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SURGICAL  OBSERVATIONS, 


&c.  &c. 


Pfinteft-Street,  London. 


TR  B 


SURGICAL  WORKS 


OF 


JOHN  ABERNETHY,  F.R.S. 

&c.  &c.  &c. 


VOLUME  THE  FIRST. 

en  THE  CONSTITUTIONAL  ORIGIN  AND  TREATMENT  OF 

LOCAL  diseases; 
aneurism;  diseases  resembling  syphilis; 

AND  diseases  OF  THE   URETHRA. 


LONDON: 

PRIVTED  fOR  LONGMAN}  HURST,  REBS»  ORMS,  AND  BROWK, 

PATXRNOSTIR-ROW. 


Stnliaii  tnd  FreftoOf 
Pkiiitei»4trMt«  Londoa 


SURGICAL  OBSERVATIONS 


OM    TUK 


CONSTITUTIONAL  ORIGIN  AND  TREATMENT 

Of 

LOCAL  DISEASES; 


AMD    ON 


ANEURISMS. 


BY  JOHN  ABERNETHY,  F.R.S. 

HOKORARY    MSMBBR    OP   THE    ROYAL  MEDICAL  SOCIETY  Of 

SDINBURGHy    AND    OP    THE    MEDICAL    SOClBriEt 

OF    PARI^,    PHILADELPHIA,   5CC. 

ASSISTANT  SURGEON  TO  ST.  BARTHOLOMEW'S   HOSPITAL^ 

AMD  TEACHER  07  ANATOMY  AND  SVROBRY. 


**  Chirurgo  neeeffariam  effe  eogmtitmeum  Phxfictt^  Chimiit,  LogUtSf 
"  omnis  (fere)  ambitiu  Medicine  ;  neque/olo  manus  exercitU 
«  veros  Mrurgos  fieri:'  Herm.  Boerhaav.  Method. 

Stad.  Med*  locupleuta  ib  Alb.  too  HaUer. 


LONDONf 

VRlHTBD  FOR  LONGMAN,  HURST,  RSBS,  AND  ORMB, 

PATERNOSTER-ROW. 

1809. 


PREFACE. 


npHE  beft  mode  of  obtaining  and  extending 
^  medical  and  fiirgical  knowledge  is,  in  my 
opinion,  to  pay  that  flri£t  attention  to 
difeafes,  which  qualifies  us  to  note  even  the 
flighter  (hades  of  difference  that  diftinguifh 
them  from  each  other.  Such  difcrimination 
leads  us  to  form  (bme  regular  arrangement 
of  them,  which,  even  if  it  be  not  cqfre^t,  may 
ultimately  enable  us  to  difcover  thdr  natural 
feries  and  order.  This  method  I  ihave  pur- 
fued  from  the  beginning  of  my  profeilioncU 
ftudies.  Whenever  the  opinions  on  fulyedVs 
of  importance,  which  an  attention  to  cafes 
had  impreffed  upon  my  mind,  differed  frcMn 
thofe  which  feemed  to  prevail  amongft  other 
pra£titioners,  I  publifhed  the  fa£ts,  and  the 
inferences  which  I  drew  from  them,  becau^ 
I  thought  that  the  former  at  leaft  deferved 
attention,  and  that  the  latter  would  either 
be  confirmed  or  confuted  by  the  refult  of 
general  experience. 

A3  It 


IV  PREFACE. 

It  is  more,  however,  on  account  of  the 
cafes,  than  of  the  conclufions  which  they  fug- 
gefted,  that  I  api  ^ciirous  of  republilhing  my 
furgical  writings.  Various  advantages  refult 
even  from  the  publication  of  opinions  j  for 
though  we  are  very  liable  to  error  in  form- 
ing them,  yet  their  prpmulgation,  by  exciting 
inveftigatipn,  and  pointing  out  the  deficien- 
cies of  pur  information,  cannot  be  otherwife 
than  ufeftil  in  the  promotipn  pf  fcicnce, 

m 

The  publication  of  the  opinions  which 
naturally,  arife  in  the  mind  of  the^furgeon, 
from  the  cafes  fubmitted  to  his  obfervation, 
pofljffes  the  further  utility  pr^  rendering  ^ 
prolix  detail  of  circumflances  unn^cefiary.  Jt 
would  be  almoil  imppflible  to  relate  every 
minute  pgcurrence,  that  tended  to  imprefs 
certain  conclufions  on  the  mind  of  the  ph- 
fcrverj  or  to  relate  every  trifling  part iculai' 
of  treatment,  by  which  the  furgepn  endea- 
voured to  accomplifh  his  objeft.  Such  4  dull 
and  tedious  narrative,  which  would  weary 
and  difguft  the  reader,  may  indeed  be  well 
fparedj  becaufe  thepraftitionermay,and  muft, 
repeatedly  perufe  the  cafe  at  large  in  tl^e 

book 


PREFACEt  ▼ 

• 

book  of  nature.  The  writer  merely  points 
out  thofe  figns  by  which  any  difeafe  may  be 
difcriminated  from  others,  and  identified  as 
one  of  the  particular  clafs  to  which  he  is 
defirous  of  exciting  the  public  attention* 

t 

With  regard  to  the  cafes,  which  I  confider 
as  the  valuable  part  of  the  book,  I  may  ob- 
ferve,  that  it  is  not  to  be  expefted  that  the  re- 
cords of  them  will  make  fo  ftrong  an  impreC- 
fion  on  the  minds  of  the  readers,  as  the  ob- 
fervance  of  them  has  done  on  that  of  the 
writer  5  but  when  the  fame  occurrences  arc 
met  with  in  praftice,  then  will  the  impret 
fion  become  more  vivid,  and  knowledge  arife, 
as  it  ufually  does,  from  perfonal  experience. 
If  the  fa^ls  contained  in  thefe  volumes  oc- 
curred fo  rarely,  that  others  could  not  be 
expefted  to  meet  with  them^  their  relation 
would  be  of  little  value.     They  may,  how- 
ever, not  improperly  be'compaied  to  certain 
fpecies  of  plants,  by  no  means  uncommon, 
which  are  liable  to  be  confounded  with  others 
by  an  inattentive  obferver ;  but  when  their 
difciiminating  charafters  are  once  |>ointed 
out,  they  may  l?e  fo  readily  diftinguifhed,  col- 

lefted 


VI  PREFACE. 

levied  and  examined,  as  to  render  a  more  mi- 
nute dcfcription  of  them  unneceflary.  If 
difeaies  could,  like  other  ohje£ls  which  we 
mean  to  delineate,  be  placed  in  various  points 
of  view,  and  illuminated  at  pleafure,  fo  as  to 
fliew  diftinftly  their,  different  parts,  one  ac- 
curate rcprefentation  would  fuffice ;  but  we 
fee  them  obfcurely,  and  as  knowledge  in- 
creafes,  it  fcrves,  like  light  fliining  from  dif- 
ferent places,  to  illuminate  the  various  parts 
of  the  objeds  of  our  examination. 

For,,  as  I  have  expreffed  it  in  the  firft  Edi- 
tion of  thefe  writings,  "  in  proportion  as  we 
advance  in  knowledge,  we  are  led  to  remark 
many  circumftances  in  the  progrefs  of  a 
diforder  which  had  before  pafied  without 
notice ;  but  which,  if  known  and  duly  at^ 
tended  to,  would  clearly  point  out  the  na- 
ture of  the  complaint.  Hence  the  records 
of  former  cafes  are  of  much  lefs  value ;  as  the 
fymptoms  about  which  we  are  now  anxious 
to  enquire,  have  in  them  been  entirely  over- 
looked." It,  therefore,  becomes  neceffary 
that  each  writer  fhould  ftate  thofe  circum- 
ftances to  which  he  has  been  particularly  at-r 

tentive  i 


PREFACE »  YU 

tcntive;  nor  need  he  further  delineate  the  cafe 
dian  by  a  general  outline^  fo  as  to  render  it 
intelligible. 

The  rdatioti  of  cafes  may  be  compared  to 
the  reprefentations  i^ch  an  artift  gives  of 
natand  ob^fts,  and  which  are  valuable  oaif 
in  as  much  as  they  are  corre6):  or  vivid  deline^ 
ations  of  reality.  Such  portraits,  fketched  by 
a  peribn  of  dull  perception^  or  by  one  whofe 
optics  are  perverted  by  prejudice  and  theory, 
are  either  valuelefs  or  deceptive ;  and  hence, 
perhaps,  has  arifen  that  obje6tion  to  books 
of  cafes  which  I  find  to  be  very  prevalent.  In 
the  imperfeft  (ketches  which  I  have  laid  before 
the  puiblic,  my  chief  objeft  has  been  to  toUch 
up  and  bring  into  view  fome  parts  of  the 
fubjefts  which  have  not  been  fo  clearly  feen 
or  ftrongiy  delineated  by  former  draftfeien. 

When  books  of  this  kind  are  publifhed, 
.mutual  forbearance  is  requifite  on  the  part 
botib  of  the  writer  and  the  reader.  The  former 
ihould  not  expeft  his  work  to  be  approved 
of,  till  the  latter  has  examined  whether  his 
reprefentation  of  difeafes  be  corredt,  end  his 

con- 


Xm  PREFACE. 

conclufions  legitimately  drawn  from  the 
fefts  which  he  has  obferved  and  collefted. 
Neither  Ihould  the  reader  condemn  the  work 
till  he  has  examined  the  fubjeft,  and  is  in 
confequence  able  to  point  out  the  errors  of 
the  premifes  or  conclufions.  The  author's 
^ew  of  a  fubjeft  may  indeed  be  correftly 
formed  from  the  fa£ts  which  he  himfelf  has 
witnefied ;  but  it  may  differ  from  that  which 
more  extenfive  experience  would  have  fug- 
gefted.  For  this  difference  no  blame  can 
properly  be  attached  to  him ;  he  relates  what 
has  &llen  under  his  own  obfervation,  and  in- 
vites others  to  attend  to  the  fame  fafts.  ^ 

1  have  been  induced  thus  to  offer  my  fen- 
timents  refpefting  the  defign,  mode,  and 
probable  advantages  of  recording  cafes,  not 
with  a  view  of  vindicating  the  plan  which  I 
have  purfued,  for  that  indeed  cannot  be 
neceffary,  fince  it  is  the  fame  that  has  been 
followed  by  the  befl  authors  on  furgery. 
My  objeft,  by  thefe  remarks,  has  been  to 
induce  others  to  refleft  how  they  may  mofJ: 
cffeftually  promote  medical  knowledge. 
No  oifc  can  luivc  thoroughly  fhldied  his  pro- 

7  feffion 


PREFACE.  IX 

feflion  without  perceiving  how  fufceptible  it 
is  of  improvement,  without  difcerning  how 
inadequate  the  efforts  of  an  individual  mufi: 
be  towards  the  accomplifhment  of  this  pur- 
pofe,  and  confequently  without  feeling  an 
eameft  wifh  to  engage  general  co-operation 
in  this  defirable  objeft* 

In  republiftiing  my  former  writings,  I 
have  left  out  all  that  part  which  relates  to 
phyfiology.  The '.  fur^cal  fafts  contained 
in  them,  will  now  be  found  incorporated  with 
my  later  publications,  under  the  fame  general 
head  of  Surgical  Obfervations.  I  have  alfo 
made  thofe  alterations  and  enlargements 
which  a  greater  (hare  of  experience  has 
diftated.  The  fubjefts  have  likewife  been 
tranfpofed.  I  have  put  at  the  beginning 
of  the  book  thofe  cafes  which  fjiew  how 
much  local  difeafes  depend  upon  the  general 
ftate  of  the  patient's  health,  becaufe  I  (hall 
have  frequent  occafion  to  refer  to  this  fubjedt 
in  the  fucceeding  parts  of  the  work* 

I  feel  much  gratified  in  finding,  that, 
though  a  larger  portion  of  experience  has 

enabled 


X  PREFACE. 

cnaUecT  me  to  add  fome  new '  and  {hiking 
fa£b  to  this  edition^  it  has  not  fhewn  me 
any  thing  that  I  ought  to  retra6l  or  ma- 
terially altcn  This,  indeed,  muft  be  the 
cafe  in  a  book  containing  only  fa£bs,  and 
opinions  not  incautioufly  deduced  from 
them.  Several  of  the  papers  contained  in 
this  volume  mef  with  very  general  and  ftrong 
obje^oQ,  which  I  confidered  as  the  greateft 
compliment  which  could  be  paid  to  them. 
For  if  tiie  views  which  I  had  taken  of  various 
|»7i£tic^  fub^e6ts  were  different  from  thofe 
of  others,  and  were  ultimately  foimd  to  be 
correft,  the  greater  was  the  ncceffity  for  their 
publication^ 


,  SURGICAL 


.*-'  •:! 


f '. 


"7r 


«    ^  # .  • 


•N- 


SURGieAL  OBSERVAtiONS. 


OM  triE  cxii^rnrnoNAS^'  tii^ioft^i  And  TREATMEinr  of 


.  ..;♦-. 


Alt^  evil  feems  to  me  to  have  arifen  frpm 
the  artificial  divifion  of  th^^he&ling;  art 
into  the  njedical  and  furgical  4cparti?ients. 
This  (l^vifipn  has  caufed  the  attentio^i  of  1j|ie 
pliyfician  ami  the  furgeon  to  be  too  exclu- 
fively  direcle^  to  thofe  difeafcs.  w^ch^cUf-• 
torn  has   afbit^arily   allotted  to  their  care. 
The  efFefts  of  local  diforders  upon  the  con- 
ftitution  have,    in  confequence,-  been  too 
little  attenaed  to;    and  indeed  I  know  of 
no  book,  to  which  I  can  refer  a  furgical 
ftudent  for  a  fatisfaftory  account  of  thofe 
febrile  and  ner\^ous  afFe6tions  which  local 
difeafe  produces,  except  that  of  Mr.  Hunter*. 
The  reciprocal  operation  of  conftitutional 
diforders  upon   local  dii^eafes  has  obtained 

*  Treatife  on  the  BIood>  Inflsmunsition^  &c. 
VOUU  B  ftill 


S  ON   THl    CONBTITUTIOKAL   ORIGIN, 

ftill  leTs  attention.  To  inveftigate  more 
particularly  fome  parts  of  thefe  fubjefts, 
and  to  fubmit  them  to  public  notice,  are 
the  propofed  objects  of  the  prelent  paper. 

No  part  of  the  animal  body  can  in  general 
be  very  confiderably  difordered,  without  occa- 
fioning  a  correfpondent  derangement  in 
other  parts  of  the  fyftem.     Such  diforder 

■  has  been  confidered  by  Mr.  Hunter  as  the 
refult  of  univerfal  fympathy.  This  confent 
of  the  whole  conftitution  with  its  parts 
nianifefts  itfelf,  in  particular  inftances,  by  a 
greater  difturbance  of  the  furi6lions  of  fome 

"  organs  than  of  thofe  of  others ;  and  from 
this  circiiiiidance  difeafes  have  derived  the 
appellations,  by  which  they  are  commonly 
diftinguiftied.  If  the  aftions  pf  the  fangui- 
ferous  fyftem  be  principally  difturbed,  and 
the  temperature  of  the  body  fubjeft  to  un- 
ufual variations,  the  difeafe  is  teimed  fever: 

'  if  the  nei-vous  fyftem  be  chiefly  sfFefted,  a 
ftate  of  vigilance  or  of  delirium  may  be  pro- 
duced :  convulfions  and  tetanus  take  place^ 
when  the  funflions  of  tlie  mufcular  fyftem 
are  more  particularly  deranged.     Though 

the 


AKD   TUSATMfiNT  Of  LOCAL  OI8XA8E8.       5 

Ae  diforder  of  particular  organs  tlftia  give 
a  charadler  and  denomination  to  the  difeaie^ 
it  is  fiifficiently  evident,  in  the  inftantcs 
adduced,  that  the  whole  conftitution  is 
difturbedj  while  certain  parts  are  chiefly 
afiefted,  perhaps  from  unknown  circum- 
ftances  relative  to  the  nervous  fyftem,  or 
from  a  predifpofition  to  diforder  exifting 
in  the  affe6ted  parts.  It  feems  to  be  afcer^- 
tained,  that  perfons  of  particular  conftitu- 
tions  are  predifpofed  to  thofe  febrile  aflipns 
of  the  fanguiferous  fyftem,  which  conftitute 
the  inflammatory  fever ;  that  there  is  a  pro- 
penfity  to  convulfions  in  children ;  and  to 
tetanus  in  the  inhabitants  of  warm  cjiip 
mates. 

Jt  may  be  a  fit  fubjef):  for  enquiry,  whe- 
ther it  be  poflible  for  particular  organs  to 
become  afl%»Eted  ptherwife,  than  through  the 
medium  of  the  nervous  fyilem  in  general* 
Though  ibme  inftances  of  fympathy  are 
ftrange,  and  perhaps  inexplicable,  there  are 
ftrong  reafons  for  believi];]g  that  the  inflam« 
matory  fever,  the  ftate  of  vigilance  and  de^ 
i,  convulfions  and  tetanus^  which  arife 

B  2  in 


4  ON  THE  CONITITUTIOKAL  ORIOIK5 

in  consequence  of  injuries  of  the  limbs^ 
are  product  by  irritation  imparted  to  the 
brain,  which,  by  a  kind  of  reflefted  ope- 
ratioh,  occafipns  a  greater  diforder  of 
fome  of  the  organs  of  the  body  than  of 
others,  and  thus  gives  a  charafter  and  deno- 
mination to  the  difeafe  *. 

*  Mr.  Hunter,  Mjrho,  with  that  patience  and  induftry 
for  which  he  was  fo  remarkable,  colleAed  and  examined 
all  the  fa&s  which  he  had  obferved  relative  to  the  fub* 
je£);  of  fympathy;  has  divided  it  into  continuous,  contigu-  < 
ous  ziid  remote.  It  is  the  remote  fympathies,  according 
to  his  diviiion,  of  which  I  am  now  fpeaking. 

The  obfervations  of  Dr.  Darwin  on  ocular  fpe£tra,  and 
indeed  the  confideradon  of  the  nervous  fun£^ions  in  ge- 
neral render  it  highly  probable  that  fenfation  is  not  pro^ 
duced  merely  by  impulfes  made  on  the  nerves,  but  by 
means  of  actions  excited  by  fuch  impulfes,  which  anions 
are  continued  to  the  fenforium.  Nervous  a£^ions,  then, 
may  take  place  without  the  ufually  exciting  caufes  ;  fuch 
a£bion8  may  be  continued  through  die  medium  of  the 
leticular  communicanons  of  nerves,  and  thus  phyfio* 
logically  we  may  explain  the  continuous  and  contiguous 
fympathies.  A£lions  alfo  produ£iivc  of  fympathetic  fen- 
fations  may  be  fuppofed  to  take  place  through  the  media 
0f  ganglia  or  plexufes.  In  remote  fympathies,  howeveff 
we  mud  fuppofe  the  a£lions  which  originate  in  an  injured 
or  difeafed  part  of  the  body  to  be  continued  to  the 
fenforium,  and  thcrt  to  excite  the  a£Uons  of  other 
nerveS)  &ۥ 

That 


AND   TREATMENt   OF   LOCAL   DISEASfiS.        5 

That  the  ftomach  and  bowels  are  difor- 
dercd  by  injuries  and  difeafes  of  parts  of  the 
body,  has  been  remarked   by  various  per- 
fons  y  but  the  fubjeft  has  never  been  exten- 
fively  furveyed,    nor   viewed  with  that  ac- 
curacy of  obfervation,  which  its  high  im- 
portance merits.     It  has  been  obferved  that 
fprains  of  tendinous  or  ligamentous  parts 
produce  fudden   ficknefs  -,  and  Mr.  Hunter 
has  attributed  that  fliivering  which  is  con- 
fequent  to  accidents,  and  attendant  on  fome 
difeafes,  to  the  ftate  of  the  ftomach.    It  is 
known  that,  in    fome    local  injuries   from 
accident  or  operations,  the  ftomach  has  ap- 
peared to  be  the   part  principally  afFefted. 
But  remarks  on  the  afFeftions  thus  induced 
in  the  digeftive  organs  have  been  made  only 
in  a  curfoiy  manner^  and  it  is  my  intention 
to  examine  the  fubjeft  more  particularly.   It 
alfo  appears  to  me  that  the  connexion  of 
local  difeafes  with  the  ftate  of  the  conftitu- 
tion  in  general  is  either  not  fufficiently  un- 
derftood,  or  not  duly  regarded  by  the  gene- 
rality of  pra6litioners ;  and  I  alfo  mean  to 
claim  their  particular  attention  to  this  fub- 
jc6t,    I  fhall  in  the  firft  place  feleft  a  cafe 

»  3  to 


^  ON  THl   PONSTITUTIONAI^  ORIOIK^ 

to  fticw  bow  the  ftomach  and  bowels,  or, 
to  fpeak  yet  more  extenfively,  the  digeftive 
organs  may  be  afie6led  from  local  diforder. 


Sudden  and  violent  local  Irritation  will  fometimes  pro^ 
duce  an  equally  fudden  and  vehement  Diforder  ef 
the  digeftive  Organs  • 

CASE  I. 

^  A  HEALTHY  gentleman,  about  twenty- 
five  years  of  age,  was  induced  to  fubmit 
to  an  operation  fqr  the  return  of  an  adhe- 
rent omental  hernia,  rather  in  order  to 
remove  the  inconvenience  and  apprehenfion 
which  the  diforder  occafioned,  than  from 
any  urgent  neceflity ;  for  any  increafed  ex- 
ertion in  walking  or  riding  produced  the 
defcent  of  a  portion  of  inteftine  behind 
the  thickened  omentum,  and  obliged  hin> 
to  flop,  and  replace  it:  and  he  frequently 
could  not  accompUfh  the  reduftion  without 
confiderable  difficulty.  The  application  of 
trufles  had  been  quit^  inefB^fiual  in  obviat-^ 
ing  theie  alarming  inconveniencies. 

The 


AND   Ti^BATMEKT.  OP  JLOCAL   DI8BABS8.       J 

The  patient's  diet  on  the  day  preqedjing 
^e  operatiou  was  icanty,  and  confifted  of 
fluid  fubftances^  He  took  on  the  morning 
of  the  op<:ration  fome  Epfom  falts  an4 
manna,  which  pwged  him  twice  and  feemed 
to  have  emptied  his  bx)wels.  A  portion  of 
the  omentum  was  cut  o£f,  and  the  remainder 
was  returned,  after  two  veffels  had  been 
tied.  The  operation  was  followed  by  gene- 
ral diforder  of  the  conftitution,  manifefted 

* 

by  a  full  and  flrong  pulfe,  furred  tongue, 
great  anxiety,  reftleflhefs,  and  total  want, 
of  fleep.  The  flomach  was  particularly 
affe£ted,  being  diflended,  uneasy  on  com- 
preffion,  and  rejecting  every  thing  tha): 
was  fwallowedti  He  was  bljed  largely  in 
the  (pvening,  and  took  faline  medicines^ 
but,  could  not  be  prevjdled  on  to  fwallow 
any  thing  elfe,  except  ibm?  toaft  and 
water.  The  iicknefs  had  in  fome  degree 
abated  on  the  next  day.  A  folutio^  pf  mag- 
^efia  vitriolata  in  mint  water  wa$  prefcribed 
in  finall  occafional  dofes,  in  order  to  re^ 
Jieve  the  diforder  a|id  d|ftenlipp  of  th?  fto- 
pjaph,  by  procuring  foine  difoharge  frouj 

»  4  the 


\ 


I  OK  THB   CONSTITUTIONAL   ORIOIN, 

thi  bowels*.  In  the  courfe  of  the  day 
he  took  an  ounce  of  the  falts,  which  was 
BOt  rejefted  by  the  ftomach,  yet  he  c6uld 
icarcely  be  prevailed  upon  to  take  any 
thing  elfe.  The  tongue  was  ftill  covered 
by  ■  a  thick  yellow  fur ;  the  fkin  was  hot 
and  dry,  and  the  pulfe  frequent.  As 
there  was  no  particular  tendernefs  about 
the  hypogaftric  region,  he  was  not  again 
bled.  The  fecond  night  pafTed  without 
any    fleep.      As    the    falts    had    produced 

^  It  is  moft  probably  the  diforder  of  the  brain  which 
affe£l$  the  ftomach ;  but  the  re-a£bion  of  the  latter  afr 
feEtion  is  liable  to  increafe  and  maintain  the  former,  by 
which  it  had  itfelf  been  produced.  The  effefts  that  refult 
Jrom  the  fympathy.of  the  whole  conftitution  with  local 
diforder  vary  greatly  both  in  nature  and  degree.  Some- 
times the  brain  is  the  part  chiefly  afFe&ed  ;  on  thefe  oc- 
cafions  thp  nervous  energy  appears  to  be  much  im- 
jpured ;  and  in  fome  inftances  of  this  dcfcription,  the 
patient  gradually  (inks,  little  fever  or  rea(ftion  of  the  con- 
ftitution being  obferved ;  in  other  inftances,  however, 
there  is  a  low  delirium,  with  a  flight  degree  of  febrile 
a^lion  ;  and  in  others  again,  the  delirium  is  more  violent, 
and  is  accompanied  with  a  proportional  increafe  of  fever, 
fubfultus  of  the  mufcles,  and  convuliions.  Sometimes 
other  parts  of  the  body  or  particular  organs  feem  to  be 
principally  affefted ;  indeed  the  variety  of  efi^efts  pn^ 
placed  under  the  circumftances  alluded  to  is  fuch  as  to 
ba£9e  defcription. 

no 


AND  TUBATMBMT  OP  LOCAL  BISBASSS.        9 

no  effeft,  the  fame  medicine  was  ordered  in 
5U1  infiifion  of  fenna,  with  the  addition  of 
ibme  of  the  tinfture,  which,  by  being  given 
in  very  fmall  dgfes,  was  retained.     When, 
however,   it  feemed    likely    that  no  effeft 
would  refult  from   this  medicine,  a  grain 
of  calomel  was  given  at  night,  and  repeated 
on  the  following  morning.     Still  the  loath* 
ing   of  food  continued.     The  third  night 
paffed,  like  the  former  ones,  without  fleep, 
and  in  great  anxiety.     On  the  next  morn- 
ing,   two  pills,    containing    five  gi'ains  of 
the  pil.  colocynth,  and  .the  fame  quantity  of 
the  pil.    aloet.    cum    myrrha,    were  given 
every  fourth  hour,    Thefe  procured  no  ftool, 
nor  produced  any  fenfation  which  inclined 
the  patient  to  believe  that  they  would  ope- 
rate.    Again  he    paffed   a    fleeplefs  night; 
but,  towards  the  morning,  he  felt  his  bowels 
apparently  filling,  to  ufe  his  own  exprefllon, 
and  a  profufe  difcharge  enfued.  A  dozen  co- 
pious, fetid,    and    black    evacuations  took 
place  between  five  and  ten  o'clock,  and  he 
had  feveral  others  in  the  courfe  of  the  day ; 
after  which  his  appetite  returned,  his  tongue 
became  clean,  and  a  foimd  and  continued 
fleep  fucceeded. 

That 


1X>       4m   THJl  COKSTITUTIONAL  ORIGIN. 

That  the  chylopoietic  organs  were  the 
parts  chiefly  afiedted  in  this  cafe^  can,  i^aicely 
|pe  queftioned;  The  fickneis^  the  tender- 
nefe  of  the  parts  in  the  epigaftric  region^ 
the  averfioa  to  food,  and  the  ftate  of  the 
tongue^  all  indicate  that  the  ftomach  wa^ 
»uch  difordered*  The  infufceptibility  of 
the  bowels  to  the  aftion  of  medicines, 
which  woxild  ordinarily  have  produced  dif- 
charges  from  them,  and  the  proftife  eva^ 
cuations  which  fubfequently  relieved  the 
patient,  prove  that  thefe  vifcera  participated 
in  the  affedtion.  The  black  colour  of  the 
difcharges  fliews,  I  think,  that  the  fecre- 
tion  of  the  bile  was  not  healthy,  and  that 
the  liver  was  affefted  with  the  other  chylopo- 
ietic vifcera* 

It  may  be  fuppofed,  that  the  injury  done 
to  the  omentum  might  contribute  to  pro- 
duce the  diforder  of  thefe  organs,  rather 
than  of  others.  We  do  pot,  however,  find 
that  fuch  efFefts  commonly  fucceed  to  fimilar 
operations.  The  confequenccs  in  the  pre- 
ibnt  cafe  were  more  fevere  than  might  have 
beei>  expe6t?d,  }£-  it  were  npt  known,  that  an 
operation  performed  on  a  heajithy  patient  is 


AV^  TR£ATMSNT   07  LdCAt   DlftEAS^S.      II 

more  apt  to  produce  confiderable  dxfbrder, 
than  when  performed  on  c^ie  whofe  coa^ 
ftitution  has  previoufly  fuftained  the  irrita^ 
tion  of  a  diieafe,  for  which  the  operation 
becomes  neceffary. 

