaying the ex- citement of the nervous system."—Sir Astley Cooper's Lectures on the Principles and Practice of Surgery, Lee. I. By Frederick Tyrrell, Esq. Surgeon to St. Thomas's Hospital, &c. * I do not include among the nervous affections which directly ensue upon injury or inflammation, the traumatic tetanus, because I consider it to be not only a secondary but proper constitutional action, although grafted upon the local injury, which I therefore designate by tho term " reflected irritation." Sre page 39. FROM INJURIES AND OPERATIONS". 327 the periodical exacerbations and remissions consti- tuting fever, are present, and which if we treat them in deference to the rules laid down for the treatment of fever, utterly disappoint and mock our efforts. Of these some never arrive at inflammation, others, ow- ing to the shock which the constitution has sustained, sink almost as soon as inflammation is established, from incapacity to maintain it. Some, as Mr. Hun- ter has observed, go on well, and when we are no longer in apprehension for the part, the constitution, exhausted by the reparative effort, can go no further, and suddenly collapses; whilst others, displaying from the commencement symptoms of high but irre- gular excitement, betray in every change, local and constitutional, an excessive and destructive re-action. The first stage of constitutional irritation ensuing upon injury or inflammation, by no means exhibits that provident faculty of nature which is so much insisted upon: for the tumult of the system, proceed- ing from the sympathy of the whole with a part, is a state with which restorative action is wholly incom- patible. The first stage of local irritation or inflam- mation illustrates this fact. The actions which en- sue aggravate the mischief rather than tend to its relief, insomuch that we have often more concern about what is to follow than about what is past, and would gladly compromise for a result. Nevertheless it is not inconsistent to regard the processes, of which ,these form essential preliminaries, as serving a salu- tary purpose. But assuredly the first actions both of the constitution and the part, are those of angry disturbance; and our first business is to compose and allay them. Having fortunately succeeded in this, the actions which require for their institution 32« OF CONSTITUTIONAL IRRITATION and maintenance an unusual but not unhealthy vigor, commence as a natural consequence. Of the particular tendency of injuries affecting different parts, and of the different modes of injury to set up irritation of the constitution, I have already spoken. Profuse hemorrhage, the implication ot many textures in a wound, the extensive detachment of cellular connections, wounds of joints and tendi- nous structures, ancj, the comminution of bone, arc the most unfavourable circumstances attending inju- ries, in reference to the constitution. Si&XSS. The removal of a mutilated limb, provided the interval of time be so short as to iden- tify the operation with the injury, anticipates, or at least infinitely diminishes constitutional irritation. I have instanced cases in which fatal irritation has en- sued upon amputation for recent injury. They are rare ; it would be easy to adduce numerous instances leading to an opposite conclusion. The lapse of a considerable interval in which the system either con- tinues prostrate, or, having in part recovered, ac- quires a morbid irritability, is exceedingly prejudi- cial. Natural constitution, health, and habit have an undoubted influence in these cases, but this is nei- ther so common nor considerable as to countervail the arguments in favour of an immediate operation. The expediency of sacrificing or saving a limb is another question, upon the merits of which, by the way, since it hinges on individual circumstances, I do not see how any abstract opinion can be delivered. But respectable authorities have recommended the delay of an operation, on the ground that a certain inurance to confinement and suffering, and the esta- blishment of a suppurative process, by gradually FROM INJURIES AND OPERATIONS. 329 conducting the constitution into a state resembling that of chronic disease, was eminently more favour- able. This reasoning is altogether fallacious ; the shock of the injury covers and identifies with itself that of the operation promptly performed. On the contrary, the continued irritation of the injury infi- nitely augments the first danger, and the state desired and promised never arrives in a vast majority of cases.* Deficient and excessive re action The treatment of deficient re- equally indicate weakness. -■ • ~ action and of that which is excessive, resulting from injury or operation, prior to the commencement of inflammation, should adapt itself to the symptoms present in the two states, with this general qualifica- tion, that both are evidences of deficient power, and that existing circumstances are often sufficient to cre- ate the diversity in the order of symptoms. Thus, hemorrhage determines the one or the other accord- ing to its extent. We find the one commonly passing into the other state ; and we discover, where in the absence of hemorrhage the former prevails, that the person has been habitually addicted to abuses of constitution; and where the latter, that some strong point of aggravation of the injury, or some extraor- dinary mental impression explains its predominance. This, it cannot be denied, has often a marked influ- ence—a maniacal tendency for example,t or even a high degree of irritability. The boy Bryan, whose * See the excellent observations on this subject of Mr. Pott, in his « Remarks on Fractures and Dislocations,' Works, Vol. I. and < On the Necessity and Propriety of the Operation of Amputation in certain Cases,' &c. Vol. III. t See the cases of sprained Ancle Joints, p, 02, and of Li- thotomy, p. 63. 42 330 OF CONSTITUTIONAL IRRITATION case is related at p. 88, had been in the hospital six months before his death,* on account of a fractured arm, occasioned by his meeting in the passage lead- ing to a slaughter shed, an over-driven ox. The boy's danger was so imminent, that he was consider- ed fortunate to have escaped with his life, and his terror was so great that it had a serious effect upon his general health and spirits for a considerable time afterwards: his broken bone, however, had united well. When I learned these circumstances, I felt disposed to regard the extraordinary issue of his case, as the result of a preternatural irritability of system thus engendered, and I am still disposed to hold this opinion. operations for chronic diseases. As regards operations for chro- nic disease, the presence or absence of visceral dis- order, the habits of life and those of the malady—as for example, of air and exercise, or of rigid confine- ment, of taking opiumf or cordials in any shape—are points for careful inquiry. The habits of long indis- position are fully as important to be known as the habits of health, perhaps more so. It is impossible for an operating surgeon to do justice to his patient or himself, who is indifferent to particulars of which his ignorance may be disadvantageous. As the most * This ill-fated boy was admitted with a fracture of the cervix humeri on the 1st of January, and discharged the 11th of February ; again admitted with a lacerated hand on the 29th of June, and died on the 1st of July of the same year, 1810. t I have known a patient suddenly attacked with colliquative di- arrhoea subsequent to an operation under which he sunk, from the discontinuance, it was supposed, of large doses of opium, which he had taken up to that time without the knowledge of the opera- tmg surgeon. FROM INJURIES" AND OPERATIONS. 331 successful artists are studious of opportunities to be- come familiar with the expression which they are about to portray, a surgeon should apply himself to the character of the individual who is to be the sub- ject of an important operation* Such a method of proceeding will not only enable him to exercise a sound discretion in the selection of his cases, and the time and mode of his operation, but will bring him to the bed-side of his patient at its conclusion, on the vantage ground of mutual confidence. The practice of performing a serious operation, and leav- ing the after-treatment to others, has, in my know- ledge, repeatedly proved disastrous. The medical treatment, a duty not less responsible than the ope- rative, belongs to the surgeon, and indeed, to be em- ployed merely as a handicraftsman, conveys an im- putation at which the dignity of a scientific mind revolts. SECTION III. OF CONSTITUTIONAL IRRITATION FROM INFLAMMATION. Inflammation is strong and effective, or the contrary, as it is free from irritation or mixed with it. Sym- pathetic fever may be of the pure inflammatory cha- racter, bold and powerful, or it may be of a vacilla- ting character. It may be sympathetic synochus, or sympathetic typhus. The latter, though it differs in character from the former, is still a mode of sympa- thetic fever, and hence it is treated, primarily at least, by medicines addressed particularly to the secreting * Many points, minute in themselves, but important in the ag- gregate, are often best obtained from the patient's relatives. 332 0F CONSTITUTIONAL IRRITATION organs. The irritation set up by inflammation hat- generally more or less of febrile action blended with it. But irritation, in my notion of the term, is not fever under any modification. Fever requires, and as Mr. Hunter justly observes, shews powers of re- sistance. In irritation we have no determinate or continued train of actions. It is " every thing by turns and nothing long.'"' Teachers appear to me to confound irritation with inflammation or fever, and because they sometimes co-exist, to conclude they coincide. Irritation may be a symptom of fever, ab fever may be an effect of irritation, but they are originally and essentially distinct forms of disease, and either may exist in the absence of the other.* sympathetic fever. Sympathetic fever is a healthy re-action of the constitution, without any impairment of its powers, such as they are, shown in the increased energy of the vascular system. If the natural powers of the constitution be deficient, the fever assumes the low or typhoid character, and in its progress gives out indications of the disturbance and distress of the nervous system from its inability to support the in- creased action of the vascular; but the nervous af- fections are secondary, strictly symptomatic of the fever, whatever be its origin, and therefore indistin- guishable from those which attend upon low fever in the absence of injury. * I am aware that in this remark I have to contend with the diffi- culty to which all writers on pathology and on many other subjects are exposed, arising from the vague and various meaning affixed to terms in common use, according to their vulgar acceptation. Thus if any reader should be startled at the idea of fever devoid of irrita- tion, I trust to his discrimination and candour to do justice to my distinction between irritation as an archetype or original disease. and irritation as a symptom. FROM INFLAMMATION. 