It  is  probable   alfo  that  the  reftlef&ef? 

and  anxiety  of  the  patient  were  aggravated, 

if  not  principally  caufcd,   by  the  ftat^  of 

the  cbylopoietic  vifcera ;  fmce  the  relief  which 

took  place  in  thofe  parts  on  the  renewal  of 

fecretions  into  them,  certainly  removed  the 

nervous  and  febrile  fymptoms.  That  the  c^ 

charges  were  the  efFeft  of  fecretion  is  prov^ 

by  the  abfence  of  alimentary  matter  in  the 

bowels,    in  confequence  of  the    afUoQ  of 

the  purgative  adminiftered  on  the  morning 

of  the  operation,  and  the  abflinence   both 

before  and  after  that  period*. 

I  could 

•  Two  Inftances  are  recorded  in  Mr,  Pottos  Wprks,  of 
the  operation  for  the  redu£lion  ef  an  hernia  being 
performed  where  no  ftrangulation  exilled.  See  Fptlft 
Works,  Vol,  ni.  pp.  295,  299,  edition  of  1783. 

The  operation  in  the  cafe  juft  related  was  undertaken 
upon  the  authority  of  thefe  cafes>  which  were  beth  iuic- 
cefsful.  I  performed  a  fimilar  operation  on  a  patiou^ 
whofe  life  had  been  twice  in  imminent  hazard  from  (Iran- 

gelation 


11        ON  THI  eONSTITTTTIONAL  ORIGIN, 

I  could  relate  numerous  cafes  in  fupport 
of  the  inferences,  which  I  have  drawn  from 
the  preceding  hiftory ;  that  local  irritation 
zQmg  on  the  nervous  fyftem  may  afFe6l 
the  digeftivc  organs  in  a  very  ferious  man- 
ner, .and  thereby  create  great  general  dis- 
order of  the  fyftem,  which  is  afterwards 
alleviated  in  proportion  to  the  amendment 
that  enfues  in  the  ftate  of  thofe  vifcera. 
Such  confequences  of  great  local  irritation 
muft  frequently  occur  to  every  one ;  it  is 
therefore  unneceflary  to  adduce  more  in* 
ftances  to  fupport  the  opinions  here  de- 
livered. 

With  refpeft  to  the  treatment  of  cafes  of 
this  defcription  it  may  be  right  to  add,  that 
the  primary  objeft  fhould  be  to  produce  fe- 
cretion  from  the  irritable  organs.  In  the  cafe 

gulation  in  a  cafe  of  adherent  epiplocele,  in  which  a  trufs 
did  not  keep  up  the  hernia,  and  the  operation  was  followed 
by  laolent  peritonitis^  which  could  only  be  fubdued  by 
fuch  copious  and  repeated  venxfe£lion,  as  endangered 
the  patient's  life.  Thefe  two  cafes  have  made  fuch  an 
impreffion  on  my  mind,  that  I  fliould  be  yery  averfe  in 
future  to  undertake  fimilar  experiments, 

c  which 


AND  TRBATMKKT  09  LOCAL  BISEAUS.     I^ 

which  has  been  related,  and  in  many  others 
recorded  in  this  volume,  the  efFeft  of  fecre- 
tions  occurring  from  the  diibrdered  organs 
in  relieving  their  irritable  ftate  is  very  mani- 
feft.  In  many  inftances  opium  will  not  pre- 
vent continual  efforts  to  vomit,  yet  when  by 
magnef.  vitriolat.  or  purgatives  admini- 
ftered  in  the  form  of  pills,  and  clyfters, 
flools  are  procured,  the  vomiting  ceafes,  the 
ftomach  retains  both  food  and  medicine, 
and  general  tranquillity  of  conititution  is  as 
ibddenly  reftored. 


^  Jl'^Z^t^T  Degree  of  continued  local  Irritation  will 
produce  a  lefs  violent  Diforder  of  the  digeJHn^i 
Organs* 

IF  then  vehement  local  irritation  can 
produce  a  violent  difturbance  of  the  chylor 
poietic  organs,  it  may  be  expefted  that  a  lefs 
degree  of  a  fimilar  caufe  will  produce  (lighter 
cffe£ts  of  the  fame  nature.  Indeed,  the  fore- 
going cafe  was  related  not  merely  becaufe  it 
feemed  worthy  of  record  by  itfelf,  but 
chiefly  to  prepare  the  reader  for   the  olv 

iervations  which  are  to  follow. 

rThis 


This  flighter  degree  of  derangemwit  occurs 
in  the  advanced  ftages  of  lumbar  abiceis, 
difeafed  joints,  comjwund  frafturcs,  and  all 
kinds  of  local  difeafe,  which  impart  confider- 
able  and  continued  irritation  to  the  whole 
conftitution.     We  alfo  find  a  lefs  important 
<lifeafe,  as  for  inftance,  a  fretful  ulcer,  keep 
up  a  diforder  of  the  fyftem  in  general,  and  of 
the    digeftive  organs   in  particular,   which 
fubfides  as  the  irritable  ftate  of  the  ulcer  di- 
miniflies.     But  as   practitioners  in  general 
may  not  perhaps  have  fo  attentively  remarked 
thefe  circumftances   as  to  be  familiarly  ac- 
quainted with  them,   it  may  be  ufeful  to 
mention  a  very  common  occurrence,  which 
cannot  have  efcaped  obfervation.     I  alliide 
to  the  effedls  of  the  irritation    of  teething 
upon  the  health  of  children.     Th^  Brain  is 
fbmetimes  fo  affeCled  as  to  caufe  convid- 
fions ;  the  digeftive  organs  are  almoft  con- 
ftantly  difordered.     The  appetite  fails  -,  the 
tongue  is  furred ;  the  fecretions  of  the  liver 
are  either  fufpended,  diminished,  or  vitiated. 
The  bowels  are  either  purged  or  coftivc, 
and  the  faeces  fetid.     The  fsecal  matter  is 
often  mixed  with  mucous  and  other  iecre- 

tions 


AKD  TRSATMl^N^'O^  LOCAL   DlftEAl^S.      15 

tions.  There  is  alfo  frcqtiently  a  very 
troublefome  cough.  Such  fymptoms  gene- 
rally  fubfide  when  the  local  irritation  ceafes, 
but  fometimes  the  diforder  of  the  digeftive 
organs,  thus  excited,  continues  and  dis- 
turbs the  general  health  of  the  patient. 

If  local  irritation  be  capable  of  diforder- 
ing  the  bowels;  it  feems  natural  to  conclude 
that  it  a£);s  upon  them  through  the  medium 
of  the  brain.  If  alfo  the  brain  and  nervous 
iyftem  fhould  be  difordered,  without  any 
apparent  local  difeafe,  fimilar  derangements 
may  be  expefted  to  take  place  in  the  func- 
tions pf  the  digeftive  organs.  In  cafes, 
where  fome  morbific  poifon  has  been  ab- 
ibrbed,  producing  efFefts  fimilar  to  thofe  of 
fyphilis,  we  ulually  find  the  irritation  of  the 
conftitution  which  enfues  to  be  accompa- 
nied with  this  (lighter  diforder  of  the 
chylopoietic  organs. 

Whenever,  alfo,  the  nervous  energy  and 
general  powers  of  the  conftitution  have  beeiti 
weakened  and  difordered  by  any  violent 
di2fea&/as  fevcr^  (mail  pox,  meafles,  hooping 

cough. 


iff       ON  TBB  CONSTlTDtlONAL  ORIOtK^ 

cough,  &c.    the   digeftive  organs    are  fre- 
quently affefted  in  confequence,  and   fuch 
afFe£lion  becomes,  as  will  afterwards  be  ex 
plained,  the  caufe  of  many  fecondary  dif- 
eafes. 

In  perfons,  likewife,  who  have  natural- 
ly a  weak  or  irritable  ftate  ^^^the  nervous 
fyftem,  we  find  the  digeftiye  organs  dif- 
ordered  in  a  fimilar  manner.  Improprieties 
in  diet  will  alfo  produce  a  fimilar  ftqte  of 
irritation,  weaknefs,  and  diforder  of  the  func- 
tions of  the  digeftive  organs. 

This  (lighter  diforder  of  the  chylopoi- 
ctic  organs  is,  in  general,  manifefted  by  a 
diminution  of  the  appetite  and  digeftion, 
flatulence,  and  unnatural  colour  and  fcctor 
of  the  excretions,  which  are  generally  de- 
ficient in  quantity.  The  tongue  is  dry, 
whitifh,  or  furred,  particularly  at  the  back 
part;  this  fymptom  is  moft  apparent  in  the 
morning.  The  fiir  is  greateft  at  the  back  part, 
and  extends  along  the  middle  of  the  tongue 
to  the  tip,  the  edges  remaining  clean.  As 
the  difeafe  advances,  a  tendemefs   is   felt 

when 


AND   TREATMENT   OF   LOCAL  OI8BA8B8#     IJ 

when  the  epigaftric  region  is  comprefled,  and 
the  patient  breathes  more  by  the  ribs,  and 
lefs  by  the  diaphragm  than  in  the  healthy 
flate.     The  urine  is  frequently  turbid^ 

In  this  general  enumeration  of  the  fymp- 
toms,  feveraL  circumftances  are  omitted 
which  occur  occafionally,  and  which  may, 
when  the  fubjeft  fhall  be  better  under- 
ftood,  denote  peculiarities  in  the  difeafe,  and 
require  correfponding  peculiarities  in  the 
medical  treatment.  I  fhall  here  notice  a 
few  of  them.  The  appetite  is  fbmetimes 
moderately  good,  when  the  digeflion  is  im- 
perfeft ;  and  the  latter  may  not  be  defedliye, 
although  the  difeafe  flill  exifls.  In  fame 
inflances,  indeed,  the  appetite  is  inordinate. 
Tcndcrnefs  of  the  epigaftric  region  on  pref- 
fure,  is  not  always  >  an  attendant,  even  on 
advanced  flages  of  the  difeafe.  The  boweb 
are  alternately  coftive,  and  lax  even  to  purg*- 
ing*.     The  urine   is    fometimes  pale-cc^ 

*  I  hare  known  perfons  whofe  bowels  were  ordinarily 
coftire,  and  whoie  general  health  was  much  deranged  by 
diforder  of  the  digeftive  organs,  though  they  were  un^ 
confcious  of  its  exiftence,  feel  pleafed  that  their  bowels 
%eie  in  a  comfortably  lax  ftate ;  yet  on  oblerving  the 

f9fit.  u  ^  loured 


it        OK  TITE   CONSTlTUrrONAL   ORIOIIT, 

loured  and  copious  like  that   of  hyftcrical 
patients'. 

Patients  afFe£l:ed  in  the  manner  abdve  de- 
(bribed  commonly  declare  they  are  in  good 
health,  except  that  they  feel  difturbed  by 
their  local  complaints  -,  yet  they  are  found, 
on  enquiry,  to  have  all  the  fymptoms*, 
which  charafterize  a  difordered  ftate  of  the 
digeftive  organs.  The  mind  is  alfo  fre- 
quently irritable  and  defpondent;  anxiety 
and  langour  are  exprdled  in  the  countenance. 
The  pulfe  is  frequent  or  feeble  j  and  flight 
cxercrfe  produces  confiderable  perfpiration 
and  fatigue.  The  patients  are  fometimes 
reftlefs  at  night,  but  when  they  fleep  ibundly 
they  awaken  unrefrefhed,  with  laflitude,  and 
fixnetimes  a  fenfation,  as  if  they  were  inca- 
pable of  moving.  Slight  noifes  generally 
caufc  them  to  ftart,  and  they  are,  to  ule 
their  own  expreffion,  very  nervous.  Thefe 
circumftances  feem  to  me  to  indicate  ^eal^• 
nefs  and  irritability  of  the  nervous  and 
mufcular  fyftems ;  which,  in  addition  to  the 
difbrder  of  the  digeftive  organs,  that  has 
been  defcribed,  are  the  dhief  circumftances 
obfervable  relative  to  the,  genenl  health  cf 

n  •    -  -  Aofe 


'  *• « * 


AND    TREATMENT   OF   LOCAL    DISEASES*     I9 

thofc  patients,  whofe  cafes  are  related  in  the 
following  part  of  this  paper.  By  correft- 
ing  the  obvious  errors  in  the  ftate  of  the 
digeftive  organs,  the  local  difeafe,  which  had 
baffled  all  attempts  at  cure  by  local  means, 
has  fpeedily  been  removed,  and  the  patient 
has  acknowledged  that  fuch  an  alteration  has 
taken  place  in  his'  general  health,  as  ex- 
cited his  furprize. 


A  Review  of  tbe  natural  Fu7iSlions  of  the  digejiive      \ 
Organs^   and  an  Enquiry  into  the  Signs  which 
denote  them  to  he  in  a  healthy  or  dif ordered  State. 

BEFORE  I  proceed,  I  may  be  allowed  to 
enter  more  fiiUy  into  a  confideration  of  the 
fyraptoms  which  denote  difbrder  of  the  di- 
geftive organs ;  in  order  to  induce  furgeons 
to  pay  that  ftrift  attention  to  them,  which 
ths  importance  of  the  fubjeft  fo  well  de- 
ferves.  It  would  indeed  be  impoffible  for 
the  reader  to  underftand,  without  fuch  pre- 
fatory obfervations,  my  objeft  in  the  treat- 
ment of  the  cafes  which  will  prefently  be 
related,  or  the  opinions  which  I  have 
formed,  relative  to  their  mode  of  cure. 

C2  The 


to        ON   Tnn   CONSTITUTIONAL   ORIGIKV 

The  changes  which  the  food  undergoes 
in  the  digeftive  organs  of  the  more  com* 
plicated  animals  are  threefold ;  and  diftinft 
organs  are  allotted  to  each  of  the  three 
proceffes.  Digeftion  takes  place  in  the 
ftomach;  chylification  in  the  fmall  intet^ 
tines ;  and  a  third  procefs,  hitherto  undeno- 
minated,  is  performed  in  the  large  in- 
teftines.  It  is  probable  that  in  fome  cafes, 
one  fet  of  organs  may  be  more  difordered 
than  the  otheis,  and  of  courfe  one  of  thcfe 
procefles  may  fail  more  than  the  reft.  For 
mftance^  the  ftomach  may  digeft  the  foc^  in 
a  healthy  maimer,  although  the  inteftines 
do  not  perform  their  ftiare  of  the  changes, 
which  they  ought  to  efFeft, 

The  food  is  ccmverted  in  the  ftomach  inter 
a  vifcid  femitranfparent  Xubftance  called 
chyme ;  and  that  this  change  is  efie£led-  by 
the  agency  of  the  fuccus  gaftricus,  is  a  point 
as  well  aicertained  as  any  in  phyfiology.  la^ 
a  ftate  of  health  this  converiion  takes  place' 
witliout  any  appearance  of  that  natural  de-^ 
compofition  which  animal  and  vegetable 
matter  would  ordinarily  undergo  in  a  wanxt 

I  .  and 


AKI>  TRBATMEMT   OF  LOCAL   I»I3SAS£$.     21 

and  moift  place.  When,  however,  digeftion 
is  imperfect,  gafeous  fluids  are  extricated 
from  the  alimentary  matter.  Vegetable 
fpod  becomes  acid,  and  oils  become  ran- 
cid. Uneafy  fenfations  are  alfo  felt,  and 
undigefted  aUment  may  be  obferved  in  the 
ffl^es. 

Diibrder  of  the  ftomach  is  however  more 
readily  perceived  by  adverting  to  the  data 
of  the  tongue,  which  often  indicates  an  ir- 
ritable and  unhealthy  condition  of  the  fto- 
mach, when  no  manifeft  fymptoms  of  indi- 
geftion  occur.  If  there  be  no  feVer  to  dif- 
tprb  the  fecretious  in  general,  the  change 
which  is  vifible  in  the  tongue  can  be  im- 
puted to  no  other  caufe  than  local  difeafe,  or 
a  participation  in  a  diforder  of  the  ftomach 
or  lungs.  I/Ocal  irritation  or  piei>^l  anxiety 
will  caufe  a  white  and  dry  tongue  ^  but  does 
not  this  efFe6t  arife  through  the  medium  pf 
an  affedtion  of  the  ftomach  ?  For  although 
the  fccretions  of  the  tongue  muft  partake 
of  the  general  difturbance  which  prevail; 
in  fever,  their  efpeciaj  diforder  may  be,  in 
that  cafe,  alfo,  not  improperly  attributeci 
to  the  ftate  of  the  ftomach. 

c  3  The 


12         ON    THE    CONSTITUTIOKAL   ORIGIK^ 

The  ftate  of  the  tongue  is,  in  general, 
an  infallible  criterion  of  a  difordered  con- 
dition of  the  ftomach ;  but  it  does  not  point 
out  the  kind  and  degree  of  that  diforder. 
Jn  recent  and  confiderable  afFe6tions,  where 
the  appetite  is  loft,  and  the  digeftive  powers 
are  greatly  impaired,  the  appearances  of  the 
tongue  are  by  no  means  fo  ftrikingly  un- 
healthy as  in  more  confirmed  cafes,  where 
heither  the  appetite  nor  digeftion  appear 
materially  deficient.  It  is  probable  that  a 
continuance  of  irritation  in  the  ftomach 
may  fo  afFeft  the  tongue,  as  to  render  un- 
natural fecrctions  habitual  to  the  part,  and 
that  ihefe  exift  independently  of  the  original 
caufe,  or  may  be  reproduced  by  tiivial  de- 
grees of  diforder.  Nay,  fometimes  the  cu-. 
tide  of  the  tongue  feems  to  have  loft  its 
tranfparency,  and  to  become  permanently, 
white,  in  confequence  of  continued  irri- 
tation. 

After  making  the  allowances,  which  fuch 
circumftances  require,  we  may  in  general 
be  enabled  to  dete6t  a  difordered  ftate  of 
the  ftomach  by;  obfervation  made  on  the 
tongue:    and,  as  it    is  of  confequence  to 

afcer- 


AND    TREATMENT   OT  LOCAL   OISEAS£5.     2^ . 

afcert^n  fuch  diforder  at  an  early  pmod, 
when  the  fymptoms  are  probably  flight, 
this  :organ  flioiild  be  obferved  in  the  morn- 
ing, when  it  will  be  found  much  furred, 
particularly  at  the  part  next  the  throat. 
Its  appearance  may  vary  in  different  parts 
of  the  day  from  varieties  in  the  ftate  of  the 
ftomach,  depending  on  the  ex<:itement  which 
is  derived  from  food,  or  a  ftate  of  irritation 
arifmg  from  too  long  fafting.  The  tongues 
of  many  pedbns  with  diforder  of  the  fto- 
mach look  moderately  healthy  during  the 
4ay,  though  they  have  been  fo  much  furred 
in  the  morning,  that  it  has  been  deemed 
jieceffary  to  fcrape  them. 

A  difordered  ftate  of  fecretion,  either  as 
to  quantity  or  quality,  will  be  the  natural 
efFe£l  of  irritation  of  a  fccreting  organ.  This 
is  evidently  the  cafe  with  the  tongue ;  and 
we  may,  with  great  probability,  conjefture 
that  the  fame  confequence  alfo  takes  place  in 
the  ftomach.  Since  the  juices  of  the  fto- 
mach are  the  immediate  agents  in  digef- 
tion,  that  procefs  muft  be  difturbed  in  pro- 
portion as  its  fecretion s  are  deficient  or 
vitiated. 

c  4  If 


M         OH  THE  CONSTZTtJTIONAL   QKlOlUfr 

If  undigefted  matter  pafs  from  the  fto- 
mach  into  the  jnteftines,  it  can  fcarcely  be 
fuppofed  that  their  powers,  are  capable  of 
converting  it  into  chyle;  and  it  may  be- 
come irritating  to  thofe  organs  in  con-, 
iequence  pf  the  chemical  changes,  which  it 
jnay  then  undergo,  When  digeftion  is  im- 
pcrfefl,  animal  and  vegetable  fubftances 
experience  confiderable  chemical  changes 
before  they  leave  the  ftomachj  and  fimilar 
changes  may  continue  to  take  place  during 
the  time  they  are  detained  in  the  bowels,  un- 
lefs  counterafted  by  the  powers  of  the  digeftive 
organs ;  powers  which  feem  f  h'c.^y  to  belong 
to  the  fluids  which  are  fecreted  into  them. 

The  extent  of  the  power  which  the  in- 
teflines  poflefs  of  converting  what  they 
receive  from  the  ftomach  into  chyle,  or  of  pre- 
venting chemical  changes,  is  unknown.  It  is 
probable  that  much  undigefted  matter  is  ab- 
forbed  by  the  lafteals,  when  the  digeftive 
powers  fail  in  their  fundlions.  This  is 
apparently  the  cafe  in  diabetes,  where  the 
vegetable  matter  floats  in  the  ferum  of  the 
blood,  renderingitturbid,  and  afterwards  com- 

bine$ 


AND  TKBATMBKT   OF.IOCAL   DI8SAMS.     Zjf 

bines  fo  as  to  form  fugar  in  its  paflagc 
through  the  kidnies.     The    ftrong  odour^ 
which  various  kinds  of  food  impart  to  the 
urine,  indicates  that  different  fubftances  arc 
abforbed  indifcriminately  from  the  inteftines. 
It  is  probable  that  a  turbid  ftate  of  the  urine, 
and  variations  from   the   natural  odour  of 
healthy    urine,  may    very   frequently  aiife 
from  a  fimilar  caufe ;  viz.  from  the  imperfe<9: 
aftion  of  the  digeftive  organs,  in  confequence 
of  which,  unaflimilated  matter  is  taken  up 
by  the  lafteals,  and  afterwards  feparated  ffom 
the  blood  in  the  kidneys.     It  may  be  rea- 
sonably conje6tured  that  the  fame  powers, 
by  which  the  kidneys  convert  the  old  mate- 
rials of  our  body  into  that  peculiar  modifica- 
tion of  animal  matter,  which  is  diffolved  in 
the  water  of  the  urine,  and  which  has  been 
called  by  the  French  chemifb  uree,    may 
9M0  enable  it,  in  a  healthy  and  vigorous 
ftate,  to  difpofe  of  much  unaffimilated  fub- 
ftance  \i\  the  fame  way.    The  further  con(i« 
deration   of   this  fubje6l   would,    however^ 
lead  to  a  difcuflion  foreign  to  the  purpofe  of 
the  prefent  paper :  it  will  be  fufficieiit  tm 
|;^ark  at  prefent,  that  the  ftate  of  tlii|^  urine 


2^         ON   THZ   COK8TITUTI0KAL   ORIGmi 

may  afford  afliftance  in  afcertaining  the 
cxiftciice  of  diforder  of  the  digeftive  organs, 
and  in  indicating  its  nature^  It  has  been 
already  mentioned,  in  the  brief  account  of 
the  fymptoms,  that  the  urine  is  frequently 
turbid.  It  fhould,  however,  alfo  be  ob- 
ferved,  that  the  quality  of  the  urine  greatly 
depends  on  the  ftate  of  the  nervous  fyftem. 
It  is  ^  fi'equcntly,  in  the  diforders  of  which 
I  am  fpeaking,  pale-coloured  and  copious ; 
which  is  probably  owing  to  a  ftate  of  ner^ 
▼ous  irritation,  fuch  as  exifts  in  hyfteria^ 
It  is  not  improbable  that  diforders  of  the 
digeftive  organs,  by  caufing  the  frequent 
fecretion  of  unnatural  urine,  may  produce 
irritation,  and  fubfequent  difeafe  of  the 
kidneys,  and  other  urinary  organs^ 

Modem  phyfiologifts  feem  to  ^gree  in 
the  opinion  that  the  fuccus  gaftricus  is  the 
agent,  by  which  digeftion  is  eftedled ;  but 
they  are  not  fo  unaniipous  as  to  the  imme- 
diate caufe  of  chylification.  It  is  not  im- 
:{>robable  that  the  fuccus  inteftinalis  is  a 
fft-iftcspal  agent,  although  its  qualities  have 
not  yet  been  enquued  into  j  for,  indeed,  th? 

invefti- 


AND   TREATMEITT   GF   LOCAL   DISEASES,     aj 

Lnveftigation  would  be  attended  with  dif- 
ficulties almpft  infuperable. 

Since  the  bile  and  pancreatic  liquor  are 
poured  into-  the  inteftines  at  a  fmall  dif- 
ance  from  the  ftomach,  it  is  natural  to  con- 
fider  thefe  fluids  as  ufeful  in  efFefting 
the  change,  which  the  alimentary  matter 
undergoes  in  the  finall  inteftines,  namely, 
its  converfion  into  chyle.  The  chyme,  or 
aliment  digefted  by  the  ftomach,  being  vifcid, 
the  pancreatic  juice  has  been  confidered  as  an 
ufeful  and  ncceffary  diluent,  and  perhaps 
this  fluid  may  have  other  properties  with 
which  we  are  unacquainted. 

The  ufes  of  the  bile  have  of  late  much 
engaged  the  attention  of  phyfiologifts.  Mr 
Hunter  obfer\'ed  tliat  it  did  not  feem  to  in- 
corporate with  the  chyle;  and  it  certainly 
cannqt  do  fo  and  retain  its  own  nature, 
fincc  its  colour  and  tafte  are  fo  intenfc, 
that  it  would  impart  thefe  properties  to 
the  chvle,  if  mixed  with  it  in  the  Imalleft 
quantity.  The  difficulty  of  conceiving  that 
the  two  fluids  can  te  agitated  together  by 

the 


aS  OW-  THE    CONSTITUTIONAL   ORIGIN, 

the  periftaltic  motion  of  the  inteftines, 
without  becoming  incorporated,  has  led  to 
an  opinion  that  the  bile  may  combine  with 
the  alimentary  matter,  and  lofe  iu  ori- 
ginal properties  s  but  nothing  of  this  kind 
is  afcertained.  Fourcroy  thinks  that  the 
alkali  and  faline  ingredients  of  the  bile 
may  combine  with  the  chyle,  and  render  it 
iiiore  fluid,  while  the  albumen  and  refin 
may  combine  with  the  excrementitious 
matter.  It  is,  indeed,  evident  that  the  bile 
combines  either  totally  or  partially  with 
fomething  feparated  from  the  chyle,  and 
cxifts  formally  in  it,  and  in  a  Ilate  of 
health  uniformly  dyes  it  of  its  peculiar 
colour;  and  therefore  t  has  of  late  been 
fuppofed,  that  the  bile  may  ferve  to  purify 
the  chyle,  by  precipitating  and  combining 
with  its  feculent  parts  ^. 

It  has  been  faid  in  the  brief  and  general 
recital  that   has   been  •  given  of  the  fymp- 

*  In  the  enquiry  into  the  probable  ufes  of  the  bile,  it; 
ought  to  be  obferved,  that  in  many  perfons,  in  whom 
that  fecretion  is  either  for  a  confiderable  time  wholly  fup<« 
prefled,  very  deficient,  or  much  depraved,  it  does  not  ap- 
pear that  die  nutrition  of  the  body  is  defective. 

toms 


AKD   TREATMENT    OF  XOCAL   DISEASES.     29 

toms,  which  charaflerize  diforder    in    the 
chylopoietic  organs,  that  the  ftools  are  of 
an  unnatural   colour   and  odour.   Medical 
men   entertain  vaiious   opinions  refpefting 
the  colour  of  the  faeces :  to  me  this  property 
feems  generally  to  depend  on  the  kind  ancj 
quantity   of  the  bile.     All  the  fecretions, 
which  are  poured  into  the  alimentary  canal, 
except  the  bile,  are  colourlefs  or  white ;  if, 
therefore,  this  fluid  were  wanting,  the  re- 
fiduc  of  the  aliment  would  be  of  the  co-^ 
lour,   which  might  be   expefted   to    refult 
from  fbmc    of   its    undigefted   parts  com- 
bined together.      When,  for  inftance,    the 
fecrction  of  bile  is  flopped  by  the  irritation 
of  teething  in  children^  whofe  diet  is  chiefly 
bread  and  milk,  the  faeces  are  white  j  when 
this  fecretion  is    obftru6led  in  adults,  the 
Aools  are  pale  like  whitilh-brown  paper. 