333 irritation anticipate* or arrests fever. In general, we have the sym- pathetic fever formed with a more or less exact cor- respondence to the occasion, according to the powers of the constitution; but in certain forms of injury, certain constitutions and modes of treatment, the in- flammation is an irritant, and gives rise to a disorder- ed action of the entire nervous system, which takes the precedence or the place of fever. Such a state of the system re-acts upon the part, and either checks or destroys the restoring process; while a state of exhaustion, or what Mr. Hunter calls " dissolution," abruptly closes the scene on the 5th, 10th, or 15th day. Treatment of sympathetic fever. In the treatment of inflammatory fever ensuing upon complicated injury, the chief in- dication is to tranquillize action without materially diminishing power. We ought not to be alarmed at fever, but at the want of it. We ought not to use any rough and permanently depressing or debilitating means to put it down, neither blood-letting nor con- tinued profuse purging and sweating. To moderate extraordinary action it is sufficient to keep up such a determination to the secreting organs, as prevents their becoming so obstructed as to increase fever. I am persuaded that practitioners are generally over anxious to cut short sympathetic febrile action, and treat fever from sudden and artificial, too much as they treat fever from gradual and natural causes. The great bearing of the constitution, under a sudden call upon its powers, is decidedly upon the nervous system. To a certain "extent the existence of fever, for which an obvious and adequate cause appears, is loss trying to that system than the employment of 334 OF CONSTITUTIONAL IRRITATION such measures as are necessary to its sudden abridg- ment. For if the inflammatory action be marked and vigorous, the nervous, which supports it, is strong and inirritable, and the former cannot be suddenly pulled down without a serious encroachment upon the strength and steadiness of the latter. I shall not be misunderstood to say that nature is to be left to herself: I say only that the less violent our measures of interference, the better. Nervous power is much more easily depressed than raised. Irritation is a very possible result of treatment as well as of malady, for by such means as too rapidly lower, we incur the danger of converting inflammation into irritation, and thus of destroying our only medium of recovery. Danger of local irritants. An indication of equal importance, is to indulge to a certain extent the first actions of the part, by an easy position, and light and soothing ap- plications. We should allow for the effects of local as well as of constitutional, re-action; the swelling and tension must not be aggravated and rendered a source of additional irritation, by nice adjustments and contrivances; undoubtedly calculated to secure the best possible results, provided we could overlook or command the intermediate changes. The application of lint, moist or dry, to a fresh wound, quickly becomes an irritant, and adhesive plasters, circular bandages, and splints, applied as they too often are, while effusion is going on, operate as strictures and ligatures. Plugging a fresh wound to force suppuration, or strapping it to prevent that process, are equally liable to be followed by injurious consequences. The attempt to render complicated wounds simple by leaving them in the original close FROM INFLAMMATION. 335 dressings lor many days in succession, has proved a common, and sometimes fatal mischief. I have seen more than one case in which the constitutional irrita- tion arising suddenly, and proving fatal in a week from the injury, was distinctly referrible to a diffused erysipelas and gangrene, set up by such local irrita- tion and stricture. A sufficient inspection of the part at intervals of two days, to satisfy an experienced eye of its well doing, may be accomplished, not only without detriment to the process of healing, but with manifest relief to the patient, and is a widely different thing from handling and disturbing the position of parts, against which I would be among the first to protest as uncalled for and injurious. Penetrating wounds attended with hemorrhage, and comminuted fractures with extensive injury of the soft parts, and in the vicinity of large joints, are especially the cases which present themselves to my mind in offering this remark. AfenSa«i^ti^0D The change which parts undergo in passing from a state of health to a state of sphace- lus, is not greater nor more remarkable than that of the nervous system from a healthy condition to that of extreme prostration. It is often synchronous; in some instances the local change is not so rapid, in others it is more so. Ulceration and acute gangrene sometimes exhibit the state of excessive re-action, terminating in exhaustion. I attended a young West Indian lady who had a blister applied to the knee- joint for a strumous inflammation. It was purposely irritated to suppuration, with the intention of being kept open. The constitution being feeble, an ulcera- tive process supervened, and rapidly destroyed the integument of the joint even to the ligaments. Am- 336 OF CONSTITUTIONAL IRRITATION monia and bark, wine and porter, and the most con- centrated forms of animal nourishment, failed to sup- port her. The same effects are sometimes witnessed after the application of blisters in weakly children. The cases of phagedena occasionally seen in our hospitals, especially in young prostitutes of delicate constitution, and rendered morbidly irritable by mer- cury and habitual dram drinking, present precisely the same form and fatal termination of constitutional irritation.* Practical inference. The general inference which I would draw, relating to the treatment of sympathetic irri- tation, as compared with that of sympathetic fever, is as follows, viz. the symptoms of excitement be- longing to the first, although resembling those of the second, are in point of fact allied to a powerless state of constitution, and will not bear to be treated after the same manner. Blood-letting, general and topical, and a forced increase of the secretions by active forms of medicine frequently repeated—the appropriate remedies for high inflammatory fever— are calculated to aggravate, in an alarming degree, the symptoms of irritation. In partial exception to this general observation, however, it sometimes hap- pens that the effect of suspended biliary secretions is evidenced in an obstinate confinement of the * In these cases I have tried in succession all the various reme- dial processes of which I had either information or experience. The result is, that although I could readily name half a dozen which have succeeded in as many cases, in allaying irritation and check- ing the destructive action, I should be at a loss to name one which had proved so successful upon repetition as to warrant any sanguine confidence in its efficacy. It has appeared to me that the stage at which the constitutional disease has arrived, determines the acces- sibleness of the system to medicine, or the contrary. FROM LOSS OF BLOOD. 337 bowels, and in this case the relief of the symptoms is not obtained until copious bilious evacuations have been procured. The aloe or colocynth extract, or blue pill combined with calomel, and repeated as required, are the best medicines with which I am ac- quainted of relieving this state. Alcohol, ammonia, aether, camphor; opium and henbane; and bark in substance, decoction, and tincture, are the articles upon which, in the circumstances respectively indi- cating their use, I believe most reliance may be placed in the treatment of acute sympathetic irri- tation. SECTION IV. OF CONSTITUTIONAL IRRITATION FROM LOSS OF BLOOD. Hemorrhage in itself is adequate to the production of prostration either pure or mixed. I am afraid it has not been uncommon for such a state to be pro- duced by the intemperate use of the lancet, the judgment of the practitioner having been misled by the temporary relief obtained, even to the last, by the detraction of blood in acute diseases. A case of pneumonia not long since occurred, in which a stroke of palsy, fatal the same evening, took place in the act of blood-letting. This was mentioned to me by the apothecary who blooded the patient, by direc- tion of the physician in attendance. Some persons cannot bear the loss of blood; it gives rise to pros- tration, attended with convulsions, in which the cir- culation fails so alarmingly as to require watching for several hours, and the repeated administration of stimulants to restore it. A very intelligent surgeon 43 338 0F CONSTITUTIONAL IRRITATION in the neighbourhood of London, in bleeding a cler- gyman to the extent of twenty ounces, whose idio- syncrasy in this respect was not known, was com- pelled to remain with him during the whole of that day; and, notwithstanding frequent recourse to bran- dy, continued long apprehensive for the patient's life. He represented the convulsions, which returned in paroxysms, as resembling the puerperal in their se- verest form. There has been reason to believe that the blood lost in operations in which hemorrhage was unavoidable, has sometimes induced this state : this, however, in the present advanced state of surgery, is rare. An interesting paper has just been published " On the Effects of Loss of Blood," by Dr. Marshall Hall of Nottingham,* which, for the general accuracy of its descriptions, and the reasoning by which they are illustrated, is in my view highly creditable to the author's talent as a pathologist. After describing the phenomena of excessive re- action among the remote effects of repeated or pro- tracted loss of blood, Dr. Hall says, " the symptoms of excessive re-action may gradually subside and leave the patient feeble, but with returning health, or they may yield to the state of sinking (pure pros- tration.) This term is adopted, not to express a state of negative weakness merely, which may con- tinue long and terminate in eventual recovery; but to denote a state of positive and progressive failure of the vital powers, attended by its peculiar effects, and by a set of phenomena very different from those of exhaustion with re-action." " It would be diffi- cult to offer any observations on the nature and cause * jVtedico-Chirurgical Transactions, Vol. XIII. Part /• FROM LOSS OF BLOOD. 339 of excessive re-action; but it is plain that the state of sinking involves a greatly impaired state of the functions of all the vital organs, and especially of the brain, from defective stimulus." " The state of sinking may indeed in certain points of view be com- pared with the state of the functions in apoplexy, and with the effects observed on abstracting the in- fluence of the brain and spinal marrow, by dividing the eighth pair of nerves, or destroying the lower portion of the latter organ." EKTys^8rofab!oondinduced Excessive re-action may subside, if the depressing cause be subdued or withdrawn; or it may become chronic and pass into the state of exhaustion, if the depressing cause be still in acti- vity ; or it may suddenly shift into that of sinking or pure prostration, if a pleurisy or a shattered limb, or any powerful irritant exist in conjunction with such a state of the system, however induced. Loss of blood acting singly, and in combination with the inflamma- tion of an important organ, forms two distinct cases. Under inflammation, as Dr. Hall justly observes, the system bears the loss of blood with less risk of ex- haustion than in health ; under irritation, exhaustion is sooner induced than in health. But an unsubdued inflammation of an important organ becomes a cause of incessant and extreme irritation. In the case re- lated by Dr. Hall,* the loss of blood might and pro- bably would have been surmounted, had the occa- sion of it, inflammation of the pleura, been overcome. Mr. Hunter was accustomed to consider even the healing action, where the constitution had passed through the inflammatory fever, and seemed to be * Case I. 340 0F CONSTITUTIONAL IRRITATION capable of performing all its functions, in the light of an irritant; and the frequent occasion of that state which he termed " dissolution,"* or " giving way to disease of every kind." Effects of hemorrhage. The effect of hemorrhage upon the nervous system is twofold ; immediate and remote. The immediate is syncope, and is in proportion to the suddenness rather than the quantity of the he- morrhage : hence the relative effect of the same loss in quantity is greater and more frequently fatal from the large trunks and near the heart, than from the small vessels and at a distance from it. The remote effect is to precipitate and contract the actions of the heart, and is in proportion to the quantity lost, as in frequently recurring hemorrhages or a slow protracted hemorrhage ; and this effect as well as the former, depends upon such an atony, from defi- cient excitement, of the nervous system, as incapa- citates it for maintaining the actions of the vascular. Transfusion. If a single hemorrhage, as in the case mentioned at page 127, has been so considerable as to deprive the system of the material of nervous ex- citement and nutriment, the transfusion of a portion of human blood seems a fair and rational expedient, and it is clear from Dr. Blundell's experiments that a much smaller quantity supplied than that which has been lost, will suffice for this purpose.t But if the system be at the same time so depressed by shock, or previously so exhausted by hemorrhages or by * See Case of Gurton, page 131. t Researches, Physiological and Pathological. By James Blun- dell, M.D. Lecturer on Physiology and Midwifery at Guy's Hos- pital. 1825. FROM LOSS OF BLOOD. 34) any chronic disease, that the loss of a moderate quantity of blood induces the state of pure prostra- tion, it is extremely doubtful if a fresh supply would renovate its powers, or be attended by any bene- ficial effect. For I should say that hemorrhage, whether active or passive, destroys, not from abso- lute default of blood to carry on the circulation, but from the complete exhaustion of nervous energy. Such a result, we have seen may follow other circum- stances as well as the loss of blood, but when this exists in addition, it extinguishes the chance of an effective re-action. The drain of an excessive sup- puration following an injury tends indirectly to the production of the same state of nervous exhaustion as repeated hemorrhages.* TiSl orwSSd.r When prostration with deficient re-action is the result of hemorrhage, support by nutriment in the most assimilable forms, given in moderate quan- tities at short intervals, and by nutritive clysters, is the most important indication. To obtain the equal influence of the attenuated circulation and to tran- quillize the nervous system, a pure and fresh atmos- phere, the preservation of a natural and warm sur- face, the sedulous exclusion of every Cause of ex- citement, and a very cautious use of vinous stimuli, the danger of serous effusion being much augmented in this case, are the only means left us to pursue. * See Cases of Boulivant and Izzard, pages 134, 136. 312 OF CONSTITUTIONAL IRRITATION SECTION V. OF CONSTITUTIONAL IRIHTATION FKOM THE ABSORPTION OF AMMAL rOISON. Having formerly fully entered into this branch of my subject, with the view of illustrating the diagnosis, I shall only briefly revert to this topic, and compress into as short a compass as possible the practical con- clusions to which I have been conducted. Of several reports of cases of this description which I have perused since my collection was print- ed, I will offer a comment upon two, viz. that of Dr. Bell, published by Qr. Butter in his " Treatise on the Plymouth Dock-Yard Disease," and that of Dr. Anthony Todd Thomson, published by himself in " The London Medical Repository for April 1825." And I select these the rather, because I consider them to be good specimens in contrast, of the speci- fic and the simple irritation. The case of Dr. Bell* parallels, except in dura- * " Dr. James Bell, aet. 58, late Surgeon of his Majesty's Dock- yard at Devonport, rather stout, sometimes dyspeptic, but gene- rally healthy : " On the afternoon of Sunday, the 19th of September, 1824, attended the examination of Gregory Nicoll's body, and scratched his right fore finger over the extensor tendon on the last phalanx, when he was directing a pupil how to sew up the body, with a sur- geon's needle, which had been previously used for that puspose. At this time the Doctor appeared in his usual state of health, and took no particular notice of the puncture or scratch so inflicted on his finger. " On the following morning, September 20th, Dr. Bell attended the surgery at the accustomed hour of nine o'clock, and complain- ed of feeling unwell. When washing his hands he first felt a smart- ing in the scratch over his right fore finger ; whereupon he became FROM ANIMAL POISON. 343 tion, with that of Mr. Dease, as Dr. Butter has shewn, and acquires, in a pathological view, a double inte- shivered, and impressed with an idea that he had caught the disease, then prevailing among the mechanics of the Dock-yard, which dis- ease had previously agitated his mind, and now made him very ap- prehensive for his safety. He remained, however, at the office about an hour and a half, and by that time the rigors and general indisposition had increased in such a degree as to produce conside- rable alarm. Pulse 96, and full. Bowels opened by an aperient, taken on the preceding evening. The wound on the finger was not inflamed. He was recommended to lose blood from the arm, and to take an emetic : to both of which propositions he had a great aver- sion, and made insuperable objections. He went to bed, however, before twelve o'clock at noon, and endeavoured to make himself sick by irritating the fauces with his fingers, and by drinking warm water. In the course of the day, his fever had increased, and a re- action or flushing followed the rigors. Dr. Dickson, Physician to the Royal Naval Hospital, at Stonehouse, and Dr. Yonge, of Ply- mouth, were consulted. He now consented to lose about sixteen ounces of blood from the left arm, by a small orifice, and to take the subjoined bolus : R : Hydr : Submur : gr. v. Pulv : Ant: gr. iv. Confect : q : s : M : which was to be followed by some of the cathartic mixture in the morning. " 21st. Passed a restless night, with an increase of fever. Pulse 130, and full; stomach very irritable ; nausea great ; tongue coated ; bowels open ; complains of pain and tenderness over his right pectoral muscle and shoulder, on which he cannot bear the least pressure ; but the wound on the right fore finger is not at all inflamed. Rep. V : S : ad | xxx. Ordered effervescing draughts, with saline medicines, every second hour. " Eight o'clock, p. m. No relief from the second bleeding. The blood was neither buffed nor cupped, the coagulum was rather lirm. Speaks of a distressing pain about his sacrum and loins. with general lassitude and great weight, and evinces considerable anxiety. There still exists much soreness over the right pectoral 344 0F CONSTITUTIONAL IRRITATION rest from the distinctive character which it preserves in the midst of epidemic erysipelas, attacking an un- usually large proportion of the artificers of the Dock- yard, who had received the local hurts, more or less severe, to which these persons are liable. muscle, and there is a great prostration of his muscular ener- gies ; but withal there is no head-ache. Pulse 130, and small. Repf. Bolus, et Contrr. Haust : efferves : cum Potassae Nitratis gr. v. 3tiis horis. Illinatur Linimt: Saponis in partes aflectas. " 22d. Symptoms all aggravated. Passed a sleepless and dis- tressing night, owing to the excruciating pain in his back, but felt relief towards morning, from profuse perspirations. Still feels pain in his right shoulder, with inability to move the arm ; complains of indistinct vision, and mistakes the distance when he attempts to take any thing. Nausea continues ; pulse 130, and irregular. Appr : Empl: Lyttae Epigastrio Medicament : Cont. " 23d. Slept a little during the night; nausea alleviated, but not gone ; back-ache mitigated ; pulse very irregular, and frequent; articulation difficult; thoughts confused ; no pain in any part but the pectoral muscle, when pressed upon ; there is no redness nor visible sign of inflammation on the skin ; the scratched part of the finger is neither inflamed nor swollen. He took camphorated mix- ture, with the nitrous spirit of aether, every two hours, and wine frequently. " Towards evening his breathing became laborious, and delirium appeared. Appr : Empl: Lyttae suris et imo Colli. " 24th. Became perfectly insensible during the night; pulse wavering, occasionally indistinct, and imperceptible ; breathing laborious ; stupor and coma present ; the sphincters relaxed, and the discharges passed involuntarily ; profuse perspiration towards morning when thc breathing improved. Took four doses of the sulphate of quinine (3 i.) without benefit. His deglutition was at last impeded, and a vacant stare occupied his countenance until seven o'clock on this evening, when he sunk without a struggle. Body not examined. " Remarks on Irritative Fever, commonly called the Plymouth Dock-yard Disease, &c. &c By John But- ter. M.D. F.R.S. &c Devonport. 