In  cafes  of  difeafe,  however,  coloured  ex- 
cretions may  take  place  from  the  bowels. 
There  is  great  reafon  for  afcribing  the 
difcharges  in  the  difeafe  called  melaena  to  a 
vitiated  fecretion  from  the  furface  of  the 
alimentary    canaL     I    was   intimately  ac« 

quainted 


5©         ON   THE   CONSTXTUTIONAL   ORIGIN, 

quanted  with  a  patient,  who  fuffered  re- 
peated and  increafing  attacks  of  conftitu.- 
tional  irritation.  When  the  diforder  was 
wrought  up,  as  it  were,  to  a  crifis,  he  was 
forewarned  by  a  fenfation,  as  if  his  ftomach 
was  filling,  of  the  occurrence  that  was  about 
to  take  place.  In  lefs  than  a  quarter  of  an 
hour  he  would  vomit  more  than  two  quarts 
of  a  fluid  refembling  coffee  grounds  in  colour 
and  confiftence.  Shortly  afterwards  very 
copious  difcharges  of  a  fimilar  darker  coloured 
and  ofFenfive  matter,  took  place  from  the 
bowels :  but  a  green  vifcid  bile,  appearing 
diftinft  and  uncombined,  was  intermixed 
with  this.  Thefe  evacuations  ceafed  in  a 
day  or  two,  and  the  conftitutional  irritation 
difappeared  with  them. 

I  examined  the  bodies  of  feveral  perfons, 
who  died  under  attacks  of  this  nature,  and 
ffund  the  villous  coat  of  the  alimentary 
canal  highly  inflamed,  fwoln  and  pulpy. 
Bloody  fpecks  were  obferved  in  various 
parts;  and  fphacelation  had  aftually  taken 
place  in  one  inftance.  The  liver  was  healthy 
in  fome  cafes,  and  difeafed  in  others.  I  con- 
clude 


AKU  tftfeATMENT   01?   LOCAL   mSKASTES.    51 

elude  therefore  that  thefe  difeafes,  which 
were  termed  haematcmefis  and  melaena,  arofc 
from  a  violent  diforder,  and  confequent 
difeafed  fecretion  of  the  internal  coat  of 
the  bowels :  and  that  the  blood,  difcharged 
when  the  affection  was  at  its  height,  did  not 
flow  from  any  fingle  veffel,  but  from  tho 
various  points  of  the  difeafed  furface. 

Indeed  I  think  it  probable,  that  the  pra- 
fufe  difcharges,  which  fometimes  follow 
the  continued  exhibition  of  purgatives,  con- 
lift  of  morbid  fecretions  from  the  bowels 
.  themfelvcs,  and  not  of  the  refidue  of  alimen- 
tary matter  detained  in  thofe  organs.  Such 
evacuations,  either  occurring  lJ)ontaneoufly, 
or  excited  by  medicine,  frequently  relieve  ir- 
ritation of  the  chylopoietic  vifcera. 

It  feems  probable  that  the  ftools  which 
refemble  pitch  are  principally  compofed  of 
difeafed  fecretions  from  the  internal  furface 
of  the  inteftines,  fince  they  do  not  feem 
either  like  the  refidue  of  the  food  or  diC* 
charges  from  the  liver.  Can  we  fuppofe 
that  all  the  black  and  fetid  matter  whiph 

was 


32         ON   THE   COMSTITUTiONAL    CEtdIN, 

was  difcharged  from  the  bowds,  in  die  firft 
cafe,  was  poured  forth  folely  from  the  liver  ? 

The  fubjeft  of  morbid  fecretions  is  how- 
ever particularly  illuftrated  by  that   wdi- 
known  alvine   difcharge,   which   fo   much 
«fembles  yeaft  in  colour  and  confidence  that 
it  cannot  be  confounded  with  faeces,  with 
blood,  or  with  a  vitiated  fecretion  from  the 
liver.     A  medical  man  of  my  acquaintance 
took,  for  fome  diforder  in  his  ftomaeh  and 
bowels,  an  aperient  medicine,  which  appa^ 
jeutly  emptied  thofe  organs.     He  ate  no- 
thing but  little  bread  in  broth  for  his  dinner, 
and  a  fmall  quantity  with  his  tea  in  the 
evening.     He  -experienced  an  uneafmefs  in 
his  bowels,  and  an  inclination  to  evacuate 
them   after  he  had  gone  to  bed  j    but  he 
refifted  this  defire  till   four  o'clock  in  the 
morning,  when  its  urgency  forced  him  to 
riffi".     He  then  difcharged,  what  he  fuppofed 
to  amount  in   quantity  to  a  gallon,  of  a 
matter  exaftly  like  yeaft,  unmixed  with  any 
bile  or  fseces.  When  he  arofe  in  the  morning, 
he  had   a  fimilar  evacuation  of    about  a 
quart  j  and  on  the  fucceeding  day  there  was 

a  folid 


AND   TREATMENT   OF  LOCAL   DISEASES*     33 

a  folid  ftool,  apparently  of  the  fame  fub- 
ftance,  coloured  of  a  light  green  from  an  ad* 
mixture  of  bile.  He  had  a  natural  ftool 
the  next  day:  his  appetite  returned,  and 
the  uneafy  fenfations  fubfided. 

An  unhealthy  colour  of  the  faeces  may 
further    be    attributed    to     fome    degene- 
racy   in    the    quality   of    the    alimentary 
matter;  fuch  as  may  be  fuppofed  to  take 
place  when  the  digeftive  organs  fail  in  the 
performance  of  their  offices,  and  different 
alimentary  fubftances    are    in    confequencc 
detained  in  the  bowels,  where  they  may  pafs 
through  chemical  decompofitions,   and  re- 
combinations.    But,  though  I  am  inclined 
to  allow  the  full  operation  of  thefe  caufes, 
the  following  reafons    lead  me  to  believe 
that  the  colour  of  the  faeces  generally  de- 
pends on  the  kind  and  quantity  of  the  bile* 
In  the  natural  ftate    of  the  d%eftive  or- 
gans, when  there  is  no  peculiarity  of  diet, 
and  no  medicine  is  taken,  the  bile  alone 
colours  the  refidue  of  the  food.     The  fasces 
voided  during  a  ftate  of  diforder  of  the*  di- 
geftive organs  arc  fometimes  partially  co- 
voL.  I.  D  loured ; 


34  ON   THE   COKSTITUTIOHAL  dX-IOIK^^ 

loured  5  which  circumftance  cannot  be  welt 
accounted  for  uppn  any  other  fuppofitioa 
than  that  of  an  irregular  fecretion  of  the  bile* 
Fluids  fecreted  from  the  intcftines  do  not 
ufually  enter  into  combination  with  the 
fecal  matter,  but  appear  diftin6lly  when 
excreted.  Thus  we  find  mucus  and  jelly 
,  difcharged  from  the  bowels,  unmixed  with 
the  feces.  Medicines'  which  affedt  the  liver 
produce  a  very  fudden  change  in  the  co- 
lour of  the  feces.  Small  dofes  of  mercury^ 
without  any  alteration  of  diet,  fometimes 
change  the  ftools  immediately  from  a  black- 
ifh  to  a  light  yellow  colour,  which  indicates 
a  healthy  but  deficient  fecretion  of  bile. 

Healthy  bile  in  the  human  fubjeft  is  gene- 
rally of  a  deep  yellow  brown  colour;  the 
brown  depending  on  a  concentration  of 
the  yellow  colour.  It  refembles  the  co- 
lour of  wAtcd  rhubarb ;  for,  if  a  finall  por- 
tion of  either  of  thefe  fubftances  be  put  into 
a  large  quantity  of  water,  the  water  will  be 
tinged  of  a  bright  yellow  colour ;  this  ap- 
pears therefore  to  be  the  proper  colour  of 
thefe  fubftances,  but  it  is  fo  concentrated  in 

the 


AND  TRBATMBKt  09  LOCAL  mSBASHS*      35 

the  mafs  as  to  appear  of  a  deep  brown. 
Sometimes,  indeed,  we  find  green  bile  in 
the  gall  bladder,  when  the  liver  is  not  dif- 
eafed.  I  cannot,  however,  but  think  that 
the  natural  colour  is  a  yellow,  fo  intenfe 
as  to  appear  brown.  Green  bile  is  ufually 
poured  out  in  circumftances,  where  there  is 
evident  diforder  of  the  digeftive  organs ;  and 
we  cannot  well  fuppofe  that  there  are  two 
kinds  of  healthy  bile.  The  quantity  of  thij 
fluid  fhould  be  fuch  as  completely  to  tinge 
the  excrement  of  its  peculiar  colour.  By 
attending,  therefore,  to  the  colour  of  the 
faeces,  the  kind  and  quantity  of  bile,  whick 
the  liver  excretes,  may  in  general  be  alcer* 
tained. 

The  colour  of  the  alvine  excretions  in 
difordercd  ftates  of  the  vifcera  is  various* 
Sometimes  they  appear  to  confift  of  the  refi- 
duc  of  the  food,  untinged  byHbile.  Some- 
times they  are  of  a  light  yellow  colour, 
which  denotes  a  very  deficient  quantity  of 
healthy  biliary  fecretion ;  they  may  alfo  be  of 
a  deep  olive,  of  a  clay  brown,  and  of  a  black- 
iih  ferewn ;  all  which  ihew  a  vitiated  ftate 
<tf  the  biliary  fecretion. 

V  2  Any 


36        ON   THE  C0K8TITUTIOKAL  ORIGIK, 

Any  kind  of  brown,  which  dilution  will 
not  convert  into  yellow,  I  (hould  confider 
as  unhealthy,  fince  the  colour  of  healthy 
bile  is  a  bright  yellow,  which  by  concen-r 
tration  appears  brown. 

Such  are  the  circumftances  which  I  have 
coUefted  from  my  own  obfervation,  and 
the  reports  of  others,  relative  to  tlie  alvine 
excretions,  in  the  diforders  which  have 
been  defcribed* 

I  have  dwelt  thus  particularly  upon  the 
fubjedl  of  the  biliary  fccretion,  from  a  belief 
that  its  quantity  and  quality  can,  in  gene- 
ral, be  afcertained  by  infjpeftion,  and  will 
therefore  ferve  to  indicate  the  prefence  of 
diforder.  Whether  the  foregoing  opinions 
be  correft  or  not,  it  will,  I  think,  be  gene- 
rally granted  that  the  excretions  from  the 
bowels  commonly  indicate  the  healthy  or  diA 
ordered  ftate  of  the  digeftive  organs. 

• 

The  efFefts,  which  medicine  or  diet  may 
have  upon  the  colour  of  the  faeces^  ought, 
however,  to  be  con^dered.     When  the  food 

i  is 


AKD  TREATMENT  OF   LOCAL   DISEASES.      37 

b  coloured,    and  this    colour    is    not  al- 

» 

tered  by  digeftion,  it  will,  of  courfe,  ap- 
pear in  the  faeces ;  hence  if  it  (hould  be 
thought  defirabk  to  know  accurately  the 
ftate  of  the  biliary  fecretion,  it  would  be 
right  to  reftri6t  patients  to  a  diet  that  is  not 
likely  to  colour  the  faces.  The  green  colour 
of  vegetables  tinges  the  faecal  refidue  of  the 
food.  Steel  alfo  is  known  to  blacken  the  faeces. 
It  fliould  alfo  be  remarked  that  the  expofure 
of  the  faeces  to  air  after  their  expulfion,  will, 
in  fome  inftances,  caufe  a  confiderable  al- 
teration in  their  colour.  In  our  endea- 
vours, therefore,  to  afcertain  whether  the 
liver  is  performing  its  office  rightly,  by  ob- 
ferving  the  colour  of  the  fseces,  attention 
fhould  be  paid  to  thefe  circumftan?es. 

I  conclude  this  review  of  the  opinions 
entertained  refpefling  chylificatidh;  by  oIk 
ferving  that  if  the  fuccus  inteftinalis  be. 
an  agent  in  this  function,  diforder  of  the 
inteftines  is  likely  to  affe6l  its  fecretion,- 
and  thus  impede  this  fecond  important  part- 
pf  the  procefs  of  affimilation. 

D  %  The 


38  ON  THX  COKSTlTUTIcmAL  O&IOIKj  . 

The  refidue  of  the  alimentary  matter^ 
mixed  with  the  bile,  paffes  from  the  finall 
iito  the  large  inteftines,  and  there  imder- 
goes  a  iiidden  change  j  it  acquires  a  pecu- 
Iliar  fgetor,  ai^d   becopies    what    we  deno- 
minate faeces.     This  change  is  fo  fudden, 
that  it  cannot  be  afcribed  to  fpontaneous 
chemical  alterations,  (which  would  be  gra- 
<Jual)  but  to  fdme  new  animal  agency.     If 
the  contents  of  the  fmall  inteftines  at  theii: 
termination,  and  of  the  large  at  their  com- 
xdencement,  be  examined,  they  will  be  found 
totally  di&rent,  even  within  a  line  of  each 
other;  the   former    being   without  foetor, 
and  the  latter  being  in  all  refpefts  what  is 
denQcnmated  faeces.     Though  chemifts  then 
might    fpeak  of    the   feculent    matter  of 
chyle  as  faeces,  yet  phyfiologifts  would  ra- 
ther apply:  tiiat  term  to  the  change  in  the 
];:efidue  of  the  food,  which  takes  place  in  the 
large  inteftines,    and   which   feems   to   be 
Qflfofted  by  the    animal    powers  of  thoie 
organs.     The  faeces  quickly  fufFer  chemical 
dccompofition  out  of  the  body,   although 
they  often  remain  in  the  bowels  without 
imdergoing  the  fame  kind  of  change.    Their 

chemical 


IMD  TUSATMENT  OE  LOCAt   PIS^^ASES.     30 

cha[nical  decompofition  is  attended  with 
the   fudden    formation    of  ammonia;    yet 

if  they  be  examined  when   recent,  they  are 

•  •  •  I 

found  to    contain    acids    which  ammonii 

•  •  • 

would  neutralize.  The  inference,  there- 
fore,  naturally  arifes^  that  this  third  procefs^ 
I  mean  the  converlion  of  the  refidue  of  the 
aliment  into  faeces,  may,  amongft  other  pur- 
pofes,  be  defigned  fo  to  modify  that  refidue, 
as  to  prevent  it  from  undergoing  thole 
various  chemical  changes,  which  might  bp 
Emulating   to  the  containing  organs,    a9 

well  as  injurious  to  the  general  health, 

< 

In  a  perfeftly  healthy  ftate  of  the  di- 
geftivie  organs,  pfobably  no  chemical  de?- 
compofition,  even  of  the  faeces,  takes  places; 
yet  fuch  changes  happen,  in  fome  degree, 
without  apparently  producing  any  injuri- 
ous confequences.  To  chemical'  changes 
we  may  probably  attribute  the  ixtricafibn 
pf  inflammable  air,  and  the  various  aiid 
unnatural  odours  of  the  faecal'mattef,  which 
afe  obfervable  in  difordefed  filiates  .of  thg 
4i§eftive  vifcera.  *  *\*    ^'^ 

U"  4         -  The 


40        ON  TRB  CONSTITimOKilL  ORXOXK^ 

The  means  by  which  this  modification 
of  the  refiduc'  of  the  food,  which  takes 
place  in  the  large  inteftincs,  is  efFefted,  are 
but  little  known.  Analogy  leads  us  to 
refer  it  to  the  eflfefts  of  a  fecrction  from 
the  lining  of  thofe  iriteftines  in  which  it  oc- 
curs. Now  if  this  fecrction  deviates  from 
the  healthy  ftate,  in  confcquence  of  an 
irritated  or  difordcred  ftate  of  thofe  or^ 
gans,  we  may  rcafonably  cxpeft  a  cor* 
refponding  derangement  of  the  procefs,  by 
which  the  refidue  of  the  food  is  converted 
into  faeces. 


Further  Enquiry  into  the  Nature  and,  Effeds  rf 
that  Dif order  of  the  digeftive  Organs^  the  Symp* 
tpms  of  which  have  been  recited  at  Page  1 6, 

Having  taken  this  general  view  of  the 
fundlions  of  the  chylopqietic  vifcera,  in 
order  to  facilitate  the  forming  a  judgment 

relative  to  thofe  ciicumftances  which  indi- 

*       •  •      • 

cate  their  derangement^  I  return  to  fpeak 
more  fully  of  that  afFeftion  of  them,  which 
I  have  defcribed,  as  ariJing  from  caufes  re^ 
cited  at  pag9  i6.    1^%  fubjeft,  it  muft  be 

acknow-* 


AND  TRBATMEKT  OF  LOCAL  OX8BA8E6.      4I 

knowledged,  is  very  important,  if  it  can  be 
fhewn  that  diforders  of  the  digeftivc  organs 
are  the  caufe  of  a  great  number  of  other  dif- 
eafes;  The  enquiry  would  then  not  only 
lead  us  to  difcover  the  fource  of  many  diA 
turbances  of  the  conftitution,  which  origi- 
nate in  thofe  of  the  digeftive  organs  (for  pa* 
tients  have  no  fufpicion  of  any  diforder  ex- 
ifting  in  them),  but  would  alio  lead  to  the 
prevention  and  cure  of  many  fecondary  dif- 
cafes  of  a  more  vexatious  and  fometimes  of  a 
more  fatal  nature,  than  thofe  from  which 
they  originated. 

If  the  tongue  be  furred  at  its  back  part  in 
the  morning,  when  there  is  no  fever,  it  is 
reafonable  to  infer  in  general  that  the  ftate 
of  the  tongue  is  owing  to  its  participating 
in  the  irritation  of  the  ftomach.  Such  par- 
ticipation produces  an  alteration  in  the  fecre- 
tions  of  the  tongye  j  they  are  either  deficient 
in  quantity,  or  vitiated  in  quality,  A  ftate 
of  irritation  in  any  fecreting  furface  is,  in- 
deed, likely  to  be  attended  with  the  fame  con- 
fequences.  It  is,  therefore,  fair  to  infer  that, 
\vhen  a  general  diforder  of  the  digeftive  or- 
gans 


/ 


4t       ON  THIS  C0K8TIT|;TV)K4JU  drioik^ 

gans  takes  place,  thofe  fluids,  which  produce 
the  changes  that  the  food  undergoes  in  them» 
are  deficient  or  depraved,  and  confequently 
that  digeftion  and  the  fubfequent  procefles 
mufl  be  imperfeftly  performed.  The  liver 
is  likely  to  participate  in  the  diforder^  and 
the  biliary  fecretion  to  be  diminifhed  or  vi- 
tiated. This  circumflance  admits  of  ocular 
demonftration;  and  I  have,  therefore^  confi- 
dered  it  as  an  evidence  of  a  more  or  lefs  ge- 
neral diforder  of  the  digeftive  organs.  A  very 
reafonable  objeftion  may,  hovsrever,  be  made 
to  confidering  the  derangement  of  the  func- 
tions of  the  liver  as  a  criterion  of  thofe  of 
the  ftomach  and  inteftines  5  fmce  the  liver  is 
independent  of  the  latter  organs,  and  may  be 
the  fubjeft  of  a  diforder  confined  to  itfelf. 
In  fome  cafes,  alfo,  the  alimentary  canal  may 
be  afFe6bed,  without  difturbing  the  liver. 
Such  circumftances  may  happen  occafion- 
ally  J  but  they  are  not  ordinary  occurrences, 
and  fhould  be  confidered  as  exceptions  to 
general  rules,  which  do  not  militate  againft 
their  ccMnmon  operation.  In  general,  affec- 
tions of  the  former  influence  the  fiinftions  of 
the  latter ;  and  the  ilate  of  the  biliary  fe- 
cretion^ 


AV9  TRBATMSKT  OF  LOCAL  PUEAaBS.     4J 

cretion  affords  a  very  ufeful  evidence  of  a 
more  or  lefs  general  derangement  of  the 
chylopoietic  vifcera,  and  fliould  excite  our 
attention  to  inveftigate  its  kind  and  degree. 

I  have  ftated,  in  defcribing  the  fymptoms 
which  denote  diforder  of  the  digeftive  organs^ 
that  the  fa^es  are  generally  deficient  in 
quantity.  This  circumftance  may  be  ac- 
counted for  in  various  ways^  It  may  be 
afcribed  to  diminifhed  or  unheali^  fecretion 
of  bile,  which  does  not  precipitate  the  ufual 
proportion  of  feculent  matter  from  the 
Chyle.  Perfons  whofe  bowels  are  lax,  and 
not  ina£tive  in  carrying  downwards  the  fe- 
culent matter,  void  it  daily  in  deficient  quan- 
tities. It  may  be  fuppofed  too  that,  either 
from  the  deficiency  of  bile,  and  confequent 
want  of  excitement,  or  from  the  cflfefts  of 
diforder,  a  torpid  ftate  of  the  bowels  m^ 
exift,  which  caufes  them  to  carry  downwards 
the  feculent  matter  in  fmall  quantities.  This 
circumftance  may  produce  a  greater  abforp- 
tion  of  the  faeces  than  what  is  natural^  or  an 
accumulation  of  them  in  the  colon* 

6  That 


\ 


44         ON   THB   CONSTITUTIONAL   ORIGIN, 

That  the  digcftive  organs  in  general  were 
'  affected  in  the  cafes  of  local  difeafe,  which  I 
am  about  to  record,  is  moft  evidait ;  but  I 
am  aware  that  many  vai'ieties  of  diforder  may 
be  included  in  the  general  defcription  of  the 
fymptoms,  which  I  have  given.  Future  ob- 
fervations  may  lead  to  further  diftinftions ; 
but  I  fee  no  impropriety  at  prefent  in  fpeak- 
•ing  of  the  difordered  ftate  as  general ;  fince  it 
is  probable  that  no  material  diforder  can  oi*- 
dinarily  take  place  in  one  of  the  digeftive 
organs,  without  difturbing  the  fiinflions  of 
the  others.  When  digeftion  is  imperfectly 
performed,  thefunftions  of  the  inteftinal  canal 
will  foon  participate  in  the  diforder  of  the 
ftomach.  Under  thefe  circumftances,  the 
fecrction  of  bile  will  alfo  probably  become 
irregular.  Should  difeafe  commence  in  the 
large  inteftines,  as  about  the  reftum,  it  dis- 
turbs the  fun6lions  of  the  ftomach,  and  fecre- 
tion  of  the  liver,  and  becomes  augmented  in 
its  turn  by  its  fympathy  with  thefe  parts. 
Should  the  liver  be  difordered  in  the  fii'ft  in- 
ftance,  the  ftomach  and  bowels  may  not  im- 
mediately fympathize,  although  they  will 
probably  foon  become  affefted^ 

Heel 


AKD   TREATMENT   OF  LOCAL   DISEASES.     45. 

I  feel  further  warranted  in  confidering  the 
iymptoms,  which  have  been  recited  in  the 
former  part  of  this  paper,  as  arifing  from  a 
general  difturbance  of  the  funftions  of  the  di- 
geftive  organs,  from  contemplating  the  efFe6ls 
of  blows  on  different  parts  of  the  belly,  which 
do  not  feem  to  have  injured  the  ftixifture  of 
any  fingle  abdominal  vifcus,  but  yet  produce 
effefls  denoting  a  general  diforder  of  thefe 
organs.  The  fymptoms  have  varied  in  feve- 
rity  in  proportion  to  the  violence  of  the  blow 
received.  In  the  cafes  which  were  the  con- 
fequence  of  the  more  forcible  injuries  the, 
fymptoms  were,  a  furred  tongue ;  great  vo- 
miting, fo  that  the  ftomach  could  ret^n  no 
food  y  difficulty  of  affefling  the  bowels  by  me- 
dicine ;  great  fever ;  and  even  delirium.  In- 
deed, all  thofe  effcfts  were  produced,  which  I 
have  reprefented  as  arifing  from  vehement 
local  irritation  of  remote  parts  of  the  body. 
The  diforder  has  generally  terminated  by  a 
profufe  difcharge  of  black  and  fetid  ftools,, 
after  which  the  patient  has  perfeftly  recover- 
ed. On  the  contrary,  where  the  fymptom? 
confequent  on  the  blow  have  been  lefs  violent^ 
fo  as  not  to  claim  fuch  ftrift  attention,  the 

4  dif^ 


diibrder  has  cDfitinued.  Perfons  who  had 
been  j)revioufly  ift  pcrfeft  health,  have  be- 
toitie  hypochondriacal,  and  have  had  all 
thofe  fymptoms  of  diforder  of  the  digeftivc 
organs,  i?vhich  have  been  already  enumerated 
as  arifing  from  a  lefs  degree  of  local  irritation, 
with  fuch  confequent  difeafes  as  originate 
from  fuch  diforder,  and  which  will  be  men- 
tioned in  the  fubfequcnt  part  of  this  paper. 

In  order  to  enquire  more  particularly  into 
the  nature  of  this  diforder  of  the  digeftivc 
ofgans,  I  have  examined  the  bodies  of  a  con- 
fiderable  number  of  perfons  who  have  died 
6f  difeafed  joints,  lumbar  abfcefles,  and  other 
great  local  difeafes.  I  knew  that  thefe  pa- 
tients had  their  digeftive  organs  difordered  in 
the  manner  that  I  have  defcribed,  and  that 
in  many  of  them  the  fecretion  of  bile  had 
beeft  fuppreffed  for  a  great  length  of  time,  and, 
when  it  was  renewed,  that  it  was  very  defi- 
dent  in  quantity,  and  faulty  in  quality :  yet, 
on  diffeftion,  no  alteration  was  difcovered  in 
the  ftrufture  of  the  chylopoietic  vrfcera^ 
which  could  be  decidedly  pronounced  to  be 
flie  cflfeft  of  difeafe.  It  naturally  excites  fur- 
'   -^  prife 


AKD  TREATMENT  OF  LOCAL   DISEA91S.      4/ 

prife,  that  fuch  a  ftate  of  irritation,  and  im- 
perfe£t  performance  of  the  natural  funftions 
of  thefe  parts,  fhould  exift  for  fo  long  a  timc^ 
as  in  many  cafes  it  is  known  to  do>  without 
producing  organic  difeafe ;  ftill  I  believe  it 
may  be  fet  down  as  a  truth,  (which  has 
been  verified  by  eveiy  obfervation  I  have 
made,)  that  a  ftate  of  irritation  leads  to 
thofe  difeafed  vafcular  adlions,  which  pro- 
duce an  alteration  of  ftrufture  in  the  irritated 
parts. 

However,  where  the  difbrdered  ftate  of  the 
bowels  had  been  of  longer  duration,  I  have 
found  the  villous  coat  of  the  inteftines  fwoln, 
pulpy,  turgid  with  blood,  and  apparently 
inflamed,  and  fometimes  ulcerated ;  and  thefe 
appearances  have  been  moft  manifeft  in  the 
large  inteftines.  Having  obferved  repeatedly 
in  diffeftions  of  thefe  cafes,  that  the  large  in- 
teftines were  more  difeafed  than  the  finall 
ones,  it  occurred  to  me,  that  the  faft  might 
be  accounted  for  in  the  following  manner :  tf 
digeftion  is  incomplete,  the  undigefted  food 
muft  be  liable  to  chemical  changes,  and  the 
products   refulting   from    this    caufe,    are 

likely 


48        ON  THE  CONSTITUTIONAL  DRlOIN^ 

likely  to  be  mod  ftimulating  to  the  large  in- 
teftines.  Indeed,  in  advanced  ftages  of  this 
diforder,  mucus  and  jelly  tinged  with  blood 
are  difcharged,  and  it  feems  probable  that  a 
kind  of  chronic  dyfentery  may  be  thus 
induced. 

In  fome  inftances,  where  the  diforder  had 
exifted  for  many  years,  the  bowels  have  been 
difeafed  throughout  their  fubftance ;  the  in- 
ternal coat  being  ulcerated,  and  the  peritoneal 
Covering  inflamed,  fo  that  the  convolutions  of 
the  inteftincs  were  agglutinated  to  each  other. 
In  thefe  cafes  the  liver,  and  fometimes  the 
fpleen  alfo,  were  much  difeafed,  being  tuber- 
culated  in  every  part.  Such  is  the  refult  of 
the  information  which  I  have  obtained  by 
di(fe£tion. 