1825/' FROM ANIMAL POISON. 345 The fiymouth cases. It appears that out of fifteen cases of injuries of different severity, received between the 25th July and the 9th October, twelve proved fatal. " The number of wounds was not greater than usual during that period, (24th June to 31st December,) but the fatal results from such appa- rently trifling causes, were unprecedented." Of these twelve cases, half at least were instances of what I term " reflected irritation," to which division ery- sipelas for the most part belongs. The local disease, in most instances trifling, went on well, the constitu- tion being unaffected; the subject, when the situa- tion of the injury permitted, continuing at his usual employ for five, seven, eleven days, and even a month from the accident. Some of the wounds were stea- dily advancing towards a cure, others had in the in- terval healed ; and the men, when reported ill, were supposed to labor under common inflammatory fe- ver, and so treated, without reference to the local injury recently sustained* Now, although I by no means disconnect the constitutional and local malady in such cases, nor believe that the former would have existed in the absence of the latter, I consider that the local pre-disposed only to the constitutional af- fection, and that the changes in the part were reflect- ed from the system, which was influenced by other and incidental causes. From these, and from the remaining five cases, that of Dr. Bell was prominently distinguished, al- though allied by the common symptoms of extreme constitutional irritation to the most rapidly destruc- tive, in wanting altogether the external sign of dis- eased action. We have seen that this is not neces- * Cases of Bate, Walkie, Taylor, Quick, Long, and Beer. 44 346 OF CONSTITUTIONAL IRRITATION sary to the fatal operation of the poison.* It is pro- bable that the local changes which appeared in Mr. Dease's case, on and after the fifth day, would" also have appeared in Dr. Bell's, had they not been antici- pated by his death. Local signs practically important. " A disease," SayS Dr. Buttd", " may be essentially the same, without, as with these (local) appearances, which can only be regarded as characters in forming nosological distinctions." I admit it; they are characters, however, of vast im- portance, inasmuch as they decide the relation be- tween the local and constitutional disorder—as for example, whether the system is suffering from a col- lection of matter pent up in a tendinous theca, and is therefore asking for relief, or from the introduction of an animal poison, of which the vesicle on the wound, or the erythema contiguous to the line of ab- sorption is a significant token. conclusions from Dr. Beiis case. The narrative of Dr. Bell's case confirms me in the belief, that he was the sub- ject of a distinct and specific irritation, viz. that of a poison, of which, allowing for all mental and other influences, he would at any other time have been the subject; under similar circumstances, probably the victim. If this opinion be correct, it follows that the local action proper to this state is an unessential feature of the disease with which we have to contend ; the disease itself consisting in a direct prostration of the vital forces, marked by an excitement of the most transitory description, and rapidly terminating in col- lapse or exhaustion. * Case of Mr. Elcock, page 141. FROM ANIMAL POISON. 347 Dr. TLomson's case. A very interesting communication o* his own case is made by Dr. A. Todd Thomson to the London Medical Repository for April 1825.* It occurred precisely in the same manner as the case of Mr. Delph, last related.! Active inflammation and suppuration of the puncture took place within twenty-four hours, and the rigors and other usual signs of symptomatic fever supervened. Like Mr. Delph, Dr. Thomson was unable to continue his vi- sits, not from the pain in the finger, for this was never very severe, but from a sense of debility, which was excessive and overpowering, attended by laborious respiration, and an acute pain under the xiphoid car- tilage, extending to a short distance along the ster- num. He was treated upon the stimulant plan, (cam- phor and cayenne,) had the feet bathed with hot wa- ter, and after a full action of the bowels from calo- mel, followed by jalap and supertartrate of potass, the fever (pulse 130, with some delirium) subsided. The finger was inflamed, and pain extended from it along the arm, and was slightly felt in the axilla. By substituting James's powder and extract of henbane for the cayenne at night, sleep was procured, and by continuing the pills and the full action of the bowels, Dr. T. had so far recovered as to sit up, and take nourishment on the fifth day, and considered himself out of danger on the sixth. Now, the inflammatory action returned; it became painfully acute in the finger an inch above the wound. An incision to the bone was made in the sound phalanx, and although a very minute quantity of pus was discharged, the incision seems to have afforded complete relief, for * " A Case of Irritative Fever arising from a scratch received iu a morbid dissection," &c. &c. t Second case of Mr. Delph. p. 261. 348 OF CONSTITUTIONAL IRRITATION on the enth day Dr. T. resumed his professional avocations. Remarks. This is a very clear case of thecal punc- ture and inflammation going on to suppuration, in which the ordinary signs of constitutional irritation were modified by the existing state of health, which was considerably below the ordinary standard. Thc treatment appears to have been very judicious, and had the subject of the accident been in robust health, pari ratione, blood-letting would have been required. What in Mr. Delph's case a full venesec- tion and purgatives did for him, the diffusible stimuli and purgatives did for Dr. Thomson. The diapho- retic and sedative medicines were calculated to be equally useful to both. The prevailing states of con- stitution, and probably the natural habits of the par- ties, were opposite, and the rate and extent of in- flammation and the pain attending it differed accord- ingly. No person in his senses would think of taking blood from a person fainting in the midst of business, unable from weakness to ascend the stairs, with la- boring respiration, vacillating and throbbing pulse, a pale and shrunk surface, and cold extremities. Of the virtues of cayenne or colchicum, as compared with ammonia, camphor, and opium in such a case, I am unable to speak, but that the principle upon which they were prescribed was correct, I think there can be no doubt: a comparison with the ge- nuine cases of absorption will demonstrate that this was not one of that class, and a reference to some of the cases which I have related, of fascial and thecal inflammation, will sufficiently account for the impres- sion made on the nervous system. But the case is extremely valuable, especially so for its clear and FROM ANIMAL POISON. 349 able exposition, to illustrate the distinction which I have endeavoured to point out, and to confirm my opinion that the symptoms of extreme constitutional irritation arising from simple and specific causes are not in their nature distinguishable, without the aid of certain associations of local characters. It is, therefore, I admit, from imperfect evidence that we decide the character of a case in which, as in that of Mr. Elcock and of Dr. Bell, the local signs are anticipated by the death of the patient. I will trouble the reader with one additional case of very recent occurrence, of much practical value, as it illustrates more forcibly than any, the superven- tion of the specific upon the simple inflammation, and a variety of the former, probably, thence re- sulting. case. « A young gentleman of delicate and irrita- ble habit, in opening the body^of a man three hours after death, who had died of extravasation of urine, having grazed the point of the fore-finger of his right hand with the blade of his scalpel, immersed it in water, and then proceeded in the examination of the parts. In returning home he shivered, but the wea- ther was very cold, (7th January 1826,) and he, sub- ject of late to shiver almost daily on exposure to the air, regarded it as the effect of cold. At this time, and for some weeks preceding it, his bowels had been obstinately costive, and his stomach much dis- ordered in consequence. He was, besides, an anx- ious and laborious student. Next day he complained of feeling unwell; he kept the finger immersed in cold water, and towards evening complained of a slight soreness along the radial side of the fore-arm. He took a calomel pill on going to bed, and some 350 0F CONSTITUTIONAL IRRITATION aperient salts in the morning. He passed a restless night, and in the morning the absorbent vessels of the arm were raised and inflamed to within a hand's breadth of the axilla, where this appearance stop- ped abruptly. Although he had suffered no acute pain, the fore-finger was swollen, tense, and painful on pressure on the palmar side, and an incision was therefore made to the bone at the tip of the finger, which bled freely on immersion in hot water. He was at this time feeling and looking poorly, and had a small hurried pulse, with depression of strength and anxiety. The bowels having been imperfectly relieved, and the evacuations unhealthy and offen- sive, he took at night three grains of calomel, with a grain of opium, and followed it with a more active aperient in the morning. On the third day, having passed a tolerable quiet night, and the bowels being freely opened, he took a draught of acetated ammonia, camphor mixture, and nitric aether in lieu of the aperient, and repeated the calomel and opium pill at bed-time. The hand and arm were freely bled with leeches and fomented. On the fourth day symptoms were much as on thc preceding, but he was considerably more sunk by continued nausea and frequent violent retching. Se- ven grains of the carbonate of ammonia and a few drops of laudanum were now added to the camphor draught, and five of the extract of henbane given at bed-time. The middle and ring finger and the palm and back of the hand, and a portion of the fore arm on the flexor side were superficially inflamed; the wounded finger had lost its tension and tenderness, and the absorbent lines had disappeared in a diffused swelling of the arm. The inflamed parts were bath- ed with a spirit-lotion. FROM ANIMAL POISON. 351 Fifth day. The erythema had spread upon both sides of the fore arm and there was a patch of in- flammation over the biceps. The general symptoms were the same, the stomach nauseated and very irri- table, with occasional slight hiccup, and having taken a small allowance of wine at intervals he was a little flushed, and sometimes incoherent. The mind was evidently weakened and irritable. Sixth day. The inflammation had extended to the neck and over a small part of the pectoral region. Large vesications appeared on the back of the elbow and hand, and clusters of small vesicles on other parts of the arm. Leeches were again applied to the inflamed surface. A pill of three grains of the carbonate of ammonia and one of extract of opium was directed to be taken hourly. The camphor draught continued, and the parts to be fomented with an embrocation of equal parts of spirits of cam- phor and tincture of opium. Seventh day. Seemed more composed in mind after having taken three of the pills. The pulse 120, soft and powerless. Tongue hitherto clean, getting a brownish fur; skin perspirable. Had dosed a good deal. Hiccup had continued through the night with little intermission. The erythema fading upon the hand and arm was vivid upon the chest, and extend- ed over the scapula to the spine. A pill of five grains of castor and a quarter of a grain of opium directed to be taken each hour, and a poultice besprinkled with tincture of opium applied to the pit of the sto- mach. Ammonia and camphor draught continued, and wine-whey given occasionally. Eighth day. Is slightly under the influence of opium. Incoherent talking, between dosing and waking, ceases when he is quite roused. The hie- 352 0F CONSTITUTIONAL IRRITATION cup continues, increases in strength, and evidently prevents his sleeping soundly. To take twenty drops of tinct. opii in a glass of red wine or of lemonade. according to circumstances, hourly. Ninth day. Countenance and powers quite sunk. Hiccup and continual rejection of fluids, without retching, most distressing. Bowels have been per- fectly soluble from the third day of his illness. The mustard-plaster, the extract of belladonna smeared on the scrobiculus cordis, and swathing the trunk with a roller have had no effect to allay the hiccup. The arm, now devoid of cuticle from the number of vesi- cations, which had broken and discharged copiously, was dressed with simple cerate. One grain of sulphate of quinine with extract of gentian, q. s. in a pill, to be taken hourly, and two grains of powdered opium in Starch gruel as an enema every third hour, while the hiccup continues. Tenth day. Hiccup much abated in violence. Pulse small, and very rapid. Skin clammy. Takes a little arrow-root and sherry wine occasionally. His mind is collected when awake, though feeble. Eleventh day. Had sunk gradually since the last report, and died at an early hour of the morning. Another gentleman in good health at the time, assisting at the same inspection, punctured his finger, The wound inflamed the same evening, but yielded to a poultice and a dose of opening medicine. This case, as regards the secondary constitutional inflammation and the disorder of the system, its dura- tion, &c. agrees strikingly with that of Mr. Hercey, related by Dr. Duncan, jun. The inflammation was in both seated upon, and ultimately diffused over the arm and shoulder; in both attended by numerous vesicles differing in size, shape, and transparency. FROM ANIMAL POISON. 353 upon a deeply colored base. Two points of differ- ence in Mr. H.'s case, are however important: 1st. a pustule formed upon the wound ; 2d. the absence of inflammation of the absorbents. I have given this case for the purpose of showing another instance of the combination of the simple and specific action, or, rather, how the latter may succeed to the former, and suspend it after an interval of two or three days. Notwithstanding the obviously unfa- vourable state of this young gentleman's habit for an inflammation of any kind, neither the local affection, nor that of the constitution, excited an apprehension until the erythema appeared.* The pain was never severe. The swelling of the finger was just sufficient to create an equal and not excessive tension, and the absorbent inflammation, though at first well marked, was no more than we continually see yield to a brisk purge.or two, and rest and fomentation of the limb- The axillary glands were unaffected with swelling or pain. In this stage if any reasonable doubt of his well-doing could have been entertained, it must have been founded upon the absence of sympathetic in- flammatory fever. Neither his pulse nor his suffer- ing warranted the proposition to take blood gener- ally, and although leeches were proposed on the first appearance of the inflamed absorbents, they were not then applied, as the affection of these vessels seemed to be purely the result of irritation. The small vesicles which were very numerous, rapidly became confluent as the inflammation and * In fact the poor young man was congratulating himself that the inflammation was confined to the absorbents, and had none of the character of erysipelas on the third day from the injury, only a few hours before the'appearance of the latter. 45 354 OF CONSTITUTIONAL IRRITATION swelling increased, and some had the appearance oi large bullae from the commencement. The irritability of the stomach and diaphragm were the most distressing and unmitigable symptoms; the vomiting begun the day before, and the hiccup thc day following the erythema. E^S!onu°orSto^rom The possible and not very infre- quent co-existence of the signs of simple inflammation, or in the commencement of these cases, theirseparate and exclusive appearance, renders the diagnosis em- barrassing, and the additional circumstances of their having a common origin from dissection, and the con- stitutional symptoms being, in some instances, indis- tinguishable, greatly add to the embarrassment. At one time doubts existed as to the real nature of the case just detailed. They gave way however to the weight of evidence in favor of its specific origin. But the existence of a doubt confirms the important fact, that the state of constitution indicates a mode of treat- ment in all respects the same. The cases of simple inflammation in which the constitutional irritation approaches, much less equals that which is common to the specific, are rare ; those which I have instanc- ed were depending upon the strict confinement of matter by a theca or fascia; the cases given by Dr. Butter are examples of erysipelas, which were clearly depending upon the state of constitution produced by atmospheric, or at least external causes. The state of constitution so far modifies the effects of all injuries, that the earlier or later developement of symptoms, and the greater or less degree of excite- ment, are perhaps principally to be referred to the constitution of the individual who labors under the irritation of a poison. FROM ANIMAL POISON. 355 A poison admitted by a wound or raw surface, and a poison admitted by the lungs, are equally excitants of a specific constitutional irritation; which shows itself in the latter case in a specific mode of inflamma- tion, if the individual should unhappily become the subject of the slightest injury.* The distinction be- tween the erythema of poison, and that mode of in- flammation following a wound, appears to me to be this; that the first is distinct from the mechanical con- dition, the second grafted upon it. The first is the action of the poison via constitution, showing itself in one or more points" upon the line of parts by which it has entered the system ; and whether it take place in a visible shape or not, depends upon the intensity of the poison, the powers of the constitution, the du- ration of life, &c. The second is the conversion of the healthy into an unhealthy inflammation, depend- ing either upon a peculiar local irritation, or upon the peculiar temperament or circumstances of the in- dividual. Hence the analogy is so close between the cases of constitutional origin, direct and indirect, as in some rare instances to render the distinction, so far as the constitution alone is concerned, inap- preciable; but upon the pathology and treatment this analogy reflects a valuable light, inasmuch as it warrants the inference that the resemblance is essen- tial, and that a similar rationale, and by consequence a similar plan of treatment are to be adopted. Ac- cordingly, the history of these cases and of the effects of different modes of treatment confirms the inferen- ces, that they are accompanied by a remarkable de- pression of nervous energy, showing itself either in pure prostration or prostration with excitement, and * Dr. Butter's cases. 356 OF CONSTITUTIONAL IRRI'l ATIO.\ exhaustion ; that all reduction of power is a violation of the leading indication, and that the antiphlogistic measures adapted to simple inflammation and its sym- pathetic fever are therefore positively contra-indicat- ed; that the action of the arterial system requires to be sustained in order to its being equalised; that pain and every incidental excitement is, if possible* to be assuaged, and repose, by whatever means, to be procured. Fatality or these eases. A considerable number of these un- fortunate cases have now been made public, and a large number it is probable, if not certain, have not been published. It is remarkable that of those which present the specific character, the instances of recovery have been very rare, I should think not more than one in seven, while of those blended and confounded with them of absorbent and glandular inflammation, including the cases of cellular and fascial inflamma- tion, and of suppuration in veins and theca?, the fatali- ty is certainly not exceeding one in twenty. Predisposition not necessary. I will not weary my reader by again discussing the question whether, a certain predispo- sition of the body is necessary for the production of this disease. For inflammation I should say certainly? and for the aggravation of the attendant sympathetic irritation—but not for the baneful operation of a poison once admitted into the system. Even in this case that the state of the health may modify results, I have admitted on the general principle—" valeat quantum valere debet," but it is insufficient to ex- plain, to my mind, the frequent cases of no effects, FROM ANIMAL POISON. 