Accurate  attention  to  the  fubje£^,  efpecially 
in  medical  cafes^  may  lead  to  important  fub<- 
di>diions,  which  I  have  not  yet  been  able  to 
make.  But  when  I  find  that  irritation  of  the 
jriervous  fyftem,  however  it  may  originate, 
deranges  the  chylopoietic  organs,  and  afFefts 
the  ftomach,  bowels,  and  liver,  apparently  at 

the 


AJiti  YJfltJ^A'fMEKT  6V  LOCAL  t^JitAiti^    49 

die  fame  time,  I  think  it  fair  to  infer,  that 
thefe  organs  are  equally  operated  on  by  the* 
Ikme  caufe*  Diforders  of  the  hrain  may  affe'6t 
the  chylopoietic  organs  5  and  it  is  well  known 
that  this  influence  is  I'eciprocaL  The  ftomach 
is  faid  to  be'chiefly  concerned  in  producing 
thefe  effects  j  but  the  c^ufes  of  the  fympathetic 
affe6tion  are  probably  more  general.     A  fit  of 
paffion  has  produced  jaundice ;  and  the  irri« 
tation  of  teething  in  children  frequently  fuf- 
pends  the  fecretion  of  bile;  fo  that  the  ftools 
aire  not  in  the  leafl:  degree  tinged  with  that 
fluidi   If  the  head  can  thus  afFeft  the  liver,  it 
is  rea(b!^able  to  infer,  that  the  liver  may  reci- 
procally afFeft  the  head.     It  is  very  difficult 
to  form  an  opinion  relative  to  this  fubjeft ; 
for,  in  the  inflances  which  have  beenmention- 
cd^  the  affedtion  of  the  liver  may  take  place, 
only  becaufe  it  forms  a  part  of  the  digeftive 
organs,  and  not  from  a  direft  fympathy  exift- 
ing  between  it  and  the  head,  ^till,  however,  I 
do  not  think'it  unreafbnable  to  conclude  that 
imtatiion  of  the  other  chylopoietic  organ? 
jnay,  as  well  as  that  of  the  ftomach^  diforder 
the  iburce  of  fenfation. 

VOL.  I,  X  Tq 


50,        ON.TH«  CONSTITUTIONAL  OVLlOWf 

To  difplay  how  much  hepatic  irritation  • 
may  afFe£t  the  -fcnforium  and  confequently- 
the  whole  nervous  fyftem,  I  infert  the  follow-^ . 
ing  caie: 

CASE  n 
A  gentleman  applied  to  me  with  a  thicken* 
cd  and  tender  ftate  of  the  periofteum  of  hist 
tibia.  This  difeafe  had  troubled  him  for 
more  than  a  year>  but  became  at  laft  fo  ex-- 
tremely  painful  that  he  declared  he  had  not 
flept  for  three  months,  and  that  his  life  was 
fb  intolerable  that  he  refolved  to  undergo  a 
courfe  of  mercury,  even  though  in  the  opinion 
of  thofe  furgeons  whom  he  had  confulted, 
his  difeafe  was  not  venereal.  This  duration 
of  the  difeafe,  as  it  had  made  no  greater  pro- 
grefs,  induced  me  to  coincide  in  the  opinion 
which  had  been  given  him.  His  tongue  was 
much  ftirred,  his  appetite  was  moderate,  and 
he  was  not  confcious  that  his  digeftion  was 
otherwife  than  good.  His  bowels  were  per- 
feftly  regular.  I  defured  him  to  take  five 
grains  of  the  pilul.  hydrarg.  every  fecond 
night ;  but  before  he  took  them  to  remark 
the  colour  of  the  difcharges  from  his  bowels,, 
and  to  obfcrve  whether  the  medicine  produced 

4  any 


AND   THEATMrKT   OF   LOCAL   fctS^ASBS.    51* 

a 

any  change  of  it.  In  a  week's  time  he  called  ^ 
upon  me,  and  faidj  I  come  to  tell  you  the* 
ftrangeft  thing  that  perhaps  you  ever  heard^ ' 
which  is,  that  I  .aftually  do  not  know  the 
precife  fpot  where  the  lump  on  my  fhin  was 
fitiiatcd,  and  doubtlefs  thefe  pills  which  you 
direfted  are  a  moft  wonderful  compound  of 
opium.  The  firftgavemefleep,  whichlhadnot 
had  for  three  months.  After  taking  a  fecond, 
I  have  flept  ifoundly  all  night,  and  feel  myfelf 
alert  in  the  day.  Every  other  preparation  of - 
opium,  which  I  have  taken,  failed  in  produc- 
ing fleep,  and  made  me  ill  during  the  fuccced-  - 
ing  day.  After  all,  continued  he,  it  cannot 
be  the  pills  that  have  made  me  well,  for  they 
have  had  no  perceptible  efFeft  on  me.  I 
aiked  him,  had  he,  as  I  requefted  him,  re- 
marked the  colour  of  the  alvine  difcharges  ? 
He  replied,  he  had,  and  that  before  he  took 
the  medicine  they  were  (to  ufe  the  patient  s 
own  words)  as  black  as  his  hat,  and  now  they 
were  of  the  colour  of  a  ripe  Seville  orange. 
The  great  relief  arifing  from  the  correftion 
of  the  biliary  fecretion  was  not  to  me  fo 
ftrange,  as  the  patient  expefted.  It  is  doubt- 
lefs fuch  remarks  that  have  imprefled  fome 

E  2  medical 


g2        0K  THE  COKfttlttlTlOKAL  O&IOIK^ 

medical. men  vnth  the  opinion  that  the  liver 
was  the  root  of  the  evil  in  all  diforders  of 
tjic  digcftivc  organs. 

Cafes  like  the  prefent,  (and  feveral  fimilar 
ones  wiU  be  found  recorded  in  this  work,) 
appear  to  me  highly  valuable  on  many  ac- 
counts«  TJhey  fhew  that  hepatic  diforder 
may  difturl>  the  fenforixrai,  either  immedi : 
ately  or  intermediately,  by  difordering  other , 
organs  concerned  in  digeftion ;  they  (hew  how 
diforders  of  the  abdominal  vifcera  may  be- 
come the  caufe  of  various  other  difeafes,  by 
difturbing  the  fource  of  fenfation  and  ner- 
vous energy  5  and  they  fiirther  (hew  that 
unirritating  and  undebilitating  do(es  of 
mercury  have,  probably  by  their  local  a6tion 
in  the  bowels,  a  great  influence  in  corre6ling 
the  iSKcretion  of  bile,  and  by  this  means  of 
relieving  hepatic  irritation^ 

Nothing  in  pathology  is  more  generally 
admitted,  than  the  reciprocal  operation  of  dif- 
orders of  the  head  and  of  the  digeftive  organs 
on  each  other;  yet  the  exceptions  to  this 
general  rule  deferve  to  be  remarked  in  a  com- 

prehenfive 


AND  TREAJTMENT  OF  LOCAL   DISEASES*     53 

prehenfive  examination  of  the  fubjeft.  Some 
perfons  have  great  diforder  of  the  digeftive 
organs,  without  any  apparent  affeftion  of 
the  nervous  fyftem ;  and  even  difeafes  of  a 
fatal  nature  may  take  place  in  the  formes 
organs,  without  afFefting  the  latter.  Indeed, 
if  we  examine  any  of  the  moft  evidently  fym- 
pathetic  affedtions,  we  fhall  find  the  fame 
exceptions.  The  ftomach  generally  fympa* 
thizes  with  diforder  of  the  uterus,  but  it 
does  not  invariably  do  fo. 

Many  of  the  fymptoms  recorded  in  the  de- 
fcription  of  the  ftate  of  health  of  thofe  per* 
fons  who  are  affefted  by  diforder  in  the  digef^ 
dve  organs,  denote  a  difturbance  of  the  ner- 
vous and  mufcular  powers.  When  we  ob- 
ferve  this  compound  diforder  we  can  ieldom 
determine  which  were  the  primarily  afFe6ted 
organs.  General  nervous  irritation  may  have 
preceded  the  diforder  of  the  ftomach  and 
bowels,  or  may  have  been  caufed  by  it.  The 
hiftory  will  generally  Ihew,  that  the  derange- 
ment of  the  digeftive  organs  is  iecondary. 
When  it  arifes  from  local  irritation,  it  can 
be  produced  only  through  the  medium  of 

53  the 


54        OK  THE  COKSTITUTIOMAL  ORIGIN^ 

the  fenforium.  When  it  is  idiopathic,  it  fre^ 
quently  originates  in  caufcs  which  afFedt  the 
nervcfus  fyftem  primarily ;  fuch  as  anxiety, 
too  great  exertion  of  mind  or  body,  and  im- 
pure air.  Sedentary  habits  and  irregularities  of 
diet  are  caufes  which  may  be  fuppofed  to  a6t 
locally  on  the  organs  themfelves.  Nervous 
irritability  and  weaknefs  are  not  perhaps  fuf- 
ceptible  of  a  direfl  cure  by  medicine ;  but 
the  diforders  of  the  digeftive  organs  are  more 
corrigible  by  medical  remedies.  In  practice, 
thefe  require  our  chief  attention ;  and  if  their 
diforders  be  corre£ted,  all  nervous  irritation 
frequently  ceafes,  and  health  is  reftored.  In 
many  inftances  the  nervous  irritation,  which 
has  induced  the  difcafe,  is  trivial,  and  would 
foon  ceafe,  were  it  not  kept  up  by  the  re-ag^ 
tion  of  its  fecondary  fymptoms. 

Whether  this  diforder  of  the  digeftive  or^ 
gans  be  primary  or  fecondary,  it  generally 
produces  irritation  in  the  brain ;  and  thus 
may  cauf?  in  many  inftances  aftual  difeafe  of 
that  organ,  as  will  be  ftated  in  the  conclufion 
of  this  paper.  But  derangement  of  the  di- 
geftive organs  arifes,  in  many  cafes,  from  efta- 

blifhed 


AND   TREATMENT   OP  LOCAL    DISEASES.     $$ 

blifhed  nervous  diforder:  indeed  there  is 
often  reafon  to  fuppofe  that  it  is  dependent 
on,  or  connefted  with,  aftual  difeafe  of  the 
brain.  In  fuch  cafes,  the  cprredlion  of  the 
difordercd  funftions  of  the  digeftive  organs 
cannot  be  accompiifhed ;  and  even  if  it  were 
pradticable,  it  would  not  cure  the  nervous 
difeafe.  It  is  however  highly  neceffary  and 
advantageous  to  attend  to  the  diforder  of  the 
digeftive  organs,  where  it  is  only  a  fymptom 
of  nervous  difeafe.  The  relief  of  the  former 
will  often  mitigate,  though  it  cannot  cure  the 
latter  *, 

The 

*  The  ingenious  Mr.  John  Bell  has  of  late  publiihed  an 
opinion,  that  all  nervous  diforders  depeiid  on  t  e  circula- 
tion of  blood  in  the  brain.  The  opinion  is  founded  on  this 
dogma  $  the  brain  being  infenfible,  there  can  be  no  fuch 
thing  as  nervous  irritation.  Believing  fimilar  opinions  to 
be  prevalent  in  the  profeflion,  I  think  it  worth  enquiring, 
whether,  if  the  motion  of  a  worm  in  the  ftomach  produces 
temporary  blindnefs  or  convulfions,  there  be  not  fome 
nervous  irritation  ?  If  a  man  has  Iiis  leg  amputated  on  ac- 
count of  a  compound  fra£lure,  and  afterwards  becomes 
delirious  and  dies  ;  I  grant  that  fullnefs  of  the  vefTels  of 
theheadwillbe  found  on  difle^ion;  but  was  not  the  yafcular 
aftion  caufed  by  preceding  nervous  irritation  ?  The  fame 
fullnefs  of  vefiels  and  figns  of  inflammatioTi  are  found  in 
()iofe  who  die  of  fevers ;  but  do  not  the  miafmata  which 

E  ^  saufe 


$6         ON   THE   CONSTITUTIONAL  ORIGINf 

The  connexion  of  local  difeafe  with  general 
diforder  has  been  often  remarked ;  it  has  been 
formerly  attributed  to  impurity  of  the  fluids; 
a  thecr/  which  is  not  irrational,  Impcrfedk 
dlgeftion  muft  influence  the  qualities  of  the 
blood,  and  all  parts  of  the  body  may  be  af- 
fefled  from  this  fource.  .  But  in  accounting 
for  tlie  reciprocal  influence  of  diforders  of 
the  head  and  the  digeftiye  organs  on  each 
other,  the  modem  explanation  of  thefe  phse- 
nomena,  by  means  of  fympathies,  is  perhaps 
preferable^i  AfflifUng  intelligence  will  de-^ 
ftroy  the  appetite  and  produce  a  white 
tongue  in  a  healthy  perfon ;  and  a  blow  on 
the  ftomach  diforders  the  head.  Thefe  phae^ 
nomena  take  place  independently  of  the  blood, 
and  can  only  be  explained  by  admitting  that 
diflurbance  of  one  organ  immediately  afle6ts 
another. 


caufe  them  affe^  (he  brain,  ^nl  fuddenly  impair  and  dif^ 
turb  its  energy,  and  is  not  then  the  yafcular  zGdon  a  con* 
fequence  ?  I  would  aik  too,  practically,  does  blood?letting 
cure  diforders  in  which  there  is  a  fullnefs  of  the  veflels  of 
theheadf  It  mud  be  granted,  that  in  many  inftances  it  tem- 
porarily alleviates  them,  but  in  others  it  fails  to  relieve  and 
even  aggravates  then^ 


AND  TSIBATMEKT   O:^  LOCAL   DISEASE^.     5/ 

The  writings  of  the  ancients  afcound  with 
paffages,  in  which  local  difeafes  are  attributed 

to  affe6lions  of  the  abdominal  vifcera,  and 
the  fame  faft  has  been  noticed  by  feveral  of 
the  modems.  The  French  furgeons  appear 
to  be  yery  folicitous  to  keep  the  bowels  in  a 
cool  and  tranquil  ftate;  and  Deifault  afcribes 
the  origin  of  eryfipelas  to  a  bilious  caufe. 
The  German  furgeons,  Richter  and  Schmuck- 
cr,  attribute  many  local  difeafes  to  gaftric  af- 
feftions  j  and  in  Italy,  Scarpa  views  the  fub- 
jefl:  in  the  fame  light.  The  Englifli  pra6l:i- 
tioners  feem  to  have  been  lefs  attentive  to  this 
clafs  of  diforders  ;  infomuch  that  Fifcher,  a 
German,  who  publifhed  an  account  of  the 
ftate  of  medicine  in  this  country,  expreflcs 
his  furprife  that  the  Englifh  fhould  be  fo 
little  acquainted  with  gaftric  difeafes.  I  know 
not  exaftly  what  ideas  thefe  gentlemen  may 
annex  to  the  terms  gaftric  and  bilious  difor- 
ders, fince  they  do  not  particularly  defcribe 
them.  I  have  reprefented  the  fubjeft  in  the 
foregoing  pages,  as  it  has  appeared  to  me  on 
the  moft  attentive  examination. 

There  is  alfo  an  excellent  differtation,  in 

which 


58         ON  THE   CONSTITUTIONAL  ORIOIK^  ' 

which  the  cfFefts  and  treatment  of  diforders 
of  the  digeftive  organs  are  particularly  dc- 
fcribed,  inferted  in  the  eighth  volume  of  the 
Memoires  de  la  Societe  Royale  de  Medicine 
of  Paris  for  the  year  1806,  at  page  310,  en- 
titled Refleftions  fur  leTraitment  de  la  Manie 
atrabilaire  compare  a  celui  de  plufieurs 
autres  Maladies  chroniques,  &  fur  les  Avan- 
tages  de  la  Methode  evacuante,  par  M.  Halle. 
After  defcribing  the  difcharges  from  the 
bowels  in  atrabiliary  mania,  he  obferves,  that 
a  fimilarftate  of  thofe  organs  is  found  in  other 
<iifeafes,  namely  dropfy,  hypocondriafis,  ac- 
companied with  difficulty  of  breathing  and 
palpitation,  obftinate  coughs,  and  a  great 
number  of  very  different  difeafes  ;  to  all  of 
which  the  fame  treatment  is  applicable. 
That  the  extremely  prejudicial  confequences 
of  diforders  of  the  ftomach  and  bowels  have 
been  noticed  at  all  times  by  perfons  of  obfer- 
vation,  and  particularly  by  thofe  who  are  in 
the  habit  of  judging  of  their  ftate  by  their  ex- 
cretions, is  lufficiently  evident.  The  antients 
fought  to  correft  the  error  by  purging  with 
hellebore,  and  the  modems  by  more  compound 
purges,  to  ufe  the  words  of  M.  Halle,  par  le 

melange 


AHD  THEATMENT  OP  LOCAL   DISEASES.    59 

melange  de  purgati^  refineux  &  des  mercu- 
liaux.  I  have  not,  however,  met  with  any 
phyfiological  inveftigation  of  the  nature  of 
thefe  difeafes,  nor  of  the  rational  objefts  of 
jcure.  It  is  to  promote  fuch  an  inveftigation, 
that  I  have  laid  before  the  public  the  fa6ls 
which  have  come  under  my  obfervation,  and 
the  refleftions  to  which  they  have  given  rife. 

In  inveftigating  the  connexion  between 
local  difeafes  and  diforder  of  the  health  in 
general,  I  can  perceive,  that  failure  in  the 
funftions  and  irritation  of  the  digeftive  or- 
gans may  aft  prejudicially  on  the  fyftem  in 
general  in  various  ways.  They  may  produce 
weaknefs,  for  ftrength  and  vigour  feem  to 
arife  from  the  converfion  of  our  food  into 
perfedt  blood.  They  may  produce  an  im- 
pure ftate  of  that  fluid,  and  they  may  pro- 
duce greiat  irritation  of  the  brain,  and  thus 
influence  the  whole  body.  However,  what  I 
have  to  obferve  refpe£ling  the  caufes  and 
cure  of  local  difeafes  will  be  moft  properly 
introduced  and  beft  underftood  after  the  cafes 
have  been  recorded,  upon  which  the  opinions 
Jiave  bcci?  founded. 

The 


€o         ON   YHE   CONSTITUTIONAL  ORIGIV, 

The  rcfuk  of  all  thefe  obfervations,  which 
I  have  been  able  to  make,  relative  to  this 
fubjefl,  has  induced  me  to  believe  that  the 
diforder  of  the  digeftive  organs,  caufed  by  the 
various  circumftances  which  have  been  re* 
cited,  confifts  in  a  weaknefs  and  irritability 
of  the  afFefted  parts,  accompanied  by  a  defi- 
ciency or  depravity  of  the   fluids   fecreted 
by  them,  and  upon  the  healthy  qualities  of 
which  the  due  performance  of  their  func- 
tions feems  to  depend.     This  opinion  is  de- 
duced immediately  from  the  confideration  of 
the  fymptoms,  and   confirmed  by  all  the 
collateral  evidence,  which   we  can  colleft. 
The  duration  of  the  affeftion,  without  fatal 
confequences,  (hews  that  it  is  a  diforder  of 
funftions,  and  not  a  difeafe  of  ftrufture.  Dil^ 
feflions  confirm  the  opinion.     Blows  which 
excite  general  irritation  of  the  digeftive  or- 
gans,   produce   alfo  the   fymptoms  which 
charafterize  the  like  diforder,  when  it  arifes 
from  nervous  irritation,  or  is  excited  by  in- 
temperance.    I  doubt  not  but  every  one  will, 
on  refle6tion,  confider  the  diforders  of  the  di- 
geftive organs  to  be  of  the  firft  importance, 
and  will  perceive  the  propriety  of  diligently 

enquiring 


AND  TREATMENT  OF  LOCAL  DISEASES.     6t 

enquiring  into  their  nature,  that  we  may  know 
th(m  when  they  exiil,  and  that  our  at- 
tempts to  remedy  them  may  be  condu£l:ed 
on  rational  principles.  This  confideration 
will,  I  truft,  vindicate  me  for  employing  lb 
much  time  in  an  inveftigation  which,  per- 
haps, fbme  may  confider  as  tedious  and  un- 
profitable. 


Occqfional   EffeSls  of  Diforder  of  the  digejlhvis 

Organs. 

IT  is  generally  admitted,  that  diforders  of 
the  chylopoietic  vifcera  will  affeft  the  fource 
of  fenfation,  and  confequently  the  whole 
body ;  but  the  variety  of  difeafes,  which  may 
refult  from  this  caufe,  has  not  been  duly 
weighed  and  reflefted  on. 

It  may  produce  in  the  nervous  fyftem  a 
diminution  of  the  funftions  of  the  brain,  or 
a  ftate  of  excitation,  caufing  delirium ;  par- 
tial nervous  inactivity  and  infenfibility,  or 
the  oppofite  ftate  of  irritation  and  pain.  It 
may  produce  in  the  mufcular  fyftem,  weak- 
nefs,  tremors,  and  palfy ;   or  the  contrary 

affcc- 


/ 

6l         ON  THE   CONSTITUTIONAL  ORIGIN, 

afFeftions  of  fpafin  and  convulfions.     It  may 
excite  fever  by  difturbing  the  aftions  of  the 
fangniferous  fyftem  5  and  caufe  various  local 
dif^es  by  the  nervous  irritation,  which  it 
produces,  and  by  the  weaknefs,  wliich  is  con- 
fequent  on  nervous  diforder  or  imperfeft  chy- 
lification.  Or  if  local  difeafes  occur  in  a  con- 
ftitution  deranged  in  the  manner  which  I  have 
defcribed,  they  will  become  peculiar  in  their 
nature  and  progrefs,  and  difficult  of  cure.  Af- 
feflions  of  all  thofe  paits  which  have  a  con- 
tinuity of  furface  with  the  ftomach ;  as  the 
throat,  mouth,  lips,  ikin,  eyes,  nofe,  and  ears, 
may  be  originally  caufed  or  aggravated  by 
this  complaint.  I  muft  obferve,  before  I  pro- 
ceed to  the  relation  of  cafes,  that  fuch  a  dis- 
order of  the  digeftive  organs  as  I  have  de- 
fcribed exifted  in  every  inftance.  I  do  not  take 
upon  myfelf  to  fay  that  it  was  the  primary 
canfe  of  the  general  derangement  of  the  con- 
ftitution,  with  which  the  local  difcafe  appeared 
to  be  conneftedj    it  might  have  been  the 
confequence,  as  indeed  has  been  ftated  in 
thefc  preliminary  obfervations. 

Treatment. 

I  fhall  now  proceed  to  mention  the  plan 

which 


AKD  TREATMBNT  OF  XOCAL    DISEASES.     6^"^ 

which  I  have  p\irfued  in  the  treatment  of 
thefe  difbrders,  when  they  have  been  con- 
ne^ed  with  fnrgieal  difeafcs :    with  what 
degree  of  fuccefs,  the  folio  <ving  cafes  will 
demonftrate.      I    do    not    feel     altogether 
competent  to  give  full  direftions  relative  to 
this  fubjeft ',  becaufe  I  have  never  attended 
to  medical  cafes  with   that  degree  of  ob- 
fervation  which  would  lead  me  properly  to 
appreciate  the  efficacy  of  different  medicines, 
when  adminiftered  either  in  their  fimple  or 
compounded  forms.     The  fubjeft  is  fo  im- 
portant, that  the  public  would  be  highly 
indebted  to  any  pra6titioner,    who  would 
point  out  the  varieties  of  thefe  difeafes,  and 
the  appropriate  modes  of  cure.     The  method 
of  treatment,  which  I  have  adopted,  is  fmiple, 
and  founded  on  the  opinions  I  have  formed  of 
the  nature  of  the  difeafe,  and  on  phy  (iological 
views  of  the  functions  of  the  affefted  organs. 
Believing  the  difordered  parts  to  be  in  a 
flate  of  weaknefs    and  of  irritability,   my 
obje£k  has  been,  to  diminifh  the  former  and 
allay  the  latter.     Believing  alfo  that  the  fe- 
cretions  into  the  ftomach  and  bowels,  upon 
the  healthy  ftate  of  which  the  due  perfor- 
mance 


64         OVr  THB   COMSTITTTTIOHAL  CRlOlN, 

mance  of  their  funflions  depends,  were,  in 
confcquence  of  fuch  difordci-,  either  deficient 
in  quantity  or  depraved  in  quality ;  I  have 
endeavoured  to  excite,  by  means  of  medicine, 
a  more  copious  and  healthy  fecretion. 

In  conformity  to  thefe  views  of  the  fubjeft, 
tiie  patients  have  been  recommended  to  be 
particularly  attentive  to  thdr  diet.  The  food 
(hould  be  nutritious,  and  eafy  of  digeflion : 
flrong  plain  broths,  animal  food  of  Joofe  tex* 
ture,  milk,  eggs,  and  farinaceous  vegetables,- 
are  the  articles  which  appear  moft  advifable* 
But,  as  cuftom  and  inclination  have  fo  great 
an  effect  in  regulating  the  a6kions  of  the  fto- 
mach,  I  have  contented  myfelf  with  recomv 
mending  patients  not  to  cat  any  thing,  which 
it  was  probable  that  they  could  not  digefti 
It  feems  reafonable  to  fuppofe,  that,  if  the 
food  be  properly  digefted,  it  will  not  irritate 
the  inteftinal  canal  j  but  that,  if  digeftion 
fails,  the  animal  and  vegetable  matters  will 
undergo  chemical  changes  in  their  pafiage 
through  the  long  traft  of  inteftines,  and  there-* 
by  maintain  a  ftate  of  irritation  in  thofe 
organs.     I  have  urged  patients  not  td  op-» 

prefs 


And  treatment  of  local  diseases.  65 

prefs  the  powers  of  the  ftomach  by  too  great 
a  quantity  of  food,  nor  to  take  a  fecond  meal, 
until  time  has  been  allowed  for  the  digeftion 
of  the  firft,  and  for  the  recovery  of  the 
powers  of  the  ftomach.  Whilft  I  have  thus 
advised  patients  to  eat  moderately  and  not 
too  frequently,  I  have  alfo  cautioned  them  not 
to  let  the  ftomach  become  irritable  by  too 
long  abftinence.  I  have  ordered  five  grains 
of  powdered  rhubarb  an  hour  before  dinner, 
with  a  view  of  inviting  lecretions  into  the 
ftomach,  and  of  preparing  it  for  the  office  of 
digeftionl  This  gentle  excitation  perhaps 
induces  it  to  expel  any  refidue  of  alimentary 
matter,  and  creates  a  kind  of  artificial  appe- 
tite ;  fo  that  perfons  habitually  fubjeft  to  in- 
digeftion  experience  very  confiderable  benefit 
from  the  praftice.  Where  rhubarb  has  dil-* 
agreed,  columbo  has  been  fubftituted. 

The  quantity  of  food  ftiould  of  courfe  be 
proportionate  to  the  powers  of  the  ftomach* 
If  it  receives  more  than  it  can  digeft,  no 
nouriftiment  is  obtained  from  the  fuper- 
fluous  quantity,  and  the  undigefted  ali- 
ment not  onJy  afts  injurioufly  'in  the  bowels, 

VOL.1.  F  but 


6^         OK  THB  C0N9TITUTI0HAL  ORIOIK^ 

but  in  the  blood,  and  in  the  urine,  a« 
has  been  mentioned.  There  is  alfo  ano^ 
ther  view  of  the  fubjefl.  Moderation  in 
diet  not  only  infures  the  complete  digeftiont 
of  the  aliment,  but  it  prevents  the  blood  vef- 
fcls  from  being  overloaded  and  kept  in  a  ftate 
of  aftion  exhaufting  to  their  ftrength.  When 
alfo  important  organs  may  be  in  a  ftate  of 
nervous  irritation  and  diforder  of  funftion,  if 
there  be  a  pletlioric  ftate  of  the  blood  veffels 
at  the  fame  time,  thofe  vafculai-  aftions  arc 
likely  to  enfue,  which  may  produce  an  al- 
teration of  their  ftruclure,  and  irremediable 
difeafe^ 

The  funftion  of  digeftion  will  not,  how- 
ever, go  on  well,  even  where  thefe  circum- 
ftances  have  been  attended  to,  if  the  ftomach 
be  deprived  of  a  ftimulus  to  which  it  has 
been  long  accuftomcd,  Uneafy  fenfations 
will  be  experienced,  denoting,  if  I  may  fo  ex- 
prefs  it,  a  difcontcnted  ftate  of  this,  organ, 
and  a  want  of  tlie  expcfted  ftimulus.  It  is  on 
this  account  injurious  wholly  to  reftrsun  thoic 
patients  from  tlie  ufe  of  wine  who  have  been 
in  the  Iwbit  ofetaking  it.  A  moderate  quan- 
:    .  8  .   tity 


AND  TREATMENT   OF  LOCAL  DtSEASBS.   6/ 

tity  of  fuch  a  ftimulus  may  be  allowed 
after  dinner,  to  prevent  uneafy  fenfations 
and  to  promote  digeftionj  but  ftrong  fer- 
mented liquors  muft  be  injurious  at  any 
other  period.  It  is  wrong  to  ftimulate  the 
ftomach  when  it  has  no  talk  to  perform. 