357 and of fatal effects, resulting from the wounds of two persons dissecting the same subject. No virus secreted in the wound, except in TKiot trio *»fYor»r r\f frif» in the case of primary vesicle or pustule. J. Urtl UJC CIJ^LA Ul IIIC 111 troduction of a virus, whether secreted by serous membranes under inflammation, or formed in all ani- mal bodies during the first stage of decomposition, is 'ocal inflammation, and the production of a similar virus in the inflamed part, as Dr. Thomson thinks, appears to me a conclusion unwarranted by the majority of the cases which I select as examples of the specific disease. For in a few instances can the part wounded be said to undergo inflammation, at least sufficient for secretion; and the characteristic inflammation usually takes place at a greater distance of space, and at a shorter interval of time, than would, according to analogy and probability, happen, if the virus were a morbid poison elaborated in the wound. The case of a vesicle or pustule formed on the wound, is probably an exception to this remark. Local diagnostic signs. In no case that has fallen under my ob- servation has the sign of pain more or less acute, and of fulness and tenderness on pressure of the breast or shoulder, been wanting. The erythema may not show itself until the fourth or fifth day, but it more frequently appears on the third. This is subject to more uncertainty as to its existence and more variety in its place and progress. It appears either on the pectoral, scapular, or iliac region, running towards the median line, and bounded by it. It is not symptomatic of deep-seated inflammation, nor does the cellular membrane take on the full sup- purative action, until the disease has attained con- 358^ 0F CONSTITUTIONAL IRRITATION 9iderable duration, and then diffusedly. I regard this. including the stages of pain, puffiness, and efflores- cence, with or without the vesicle, as the surest local and visible character of the disease. Its locality is in the first instance determined, by the passage of the irritant into the circulation, corresponding to that of the previous pain. As it becomes more complete- ly a constitutional action, after the lapse of some days, it is subject to become erratic, and appear not only on the flank or loin on the same, but even on the op- posite side of the trunk, or opposite limb, without any obvious cause of local irritation. Of the varieties of the primary action which may be exhibited, I have before spoken, viz. vesicle or pustule, or abscess of the wound, whitlow, cellular or thecal, or gangrenous inflammation. The absorbent vessels and glands of the arm may also be inflamed, tumefied, and tender; on the other hand, these signs one or all, may be wanting. The vesicular erythema, a variety of the former, and probably depending on the pre-occupation of the limb by simple continuous inflammation, as of the superficial absorbents, begins in the injured finger and extends to the next, the hand, fore-arm, elbow, and upper arm in succession. It may either be thus progressive and creep along the surface, the part first affected fading as the next is attacked, or isolated patches may appear on the elbow, biceps, deltoid, or pectoral, the interspace remaining clear; or these actions may be simultaneous in different parts of the limb. Ultimately, the whole arm and side of the trunk are involved in the disease. Sometimes the swollen surface presents numerous small elevations, described by Dr. Colles as to the eye like vesicles, but hard to the touch, resembling the cicatrices of a FROM ANIMAL POISON. 359 part which had been scarified, when affected with swelling; at other times large and numerous small vesicles, some clear and others sanious. I have called this inflammation by the term erythe- ma, meaning thereby to designate by the simplest appellation, inflammation of the common integument. As puffiness and pain generally precede discoloration, it would appear that the cellular texture is first affect- ed. Its ordinary termination is in diffused suppura- tion of the cellular membrane. The vesicular ter- mination is a variety. To the term erysipelas I ob- ject, as undefined in its application, complicated with endless varieties, and a perplexing catalogue of different species, which seems to augment in the hands of every additional describer. Local treatment. For the local treatment of wounds receiv- ed in dissection, very different plans have been re- commended—some advising incision, others a caustic acid or alkali; some cold and sedative washes, as goulard and opium; others stimulants, as ammonia, turpentine, or alcohol; others again a tepid fomentation and bread-poultice. I conclude it is to quicken and augment the suppurative action, that a stimulus is advised. Dr. Pett's case is a warning against the use of caustic after the setting in of inflammation and pain. It is plain that an escharotic should be appli- ed, if at all, at the moment of the injury, in cases of such rapid absorption as these prove themselves to be ; rapid at least as compared with the poison of hydrophobia, though slow compared with that of some of the Indian serpents. irecautions Since it cannot be known, at the moment of infliction, what may be the nature of the injury, it i^ 360 OF CONSTITUTIONAL 1KRITATI0M as little to be expected that young men will habitu- ally apply a caustic, on the instant, as that they will smear their fingers with oil or pomatum, or clothe them with gloves before handling a body. Neither are such things, in my opinion, worthy of men in earnest in their pursuit; but I must take leave to deprecate the absurd and affected hardihood of persevering in dis- section, and especially in visceral examinations, with recently cut or chapped fingers, affording every faci- lity for absorption; and thus needlessly exposing themselves to the imminent risk of a disease from which so few, even of the most robust, escape with life. When inflammation is set up sufficient to draw the patient's attention to the injury, the same simple and soothing applications which would be made to any inflamed part, are, in my belief, the most eligible. If much tension be present, emptying the vessels free- ly by a deep incision with a keen lancet, through the line of the wound, and then enveloping the part in a poultice, is a practice which I have commonly em- ployed, and I have thought with advantage. For the erythema of the arm or trunk, folds of linen moistened with the diluted liquor plumbi or liquor ammoniae acetatis, are probably the best applications. Poultices oppress by their weight, irritate when they lose their moisture, and can seldom be borne, how- ever well prepared. If, in protracted cases, the cel- lular membrane becomes much loaded, incisions are beneficial to quicken the slow and imperfect suppu- rative action. In Mr. Delph's case they were un- doubtedly advantageous. constitutional treatment. It appears to me that no rules for constitutional treatment, to hold in all cases, can pos- FROM AjMMAL POISON. 361 ibly be laid down; that we should err equally in uniformly prescribing a stimulant or a depressing treatment for these cases. The cause of irritation, the symptoms, and the habit and state of health must be referred to, and from the aggregate the inference must be formed. As regards the first, I feel war- ranted in saying, that the plan of early support for- merly adopted in these cases of animal poison, under the notion, however erroneous, of a rapid putrescen- cy of the fluids, is more consistent and rational than the antiphlogistic, which assimilates them to inflam- mation. Venesection, it is true, is one mode of re- lieving congestion ; but a more pernicious one could not be devised, where the congestion is the obvious result of a sudden and extreme depression of ner- vous power. This practice may be said to have had a fair trial in the cases of Mr. Dease and Dr. Bell; in neither did it afford sensible relief, nor did the blood assume any character of inflammation. symptoms Nevertheless if a case presented itself bear- ing the specific local character, in which acute pain was combined with steady, contracted pulse, and other signs of inflammatory excitement, I should con- sider the trial of copious blood-letting in the com- mencement indicated, nay called for; but I never met with such a case; and for pain upon a vacilla- ting, throbbing, or faltering pulse, the experiment would be unwarrantable. Certain symptoms of de- pression, however, which are more of a moral than a physical cast, are sometimes sufficient to mask the actu \\ energies of the system, as the full and swing- ing pulse, peculiar to irritation, deceives an inexpe- rienced person with the idea of strength. Where the use of the lancet is prohibited, pain should, if 46 362 OF CONSTITUTIONAL IRRITATION possible, be allayed by opium. It is of itself, as wt have seen, a disease, capable of proving destructive. Health and uabit Since the course and severity of spe- cific as well as of simple inflammatory diseases, are liable to be influenced by the state of health and habit of the patient, these must have their due weight in determining the appropriate treatment. G?n"i™Mfe™iderthe I must refer my reader to the obser- vations I before made upon the pathological relation between cases of simple and poisoned wound,* the tendency of which was to show that neither history nor preconceived opinions ought to countervail ex- isting indications, and that we are warranted by an analogy of symptoms clearly made out in pursuing similar modes of treatment in both cases. When I speak of existing indications I do not mean to refer to this or that symptom, but to the assemblage; and it is the general character thence deduced that ought, in my judgment, to decide the treatment. ^fflyffiriTerion" Tne impression arising from a be- lief that a solitary symptom is sufficient to constitute a guide, is a most mistaken one; for example, a rapid pulse, if frequency be considered an insuperable ob- jection to tonics; a wandering or asthenic delirium, if, as is generally thought, it forbids the use of opium; a white-furred tongue, which 1 have heard intelligent physicians declare prohibitory to the exhibition of bark, &c. As to frequency of the pulse, it is oftener a sign of weakness than the opposite; and I know no period of acute irritation at which it would be "1 See page 263. et seq. FROM ANIMAL POISON. 36a possible to institute a tonic regimen, if this amount to a prohibition. In local inflammations, the benefit of astringent and tonic remedies is lost, if their use be deferred until the elevated sensibility of increas- ed action has entirely subsided, and the action is be- coming habitual to the part or chronic. And so it is with the constitutional excitement of irritation, which begins in weakness. It is the active and sensitive stage alone, upon which any favorable impression is to be made by medicine. I offer this observation to enforce the distinction between action as a sign of power, and action as a proof of weakness. Again, for the state of mild delirium, or rather the state of prostration, of which it is characteristic, my expe- rience teaches me that opium, in certain proportions and combinations, oftener than any other medicine, affords a remedy. If a peculiar state of the tongue, whatever that may be, counter-indicates the early employment of bark and ammonia, it sets aside the remedies of which I entertain a higher opinion than of any, in the prostration of irritation from external causes.* The proper treatment of the disease which I have described under the name of irritation, offers a yet * As I have mentioned bark—in a firm belief of the virtues of which medicine I agree with Mr. Hunter, a belief founded on some experience—it is right to say that my mind is yet undecided on the actual and comparative merits, in the more urgent cases of this class, of the preparation lately imported from France, under the denomination of sulphate of quinine. It is the misfortune of every new remedy to be put upon the forlorn hope, and thus to encounter a very unfair mode of trial. Its efficacy in the cure of the ague appears to be satisfactorily established. 361 OF CONSTITUTIONAL IRRITATION uncultivated, if not untrodden field for intelligent observers. cimicai observation. The alliance between certain local changes and particular states of the constitution, is a study of the deepest interest, and furnishes us with a clue to the treatment which might otherwise be ob- scure. But as we cannot always have the advantage of this guide, we are by close and repeated observa- tion to ascertain in what degree and manner the ner- vous system is implicated and affected, to separate the simulated from the real signs of inflammatory action, functional disorder from organic disease, and asthenic from sthenic excitement. Morbid anatomy. Upon the great importance of anatomi- cal examinations, not only to test the accuracy of our past opinions, but for the chance of obtaining some gleam of light to.direct our future steps, I need not insist. It is in these cases most desirable, after the inspection of the parts affected, and the thoracic and abdominal viscera, that the entire trunk of the ner- vous system should be attentively examined; and the general distribution of the blood in both orders of vessels carefully noted. To conclude : the general character of inflamma- tion is power, that of irritation weakness; these may be more or less strongly marked in individual cases. and the symptoms must therefore guide the treat- ment, subject to the modification which the general character imposes. I am disposed to believe that a species of intellectual indolence, which too often leads us to receive rather than to reflect, and to per- suade ourselves that things to a certain extent alike FROM ANIMAL POISON. 365 and often connected, are in reality the same, has con- tributed to render our measures indecisive in these cases. Inflammation and irritation, the phenomena of two systems so combined as not to admit of separation, are nevertheless to be viewed and considered some- what distinctly in their pathological relations; and if I mistake not, such a course of observation will jus- tify, as regards the latter, an earlier and freer use of the means best suited to support and renovate the powers of the nervous system, than is consistent with the prevailing practice. APPENDIX. Xo. I. The authority of Dr. Farre as a pathologist is so eminent, that 1 thankfully embrace an opportunity of laying before my reader the result of his observations on the important subject of wounds receiv- ed in dissection. It forms the remainder of the communication from which I formerly offered an extract.* The doctor, it will be seen, employs the term '' erythema," in a generic sense. " The absorbents are liable to an erythema from any wound, however slight, which so injures the cutis as not readily to admit of its healing by adhesive inflammation. The symptomatic fever at- tending this apparently trivial injury is irritative in a high degree, and its access is usually strongly marked by rigor. The red line or lines, which may be traced from an injured finger or toe to an in- flamed gland in the axilla or inguen, gives us some faint notion of the impetuosity of the arterial action, which so minutely injects with red blood the colourless arteries that nourish the coats of an absorbent vessel. '' This disease, which I trace amongst my earliest recollections, long before I commenced the study of medicine, prevails much in warm climates not only as a symptomatic, but also as an idiopa- thic affection. Heat and moisture predispose to it, for I first ob- served it in Barbadoes in low and damp situations, especially near stagnant water. The coats of the absorbents if frequently inflamed lose their elastic power, and so dilate as to be incapable of per- forming their function, whilst the exhalent arteries effuse into the i-ellular membrane a morbid lymph which permanently enlarges the limb. Under any circumstances which depress the power of the arterial system, this lymphatic erythema is apt to supervene on the most superficial abrasion or wound of the cutis, simply from the in- jury, especially if it be a punctured wound. ' See page 250. 368 APPENDIX. " This reference to an endemic disease of the absorbents in » warm climate which I have had the opportunity of observing, ma> perhaps be acceptable to you, as throwing a light upon the object of your inquiry respecting the dangers to which the practical and morbid anatomist is exposed even in the most temperate climates from the irritability of the absorbent system ; especially if predis- position, arising from previous residence in a warm climate, or from being too much exposed to miasma or putrid effluvia, or from any organic or functional defect of the cardiac system, invite the erythema under slight injuries of the cutis, which the more vigor- ous arterial action of health would have healed by the adhesive or at least by a superficial suppurative process. " The lymphatic erythema of temperate climates is far more dangerous than that of warm climates, and sometimes rapidly proves fatal, through the injury sustained by the cerebral system at the ac- cess of its irritative or symptomatic fever. I think that West Indians are more susceptible in Europe of the lymphatic erythema than Europeans, owing to a predisposition to the affection induced by climate ; but an European by residence in a warm climate will also acquire this predisposition. A British merchant after long residence in the West Indies applied to me in London many years ago for prolapsus ani consequent on internal piles. I thought it necessary that a cluster of considerable size should be removed. The opera- tion by excision was performed and thrice repeated, the larger piles in the cluster being removed singly. After each operation sensations like those which are produced by electric sparks, were felt in the thigh of the corresponding side- inflamed absorbents were seen extending down the thigh from the groin, and an ephemeral fever, such as accompanies the disease in the West Indies, was manifested. It readily yielded to the ordinary practice in that cli- mate of giving an opiate combined with an antimonial on the ac- cession of the disease, and saline purgatives on the following morn- ing. " My late friend Mr. Saunders soon after he began to distinguish himself by his application to anatomy, was affected, in consequence of wounding his finger, with lymphatic erythema of the arm, to an extent which had nearly proved serious. He was preserved chiefly by very free local bleeding and fomentation. He rejected the advice, although offered by high authority, of treating his case, which was considered hopeless, by bark. I think that I have twice- attended yourself with pretty severe attacks of lymphatic erythema in its mo-*! simple form, i. e. irri,;jfive from wound. APPENDIX. 369 •'From my own observations I am led to conclude that the majority of these accidents prove to be cases of simple irritation, i ml I am persuaded that they may in general be prevented by pro- tection of the wounded surface. " I believe that the lymphatic erythema may arise from constitu- tional predisposition independently of any fretting or mismanage- ment of the wound which excites it, and I think that those who are much engaged in anatomical pursuits ought not to reside in situa- tions that are confined, or that are low and near the banks of large rivers. " The application of morbid fluids or putrid matters to an abrad- ed and punctured part, or even to the cutaneous and mucous sur- faces of the body in general, may also induce diseases of a very serious kind, sometimes apparently allied to lymphatic erythema, at others to the effects of morbid poisons or to those continued fevers which begin with gastric derangement. From my own experience I am inclined to believe that the dangers of the dissecting-room may, in a great measure, be averted by the strictest attention to cleanli- ness, ventilation, and an open healthy residence. '' These remarks prepare me for the notice of a very serious disease, differing in many points from the lymphatic erythema before described, and which I have uniformly traced either to the dissecting- room, or to the examination of morbid bodies in private. " The following case will sufficiently illustrate the ordinary train of symptoms of the disease which I am about to describe. "In November 1823, Mr. S. a young gentleman from Barbadoes, a student of medicine, wounded with his forceps the cutis over one of his knuckles in his first dissection. On the second or third day after this accident the wound slightly suppurated and he felt a pain and stiffness in the axilla, which was soon followed by rigor, and a very high degree of irritative fever. At this period, November 30th, I saw him, and carefully examined the hand. The knuckle was nearly well, and no inflamed absorbents were, or had been apparent on the fore or upper arm. " Although the irritative fever did not diminish during the first fortnight, notwithstanding means proportioned to his strength were used to diminish the force of the heart and arteries, yet no sensorial disturbance was manifested, as it usually is in the higher degrees of Ivmphatic erythema. " On the I lth of December, T discovered a very extensive col- lection of puriform fluid under the latissimus dorsi. Sir Astley Cooper met me in consultation on the following day, and discharg- 47 J70 \PPE'\l»IX ed the matter. The edge of the lattisimus dorsi so much confined the subsequent, accumulations of puriform fluid, that it became ne- cessary to enlarge the external orifice, which was done by Mr. Key. " Although the immediate danger was now diminished, yet the case assumed so much of the hectic character, that for upwards of two months I despaired of