Even  our  food  muft  be  confidered  as  ex- 
erting a  medicinal  influence  in  diforders  of 
the  ftomach,  when  that  organ  is  irritable.  A 
Y^etable  diet  and  abftinence  from  fermented 
liquors  may  tend  to  tranquillize  it.     On  the 
contrary,  when  it  is  weak  as  well  as  irritable, 
that  aliment  which  is  moft  readily  digefted 
is  to  be  preferred,  and  cordials  are  fometimes 
beneficial.     The  efFefts  of  food  and  medicine 
can  never  be  confidered   as  refulting  from 
their  operation  on  the  ftomach  folely,  but 
from  their  conjoint  influence  upon  the  ner- 
vous fyftem  in  general.     Irritability  of  the 
ftomach  may  irife  from  that  of  the  biain, 
and  unftimulating  diet  may  tend  to  tranquil- 
lize the  latter  organ,  and  thereby  alleviate  the 
diforder  of  the  formef.     On  the  contrary,  a 
more  generous  diet  may,  by  exciting  the  ner- 
vous:^A^,  produce  that  d^ree  of  energy 

F  2  in 


68"  ok   THE   CONSTITUTIONAL   ORIOIK, 

in  its  adions,  which  invigorates  the  fto- 
mach,  and  tranquillizes  its  diforder.  It  may 
further  be  obferved  in  fome  cafes,  that  the 
kind  of  medicines  or  diet  which  is  ferviceablc 
to  the  ftomach,  may  aggravate  the  nervous 
diforder  5  and  on  the  contrary,  that  thofc 
means  which  feem  to  tranquillize  nervous 
irritation  tend  to  diminifh  the  powers  of  the 
ftomach. 

Bark  and  fteel  are  not  uncommonly  given 
in  thefe  difeafes  to  increafe  the  powers  of  the 
ftomach:  they  ought,  I  think,  to  be  ad- 
miniftered  in  fmall  dofes,  and  never  when 
the  tongue  is  dry  ;  as  they  feem  to  fupprefs 
thofe  fecretions,  which  in  many  cafes  arc 
already  deficient ;  and  the  increafe  of  which 
would  tend  to  relieve  irritation  in  the  affefled 
organs.  1  mention  this  opinion,  however, 
rather  to  account  to  the  reader  for  thefe  medi^ 
cinefe  not  having  been  prefcribed  in  the  fubfe- 
quent  cafes,  than  from  any  other  motive  j  as 
I  do  not  feel  perfeftly  competent  to  decide 
upon  their  degree  or  kind  of  utility. 

Vegetable  diet-drinks  appear  to  nif  very 

ufeM 


AND   TREATMENT   OF   LOCAL   DISEASES.     6^ 

tifeful  in  tranquillizing  and  correfling  dif^ 
orders  of  the  ftomach  and  bowels,  for  this  is 
the  manner  in  which  they  feem  to  be  efScaci- 
ous  in  the  cure  of  local  difeafes.  The  vege* 
tables  prefcribed  in  tlie  different  formulae  are 
ib  diffimilar,  that  we  can  fcarcely  fuppofe  that 
they  aft  fpecifically  upon  the  local  difeafe. 
Even  Sweet-wort  has  obtained  confiderable 
celebrity.  When  diet-drinks  fail  to  corre6t 
tlie  diforders  of  the  digeftive  organs,  they  alfo 
^  to  produce  any  amendment  on  local  dif- 
eafes.    Such  obfervations  have  induced  me  to 

■ 

believe  that  they  have  the  utility,  which  I 
have  afcribed  to  them,  of  tranquillizing  and 
€orrecling  diforders  of  the  ftomach  and  bowels. 
It  is  allowable  to  form  an  opinion  from 
fuch  obfervations,  though  I  am  fenfible 
of  their  invalidity  as  arguments  to  prove  its 
trutli, 

A  regular  diurnal  evacuation  of  the  bowels 
is  particularly  neceflary,  fince  the  detention 
^f  the  faeces  muft  prove  irritating  to  thefe 
organs.  Purging  medicines  fpmetimes  relieve 
unpleafant  fenfations  j  but  they  do  not  in  ge- 
jicral  produce  even  this  effcft ;  and  all  adlive 
'  F  3  purges 


yo  on   THE  CONSTITUTldNAL   ORIGIN, 

purges  feem  to  me  to  increafe  the  diforder 
It  is  natural  to  fuppofe  that  ftrong  ftimuli 
will  aggravate  the  unhealthy  condition  of 
weak  and  irritable  parts. 

I  haveexpreffed  my  opinion  ofthemanncrin 
which  the  continued  exhibition  of  purgative 
medicines,  in  fuch  dofes  as  do  not  irtimedi- 
diately  purge,  relieve  diforders  of  the  digdlive 
organs,  by  producing  morbid  fecretions 
which  afford  confiderable  relief,  both  when 
they  occur  _  fpontaneoufly  or  are  thus  in- 
duced. This  plan  of  praftice  is  what  Dr. 
Hamilton  has  fuggefted,  and  the  utility  of 
which  he  has  fo  fuccefsfully  ■  elucidated.  I 
am  aware  that  laxative  medicines  may  relieve 
irritation  merely  by  augmenting  the  natural 
fecretions  of  the  vifcera,  and  thus  unloading, 
their  veflels;  and  alfo  by  determining  the 
fluids  from  the  head,  when  the  nervous  fymp- 
toms  are  aggravated  by  a  plenitude  of  the  vef- 
fels  of  the  brain.  As  i  have  found  the  le- 
nient  plan  of  treatment,  (that  of  exciting  the 
periftaltic  aft  ion  of  the  bowels,  fo  as  to  in- 
duce them  to  clear  out  the  whole  of  the  re- 
fidue  of  the  food  3  without  irritating  them. 


AND   TR£ATMfiNT   OF   LOtAL   DKSJftASES.    ^t 

fo  as  to  produce  what  is  ordinarily  called 
purging,)  particularly  fuccefsful,  I  have  r^t- 
ly  deviated  from  it.  I  am  not,  therefore, 
warranted  from  experience  in  fpcaking  dei 
cifively  refpefting  the  moie  free  \ifh  of  puri 
gative  medicines. 

It  is  difficult,  in  many  cafes,  to  regulate 
the  actions  of  the  bowels  either  by  diet 
or  medicine.  They  are  coftive  for  a  time, 
and  then  fits  of  purging  come  on.  The 
former  ftate  muft  be  obviated,  in  order 
to  prevent  the  latter.  Medicines  which 
excite  a  healthy  a6lion  of  tl\iB  bowels  iti 
one  perfon,  are  either  inert  or  too  aftive  lA 
another.  Dofes,  which  would  have  no  6ffe6l: 
in  a  ftate  of  health,  become  purgative  in  this 
diforder  j  a  circumftance  which  fliews  that  the 
bowels  are  irritable.  There  are  fome  rare  in- 
ftances  of  the  contrary,  in  which  it  is  exceed- 
ingly difficult  to  excite  the  a6lions  and  fecre- 
tions  of  thefe  vifcera.  The  obje£l  which  I 
have  had  in  view,  in  all  cafes,  is  to  excite 
the  periftaltic  aftion  of  the  bowels,  \vith- 
i)ut  irritating  them,  fo  as  to  induce  them  to 

F  4  pour 


JZ  OK  THE  CONSTITUTIONAL  ORI6IK9 

» 

pour  forth  and  evacuate  their  own  fluids^ 
The  adminiftration  of  puigative  medicines 
in  very  fmall  dpfes,  at  regular  intervals,  is  in 
inany  cafes  the  bell:  mode  of  effedting  this 
purpofc. 

In  giving  purgative  medicines  I  have  en ' 
deavoured  to  combine  them,  fb  as  to  excite 
and'ftrengthen  at  the  fame  time.  Rhubarb^ 
columbo,  and  kali  vitriolat.  have  been  given 
together;  or  an  infiifion  of  gentian  with 
ienna  or  tinfture  of  rhubarb.  When  the  in« 
fiiiion  of  gentian  with  fenna  has  been  given, 
it  has  been  prefcribed,  in  the  fubfequent 
cafes,  according  to  the  following  foimula, 
which  is  in  ufe  at  St.  Bartholomew's  hof- 
pital : 

R.     Infuf.  gentian,  comp.  g  j. 

Infuf.  fennae,  3  ij. 

Tinft.  cardamom,  comp.  ^  j.  M. 
Fiat  hauftus,  bis  quotidie,  vel  pro  re  nata, 
fumendus. 

It  is  fometimes  neceflary  to  incrcafe  the 
quantity  of  infiifion  of  fenna.    I  have  found 

.     '  in 


4KI>  TftEATMBl^lT   OF   LOCAL   DIS^A^E^.   JJ^ 

Jii  fome  cafes,  that  the  purgative  medicine? 
and  fpices  diflTolved  in  fpirit  and  water,  have 
anfwered  better  than  any  thing  elfe,  in  pror 
ducing  a  fufficient,  hut  not  too  copious  difr 
charge  from  the  bowels.  Equal  parts  of  com- 
pound tin6ture  of  rhubarb  and  fenna  is  the 
formula  to  which  I  allude.  When  irritar 
tion  in  the  lai'ge  inteftines  has  been  denoted 
by  the  mixture  of  mucus  and  jelly  with  the 
fa^ctSy  and  fudden  and  urgent  calls  to  void 
them,  I  have  adyifed  oily  and  mucilaginous 
medicines  as  aperients :  as  caftor  oil,  mixed 
with  a  large  proportion  of  mucilage.  My 
Ible  objeft,  however,  has  been  to  regulate 
the  f  tate  of  the  bowpls ;  and  when  they  have 
been  regular  without  medicine,  I  have  rarely 
recommended  any. 

At  the  fame  time,  I  have  not  been  inat- 
tentive to  the  error  in  the  biliary  fecretion, 
which  exifts  in  the  greater  number  of  thefe 
cafes.  I  have  endeavoured  to  correal  this 
scrror  by  the  adminiftration  of  fuch  fmall  dofes 
of  mercury,  as  do  not  irritate  the  bowels,  and 
are  not  likely  to  affedl  the  conftitution,  even 
though  perfevered  in  for  a  confiderable  time* 
12  In 


74  OV  THE   CONSTITUTIONAL   ORIGIN, 

In  this  ftate  of  the  digeftive  organs,  calomel, 
in  fmall  quantities,  fometimes  proves  irri- 
tating. I  have  combined  it,  as  in  Plummer's 
pill,  and  have  given  one  grain  every  other 
night.  Where  this  dofe  produced  imeafy 
Icnfations,  crafted  as  an  aperient,  five  grains 
of  the  pil.  hydrarg.  were  fubftituted  in  its 
place ;  and  even  this  quantity  has  been  dimi- 
nifhed  in  fome  cafes.  When  it  appeared 
neceffaiy,  on  account  of  the  biliary  fecretion, 
and  when  the  calomel  did  not  irritate  the 
bowels,  I  have  increafed  the  dofe.  The  re- 
lief, which  arises  from  the  increafe  or  cor- 
region  of  the  biliary  fecretion,  in  the  majority 
of  thefe  cafes,  (hews  how  much  the  liver  is 
concerned  in  caufmg  or  aggravating  the 
fymptoms  in  thefe  difeafes. 

Thefe  are  numerous  and  undoubted  proofs 
of  the  utility  of  mercury,  in  correfting  and 
augmenting  the  biliary  fecretion;  but  the 
mode  of  adminiftering  it  has  not,  perhaps, 
been  fufficiently  attended  to.  I  have  known 
patients,  who  had  voided  nothing  but  blackifh 
ftools  for  fome  months,  difcharge  faeces  of 
a  light  yellow  colour,  denoting  a  healthy, 

but 


AND   TREATMENT   OF   LOCAL    DISEASES.    75 

but  deficient  fecretion  of  bile,  upon  taking 
fuch  fmall  dofes  of  mercury.  The  effeft  of 
this  change  on  the  conftitution  and  fpirits 
has  been  furprifingly  great ;  though  the  ftatc 
of  the  ftomach  did  not  appear  to  be  altered. 
The  ufe  of  mercury  by  inunftion,  fometimes 
afts  beneficially,  in  correfting  the  biliary 
fecretion  5  but  if  the  conftitution  be  irritated, 
arid  weakened  by  that  medicine,  the  aftions 
of  the  liver  are  difturbed ;  and  the  digeftive 
organs  in  general^  become  deranged.  Mer- 
cury, in  my  opinion,  afts  moft  certainly  and 
efficacioufly,  when  taken  into  the  bowels, 
and  a  much  finaller  quantity  will  fuffice,. 
when  its.  application  is  in  this  manner  ren- 
dered chiefly  local. 

Although  experience  bas  made  me  think 
very  highly  of  the  efficacy  of  fmall  dofes  of 
mercury,  in  exciting  and  correcting  the  bili- 
ary fecretion ;  yet  it  ought  to  be  mentioned, 
that  in  fome  few  cafes,  this  medicine  fails  to. 
produce  its  ufual  effefts,  and  that  the  biliary 
iecretion  becomes  healthy  without  its  admi- 
niftration.    • 

Fafts 


y£         OW   THE   CONSTITUTIONAL   ORIGIN, 

Fafts  are  wanting,  to  Enable  us  ta  afccrtain^ 
whether  mercury  meliorates  and  augments 
the  fccretions  of  the  other  digeftive  organs, 
as  it  does  that  of  the  liver.  The  ftomach 
frequently  appears  wqrfe  during  its  employ- 
ment, \yhilft  the  ftools  are  cpnfiderably 
better;  I  have,  in  fuch  cafes,  difcQjitinued 
the  medicine^  and  returned  to  it  again  if  th? 
ftate  of  the  liver  niade  it  neceflary.  When 
benefit  is  obtained  from  a  linall  quantity  of 
medicine,  we  naturally  expedl  an  increafed 
advantage  from  an  augmented  dofe  -,  fljis  is 
fo  natural  an  errpr,    that  an  admonition 

•  -  ■       t 

^  agaipft  it  appears  neceflary.  I  have  obferved 
in  fome  inftances,  wherq  fmall  dofes  of  mer- 
cury have  unexpeftedly  afFefted  the  moutli^ 
that  confiderable  benefit  feemed  to  arife  from 
this  circumftance.  Yet  it  is  wrong,  in  gene- 
ral, to  augment  the  dofe  of  the  medicine,  fo 
as  to  create  even  local  irritation  in  the  bowels 
by  it.  The  various  efFe6ts  of  mercury  in  dis- 
orders of  the  digeftive  organs  cannot,  I  think,. 
be  underftood,  but  by  confidering,  not  merely 
its  local  operation  on  thefe  organs,  but  alfo 
its  a6lion  on  the  conftitution  at  large.  When 
we  fee  the  biliary  fecretion  coirc6led  by  a  few 

grains 


AND   TREATMENT   0?  LOCAL   tllSEA^ES.    7*/ 

grains  of  the  pilul.  hydrarg.,  as  In  the  fecond 
cafe,  we  cannot  but  believe  its  aftion  to  be 
local.  -When  the  medicine  is  given  in  larger 
dofes,  it  exerts  an  influence  on  the  whole  con- 
ffitution,  and  alters  the  ftate  of  the  nervous 
fyftem.  It  thus  controuls  difeafes  dependant 
en  an  irritable  and  difturbed  ftate  of  the  ner- 
vous fun6lions :  this  I  think  I  fhall  be  able  to 
ihew  by  cafes  related  in  that  part  of  this 
lx)ok  which  treats  on  difeafes  induced  by  the 
abforption  of  morbific  animal  poifons ;  and 
thus  mercury  may  relieve  diforders  of  the  di- 
geftive  organs  by  relieving  the  nervous  diforde? 
which  caufed  them.  But  when  mercuiy  is 
pven  in  ftill  larger  dofes,  as  it  is  for  the  cure 
of  fyphilis,  it  never  fails  to  irritate  and  weak- 
en the  conftitution,  and  thus  to  diforder  the 
digeftive  organs.  Perfons  who  are  falivatcd 
have,  as  far  as  I  have  remarked,  the  func- 
tions of  the  liver  and  digeftive  organs  con- 
ftantly  difturbed  by  that  procefs.  I  canhot, 
therefore,  but  think  that  it  is  wrong  to  ufe 
mercury  in  hepatic  afFeftions  to  that  extent, 
which  would  diforder  the  funftions  of  the 
liver,  if  they  were  previoufly  healthy.  In 
the  majority  of  cafes  the  diforder  has  exifted 

for 


jt  ON   THE   CONSTITUTIOKAX.   O&IOIK, 

for  a  long  time,  and  has  become  habitual ; 
therefore  it  is  not  likely  to  be  cured  fuddenly. 
For  this  reafon,  we  fhould  adapt  our  treat- 
ment to  the  more  rational  expeftation  of 
effecting  a  gradual  recoveiy  than  a  fudden 
cure.  The  moft  judicious  treatment  will 
not  remedy  the  difeafe,  if  the  exciting  caufes 
continue  to  operate ;  fuch  as  improprieties  of 
diet,  agitation  of  mind,  fedentary  habits,  oi 
impm*e  air. 

The  following  cafes  will  afford  fufficient 
teftimony  of  the  efficacy  of  fuch  fimple  treat- 
ment, as  I  have  recommended.  In  fome  in- 
veterate cafes,  apparently  depending  on  efta* 
blifhed  ftervous  diforder,  it  has  been  ineffec- 
tual. Under  fuch  circumftances,  the  nervous 
affection  appears  to  require  the  principal 
attention. 

When  the  flatc  of  the  health  required  it, 
or  the  difeafe  did  not  yield  to  tlie  treatment, 
which  I  have  defcribed,  I  have  referred  the 
cafe  to  the  phyfician ;  under  whofe  diredlion 
benefit  has  been  obtained  by  medicines  of 
xnore  aftivity  than  thofe  which  I  had  ven-  , 

tured 


AKD  TB.BATMENT   OF   LOCAL    DISEASES.    79  * 

tured  to  recommend,  conjoined  with  tonics, 
and  thofe  medicines  which  ^e  ufually  termed 
nervous* 

In  inveftigating  the  treatment  of  thefe  diC- 
orders,  it  is  neceffary  to  afcertain,  not  only 
what  medicine  is  beneficial,  but  alfo  what 
change  it  produces  in  the  circumftances  of 
the  diforder.  The  adminiftration  of  a  medi- 
cine may  in  one  cafe  be  fucceeded  by  a  dis- 
charge of  bile,  and  a  flriking  relief  from  long- 
continued  and  diftrefsful  feelings :  yet  the 
fame  medicine  may  be  given  in  many  other 
inftances  without  the  fame  confequence.  Was 
the  change,  then,  in  this  inftance  accidental  ? 
or  muft  it  be  attributed  to  fome  unnoticed 
peculiaiity  in  the  difeafe  or  conftitution  ? 

I  have  generally  explained  to  the  patients 
the  objefts  which  I  had  in  view,  in  corre6t-» 
ing  diforders  of  the  digeftive  organs,  by  fay- 
ing that  there  are  three  things  which  I  confi- 
der  as  right  and  neceflary  to  the  cure  of  dif- 
order. Firft,  that  the  ftomach  fliould  thorough- 
ly digeft  all  the  food  that  is  put  into  it.  The 
patient  perceiving  the  neceflity  of  obtaining 

this 


86         ON   THE   CONSTlttJtiONAL  6RI6i!^,' 

this  end,  becomes  attentive  to  his  diet,  andob^ 
ferves  the  efFeft  which  the  quantity  and  qua- 
lity of  his  food  and  medicines  have  upon  his 
feelings,  and  the  apparent  powers  of  his  fto- 
mach.  Secondly,  that  the  refidue  of  the  food 
fliould  be  daily  difcharged  from  the  bowels  : 
here  too,  the  patient  apprized  of  the  defign, 
notes  what  kind  and  dofe  of  purgative  medi- 
cine beft  efFeft  the  intention ;  and  whether 
it  anfwers  better  if  taken    at  once,    or  at 
intervals.    Thirdly,  that  the  fecretion  of  bile 
fhould  be  right,  both  with  rsfpeft  to  quan- 
tity and  quality.  In  cafes  wherein  the  fecretion 
of  bile  has  been  for  a  long  time  deficient  or 
faulty,  I  recommend,  as  I  have  faid,  unirritat- 
ing  and  undebilitating  dofes  of  mercury  to  be 
taken  every  fecond  or  third  night,  till  the  ftools 
become  of  a  rhubarb  colour.     This  mode  of 
exhibiting  the  medicine  has  at  leaft  the  ad- 
vantage of  being  innocent,  and  if  months 
clapfe  before  the  objeft  is  accompJiftied  wc 
cannot  wonder  at  the  tardinefs  of  the  cure, 
when  we  conlidcr  the  probable  duration  of 
the  diforder,  prior  to  our  attempts  to  cor-* 
re6l   it.     The  patient   is  relieved  in  pro- 
portion as  the  end  is  accompUftied,  which 

feelingly. 


AKD  tlLSATM£NT   OF   LOCAL   DldEASES.      Si 

feelingly  induces  him  to  perfevere  in  fuch 
innocent  meafuies.  By  thus  engaging  the 
co-operation  of  the  patient,  the  praftitionei? 
will,  in  my  opinion,  derive  confiderable  ad- 
vantage in  the  treatment  of  the  cafe. 

Whenever  citcumfiances  would  permit,  I 
have  recommended  the  patients  to  take  as 
much  exercife  as  they  could,  ftiort  of  pro- 
ducing fatigue;  to  live  much  in  the  open 
air ;  and,  if  poffible,  not  to  fuffer  their  minds 
to  be  agitated  by  anxiety,  or  fatigued  by  ex- 
ertion. The  advantages  of  exercife  in  nervous 
diforders,  upon  which  thofe  of  the  digeftive 
organs  in  general  fo  greatly  depend,  appear  to 
me  very  ftriking*  It  were  to  be  wiftied  that 
we  had  fome  index  to  denote  the  ftrength  and 
irritability  of  the  nervous  fyftem,  ferving  as 
the  pulfe  does  with  regard  to  the  fanguiferous 
organs.  Perhaps  the  ftrength,  agility-^^and 
indefatigability  of  the  mufcles  may  be  reggurd- 
cd  as  the  fureft  evidence  of  energy  of  nervous 
power  and  bodily  vigour.  If  this  were 
granted,  however,  it  would  follow  that  many 
perfons,  poffeffing  great  nervous  power,  have 
neverthelefs  great  nervous  irritability.   Many 

VOL.  I.  o  people. 


82  ON    THE    CONStlTUTIOKAL   ORIOIK^ 

people,  who  are  extf emcly  irritable  and  hypo^ 
condrical,  and  are  conftantly  obliged  to  take 
medicines  to  regulate  their  bowels  whilft  they 
live  an  inaftive  life,  no  longer  fuft'er  from 
nervous  irritation,  or  require  aperient  medi- 
cines, when  they  ufe  exercife  to  a  degree  that 
would  be  exceffive  in  ordinary  conftitutions. 
The  inference  which  I  draw  from  cafes  of 
this  defcription  is,  that  nervous  tranquillity 
is  rellored  in  confequence  of  the  fuperfluous 
energy  being  cxhaufted  by  its  proper  chan- 
nels, the  mufcles.  When,  on  the  contrary, 
the  nervous  fyftem  is  weak  and  irritable, 
exercife  feems  equally  beneficial;  but  cau- 
tion is  here  requifite  as  to  the  degree  in 
which  it  fhould  be  taken.  A  weak  and 
irritable  patient  may  not  be  able  to  walk 
more  than  half  a  mile  without  nearly 
fainting  with  fatigue  on  the  firft  day  of 
theiexperiment ;  but  by  perfevering  in  the 
efFoi't,  he  will  be  able  to  undergo  confider- 
abK  mufcular  exertion  without  wearinefs 
Docs  not  this  imply  a  confiderable  in- 
cieafe  of  bodily  ftrength,  and  is  not  the 
acquifition  of  ftrength  the  chief  defidera- 
tuni  In  the  cure  of  many  diforders?     TJie 

9  .   nervous 


r 

AND   TREATMENT   OF   LOCAL   DISEASES.      83 

nervous  irritability  alfb  when  dependant 
on  weaknefs  alone  will  proportionately  di- 
minifti  with  its  caufe.  In  the  latter  cafe, 
the  nervous  energy  feems  to  be  augment- 
ed in  confequence  of  our  increafmg  the 
demand  for  it,  I  am  induced  to  make  thefe 
thefe  obfervations,  from  a  belief  that  exercife 
is  not  employed  as  a  medical  agent,  to  the 
extent  that  its  efficacy  feems  todeferve.  When 
the  diforders,  which  have  been  the  fubjefl  of 
this  paper,  have  been  long  continued,  they 
do  not  admit  of  a  fpeedy  cure ;  hence  atten- 
tion to  diet,  air,  exercife,  and  mental  tran- 
quillity, are  more  decidedly  beneficial  than 
medicines.  Surgeons  in  London  meet  with 
frequent  and  convincing  inftances  of  the 
efficacy  of  pure  air.  Patients  under  the 
irritation  of  a  local  difeafe,  who  fcarcely  eat 
or  fleep  in  town,  recover  their  appetite,  digef- 
tion,  and  fleep,  fo  fuddenly  on  their  removal 
into  the  country,  as  to  leave  no  room  for 
doubting,  that  the  change  of  air  has  produced 
this  beneficial  alteration  in  their  health.  The 
whole  of  the  plan  of  treatment  which  is  here 
recommended  is  fo  fimple,  and  apparently  fo 
inefficient,  that  its  power  might  reafonably 

G  2  be 


\ 


84    ON   THE   CONSTITUTIONAL   ORIGIN,  &C. 

be  doubted,  did  not  fafts  atteft  its  utility. 
I  fhould  not  have  thought  it  right  to  have 
thus  related  it  in  detail,  but  for  the  purpofe 
of  avoiding  repetition  in  the  recital  of  the 
chafes  which  are  to  follow ;  and  alfo  becaufe 
it  feemed  right  to  ftate  as  explicitly  as  poflible 
to  the  younger  part  of  the  profeffion  what 
are  the  curative  intentions  in  diforders  of 
this  nature*. 


•  After  I  had  written  the  above  account  of  the  treatment, 
which  I  had  found  the  mod  fuccefsful  in  the  corre£Hon  of 
difordered  dates  of  the  digeftive  organS)  I  was  much  gratU 
fied  by  the  perufal  of  Dr.  Hamilton's  publication  on  the 
Effefits  of  Purgative  Medicines.  I  think  there  is  a  great 
xroincidence  in  the  mode  of  treatment  which  I  have  de« 
fcribed,  and  that  which  is  fandioned  by  his  more  extenfive 
experience.  He  prefcribes  purgative  medicines  to  act  as 
eccoproticsy  to  excite  but  not  to  ftimulate  the  bowels  ;  and 
he  combines  with  them  generally  unirritating  dofes  of  mer* 
cury.  Dr.  Hamilton's  plan  of  treating  thefe  difeafesalfo 
accords  very  much  yrith^that  of  M.  Hall^,  to  whofe  Me- 
moir I  have  referred  the  reader* 


CASES. 


(    85    ") 


» 


CASES. 


SECTION  I. 
On  Nervous  and  Mufcular  Diforders. 

T  ONG  before  my  attention  was  excited  to 
^  diforders  of  the  digeftive  organs,  I  had 
remarked  that  there  was  a  paralytic  afFe6lion 
of  the  lower  extremities,  refembling  that 
which  is  produced  by  a  diforder  of  the  me- 
dulla Ipinalis,  in  confequence  of  difeafe  of  the 
bodies  of  the  vertebrae.  This  paralytic  af- 
fe6Hon  alfo  appeared  to  me  to  vary  with 
the  ftate  of  the  patient's  health. 

Thefe  obfei-vations  led  me  to  propofe  » 
method  of  treatment,  which  proved  fuccefs- 
fill  in  the  cafes  of  two  young  ladies,  who 
were  afFefled  in  this  manner.  The  ifTiies, 
which  had  been  inefFeftually  kept  open  in  the 
back,  were  healed;  and  the  ftate  of  the 
health  in  general  was  amended  by  coxmtry 
air,  exercife,  attention  to  diet,  and  a  few 

G  3  .  fimple 


88        ON   THI   CONSTITUTIONAL  ORIGIN^ 

chiefly  felt  at  the  junftion  of  the  ilium  and 
facrum.  It  was  fuppofed,  that  difeafe  had 
taken  place  in  the  bone  from  fome  injury, 
and  had  affefted  the  facral  nerves:  for  fhe 
could  not  ftand  without  fupport,  fo  great 
was  the  weaknefs  in  the  front  of  the  thighs. 
There  was  no  projeflion  of  the  vertebrae.  If 
the  facral  nerves  had  been  affefted,  the  leg 
ought  to  have  fuflfered  the  greateft  fhare  of 
pain  and  weaknefs;  but  that  was  not  the 
cafe.  She  had  no  appetite ;  her  tongue  was 
greatly  furred ;  her  bowels  coftive ;  and  pulfe 
generally  no.  I  ftrongly  objefted  to  mak- 
ing ifTues  in  this  cafe ;  but  as  the  patient's 
fi^fferings  increafed,  it  was  done.  She  went 
into  the  country,  and  died  in  four  or  five 
months.  The  bone  was  found,  upon  exa^ 
mination,  to  be  perfeftly  healthy ;  but  the 
itiefenteric  glands  and  lungs  were  difeafed, 
and  it  was  concluded  that  fhe  died  of  con- 
fumption.  I  could  not  learn  the  ftate  of  the 
liver,  nor  do  I  know  whether  its  appearances 
were  particularly  attended  to. 