his recovery, and three months had elaps- ed before the amendment was very decisive. " During the whole of this period his pulse was remarkably quick, small, and irritable, and he became exceedingly emaciated, notwith- standing the greatest attention was paid to his regimen. His dis- eased arm remained rigid at the shoulder joint, and did not admit of any useful motion. He was treated in the beginning by thc free application of leeches on the fore arm, and poultice on the wounded surface, and subsequently by the same means about, the shoulder and axilla. He took chiefly mercurial purges and saline medicines during the acute stage, and the cinchona, with the min- eral acids and occasional doses of rhubarb, and a generous diet, during the asthenic stage of the disease. The puriform collections occasioned him the protracted suffering which I have already noticed, and induced me to propose to Mr. Fernandez, who dress- ed him with the kindest professional care, to pass a seton through the most depending part of the diseased cellular membrane. It con- tinued to discharge for a very long period, and although there was a subsequent collection of puriform fluid above, near the long head of the biceps, yet there was none below the seton. About this time the extract of sarsaparilla was freely given to him with much more apparent benefit than he derived from the cinchona. As soon as he was convalescent I sent him to Hastings, and I have la'dy seen him in perfect health, the use of his arm having been long since com- pletely restored. " A certain morbid appearance on the inoculated surface gener- ally affords a precise diagnostic sign of a morbid poison ; but al- though this local symptom, with the exception of the cases resulting from Pestis Bovilla, be wanting in the examples now adduced, yet rigor, pain in the axilla, irritative fever, and extensive puriform effu- sions into the cellular membrane of the muscles of the trunk, con- sequent on a wound which has been imbued with the morbid fluid.- of a subject under anatomical examination, are sufficiently uniform and determinate symptoms to induce me to think, that they are ex- cited rather by a morbid fluid applied to the punctured or abraded APPENDIX. 371 surface, than by the wound itself. For it seems to me that there are manifestly two species of erythema to which the morbid anato- mist is exposed ; one simply irritative from the wound, the lympha- tic erythema, in which inflamed absorbents are seen under the skin ; the other a cellular erythema, in which, although the first series of lymphatic glands inflame, as is usual in cases of morbid poison, yet inflamed absorbents are not apparent, or do not extend from the puncture to the inflamed lymphatic glands ; but the cellu- lar membrane contiguous to the inflamed lymphatic glands succes- sively inflames through an indefinite portion of its surface, and be-A comes charged with a puriform effusion, without its being so dis- tinctly bounded by coagulable lymph, as to acquire the characters which define phlegmon or common abscess. " The cutis is unquestionably the proper seat of erythema, and it may be doubted whether lymphatic, venous, arterial, and cellular erythema, which may be considered as some of its species, are not usually excited by the previous erythema of the skin." No. II. The case of Mrs. P. given at page 252, has, I find, been shortly stated in the Medical and Physical Journal for February 1825, by Mr. Anderson her medical attendant. I should have noticed this document had I been aware of its existence when I drew up the case. I now refer to it because a circumstance is therein stated which I had omitted to mention, viz. that the lady was in the daily habit of dressing a strumous sore in the neck of one of her chil- dren. I attach no importance whatever to the fact. No. III. The following simple and ingenious argument was stated a short time since in conversation by Sir James Mackintosh, whose interest 372 APPENDIX. in science is as ardent as universal. I requested him to put it on paper, and venture without apology to lay it before my reader.— " The report of MM. Humboldt, Halle, and Percy on some physiological experiments of M. Le Gallois, of which a translation is prefixed to Dr. Wilson Philip's late work on the vital functions, discusses the celebrated question—why certain muscular actions, though affected by the passions, are independent of volition. " The most conspicuous of these actions are the movements of the heart, which may serve as a sufficient example of the whole. The heart is supplied with nerves which are in other cases the in- struments of volition ; it is often powerfully affected by pleasurable or painful emotions ; it is probably influenced in some degree by the mere operation of the understanding; yet in the ordinary course of nature it is never subject to the power of will. What is the circumstance which deprives the mind of the power of quickening or retarding the action of the heart, as it quickens or retards that of the voluntary muscles ? " In this discussion it is tacitly assumed that the question is phy- siological or dependent for its answer on the laws of the animal frame. If it were so, I should not hazard an observation on it. But it seems to me at least doubtful whether it does not rather be- long to the philosophy of the human mind. '' In order to make what follows more plain, it is convenient to premise a few words on will and desire. Some philosophers repre- sent volition as the last desire or aversion which immediately pre- cedes action. Others think it more exact to say that there is an exertion of a simple and undefinable mental power interposed be- tween either desire or aversion and muscular action, which exertion the word ' volition' properly denotes. For the purpose of the pre- sent question this difference of opinion (if it be not rather a differ- ence of language) is unimportant. For those who hold the first opinion must at least acknowledge that will and desire are suffi- ciently different to justify the distinction made in common language between them. If will be a species of desire, it is essentially dif- ferent from all other desires. The object of what is commonly called desire is always some outward thing ;—that of will is always an action of the man who wills. Desire seeks an end ; will em- ploys means. Desire pursues enjoyment; will exerts the bodily powers to obtain that enjoyment. In short a man desires to enjoy, but he wills to do it. He desires an apple which he sees hanging on a tree—he wills the succession of acts by which the apple is brought into contact with the palate. A man only wills to do thai APPENDIX. 373 which lie believes he can do. Children are said to cry for the moon—unreasonable persons allow themselves to wish for, or desire objects which are altogether unattainable. Transient wishes of that kind often shoot across the mind of the wisest. But no crea- ture wills an action which he does not think possible. Children learn gradually that by various movements of different parts of their body they may obtain objects of desire, or avoid those of aversion; they thus learn to will; they acquire a voluntary power of moving certain muscles. It does not seem to be so much the progress of strength, as of skill derived from experience, which enables a child at a certain age to stand and to walk. But no motion either of the heart, or of the stomach, or of any other internal organ, is ever dis- covered to any man by experience, to be the means of attaining an object of desire. " We are taught by science that there are changes in the move- ments of these organs, but no such changes are revealed to us by sense. We infer them from appearances, but we never perceive and we cannot imagine them. We may sometimes perceive the effect of such movements, but we do not see the movements them- selves. For that reason the mind never wills any action of these organs. It is not a just representation of facts to say, that their motions are not subject to will. The truth is, that no will is formed concerning them. " With respect to the voluntary action, indeed, the mind does not will the contraction of certain muscles ; the co-operation of which is known only to few, and at the moment of action thought of by none. But it wills a certain change in the posture of some bodily organ, which may be perceived and imagined, by which change some object is expected to be attained. Some muscular actions are voluntary, because knowing them to be the means of gratifying desire, we will their production. Others are involuntary, because not knowing them to be such instruments, we have no mo- tive for volition about their motions. " These notions, suggested by the perusal of the report on M. Le Gallois'' experiments, I communicated to several of my medical friends, who seemed to think them apparently just. Since these communications, I find that the same explanation is less fully, but in substance is given by Dr. Wilson Philip himself, in the tenth chap- ter of his work. He too seems to think the explanation new. } am gratified by the concurrence of the judgment of so ingenious a man with mine. - The difficulty which seems to be insuperable, if this question 374 APPENDIX. be considered as anatomical, is that a communication lor every pur- pose but that of will is kept up by nerves between the heart and the immediate instruments of the mind. '' It has been objected that there must be an organic difference between the nerves which supply the voluntary muscles and those which go to the vital organs, because the former are fatigued by long exertion, whereas the latter are not so by constant action. But wherever constant action is from any cause the habitual state bf a muscle, no fatigue is produced by it, as appears in the volun- tary muscles which contribute to respiration. Fatigue is produced only by an action greater or longer than that to which the muscle is accustomed, and when the heart is violently excited, a proportional exhaustion and feebleness are the consequence. The peculiar spe- cies of pain called weariness, does not indeed follow, but the gene- ral succession of exhaustion to more than usual excitement is the same. " Every organic explanation of the involuntary motions assumes some circumstance in the structure of the brain or its appendages which is not proved by experience to be real. The best of them is therefore an hypothesis. " The above attempt to refer the phenomena to the philosophy of mind requires no fact to be presupposed, and is founded solely on those facts of which we are conscious. It can only be objected to therefore on the ground of its inadequacy to explain the pheno- mena, and if it does explain them, it is a legitimate theory. " J. MACKINTOSH.1 ■; 13th March, 1826.v v v>