CASE  V. 
A  young  lady  had  been  confined  about  fix 
months  to  her  chamber,  on  account  of  pain 

in 


AND  TREATMENT   OF  LOCAL   DISEAS&S.    89 

in  the  loins,  and  weaknefs  of  the  lovyer  extre- 
mities, which  prevented  her  from  ftanding  or 
walking.  •  The  weaknefs  of  her  limbs  had 
been  gradually  increafing  for  a  year  and  a 
half,  before  it  became  fo  bad  as  to  make  her 
incapable  of  moving  about.  Iffues  had  been 
kept  open,  during  that  time,  on  each  fide  of 
the  fpine ;  but,  as  the  patient  received  no  be- 
nefit, my  opinion  was  afked  refpefting  the  feat 
of  the  difeafe  of  the  bone:  for  it  was  conclud- 
ed, that  the  iffues  had  only  failed  from  not 
having  been  made  in  the  right  place.  I  found, 
upon  inquiry,  that  the  chief  feat  of  her  pain 
was  in  the  pofterior  edge  of  the  liver.  Indeed, 
that  \dfcus  was  enlarged,  fo  as  to  be  felt  in  the 
epigaftric  region,  and  was  fb  tender  as  to  caufe 
much  pain  on  >  being  cofnpreffed,  at  any  part^ 
along  the  cartilages  of  the  ribs.  Her  tongue 
was  furred  ^  her  appetite  deficient ;  digeftion 
bad  5  bowels  coftive ;  and  ftools  black,  or  elfe 
untinged  with  bile.  I  had  no  hefitatibn  in 
advifing,  that  the  iffues  fliould  be  difcon- 
tinued ;  and  that  attention^  ftiould  be  chiefly 
direfted  to  re6lify  the  diforder  of  the  chylopoi- 
ctic  vifcera.  Mild  mercurials  and  aperients 
were  given,  by  which,  with  other  means,  fhe 

got 


90         ON   THE    COKSTITUTXOKAL   ORIGIN, 

got  materially  better  in  health,  and  was  able 
to  walk  about  as  well  as  ever.  The  gentle- 
man who  attended  this  patient,  met  me  acci- 
dentally, two  months  afterwards,  and  in- 
formed me  that  (he  was  quite  well.  I  faid, 
that  as  her  difeafe  had  been  a  long  time  in 
forming,  it  could  hardly  be  expelled  that  fhc 
fhould  recover  fo  fuddenly.  He  confidered 
this  expreffion  as  implying  fome  doubt  of  his 
accuracy,  and,  therefore,  fent  the  patient  to 
me  in  the  morning.  She  came  from  Lambeth, 
in  a  hackney  coach,  and  looked  very  well : 
{he  obferved  j  that  long  before  her  confine- 
ment, flic  could  not  have  borne  the  agitation 
Cjf  a  carriage ;  but  that  now,  flie  did  not  feel 
it.  I  have  been  informed,  by  feveral  intelli- 
gent ftudents,  that  fimilar  cafes  have  occur- 
red in  the  hofpital :  as  I  was  not  a  witnefs 
of  thefe,  I  fliall  not  relate  them.  I  fliall, 
however,  mention  one,  which  I  faw,  and  fu- 
perintended  myfelf  s  although  it  is,  in  fome 
meafure,  imperfeft,  as  the  patient  quitted  the 
hofpital  fuddenly,  without  our  knowing 
where  he  went  to. 


CASE 


AND   TREATMENT   OF   LOCAL   DISEAStS.     gi 

CASE    VI. 

Thomas  Crighton,  aged  twenty-three,  was 
admitted  into  St.  Bartholomew's  Hofpital,  on 
account  of  a  palfy  of  his  limbs.  About  a  year 
before,  while  the  ufe  of  his  limbs  was  yet  un- 
impaired, he  was  attacked  repeatedly  with 
violent  pain  in  the  bowels ;  uniformly  pre- 
ceded by  coftivenefs,  and,  generally,  termi- 
nated by  a  copious  difcharge  of  loofe,  fetid, 
black  ftools.  The  relief  afforded  by  the  diar- 
rhoea was  (jpeedy  and  uniform.  In  the  courjfe 
of  fix  months  his  lower  extremities  became 
affefted  with  occafional  twitchings,  and  he 
found  that  he  could  not  regulate  their  mo- 
tions in  walking :  this  increafed  to  fuch  a 
.  degree  as  to  make  him  incapable  of  taking  any 
exercife.  He  had,  at  the  commencement  of 
his  illnefs,  a  confufion  of  vifion ;  and  a  con- 
flant  and  violent  pain  in  the  head.  The  for- 
mer fymptom  increafed  fo  much,  that  he 
could  difcern  no  objeft  diflinftly  5  a  candle, 
for  inflance,  although  held  near  him,  ap- 
peared as  large  as  the  moon.  The  fenfation 
of  his  lower  extremities  continued  perfeft ; 
but  the  aftions  of  the  bladder  were  no  longer 
under  the  controul  of  the  will  5  the  urine 

fome- 


92         ON  THE   CONSTITUTIONAL  ORIGIN, 

fometimes  flowing  involuntarily  ;  and,  at 
others,  being  retained  for  fome  hours,  with 
confiderable  pain.  He  afterwards,  began  to 
lofe  the  ufe.of  his  upper  extremities :  the  left 
Iiand  and  arm  were  more  afFefted  than  the 
right  5  but  there  was  no  difference  in  the  af- 
feftion  of  the  leg  on  the  fame  fide.  His  fpeech, 
alfo,  became  much  impaired ;  he  hefitated  and 
faltered  confideraWy,  and  the  tones  of  his 
Toice  were  irregular,  fo  that,  at  length,  he 
could  fcarcely  make  himfelf  undcrftood.  At 
the  time  of  his  admiflion  into  the  hofpital^ 
there  was  an  entire  lofs  of  voluntary  motion 
of  the  lower  extremities,  and  a  great  diminu- 
tion of  that  of  the  upper.  The  bowels  were 
deranged  J  there  was  conftant  head-ache ;  the 
^cech  was  very  indiftindl ;  and  vifion  fo  im- 
perfeft,  that  he  could  not  read  the  largeft 
print*  An  iflue  was  made  iii  the  neck,  and 
fome  medicines  were  prefcribed,  under  the  di- 
reftion  of  the  phyfician.  As  the  treatment  did 
not  prove  beneficial,  I  was  defired  to  examine 
the  fpine,  and  found  fuch  a  curvature  and  pro- 
jeftion  of  the  fpinous  proceffes  of  the  upper 
lumbar  and  lower  dorfal  vertebrae,  that  I 
thought,  the  bodies  of  thofe  bones  muft  be 

13  dif- 


AKD   TR£ATM£KT   OF   LOCAL    DISEASES.      93 

difeafed.  I  was,  therefore,  inclined  to  attri- 
bute the  paralyfis  of  the  lower  extremities  to 
this  difeafe  of  the  fpine ;  and,  confequently^ 
direfted,  that  iflues  flMuld  be  made  on  each 
fide  of  the  projefting  vertebrae.  As  this 
fuppofition  would  not  account  for  the  pa- 
ralytic afFeflion  of  the  parts  above,  and  as 
the  bowels  were  deranged,  I  ordered  two 
grains  of  calomel  with  eight  of  rhubarb,  to 
be  taken  twice  a  week,  and  fbme  infufion  of 
gentian  with  fenna,  occafionally.  After  ufing 
thefe  medicines,  for  about  three  weeks,  his 
bowels  became  regular,  the  biliary  fecretion 
healtliy,  and  his  appetite  good.  He  could 
move  his  haiids  and  arms  neaily  as  well  as 
ever ;  and  his  eye-fight  was  fo  much  improved 
that  he  could  read  a  news-paper ;  indeed,  it 
was  nearly  welL  The  funftions  of  the  blad- 
der were  completely  reftored  *  -,  liis  fpeech 
became  articulate ;  and  his  general  health,  in 
every  refpeft,  much  improved.  He  remained 
in  the  hofpital  about  two  months,  but  with 

♦  I  have  feen  feveral  cafes  which  induce  me  to  believe 
that  the  weaknefs  of  the  fphindier  veficae,  which  occafions 
young  perfons  to  void  their  urine  during  fleep,  very  fre- 
quently ariies  from  the  fame  caufe. 

very 


94  ON    TUB   COKStlTUTIONAL   ORIGIN^ 

very  little  amendment  in  the  ftate  of  the  lower 
extremities,  when  his  friends  fuddehly  re- 
moved him,  on  account  of  fome  difagreement 
with  the  nurfes,  and  I  was  unable  to  learn 
whither  they  had  conveyed  him. 

The  hiftory  of  the  preceding  cafe  was  taken 
by  Mr.  Cruttwell,  now  pra6lifing  as  a  furgeon 
in  Bath,  who  had  been  for  feveral  years  a 
moft  induftrious  ftudent  at  the  hofpital,  and 
whofe  accurate  obfei-vation  and  extenfivc 
infonnation  induce  me  to  place  entire  con- 
fidence in  any  ftatem^nt  of  a  cafe  which  I 
receive  from  him.  To  that  gentleman  I  am, 
alfo,  indebted  for  the  following  particulai's 
relating  to  a  patient,  who  died  fome  little 
time  ago  in  the  hofpital,  and  whofe  body  was 
examined.  The  difleftion  ferves  ftill  further 
to  elucidate  my  prefent  fubjefl. 


CASE  vn. 

Elizabeth  Griffin,  twenty  years  of  age,  was 
admitted  into  St.  Bartholomew's  hofpital  in 
Auguft  1805,  on  account  of  an  inability  to 
move  her  lower  limbs  j  which  was  fuppofed 

to 


AKD  TREATMENT  OF  LOCAL  DISEASES.      95 

to  originate  from  a  difeafe  of  the  fpine.     On 
examination,  however,  there  were  no  appear- 
ances, which  indicated  caries  of  the  vertebrae. 
Her  voice  was,  at  times,  conliderably  affefted: 
and  (he  was  fubjefl  to  occafional  attacks  re^ 
fembling,  in  fome  degree,  epileptic  paroxyfms. 
The  afFeftion  of  the  limbs  was  liable  to  con- 
fiderable  variations.     At  times,  as  (he  affured 
me,  (he  could  walk  acrofs  the  ward  with  very 
little  difficulty ;  at  others,  flie  could  not  even 
ftand  without  afliftance.  Her  tongue  was  ex- 
tremely, and,  I   believe,  conftantly   white; 
her  pulfe  natural.     Her  bowels  were,  gene- 
rally, coftive,  and   it  was   neceflary  to  em- 
ploy aftive  medicines  in  order    to  procure 
ftools,  which  were  always  of  a  dark  colour. 
A  flight  temporaiy  diarrhcea  fometimes  hap- 
pened, and  flie  invariably  remarked,  that  the 
eafe  or  difficulty  with  which  ftie  could  walk, 
and  the  pain  in  her  head  with  which  flie  was 
troubled,  were  in  exa6l  conformity  to  the 
ftate  of  the  bowels,  all  the  fymptoms  being  re- 
lieved by  the  diarrhoea,  and  returning  as  the 
bowels  became  again  cofl:ive.     There  was  an 
appearance;  of  irritability  and  languor  in  the 
eye,  which  I  have  before  obferved  in  thefe 

cafes. 


9^        OK  tflfi   COHSTITUTlONAl  OftlOIN^ 

cafes,  and  the  pupils  were  generally  much  di-' 
lated.  After  the  patient  had  continued  irt 
the  hofpital  about  feven  weeks,  (he  was  at- 
tacked with  fever,  and  died,  To  this  brief' 
account  of  the  fymptoms,  I  now  fubjoin  the 
diffeflion. 

No  difeafed  appearances  were  obferved  in 
the  brain,  though  it  was  examined  with  the 
moft  particular  attention :  neither  was  there 
any  difeafe  of  the  vertebrae.  No  difeafe,  in 
fliort,  was  obferved  except  in  the  abdominal 
vifcera.  The  chief  morbid  appearance,  in 
them,  confided  in  an  ulcerated  ftate  of  the 
villous  coat  of  the  ilium  near  to  its  termina- 
tion in  the  caecum.  The  ulcers  were  numer- 
ous, and  fituated  where  the  mucous  glands 
are  chiefly  found.  The  internal  coat  of  the 
large  inteftines,  alfb,  appeared  inflamed. 

The  liver  was  healthy  in  its  flrifChire,  In 
the  gall  bladder  about  one  ounce  and  a  half 
of  a  light  green  ferous  fluid  was  found,  which 
had  not  in  the  leafl:  degree  the  foapy,  or  mu- 
caginous  feel  of  bile. 

Cafe.% 


AkD  TILEATMEKT  Oi  LOtiAL  DI8CASS3.    97  : 

Cafes^  like  thofe  which  have  beea  related, 
are  not,  if  I  may  judge  from  my  own  experi- 
ence, at  all  uncommon.  They  fufficiently 
prove,  in  my  opinion,  that  local  nervous  dif- 
orders  and  mufcular  <iebility  may  arife  from 
a  general  diforder  of  the  health,  in  which  the 
digeftive  organs  are  chiefly  afFe£ted.  This 
diforder,  as  has  been  flated  in  the  prelimi- 
nary obfervations,  may,  fometimes,  be  the 
caufe,  and  fometimes  the  efFeft,  of  the  ner- 
vous afFedlion.  In  either  cafe,  however,  its 
correftion  is  of  high  importance  in  the  me- 
dical treatment  of  the  difeafe.  In  the  fifth 
aad  fixth  cafes,  a  diforder  of  the  digeflivo 
organs  muft,  I  think,  be  allowed  to  be  the 
caufe  of  the  nervous  afFeftion,  from  the  fiid- 
den  and  complete  ceflation  of  the  latter,  when 
the  cure  of  the  former  was  accomplifhed. 
Decifive  inftances  like  thefe  are  particularly 
valuable ;  they  fhew  what  great  nervous  dif-- 
order  mty  be  produced  by  that  of  the  digef- 
tive  organs,  and  confequently  how  much  the 
latter  diforder  is  likely  to  aggravate  the  for- 
mer, when  it  occurs  even  fecondarily  as  its 
efiefl:.  I  have  feen  a  confiderable  number 
of  fuch  cafes,  which  I  cannot  relate  with' 

VOL,  I*  II  preci- 


98        OK  rrHB  -  CONSTITUTIONAL   ORIGIN^ 

precifion,  becaufe  I  had  not  fufficient  oppor-* 
tunities  of  obferving  the  patients,  to  enable 
me  to  note  the  progrefs  of  the  difeafe  with 
accuracy. 

Of  thefe  I  can  only  obferve,  in  general 
terms,  that  I  have  feen  feveral  inftances  of 
pain,  imbecillity,  and  wafting  of  the  mufcles 
in  one  of  the  lower  extremities,  which  were 
confidered  as  the  effe6t  of  difeafe  about  the 
hip  joint ',  yet  the  event  proved  that  there 
was  no  organic  affeftion  of  that  part.  The 
complaint  was  connedled  with  that  ftate  of 
conftitution  which  I  have  defcribed,  and  was 
amended  as  the  health  in  general  improved^ 
I  have  alfo  feen  feveral  inftances  of  wafting 
of  the  mufcles  of  one  of  the  upper  extremi- 
ties in  children ;  fo  much  indeed  were  the 
muicles  ftirunk,  that  tlie  bones  and  joints 
could  be  as  diftinctly  examined  as  in  a  Ikele- 
ton.  The  local  afFeftion  in  thefe  cafes  c^me 
on  fuddenly.  I  lately  law  a  little  boy,  who 
had  an  attack  of  this  kind  in  his  left  arm 
feveral  years  ago,  and  on  whole  cafe  I  was  at 
that  time  confultcd.  The  bowels  had  been 
violently  difordered  previous  to  the  paralytic 

1 2  afFeftion, 


AKD  TREATMEKT  OF   LOCAL    DISEASES.      99 

• 

afFe£tion,  and  were,  at  the  time  I  faw  him, 
in  an  extremely  unhealthy  .ftate.  I  reconv. 
mended  that  the  chief  attention  (hould  be 
paid  to  correft  the  diforder  of  thefe  organs, 
and  that  the  arm  (hould  be  fupported  by  a 
fling*  The  limb  gradually  recovered,  and 
though  it  is  not  at  prefent  quite  fo  large  and 
ftrong  as  the  other,  yet  the  difference  is  fo 
flight,  that  it  would  not  attraft  the  attention 
of  a  common  obferver.  About  fix  months 
ago  I  faw  a  little  boy  in  very  (imilar  cir- 
cumftances,  and  in  his  cafe,  the  arm  quick- 
ly recovered  its  powers  of  motioti,  as 
the  ftate  of  the  digeftive  organs  became 
healthy; 

I  have  alio  feen  cafes  in  children,  in  whom, 
after  fome  general  diforder  of  the  health, 
accompanied  by  derangement  of  the  ftomach 
and  bowels,  an  afFe6tion  of  the  mufcles  of 
the  extremities  has  taken  place,  like  that 
which  produces  the  varus  and  valgus ; 
I  mean  a  predominance  of  the  adlions  of 
fome  mufcles  over  others,  producing  diftor- 
tion  of  the  limb.  I  have  feen  this  happen . 
fometimes  in  otie,.  fometimes  in  botli  the 

H  2  lower 


I  CO       ON  THE   CONSTITUTIONAL  ORICTIN^ 

lower  extremities.     I  have  alfo  feen  the  arm 
fimilarly  afFeded. 

That  the  local  fymptoms  in  thefe  cafes,  as 
well  as  in  thofe  which  have  been  more  fully 
detailed,  arife  from  a  nervous  affcdtion  of 
the  brain,  and  not  from  any  caufe  a£ting 
locally  on  the  nerves  of  the  affefted  part, 
will,  I  believe,  on  due.confideration  be  grant- 
ed,    I   fufpeft  however  that  fome  perfons 
may  hefitate  to  admit  fuch  an  opinion,  from 
the  belief  that  diforder  of  the  brain  muft  ope- 
rate generally,  and  not  partially,  on  the  ner- 
vous fyftem.     Perhaps  the  contemplation  of 
the  confequences  of  flight  apopleftie  effiiifions 
in  the  brain,  may  aflift  us  in  forming  jufl:  no- 
tions on  this  fobjeft.     Such  flight  efFufions 
of  blood,  occurring  in  various  parts  of  the 
brain,  have  been  known  to  paralyfe  one  leg 
or  one  arm,  or  the  mufcles  of  the  tongue,  or 
of  one  half  of  the  face,  without  afFefting  the 
reft  of  the  nervous  or  mufcular  fyftem. 

Another  opinion  which  I  wifli  to  be  con- 
fidered  is,  whether,  when  there  is  confider-* 
able  and  continued  paralyfis,  there  muft  ne- 

4  ceflarily 


AND   TREATMENT  OF  LOCAL   DISEASES;   lOI 

ceflarily  exift  fome  preffure  or  organic  difeafe 
in  the  brain.     That  this  exifts  in  many  in- 
ftances  is  undoubted;    but  the  number  of 
cafes  in  which  the  paralytic  afFeflion  is  mere- 
ly nervous,  and  independant  of  visible  difeafe, 
is  in  my  opinion  very  confiderable.     The  in- 
ftances  which  have  been  related  warrant  this 
conclufion,  and  fliew  fuch  cafes  to  be  more 
frequent  than  is  generally  fuppofed.     When 
there  is  organic  difeafe  of  the  brain,  the 
cafe  is  very  hopelefs  j  and  probably  no  con- 
fiderable  alleviation  of  the  fymptoms  will 
take  place,  by  that  attention  to  the  ftate  of 
the  digeftive  organs  which  I  have  recom- 
mended.    In  dubious  cafes,  and  fuch,  on 
the  firft  examination  of  them,  the  majority 
of  thefe  inftances  will  probably  be,  it  feems 
right  to  try  the  effect  of  corre6ling  difordcr 
of  the  digeflive  organs,  with  a  view  to  alle- 
viate nervous  irritation,  before  we  proceed 
to  thofe  fqverer  methods,  which  the  belief  of 
the  exiflence  of  organic  or  vafcular  difeafe 
in  the  brain  would  induce  us  to  inftitute. 
For  if  blood-letting  and  counter  irritation 
be  employed,  in  order  to  diminifh  vafcular 
a6iion ;  or  if  mercury  be  employed  to  fome 

H  3  extent 


102      ON   THE   CONSTITUTIONAL   ORIGIN, 

extent  in  order  to  induce  the  abforption  of 
depofited  fubftance;  thefe  meafures  muft 
aggravate  that  diforder  of  the  general  hedlth, 
upon  which,  in  many  inftances,  the  nervous 
afFeflion  depends. 

My  objefl,  in  the  recital  of  the  foregoing 
cafes,  is  to  point  out  a  caufe  of  paralyfis  iil 
paitioilar  mufcles,  which  from  its  locality 
would,  I  fufpeft,  be  generally  attributed  tb 
fome  local  diforder  of  the  ner\'es  of  the  affe6l- 
cd  part,  and  therefore  be  treated  erroneoufly. 
If  my  opinion  of  the  nature  of  thefe  cafes 
be  correft,  they  can  only  be  fuccefsfiilly 
treated  by  means  which  operate  upon  the 
conftitution  in  general.  I  have  particularly 
recommended  that  our  efforts  (hould  be  dir- 
ie6led  to  correfl  any  errors  that  may  exift 
.  in  the  funaions  of  the  primae  viae,  for  reafons 
that  have  been  ftated  in  the  preliminary  ob- 
fervations.  Of  the  efficacy  of  fuch  endeavours 
I  have  feen  many  more  inftances  than  I  have 
brought  foi-ward ;  indeed  the  propriety  of 
fuch  attemj)ts  feems  fo  obvious,  that  I  doubt 
not  but  they  will  be  made,  and  the  effefl  of 
them  will,  by  that  means,  be  generally  demon* 

ftratcdi' 


. .  *  k  * 


Al»   TREATMENT  OF  XOGAL  DItEASBI.    IC3 

ftratcd.  It  is  right  however  to  mention, 
that  in  fome  cafes  to  which  I  have  attended, 
I  have  been  foiled  in  my  endeavours  to  cor- 
reft,  by  the  fimple  meafures  which  I  have 
related  in  the  introduftory  remarks,  thedif- 
orders  of  the  digeftive  organs  3  probably  be- 
caufe  their  derangement  depended  on  fome 
eftablifhed  difeafe  in  the  brain. 

In  other  cafes,  when  the  funftions  of  the 
digeftive  organs  had  been  partially  reftored, 
the  nervous  and  mufcular  afFeftions.were  mi- 
tigated but  not  cured.  I  have  alfo  met 
with  one  inftance,  in  which  the  bowels  be- 
came moderately  correft  in  their  funftions, 
without  any  evident  amendment  in  the  ftate 
of  the  limbs ;  and  I  have  known  two  inftances 
of  perfons,  who  were  fuddenly  feized  with 
paralyfis  of  the  lower  extremities,  apparently 
depeudant  on  general  nervous  diforder,  in 
which  the  digeftive  organs  fcarcely  feemed 
^e6led. 

In  feveral  of  the  cafes  which  I  have  related, 
there  were  nervous  pains  in  the  afFedted  limbs, 
f  hat  this  fymptom  may  arife  from  general 

H  ^  nervous 


104      ON  TH2   eOMSTITUTIONAL  ORIOIH» 

nervous  difbrder  feems  to  me  very  probable  i 
at  kaft,  I  can  affirm,  that  I  have  known  fuch 
pains  cured  by  correfling  the  ftate  of  the 
digeftive  organs.  In  the  cafes  of  tic  doulou- 
reux, which  have  fallen  under  my  obfeiva^ 
tion,  thefe  parts  have  been  greatly  deranged; 
and  I  have  cured  patients  of  fuch  complaints, 
by  corrpdHng  this  difturbance, 

I  wifh  finally  to  excite  the  attention  of 
Surgeons  to  ^the  ftate  of  the  bowels  in  tc- 
tanus.   The  occurrence  of  this  diforder  occa*^ 
fionally,  when  the  wound  which  produced  it 
is  healing,  feems  to  indicate  that  the  efFefts 
which  have  been  produced  by  its  irritation, 
continue.     It  has  been,  I  think,  fully  fhewn, 
that  local  irritation  may  diforder  the  digeftive 
organs ;  which  diforder  continuing,  and  ag-^ 
gravating  the  affe6lion  of  fenforium,  may 
poffibly  lead  to  the  produdlion  of  tetanus, 
at  a  time  when  the  wound  is  no  longer  irri- 
table.    In  four  cafes  of  tetanus,  in  which  I 
had  an  opportunity   of  inquiring  into  the 
ftate  of  the  bowels,  the  evacuations  from  thenj 
were  not  like  faeces.     I  wifh  to  propofe,  in 
jnvefti^ating  the  caufe  of  tetanys,  as  a  quel^ 

tioR, 


ANP  TigUTtl£NT  OP  LOCAL  DI8EABE6.   I05 

tion,  What  is  the  ftate  of  the  bowels  between 
the  infU6lion  of  the  injury  and  the  occur- 
rence of  that  dreadful  malady  *  ? 

*  Such  cafes  as  I  have  related^  with  others  that  it  would 
be  foreign  to  my  prefeivt  purpofe  to  mention^  haveimprefied 
the  opinion  on  my  mind,  that  diforders  of  the  digeftive 
organs  may  originally  caufe,  or  may  fecondarily  aggravate, 
a  nervous  diforder ;  and  produce,  as  has  been  *^  mention- 
ed,  in  the  nervous  fyftem,  a  diminution  of  the  fundions 
of  the  brain ;  or  a  ftate  of  excitation  caufing  delirium, 
partial  nervous  ina£tivity,  and  infenfibility  ;  or  the  oppo* 
lite  ftate  of  irritation  and  pain :  in  the  mufculsir  fyftem, 
weaknefs,  tremors,  and  palfy;  or  the  contrary  affedbns 
of  fpafms  and  convulfions/'  Could  thefe  circumftances  be 
proved,  it  would  be  fcarcely  neceflary  to  add,  that  thofe 
painful  afitsdions  of  parts,  to  which  perhaps  fome  pre« 
difpofition  exifts,]1iay  be  excited  in  a  fimilar  manner.:  fuch 
as  gout  and  rheumatifm.  Indeed  rheumatic  pains  are  very 
lifually  concomitant  upon  that  ftate  of  conftitution,  which 
in  ibe  patients,  whofe  cafes  J  am  rdatiog. 


CASES. 


1C5        ON  THE  CONSTIT0TIOKAL  ORiaiK^ 


.CASES, 


SECTION  n. 


On  ibe  EffeStt  of  Diforders  of  tU  digeftive  Orgartf 
attending  Injuries  of  the  Head. 


I 


SHALL  next  fpeak  of  thofe  cafes,  in  which 
local  diforders  of  the  head,  produced  by 
blows,  are  kept  up  and  aggravated  by  affec- 
tions of  the  digeftive  organs.  After  what 
has  been  obferved  refpefting  the  reciprocal 
influence  of  the  difeafes  of*'  the  brain,  and  of 
the  chylopoietic  vifcera,  it  will  readily  be 
admitted,  that  an  injury  pf  the  former  may 
difturb  the  fiinftions  of  tlie  latter.  Thus, 
concuflion  of  the  brain  occafions  vomiting  as 
one  of  its  immediate  confequences,  and  will 
alfo  be  found  to  produce  almoft  conftantly, 
at  a  more  remote  period,  that  difturbance  of 
the  digeftive  organs,  which  I  have  dcfcribed 
in  this  paper.  If  the  difl:urbance  be  only 
moderate  in  degree,  but  continued,  it  will 
often  re-aft  upon  the  head,  fo  as  to  occafioa 

ai^ 


ANP  TRBATMSNT   OF  LOCAL   DISEASES.    X07 

Jin  irritable  ftate  of  the  injured  parts,  and 
impede  their  recovery. 

In  jtnany  cafes  of  blows  upon  the  head,  a 
flow  inflammatory  affeftion  continues  in-  the 
parts  chiefly  injured,  and  ultimately  produces 
dellruftive  difeafes.    The  bone  fbmetimes  be- 
comes difeafed,  or  an  exofliofis  grows  from 
its  internal  table ;  the  dura  mater  becomes 
thickened,  or  matter  flowly  coUefls  on  its  fur- 
face.     Such  local  diforders  produce  others  of 
a  more  general  nature,  and  deftroy  the  pa- 
tient. Thefe  occurrences  are  however,  in  my 
Qpinion,  rare  in  comparifon  with  the  cafes 
firft:  defcribed ;  in  which  a  painful  ftate  of 
the  injured  parts  is  kept  up  by  means  of  dif- 
order  exift»ng  in  the  digeftive  organs.     The 
ncceflity  for  an  accurate  difcrimination  be- 
tween thefe  diforders,  muft  ftrike  us  on  the 
moft  fuperficial  view  of  the  fubjeft ;  for  the 
lowering  treatment,  which  is  neceflary  in  the 
firft  and  rarer  cafe,  would  be  detrimental  in 
the  fecond  and  more  frequent  ones.     By  at- 
tending to  the  ftate  of  the  digeftive  organs 
m  thefe  dubious  cafes,  we  may  be  enabled  to 
Ifbrm  a  probable  opinion  of  the  nature  of  the 

local 


,  J* 


I08      ON  THE  CONSTITUTION  At  ORIOIN^ 

local  couiplaint;  for,  if  there  be  nothing 
wrong  in  the  general  health  to  excite  or 
maintain  it,  we  may  reafonably  conclude 
that  it  was  merely  local ;  on  the  other  hand, 
the  inefficacy  of  evacuations  in  curing  the 
local  difeafe  would  naturally  fuggeft  the 
opinion,  that  it  proceeds  from  irritation,  and 
is  dependant  on  a  diforder  of  the  health  in 
general.  It  fliould  be  further  obferved,  that 
when  the  local  difeafe  is  of  an  inflammatory 
nature,  and  likely  to  induce  morbid  alterations 
in .  the  ftrufture  of  the  aftcfted  parts,  ftill  it 
may  be  maintained  and  aggravated  by  dis- 
order of  the  digeftive  organs.  I  have  very 
frequently  feen  patients  fufFer  fo  fevercly  ai5 
to  warrant  a  fufpicion,  that  local  difeafe  of 
the  moft  formidable  nature  exifted ;  in  thefc 
the  ufual  methods  of  treatment  were  ineffec- 
tual ;  and  they  recbvered  fuddenly  or  ilowly, 
in  proportion  as  the  flate  of  the  digeftive 
organs  was  corredled.  I  fhall  relate  fome 
examples  of  the  difeafe  under  confideration, 
which  will  enable  the  reader  to  identify  the 
cafe,  when  it  occurs  in  pra6tice. 


CASE 


AND  TRBATIIIMT  OP  LOCAL  0liBA8ltit   IO9 


CASE  vra, 

A  young  gentleman,  about  ten  years  of 
age,  fell  out  of  a  window,  fix  feet  high,  and 
ftruck  the  back  part  of  his  head  againfl  fbme 
ftones.    He  was  ftunned  by  the  blow,  but 
perfectly  recovered  from  the  effefts  of  the 
accident  by  bleeding,  purging,  and  a  tow 
diet.     He  caught  the  fcarlet-fever  about  fix 
weeks  afterwards;  and  recovered  from  that 
alfo.    But,  whilft  he  was  convalefcent,  the 
pains  returned  in  that  part  of  the  head  which 
had  been  ftfuck,  with  fo  much  violence,  as 
to  induce  the  belief  that  fome  ferious  local 
mifchief  would  enfue.     After  they  had  con* 
tinued  without  abatement  for  a  few  days,  I 
was  defured  to  fee  him.     He  was  lying  in 
bed,  and  could  fcarcely  be  prevailed  on  to  lift 
his  head  from  the  pillow.  *  The  integumentsr 
of  the  occiput  were  fo  tender,  that  he  would 
hardly  allow  me  to  examine  the  part ;  I  afcer« 
tained, .  however,   that   there  was  no  fluid 
under  the  fcalp,  nor  any  inequality  in  the 
bone.     He  dozed  a  good  deal,  and  lay  in  * 
comatofe  flate,  but  was  occafionally  refltefs. 

His 


no       ON  .THS  CONSTITUTIONAL  ORIGIN/ 

His  pulfe  was  very  frequerif,  his  (kin  hot  zad 
dry,  and  his  tongue  covered  with  a  thick  yel- 
low fiir.  He  breathed  almofl:  without  moving 
the  diaphragm,  and  complained  much  if  the 
q>iga{tiic  region  was  comprefTed.  He  loathed 
food;  his  bowels  were  coftive,  sjnd  his  ftools^ 
of  a  blackifh  colour.  He  was  ordered  ta 
take  imall  dofes  of  calomel  at  night,  and 
draughts  with  rhubarb  and  kali  vitriolatum 
in  the  morning.  The  tongue  foon  became 
clean^  and  the  ftools  natural;  his  appetite^ 
and  fpirits  returned,  and  he  no  longer  conw 
plained  of  any  uneafinefs  in  the  head^ 

This  cafe  prelents  us  with  a  ftriking  ex- 
ample of  what  I  believe  to  be  a  common  oc- 
currence ',  I  mean,  a  difordered  ftatc  of  the 
digeftive  organs  taking  place  fubfequently  ta 
a  coniiderable  febrile  afFe6Hon.  Indeed; 
when  we  refleft  in  how  weak  and  initable  a 
ftate  the  brain  muft  be  left  upon  the  fubfi- 
dence  of  fuch  a  diforder,  and  how  much  the 
chylopoietic  vifcera  muft  fufier  from!  the  im** 
paired  and  difordered  energy  of  the  brain,  we 
might  naturally  expeft  fuch  a  derangement 
of  the  functions  of  the  digeftive  organs  ta 

cnfue. 


*  AUnf  TREATMENT   OF  LbCAL  DISEASES,  fit 

enfue.     When  (lich  diforder  happens  in  this 
manner,  it  frequently  produces  many  local 
difeafes,  to  which  the  conftitution  may  per- 
haps be  predifpofed;  a  circumflance  lihalL. 
fpeak  of  in  a  future  part  of  this  paper.     In 
the  prefent  cafe,  it  brought  on  a  painful  ftatc 
of  partis  recently  injured,  with  a  confiderable 
degree  of  fever.  That  the  morbid  ftate  of  the 
flomach  and  bowels  was  the  caufe  of  both  is 
fairly  to  be  inferred  from  their  ceafing  fo  im- 
mediately, when  the  diforder  of  the  digeftivc 
organs  was  correfted.     A  cafe  of  this  kind, 
prefenting  an  example  of  fudden  recovery,  is 
particularly  valuable,  becaiife  it  clearly  de- 
monftrates  the  caufe  and  the  eflfeft  in  fuch 
difeafes.     The  caufe  can  indeed  be  feldom  lb 
fuddenly  removed ;  ahd  tlie  gradual  ceiTaticm 
of  it  under  any  plan  of  tieatment  leaves  room 
for  a  variety  of  conjeftures,  as  to  the  mode  of 
cure  or  of   recovery  from  thofe  difbrders 
which  I  have  confidered  as  efFe6ts.     I  could 
relate  many  cafes  of  fimilar  but  lefs  feverc 
iymptoms  produced  by  the  fame  caufe,  which 
gradually  got  well,  in  proportion  as  the  dif- 
orders  of  the  digeftive  organs  were  corre6led. 
As  it  does  not,  however,  appear  to  me  nccet- 

fary 


112     ON  THB  CONSTirOTIONAL  ORIOIH^ 

lary  to  accumulate  inftances  to  prove  fb  ohn-^ 
ous  a  fa6l,  I  fhall  content  myfelf  with  ad« 
ducing  two  more  cafes,  to  exhibit  fuch  effefta 
in  different  points  of  view. 

CASS   DC 

A  lady  fell  down  in  frofty  weather,  in  con* 
fequence  of  her  feet  flipping  from  under  her, 
and  the  occiput  ftruck  againft  a  fmooth  flone 
pavement.     She  was  ftunned  by  the  fall,  but 
loon  recovered ;  nor  had  ftie  for  fome  weeks 
the  fevere  fymptoms,  which  appeared  in  the 
fcquel.    This  circumftance  fhews  that  there 
was  nothing  produced  by  the  blow  that  ne- 
ceflarily  caufed  the  fubfequent  lymptoms; 
which  muft  therefore  be  attributed  to  inflam- 
mation or  irritation  taking  place  afteiwards. 
When  fome  weeks  had  clapfed  from  the 
time  of  the  accident,  the  parts  which  had 
been  flruck  became  extremely  painful;  and 
the  pain  extended  forwards  over  the  fcalp  to 
the  right  eye,  the  fight  of  which  became  im- 
perfeft.    The  integuments  upon  which  the 
blow  had  been  received  were  extremely  ten- 
der, and  the  patient  became  faint  when  they 
were  examined   even  flightly.     Thefe  cir- 

cumflances 


AKiy  TRBATIfEKT  OF  LOCAL  DI8&A8X8.  II3 

cumftances  naturally  induced  a  belief  that 
ibme  difeafe  was  taking  place ;  and  bleeding 
and  purging  were  employed  to  prevent  its 
progrefs.  The  (ymptoms  were  mitigated 
for  a  time  by  thefe  means,  but  they  quickly 
returned  with  as  much  feverity  as  before. 
After  three  months  the  patient  came  to  Lon- 
don, ftilly  perfuadcd  that  nothing  but  an 
operation  would  be  of  permanent  benefit. 
When  I  firft  faw  her,  (he  tottered  in  moving 
ftom  one  chair  to  another,  and  replied  to 
queftions  with  hefitation  and  effort.  Her  eye- 
fight  was  fo  much  affefted,  that  (he  could 
not  read  j  and  fhe  entertained  an  apprehen- 
fion  that  (he  (hould  lofe  her  fenfes.  Her 
tongue  was  but  (lightly  ftirred  j  her  bowels 
were  habitually  coftive,  and  the  flools  dark 
coloured.  It  was  evident  where  the  injury 
had  been  received  >  for  the*  aponeurofis  had 
been  fcparated  from  the  pericranium  by  an 
effufion  of  blood ;  and,  though  this  blood 
had  been  abforbed,  the  detachment  of  the 
fcalp  was  diftinguiihable  by  the  touch.  No 
inequality  was  perceptible  in  the  fiirface  of 
the  bone.  When  I  mentioned  my  fufpicion 
that  thefe  fymptoms  were  rather  the  eSkSt 

'      VOU.U  I  of 


114     OK  T»B  CON8TITI7TK>KAI-  OEIfVHf 

of  irritability  of  conftitution,  dependent  on 
the  ftate  of  the  ilomach  and  bowels,  than  of 
local  mifchief,  fhe  gave  not  the  leaft  credit  to 
the  opinion ;  but  faid  fhe  was  perfuaded  that 
the  bone  was  ftarred,  and  that  three  fif- 
fures  extended  in  different  directions.  I 
ordered  her  to  take  five  grains  of  the  pili4. 
hydrarg.  every  fecond  night,  and  a  draught 
twice  a  day,  containing  one  ounce  of  the 
compound  infufion  of  gentian,  two  drams 
of  the  infufion  of  fenna,  and  one  dram  of 
the  compound  tinftuie  of  cardamoms.  Thcfe 
medicines  produced  a  confiderable  purgative 
efFeft.  On  the  fecond  day  there  was  but  little 
pain  in  the  head  5  the  patient  walked  about 
the  room  very  fteadily,  and  had  read  a  news- 
paper in  the  morning.  When  I  afked  her 
opinion  of  this  furprifing  alteration,  fhe  im- 
puted it  to  the  evacuations  which  had  taken 
place  J  but  fhe  was  flill  perfuaded  that  the 
bone  was  injured,  and  flill  apprehenfive  that^ 
without  fome  operation,  fhe  fhould  ultimately 
lofe  her  fenfes.  The  medicines  were  con- 
tinned  in  fuch  quantity  as  to  procure  only 
one  alvine  evacuation  daily.  A  fortnight 
elapfed  under  this  plan  of  ti*eatment>  during 

14  whidk 


AltD  f lUlAtAtENT  OF  LOCAL  OISfSABS.    Xi$ 

Which  the  ftools  became  nearly  of  a  natural 
Colour,  and  the  patient's  health  was  confider- 
ably  amended.  There  were  times  when  no 
uneafinefs  was  felt  in  the  head ;  and,  during 
fomc  nights,  the  pain  was  fo  trivial  as  to 
give  but  little  interruption  to  her  fleep^  It. 
was,  however,  occafionally  difturbed  by  pains^ 
which  were,  in  her  opinion,  as  intenfe  as  at 
any  former  period  of  the  complaint*  Her 
pulfe  was  good,  and  her  mufcular  ftrength 
greatly  improved.  The  occurrence  of  the 
pain  in  paroxyfms  ftrongly  impreflfed  me  with 
the  belief  that  it  was  nervous,  rather  than 
depending  upon  local  difeafe*  Under  thefe 
circumftances  all  ideas  of  an  operation  were 
difiniffed  from  my  mind,  but  it  was  far  other- 
wife  with  refpe6l:  to  the  patient.  Being  obliged 
to  return  into  the  country,  (he  confidered  the 
poffibility  of  a  relapfe  with  horror ;  and  was 
fo  convinced  that  the  bone  had  been  injured, 
tliat  {he  earneftly  requefted  it  might  be  ex- 
amined, were  it  merely  to  afcertain  what  was 
the  fa£t.  I  faw  no  objeftion  to  this  examina- 
tion, but  thought,  on  the  contraiy,  that  ad- 
vantage might  poflibly  arife  from  an  incifion, 
which  would  loofen  the  tenfion  of  the  fcalp, 

1  2  and 


11(5      OK  THX  CONSTltUTlONAL  ORIOIKf 

and  produce  a  difcharge  that  might  relieve 
the  irritation  of  the  part,  I  accordingly 
made  an  incifion  of  a  femicircular  form,  ex^ 
tending  farther  back  than  the  part  which  had 
been  ftruck,  and  turned  up  a  portion  of  the 
icalp,  fo  as  to  fee  the  bone,  covered  by  its  peri- 
cranium, to  the  extent  of  a  crown  piece. 
The  bone  was  uninjured,  and,  together  with 
the  pericranium,  appeared  perfeftly  natural. 
The  fcalp  being  replaced,  the  wound  was 
dreffed  fuperficially,  without  any  attempt  to 
favour  the  union  of  the  parts.  If  they  united 
under  thefe  circumftances,  there  would  be  an 
additional  reafon  for  believing,  that  neither 
the  bone  nor  the  fubjacent  parts  were  difeafed. 
The  pain  was  as  fevcre  for  the  two  firft  days 
and  nights  after  this  examination  as  it  had 
been  at  any  former  period  j  it  abated  when 
the  wound  began  to  difcharge,  and  had  en- 
tirely ceafcd  on  the  fifth  day.  This  flate  of 
tranquillity  continued  as  long  as  the  patient 
remained  in  town,  which  was  about  three 
weeks  after  the  divifion  of  the  fcalp.  The 
wound  at  that  time  had  nearly  healed.  She 
has  fmce  had  occafional  returns  of  pain  in  the 
head  when  her  general  hc^th  has  been  difbr- 

dered. 


AKD  T1UBATM£NT  OF  LOCAL  DI8BA8XS.    It/ 

dered,  but  never  to  that  degree  as  to  induce 
a  fufpicion  that  any  local  vafcular  difeafe 
exilled. 

To  exhibit  the  efFefts  of  the  re-a6^ion  of 
diforders  of  the  digeftive  organs  upon  thofe . 
of  the  head  in  another  point  of  view,  I  fub* 
join  the  following  cafe. 

CASE    X- 

May  29,  1805,  a  labouring  man,  aged 
forty-five,  fell  from  a  confiderable  height 
upon  his  head,  and  was  immediately  brought 
to  St.  Bartholomew's  Hofpital.  No  fraftare 
of  the  fkull  could  be  difcemed :  and  the 
patient  feemed  to  labour  under  the  efFefts  of 
violent  concuflion  of  the  brain.  By  vene- 
ie6lion,  and  other  antiphlogiftic  means,  he 
loon  recovered  his  fenfes,  Eveiy  thing  went 
on  very  favourably  for  three  days,  when  he 
was  attacked  with  (hivering,  naufea,  pain  in 
the  head,  impatience  of  light,  and  other  fymp- 
toms,  which  ufually  are  confidered  as  denot-^ 
ing  inflammation  of  the  membranes  of  the 
brain.  JFIe  was  confequently  Med;  and  had 
a  bliiler  applied  on  the  head.     He  was  fud* 

I  3  d?nly 


>l8       OK  THE  CONSTITirTIONilL  0&IOm« 

dcnly  feized  in  the  evening  with  a  more 
excruciating  pain  in  the  head,  which,  after 
lafting  half  an  hour,  was  fucceeded  by 
convulfions,  fb  violent  that  three  men 
could  fcarcely  hold  him.  When  the  fit 
abated,  he  expreffed  himfelf  much  reKev- 
ed,  and  faid  that  he  was  eafier  than  be- 
fore its  acceflion.  Some  calomel  and  rhu- 
barb were  given  to  obviate  a  coftive  ftate 
of  his  bowels.  On  the  next  morning  (June 
2d)  he  had  a  return  of  the  pain  and  con- 
vulfions 5  and  the  fymptoms  were  fo  violent, 
that  he  was  bled  four  times  in  the  courfe  of 
the  day.  This  treatment,  however,  had  no 
efFefl  in  diminiftiing  thp  pain  and  other 
fymptoms,  and  another  fit  of  convulfions  took 
place  in  the  evening.  The  purgative  ope- 
rated 01)  the  fucceeding  night,  and  brought 
away  a  large  quantity  of  highly  offenfive  fecu- 
lent matter  of  a  light  greenifti-yelk>w  colour. 
On  the  3d  of  June  his  breath  was  extremely 
offenfive;  his  fkin  hot  and  dry;  his  pulfe 
quick;  his  tongue  thickly  furred;  and  he 
had  great  tendernefs  in  the  epigaftric  region, 
and  right  hypochondrium.  He  was  ordereck 
to  t^ke  two  grains  of  calojncl  immediately^ 

and 


ANB  TltrATttSKT  Of  lOCAL  mSSASE'S*    tf^ 

and  a  faKnc  medicine  at  intervals ;  thi^  pro- 
duced two  motions  in  the  courfe  of  the  day. 
By  purfuing  this  plan  for  a  few  days,  the 
ftate  of  his  bowels  were  rendered  more  regu- 
lar, and  the  difcharges  acquired  a  healthy 
colour ;  in  proportion  as  this  was  efFe6ted; 
the  tcndemefs  of  the  abdomen  was  removed, 
and  the  tongue  became  clean.  He  had  no 
return  of  convulftons,  the  pain  and  other 
lymptoms  fubfided,  and  in  a  Ihort  time,  whenf 
the  digeftivc  organs  had  been  reftored  to  a' 
natural  ftate,  he  went  out  of  the  Hofpital  per- 
feftly  well. 

Cafes  of  this  defcrijption  have  been  noted 
from  the  earlieff  ages.  Many  pafTages  ia 
the  works  of  Galen  fhew  that  he  was  well 
acquainted  with  the  circumftances  that  have 
been  flated  in  this  fe6lion.  Bertrandi  *  hay 
related  inf^ances  of  abfcefTes  taking  place 
in  the  .liver  confequent  to  injuries  of  the 
head.  .  Andouille  •f  relates  additional  cafes, 
and  makes  further  obfcrvations  on  the  fame 

*  M^moires  de  ^Ae^eIx^e;d9  Chinucg^^toia*  vi^  j^i  484* 
t Ibid.  jp.  ijo6.         '     .f    •. 

''14  lUb- 


I20     OH  THE   CONSTITUTIONAL   OiLlCIK, 

fubjeft.  of  late,  Richter  *  has  delivered 
fimilar  opinions,  and  has  directed  the  prac- 
tice which  ftiould  be  purfued,  when  the 
head  is  difordered  by  the  re-a6lion  of  affec- 
tions of  the  digeftive  organs.  Still  however 
thefe  circumftances  feem  to  me  to  be  ftated 
rather  as  occafional,  than  as  occurrences 
which  are  common  and  naturally  to  be  ex- 
pefted  ;  and  I  therefore  think  myfelf  war- 
ranted in  fuppofmg,  that  they  have  not  made 
a  fufficient  impreflion  on  the  minds  of  Sur- 
geons, in  this  countiy  at  leaft-f . 

I  beg  leave,  in  the  conclufion  of  this  fec- 
tion,  to  repeat  what  was  faid  in  the  former 
one,  viz.  that  I  confider  the  difeafe  as  depend- 
ing on  nervous  irritation  in  the  parts  afFedled, 
which  is  either  caufed,  maintained,  or  ag- 
gravated by  diibrders  of  the  digeftive  organs. 
Yct  as  the  local  difeafe  muft  be  regarded  as 
chiefly  nervous,  it  might,  in  fome  rare  in- 
ftances,  exift  independently  of  any  manifeft 
diforder  of  thofe  organs.  I  may  fiuther 
add,  that  much  nervous  Irritation  in  any 

*  Chinirg.  Biblloth.  b.  Tui.  p.  538. 
•J-  In  Do£tor  Cheflon's  Pathological  Ohtemtions,  how- 
erer,  cafes  of  Uus  defcriptionare  noticed. 

part 


AND  T&BATMBNT  OF  LOCAL  DlfllASM.    121 

part  generally  excites  vafcular  a£lion.  Jt  be-> 
comes  therefore  highly  important  to  attend 
to  the  nature  and  cure  of  fuch  diforder,  as  it 
might  ultimately  lead  to  the  production  of 
organic  difeafe,  which  would  deflroy  the 
patient. 


CASES. 


nrti    •'oaifrai  tiomnintrnaHJtt;  oKnm^ 


C  A  IS  E  S. 


SECTION  in. 

« 

On  undefined  and  undenominated  Difeafes  artjing 
from  Diforder  oj  the  Conjiitution. 

rpHE  next  clafs  of  cafes,  to  which  I  (hall 
-*^  call  the  reader's  attention,  is  that  of  un- 
healthy indurations,  abfcefles,  and  fores. 
Sometimes  but  one  local  difeafc  of  this  de- 
fcription  exifts,  but  in  general  they  break  out 
in  fucceffion  in  different  parts  of  the  body. 
The  circumftance  of  their  fucceflive  forma*- 
tion  is,  I  think,  a  proof  that  they  depend  up- 
on fome  error  in  the  health  in  general ;  and 
I  have  accordingly  obferved  that  they  are 
ieldom,  if  ever,  unattended  with  diforder  of 
the  digeftive  organs.  The  imperfefl  hiftory, 
which  the  patients  generally  give  of  their 
previous  ftate  of  health,  will  not  enable  us  to 
determine  with  certainty,  that  the  diforder  of 
the  bowels  was  the  caufe  of  their  ill  health 
and  fubfequent  local  difeafes ;  but  I  can  con- 
fidently affirm,  that  thofe  difeafes  in  general  be* 
/'.  <     J  come 


AK1>  TRTATMIKT  OF  LOCAL   XHSBASSS.  II3' 

come  tradable,  in  proportion  as  the  difordcf 
of  the  vifcera  is  correftedj  and  that  fre- 
quently no  new  local  fymptoms  occur,  ^ter 
{omt  attention  has  been  paid  to  the  ftatc  of 
the  digeftive  organs.     The  difeafes,  to  which 
I  allude,  have  not  been  defcribed  in  book^ 
of  Surgery  y  and  indeed  it  is  fcarcdy  poffible 
to  delineate  with  preeifiori  their  various  apM- 
pearances«     It  would  be  quite  imprafticabfe 
to  defcribe  all  the  difeafes,  which  make  the 
fubjefV  of  the  prefent  feftion  •  namely,  un- 
healthy indurations,  abfcefles,  and  fores.  They 
may  be  compated,  not  improperly,  in  variety 
and  number,  with  the  infinitely  diverfified 
combinations  and  ihades  of  colour.     Yet  a 
brief  aiid  general  defcription  of  them  will 
alfift  to  recall  them  to  the  remembrance  of 
the  experienced  furgeon ;  and  to  enable  the 
inexperienced  pra^itioneF  to  recognize  them^ 
when  they  occur. 

Some  of  thefe  affeftion^  are  quite  ihpeir- 

ficiaV  occupying  merely  the  fkin.    Theikft 

that  I  fhaft  defcribe  is^  I  believe,  weH  ktii^Wh 

to  furg^onsiy  as  a  diiesife,  which  is  frequeniff, 

thoi^h  Ilea  conftawtly,  eored  by  giving  wet^ 

cury 


194       ^V  TKS  0ON6TITUTIONAL  OUOIK9 

cury  to  fuch  an  extent  as  flightly  to  afFe£t 
the  conftitution.  A  fmall  induration  or  tu- 
bercle takes  place  in  the  Ikin,  and  this  is 
followed  by  the  fucceffive  formation  of  others 
at  iinaU  diftances  from  the  original  one.  The 
fldn  between  thefe  tubercles  becomes  thick- 
ened. Chord-like  fubftances,  which  are  pro- 
bably indurated  abforbents,  may  fometimes 
be  felt,  extended  along  the  thickened  ikin. 
The  tubercles  ulcerate,  and  form  foul  ulcers, 
which  heal  flowly  and  break  out  again. 

Another  fpecies  of  fuperficial  or  cutaneous 
ulcer  begins  generally  in  one  point,  and  ex- 
tends in  every  direftion.  The  chaiin  of  the 
ulcer  is  farmed  either  by  a  very  fudden  ulcera* 
tion,  or  by  floughing,  A  fore  is  left,  which 
firft  fecretes  a  famous,  and  then  an  ichQrous 
fluid.  Granulations  afterwards  ariie,  and  the 
fore  heals.  The  granulations  are  however 
indurated  and  unfound ;  and  when  thepatient 
fuppofes  that  the  fore  is  cured,  it  is  fuddenly 
reproduced  by  ^  procefs  fimiJar  to  that  by 
which  it  was  originally  occafioned.  After 
fome  time  the  ulcer  again  heals,  and  again 
breaks  out.    Whilfb  theie  procefles  are  going 


AND  TRBATMBNT  OP  L6CAL  t>I8EA8B8.  I25 

on  in  the  middle,  the  fore  enlarges  in  its 
circumference ;  the  edges,  which  are  thick- 
ened, become  at  times  highly  inflamed,  and 
either  ulcerate  or  flough.  The  difpofition 
to  d|ifeafe  is  aggravated  by  fits,  and  there 
are  intervals  when  it  is  apparently  tranquil. 
When  this  fore  has  enlarged  to  a  confiderable 
extent,  in  the  manner  already  defcribed,  thfe 
central  parts,  which  have  healed  unfoundly, 
break  out  into  feparate  ulcers ;  and  thus  pre- 
fent  an  appearance  of  feveral  fores,  connected 
with  each  other  by  indxirated  Ikin  or  newly- 
formed  fubftance. 

I  fhall  briefly  mention  fome  of  the  principal 
circumflances  relating  to  the  laft  fore  of  this 
defcription,  which  came  under  my  care.  The 
patient,  who  had  been  ill  for  more  than  two 
years,  and  had  taken  a  great  deal  of  mercury, 
came  from  the  country  in  very  bad  health, 
and  with  his  digeflive  organs  much  dif^ 
ordered.  The  fore  was  fo.  painful,  particu- 
larly at  night,  that  he  was  in  the  habit  of 
taking  large  dofes  of  opium  to  procure  reft.  It 
occupied  the  back  of  the  hand  and  wrift. 
He  had  had  fbmewhat  fimilar  fores  on  hk 

head 


|ft6     OK  THE  coh9Titi;txomai«  cmicittf 

head  and  face ;  but  they  were  nearly  healed, 
though  difpofed  to  ulcerate  again.  By  that 
attention  to  the  ftate  of  the  bowels  which 
I  have  defcribed,  and  by  dreifing  the  fi>re 
with  an  aqueous  folution  of  opium,  the 
greater  part  of  it  was  healed  in  the  fpace  of 
three  weeks ;  and  the  remainder  was  (o  much 
amended,  and  fo  little  painful,  that  he  had 
left  off  his  opium  fhortly  after  the  commence^ 
nient  of  this  treatment*  As  the  patient's  cir- 
cumftances  made  it  inconvenient  to  him  to 
remain  in  town,  he  went  into  the  country, 
where  the  fore  broke  out  again.  He  then 
applied  to  a  perfon  who  fold  a  famous  diet- 
drink  ;  and  before  he  had  taken  twelve  bottles, 
the  fore  was  perfectly  heaied,  and  has  not 
fince  broke  out.  The  diet-drink,  he  fays,  had 
no  fenfible  operation ;  but  his  bowels  became 
regi^lar  and  comfortable,  and  his  appetite 
amended  by  taking  it. 

Another  variety  of  thefe  fores  originates  in 
a  more  deeply  feated  difeafe.  The  cellular 
ftibftance  under  the  fkin  becomes  thickened, 
.and  an  unhealthy  abfcefs  follows ;  after  the 
Imriling  of  which,  a  foul  fore  is  formed.     In 

conr 


AND  TJLEATMBNT  Pt  LOCA|i  PX9S^B8.  l%f 

confequence  of  this  procefs,  the  fafcia  of  tliB 
limb  is  fometimes  expofed  to  view,  and  feeras 
to  have  floughed :  when  the  flough  has  fepa^ 
rated,  the  difeafe  may  get  well  flowly.  In 
maay  cafes,  however,  there  is  no  expofure,  nor 
feparation  of  the  fafcia.  Sometimes  the  fore 
does  not  extend  beyond  the  limits  of  the 
original  induration,  but  heals  flowly ;  while 
other  difeafes  of  the  fame  kind  occur  in  fuc-* 
ceflion  in  various  parts  of  the  body.  In  other 
cafes,  the  ulceration  of  the  original  fore 
fpreads  along  the  contiguous  parts,  whilft 
thofe  which  were  firft  affefted  get  well ;  and 
thus  the  fore  afliimes  an  herpetic  chara6ter« 
In  many  cafes  the  ulceration  extends  from  the 
whole  circumference  of  the  fore,  and  thus  the 
fear  and  ulcerated  edges  have  a  circular  or 
oval  form;  in  others,  the  difeafe  is  pro- 
pagated in  particular  direflions,  fo  that  the 
ulcerated  lurface  prefents  the  moft  irregular 
and  fmgular  figures. 

Thefe  cUfeafes  fometimes  are  finall  in  extent 
in  the  beginning,  but  enlarge  confiderably 
before  the  fkin  gives  way ;  and,  when  this 
happens,  it  proves  a  kind  of  criiis  to  the 

dif- 


taS      OH  THB  CONSTIttJTlOKAL  OUOIKf 

diieafe,  which  afterwards  heals  (lowly.  In 
thefe  cafes  it  becomes  the  obje6l:  of  furgery  to 
bring  the  difeale  to  a  crifis,  v^rhilft  it  is  yet  of 
fmall  extent ;  which  may  be  efFefled  by  pro- 
producing  ulceration  of  the  fkin  by  means  of 
cauftic. 

Some  of  thefe  fores  are  formed  from  difeafes 
beginning  in  the  ablbrbent  glands  ;  in  which 
cafe  the  gland,  having  firft  been  indurated, 
fuppurates  and  burfts,  and  ulceration  enfues. 
When  this  circumftance  has  taken  place,  in 
an  abforbent  gland  of  the  neck  for  inftance, 
another  ulcer  may  form,  in  the  manner  above 
Aated,  in  the  fkin  and  fubjacent  parts,  with- 
out any  gland  being  involved  in  it.  A  third 
ulcer,  having  a  difeafed  gland  for  its  caufei 
may  form  in  the  vicinity ;  and  thus  the  dif- 
cafe  proceeds  without  any  regularity. 

I  once  thought  it  a  neceflary  but  moft  dif« 
ficult  tafk  for  a  furgeon  to  remark  the  varie- 
ties of  thefe  difeafes,  in  order  to  imderftand 
his  profeffion,  and  contribute  to  its  improve- 
ment. But,  iince  I  have  found  that  thefe 
difeafes  indicate  fome  diforder  of  the  health 

\  in 


AKO  TRBATMEKT  OF  LOCAL  BI6BASES.  I  dp 

in  general,  the  correftion  of  which  is  the 
great  objefl  in  their  cure  and  prevention,  I 
have  perceived  that  there  is  lefs  neceflity  for 
undertaking  this  moft  arduous  inveftigation; 
which,  indeed,  could  never  be  accomplifhed 
without  very  extenfive  opportunities  and  in* 
deiatigable  diligence. 

It  will  be  found  in  the  majority  of  thefe 
peculiar  difeafes,  that  the  patient  had  been 
indifpofed  for  fome  time  before  the  occur- 
rence of  the  complaint,  and,  that  afterwards 
tlie  health  had  become  more  evidently  de- 
ranged^ The  digeftive  organs  are  difordered. 
The  tongue  is  furred  at  the  back  part,  chiefly 
in  the  morning  -,  and  the  biliary  fecretion  is 
deficient  or  depraved.  My  attention  has  been, 
direfted  to  the  corre6lion  of  this  diforder  j 
and  the  moft  beneficial  effedts  have  refulted 
from  this  attention.  The  fores  have  healed 
readily  in  ibme  inflances ;  and,  in  thofe  cafes 
wheremany had  previoufly  formed  in fuccef* 
iion,  no  new  difeafe  has  in  general  taken  place. 
In  ibme  few  inftances,  new  fores  have  formed 
after  the  medical  treatment  of  the  diforder 
had  commenced^  and  even  after  it  had  been 

VOL.  I.  K  for 


130       ON  rm  CONSTITbTlOKAL  omiGIKy 

for  foirie  time  continued.  This  probaWy 
arifes  from'the  difficulty,  which  is  experienced, 
in  corredting  an  habitual  and  long  continued 
conftitutional  diforder.  In  fome  ftill  rarer 
tafes  I  have  found  funilar  but  much  milder 
difeafes  arife,  after  the  diforder  of  the  digef- 
tive  organs  had  been  in  a  great  degree 
corredled* 

* 

Whilft  I  am  writing  this,  there  are  four 
patients,  whom  I  have  attended  in  St.  Bar- 
tholomew's hofpital,  with  thde  difeafes ;  which 
I  mention,  to  fhew  the  younger  part  of  th^ 
profeffiori  how  frequent  they  are.  The  h»lth 
of  thefe  patients  has  been  furprifingly  amend- 
ed in  a  very  Ihort  period,  by  employing  the 
means  which  I  have  defcribed ;  and  the  fores 
have  healed  rapidly,  although  nothing  but 
fimple  dreffings  have  been  applied  to  them. 

It  is  not  meant  by  thefe  obfervations  to  de- 
preciate the  utility  of  topical  applications  to 
uhhealthy  ulcers,  but  merely  to  fhew  how 
much  they  depend  on  the  ftateof  the  health  in 
general)  for  fomeof  them,  which  have  renudn- 
cd  uncorrefted  by  a  great  variety  of  load 

15  appli- 


AND  TREA/TMEKT  OF  LOCAL  DISBA8E8.  I^ 

applications,  will  get  well  under  fimple  dret* 
fings,  when  the  ftate  of  the  conftitution  is 
amended.  It  is  not,  however,  to  be  expedled 
that  this  will  generally  happen  j  for  local  diC- 
eafed  a6tion  having  been  excited,  becomes 
eftablifhed,  and  may  continue,  independently 
of  the  caufe  which  produced  them.  Topical 
remedies  will,  under  thcfe  circumftances,  be 
employed  with  the  greatcft  advantage.  Again, 
topical  applications  are  of  the  higheft  utility 
m  general  praftice,  becaufe  an  irritable  fore 
afFe£ts  the  whole  conftitution,  and  aggravates 
and  maintains  that  diforder  by  which  it 
might  have  been  originally  caufed.  The  dif^ 
order  of  the  digeftive  organs  cannot  in  many 
inftances  be  corre6ted,  till  the  fretful  ftate  of 
the  local  difeafe  is  diminifhed.  I  may  furw 
ther  mention,  with  relation  to  this  fubjeft, 
that  I  have  feen  patients,  who  fcarcely  ever 
flept  from  the  pain  of  the  local,  difeaft^ 
whofe  ftomachs  were  greatly  difordered,  and 
who  had  a  diftreffing  purging,  which  could 
only  be  controlled  by  opium,  fleep  without 
interruption  during  the  night,  regain  their 
appetite,  and  have  their  bowels  become  tran* 
quil  and  regular,  when,  after  various  trials, 

K  2  adref- 


'13  2       ON  THE  COKSTirUTIONAL  ORlOtK, 

a  drefling  has  at  laft  been  applied,  which 
quieted  the  irritable  ftate  of  the  fore.  It  is 
right  however  to  mention,  that  the  efFefts  of 
fuch  an  application  are  not,  in  general, 
permanent;  but  after  a  time  the  fore  be- 
comes again  fretful,  and  requires  fbme  new 
drefling  to  foothe  or  control  its  irrita- 
bility. 

I  have  feen.  fbme  cafes  of  fuch  difcafed 
fores  as  I  have  defcribed,  in  confultation 
with  other  furgeons,  who  have  become  con- 
vinced that  my  opinions  are  well  founded. 
Others  have  occurred,  even  in  the  perfbns 
bf  medical  men,  whofe  feelings  co-operated 
to  render  their  conviftion  more  flrong. 

Having  thus,  from  general  obfervation,  ac- 
quired the  opinion  that  the  peculiarities  of 
local  difeafe  depend  chiefly  on  the  flate  of 
the  conflitution,  I  fhall  relate  fome  cafes, 
which  vvere  treated  in  conformity  with  the 
principles  which  fuch  an  opinion  would  na- 
turally fuggefl.  I  mufl,  however,  previoufly 
caution  the  reader  againfl  inferring,  that  I 
attribute  all  focal  difcafes  to  fome  general 
•-  error 


AND   Tll£ATMENT  OF  LOCAI»  DISBA8ES.  1 33 

error  in  the  ftate  of  the  health.  I  have  feen 
local  difeafes,  which  could  not  be  deduced 
from  any  general  indilpofition,  nor  correfted 
by  remedies  which  aft  fimply  on  the  confti- 
tution  at  large.  I  wijfh  to  guard  againft  the 
fufpicion  of  being  inclined  to  make  general 
affertions  j  while  I  avow  at  the  fame  ^  time, 
that  my  obfervations  induce  me  believe,  that 
the  peculiarities  of  local  difeafe  generally 
depend  upon  conflitutional  caufes.  Reafon 
alfo  fuggefts  the  fame  opinion  j  for  if  fores 
of  the  fame  charafter  break  out  in  fucceffion 
in  different  parts  of  the  body,  can  we  doubt 
that  they  arife  from  the  ftate  of  the  health 
in  general  ? 

There  appears  to  me  a  combination  of  ner- 
vous irritability  and  weaknefs,  and  to  fuch  a 
combination  I  am  inclined  to  attribute  the 
peculiarities  of  thefe  variable  and  imclaffed 
local  difeafes.  Perhaps  I  may  explain  my 
meaning  further,  by  adverting  to  what  hap* 
pens  not  unfrequently  in  cafes  of  venereal 
and  other  buboes.  The  part  and  the  confti,- 
tution  have  been  both  weakened  by  the  difeafe 
that  has  occurred  s  they  have  been  furtl^ 

K  3  debiii- 


1^6     ov  THE  ccmrrrruTtoKAL  oAionr, 

fo  as  to  rife  fully  half  an  inch  above  thcrr 
natural  level.  The  fore  was  of  an  oval 
figure;  meafuring  about  an  inch  and  a  half 
in  length,  and  half  an  inch  in^  breadth 
and  depth ;  indeed  I  could  fcarcely  fee  its 
bottom.  The  forface  was  covered  by  ad- 
hering matter  of  a  grcenifti  hue.  The  cuticle 
round  the  margin  was  thickened,  and  had 
in  fome  paits  fcaled  off.  The  patient  had 
been  rubbing  in  the  mercurial  ointment  for 
this  complaint.  He  declared  that  he  had 
had  no  chancre  for  many  years,  but  had  con- 
trafted  a  gpnorrhcea  about  a  year  before  his 
prefent  diforder.  His  health  was  much  dif- 
turbed ;  he  had  no  appetite ;  his  tongue  was 
much  furred  and  tremulous  j  his  bowels  al- 
ternately coftive  and  lax ;  his  fasces  blacki(h« 
I  advifed  him  to  take  five  grains  of  rhu- 
barb about  an  hour  before  dinner,  and 
five  grains  of  the  pil.  bydrarg.  every  fecond 
night,  witli  caftor  oil  or  fenna  tea  occafion- 
ally,  fo  as  to  procure  a  motion  daily.  The 
fore  was  drefled  with  fpermaceti  cerate.  I 
faw  him  again  in  three  days;  when  he  faid 
that  he  felt  himfelf  under  the  greateft  obli- 
gations to  me.  He  had  been  entirely  free 
from  pain  and  diftrefsful  fenfations,  fince  he 

begaii 


AMD  TUBATMBKT  OF  LOCAL  BISEASBS.  I^ 

b^gan  to  take  the  medicines ;  although  he 
declared,  that  before  that  time,  he  (hould 
have  been  thankful  to  any  one  who  would 
have  deftroyed  him.  I  mention  this,  becaufe 
I  have  often  remarked  in  thefe  cafes,  the  fur- 
prifmgly  great  relief  and  comfort  wWch  have 
arifen  from  a  change,  produced  by  means 
apparently  infignificant  and  inadequate.  The 
bowels  now  a6led  regularly,  and  the  ftools 
were  more  copious  and  of  a  more  natural 
colour,  and  to  this  corre6tion  of  the  biliary 
iecredon  I  am  inclined  to  impute  that  relief, 
which  he  fo  forcibly  depifted.  The  fore 
had  difcharged  profufely;  the  furrounding 
fwelling  and  inflammation  were  much'  lef^ 

• 

fened.  He  purfued  the  fame  plan  of  treat- 
ment for  a  month ;  during  which  jtime  he 
recovered  his  appetite;  his  tongue  became 
clean ;  his  bowels  regular;  and  the  biliary 
iecretion  natural.  The  •fore  had  contrafted 
into  a  fmall  compafs,  but  without  the  ap- 
pearance of  granulations ;  and  the  furround* 
ing  parts  were  not  fwoln,-  though  ftill  red. 
His  health  became  at  this  time  again  much 
ilifordered,  in  confequencc  of  his  catching » 
cold,  from  expofure  to  rain.    He  had  pain 

in 


ON  THE    CONBTITOTKJKAX.  OmoiN, 

in  the  bowels,  with  a  flight  purging  ;  his  ap- 
petite failed ;  his  tongue  was  furred  ;  and  he 
had  a  feveie cough,  attended  with  copious  ex- 
pefloration.  The  fore  on  the  cheek  alfo  en- 
larged to  about  one  half  of  its  former  fize : 
and  the  furrounding  parts  became  tumid.  I 
had  the  patient  admitted  into  St.  Bartholo- 
mew's Hofpital,  where  he  took  the  decoilion  of 
caicarilla  with  fquills.  His  cough  became  ma- 
terially better  in  a  (hort  time :  the  ftate  of  his 
ftomach  and  bowels  alfo  greatly  improved. 
The  fore  again  diminiftied  in  fize.  About  a 
fortnight  aftei"  his  admifiion  into  the  hofpital, 
an  eruption  came  out  over  liis  whole  body. 
The  fpots  were  of  a  copperifli  hue,  but  rather 
linaller,  and  more  elevated,  than  venertal 
ciiiptions  generally  are  *.  Some  of  the 
eruptions  gradually  difappeaied ;  and,  in 
about  a  fortnight,  it  was  certain  that  many 
were  entirely  gone.  About  this  time  he  be- 
gan to  complain  of  his  tliroat ;  and  an  ulcer, 
of  the  fize  of  a  fhilling,  formed  in  each  tonfil. 
The  edges  of  thefe  fores  were  elevated,  sn^ 

*  Many  pertbnf  who  faw  the  pstient  did  not  entertaia  t 
doubt  but  that  all  the  rymptoms  arofe  from  fyphilis ;  it  WM 
their  progrefs  sdonc  which  evinced  the  contnrj.  * ' 

uneven, 


AHO  TRSATMEHt  OF  LOCAL   DISSAUS.   I39 

uneven,  without  any  appearance  of  granu- 
lations 5  the  furfece  was  covered  with  yellow 
adhering  matter.  The  patient  now  agaia 
caught:  cold :  he  was  attacked  with  pain  im 
the  bowels,  and  purging,  which  obliged  him 
to  get  up  frequently  in  the  night,  and  to  re- 
main for  fome  time  out  of  bed.  The  cough  and 
expe£loration  returned:  he  loft  his  appetite; 
and  he  had  a  furred  tongue*  Dr.  Roberts^ 
whom  I  met  at  the  hofpital,  did  me  the  fa- 
vour  to  prefcribe  for  him.  In  a  day  or  two 
afterwards,  an  eryfipelatous  inflammation  ap- 
peared on  the  right  fide  of  his  face,  oppofite  to 
the  fituation  of  the  fore.  The  eye-lids  were 
(o  tumid  that  he  could  not  open  them :  the 
eryfipelas  fpread  to  the  other  fide  of  the  face; 
and  the  other  eye  was  equally  doled.  The 
fever  aUb  ran  very  high,  and  the  patient 
became  delirious ;  fo  that  he  was  obliged, 
for  many  days,  to  be  confined  by  a  ftxait  waift- 
coat^  Thefe  fy  mptoms  gradually  abated,  and 
he  recovered,  fo  as  to  be  in  better  health 
than  I  had  ever  feen  hin\^  He  was  difcharged 
in  about  fix  weeks,  in  a  ftate  of  conva- 
Jefcehce;  and  attended  Dr.  Roberts  as  an 
out-patient.    The  eruption  and  fore  throat 

had 


140      ON  THE   CONSTITU^TIONAL  oAiOIN, 

had  entirely  difappeared ;  the  original  ulcer 
was  firmly  healed ;  and  the  contiguous  (kin 
had  become  foft  and  natural,  though  it  was 
ftill  diicoloured.  A  year  has  iince  elapfed, 
and  he  has  had  no  return  of  his  com- 
plaints* 

It  is,  I  thinlc,  fufficiently  evident,  in  the 
prefent  inftance,  that  the  peculiarities  of  the 
local  difeafes  had  their  origin  in  the  ftate  of 
the  conftitution. 


CASE   xn. 

I  was  confulted,  by  a  medical  gentleman  in 
my  neighbourhood,  on  the  cafe  of  a  lady 
about  forty  years  of  age ;  who  had  been  long 
lubje(5t  to  dyfpeplia,  and  fevere  head-aches. 
Her  prefent  and  chief  complaint  had  been  of 
about  three  months  duration.  It  began  with 
weaknefs,  and  an  apparent  irregularity  in  the 
motions  of  the  lower  extremities,  attended 
with  confiderable  pains  refembhng  rheuma- 
tifin,  and  rigidity  of  the  calves  of  the  legs. 
Thefe  fymptoms  increaling,  (he  was  unable 
in  the  courfe  of  a  month,  to  move  about  at 

all  i 


AND  TRBATBffSKT  0^  LOCAL  Dl8]SX8BS«   t4f 

all ;  but  was  obliged  to  be  lifted  in  and  out 
of  bed.  At  this  time  an  induration  of  the 
mufcles  of  the  calf  of  each  leg  had  taken  place. 
The  indurated  fubftance  was  ,  about  thjx» 
inches  in  length,  and  between  two  and  three 
in  breadth.  It  was  feverely  painful  at  times^ 
and  the  integuments  covering  it  were  occa- 
fionally  inflamed.  There  was  alfo  fomc 
pdn  and  fwelling  in  the  ham.  Leeches,  (eda- 
tive  lotions,  and  mercurial  ointm^it  had  beeil 
applied  j  cicuta  and  tonics  had  been  given, 
but  without  alleviating  the  fymptoms.  I 
firfl:  faw  the  patient  about  fix  weeks  after 
fhe  had  been  obliged  to  keep  her  bed  entirely; 
and  the  peculiarities  of  the  prefent  cafe  led 
me  at  once  to  refer  its  origin  to  the  ftate  oi 
the  health  in  general.  The  appetite  and  di- 
geftion  were  impaired,  the  tongue  was  much 
furred,  and  the  faeces  blackifli.  I  merely  re- 
conunended  fomentations  to  the  indurated 
parts,  confidering  it  the  primary  objeft  to  cor- 
reft  the  morbid  flate  of  the  digeftive  organs. 
With  this  view  the  compound  infufion  of 
gentian  with  tlie  infufion  of  fenna  and  tinc- 
ture of  cardamoms  was  given,  in  fuch  dofes 
as  to  procure  an  adequate  evacuation  daily, 
14  and 


§4^     ON  TBS  OOKaTlTUTIOKAL  .OUOIK9 

9nd  five  grains  of  the  piL  hydrarg.  were  taken 
every  fecond  night.  Thefe  fimple  medicines 
were  completely  fuccefsf ul :  after  taking  them 
a  fhoft  time,  the  difcharges  from  the  bowels 
were  natural,  and  properly  coloured  with  bile« 
The  appetite  returned ;  the  tongue  became 
dean^  and  the  pains  almoil  immediately 
oeaied.  No  cutaneous  inflammation,  indicate 
ing  a  diipofition  to  fuppuration,  appeared 
9B3im  over  the  indurated  parts,  which  gradu* 
idly  recovered  their  natural  flate«  In  a  fort* 
nigixt  the  patient  could  go  about  with  a  ftick^ 
and  in  two  months  could  walk  as  well  as 
before  her  complaint.  She  has  enjoyed  better 
health,  fince  this  time,  than  for  many  years 
))efore  *• 

*  The  (late  of  the  Indurated  mufcles,  in  this  cafe,  was 
fttch  as  would  lead  to  the  belief  that  fuppuratlon  would 
take  place  in  different  parts  of  the  hardnefs ;  indeed,  I 
liave  feen  many  cafes  iefs  formidable  in  appearance  termi* 
Hate  in  that  manner.  Seeing  how  much  the  irritability 
of  mufcles  isdifordered  by  that  ftate  of  conftitution  which 
I  have  been  defcribing,  I  think  it  is  allowable  to  conclude 
that  most  of  the  organic  difcafes  of  mufcles  originate  from 


i. 


CASE 


AVm  TRBATIiBHV  OP  LOCAL  OXSIAAM.  143- 


A  gentkm^ui,  thirty-two  years  of  age,  who* 
had  been  fubje£t  for  feveral  years  to  occsh* 
fional  attacks  of  fever e  pain  in  the  bowels^ 
was  ieized,  about  the  end  of  Auguft,  with 
a  violerit  purging,  which  continued  for  a 
fortnight,    and  was    attended   with  ft^fet^ 
About  a  month  afterwards,  he  fdit  psdn  in 
his  leg  at  night,  which  graduaUy  became  con« 
tinued  even  during  the  day,  and  obliged  him 
to  confine  himfelf  to  bed.     In  the  beginnii^ 
€^  Oftober  a  fwelling  was  percdved  neat 
the  inner  ankle,  which  fuppurated^  and  was 
opened  on  the  twentieth  of  the  ^tme  mojnttu 
Two  large  tea   cups  foil  of  dark  bFOWn 
matter  were  evacuated.    The  difcharge  conti« 
nued  profoie  for  tome  time>  and  afterwards 
diminifhed*    Four   other  fmall  gatherings 
then  took  place  in  fucceflion,  and,  buiffing^, 
continued  to  difcharge;  each  aperture  fretting 
out  into  a  foul  fore.     About  the  beginning 
of  February  I  firft  iaw  this  cafe,  which  was 
confidered  as  a  difeafe  of  the  bone.    The  five 
ibres  had  apertures  in  them  leading  tafinufes^ 

which 


144-      OH   THC   CONSTITUTIONAL   ORIOIKy   i 

which  communicated  with  ench  other.  A 
probe  introduced  into  one  of  thefe,  near  the 
bottom  of  the  tibia,  could  be  moved  upwards 
and  downwards  along  the  furfacc  of  the 
bone,  which  was  not,  however,  denuded. 
From  an  upper  ulcer  the  probe  could  be 
pafled  behind  the  bone,  and  under  tlie  muC- 
des  of  the  calf;  this  indeed  feemed  to  be 
the  original  feat  of  the  abfccfs,  from  which 
the  finufes  proceeded  to  their  different  out- 
lets. The  integuments  were  ccdematous,  and 
firm  to  the  touch ;  fo  that  I  could  not  dif- 
tindtly  feel  the  outline  of  the  tibia  j  but  I 
thought  that  the  bone  was  nut  alta'ed  either 
in  form  or  fize.  The  finnnefs  with  which 
the  patient  ftood  upon  tlie  limb,  and  the  want 
of  aching  pain  in  the  bone  contributed  alfo 
to  make  mc  believe  that  it  was  not  difeafed, 
and  tliat  the  whole  diforder  confifted  in  an 
unhealthy  abfcefs,  the  difcharge  from  which 
ifTued  from  the  various  fmufes  in  the  manner 
already  defcribsd.  I  could  not  but  attribute 
fuch  a  difeafe  to  a  general  diforder  of  the 
health,  and  indeed  the  patient's  countenance 
and  appearance  indicated  a  confKtution  much 
weakened  and  harrafled  by  illnefs.  His  tongue 


1 


And  trsatmsnt  of  local  di$£abis«  14^ 

was  furred,  and  the  difcharges  from  the  bow- 
els were  irregular,  deficient  in  quantity,  and 
of  a  blackifti  colour.     With  a  view  to  the 
corre£tion  of  thefe  fymptoms,  I  dire6ted  the 
patient  to  take  five  grains  of  the  piL  hydrarg. 
every  fecond  night,  and  the  infufion  of  gen- 
tian with  fenna,  fo  as  to  procure  one  motion 
€lail3^  ^^^  ^^^^^  benefit  was  obtained  by  thefe 
jmeafures ;  and  in  about  a  fortnight  after-i 
"vrards  a  thickening  of  the  integuments  took 
^lace  over  the  fibula ;  a  confiderable  fwelling 
gradually  aiofe,  and  another  abfcefs  formed, 
^%«rhich  burft  in  about  three  weeks,  and  dif- 
^charged  a  confiderable  quantity  of  brownifti 
:xiiatter  mixed  with  blood.     During  this  time 
^he  limb,  was    merely  poulticed,    and  the 
;^atient  could  not  l^eave  his  bed.     His  pain 
"xvas  extreme,  and  he  had  no  reft  at  night. 
*^he  ufe  of  opium  wa,s  neceflary  to  alleviate 
fufFerings,  and  opening  medicines  occai- 
lopally  to  procure  ftools.      He  took   but 
Xittie  nouiiihment,  and  his  health  greatly  de- 
c^lined.     The  difordered  ftate  of  the  ftomach 
^uid  bowels  was  much  aggravated  by  this  I0C9I 
irritation.  ^   Indeed,  the  fitu^tion  of  my  pa- 
tient was  now  particularly  perplexixig.    The 
VOL.  I.  L  local 


t 


I 

i(4^     (5*1  THE  CONSTITUTIONilL  OKtOIH't 

local  difeafe  made  the  general  health  worfej 
and  the  aggravation  of  this  general  diforder, 
Whifch  appeared  to  have  been  the  caufe  of  the 
local  difeafe  and  of  its  continuance,  propor- 
tionatfely  increafed  the  latter  malady.  The 
confinement  to  bed  afforded  an  additional 
obftacle  to  recovery ;  yet  it  was  impoflible  to 
remove  him  in  his  prefent  flate,  on  account 
of  the  pain  which  motion  occafioned.  The 
leg  was  infupportably  painful  in  a  dependent 
pofbare.  As  change  of  air  and  cxercifc 
feemed  effential  to  his  recoveiy,  I  was  in 
duced  to  try  if  Mr.  Baynton's  excellent 
bandage,  by  fupporting  tl^e  weakened  vef^ 
fels,  would  prevent  their  diftention,  and 
the  confequent  pain.  The  fores  Were  dref- 
-fed,  after  as  much  matter  had  beea  exprefTed 
from  thb  finufes  as  could  be  done  without 
occafionnig  pain.  Strips  of  fticking-plaifter 
were  applied  after  the  manner  of  a  many- 
tailed  bondage  ^  and  the  limb  vvtis  aftei-wards 
iT)lled"Witli  a  caircb  roller.  The  patient 
felt  comfortable,  and  found  his  limb  flrength- 
rned.  -  lie  was  directed  to  wet  the  roller, 
if  the-jiafts  becalme  hbted.  The  efFeft  of 
this  trdatment  was  furpiifrng  both  to  the 
patient 


ANI>  YABATAlBNT  00  LOCAL  DliGASES.     I47 

patient  and  myfelf.  The  pain,  which  had  been 
conftant  before  preffure  had  been  employe^i, 
cealed  from  the  time  of  dreifing  till  five 
o'clock  on  the  following  morning ;  but  from 

If 

that  time  ^it  gradually  increafed   till  noon, 
wl^en  tlie  dreillngs  were  renewed.     The  caufe 
of  this  occurrence  now  became  manifeft  5  iot^ 
upon  openin^g  the  bandage,  more  than  a  tea-^ 
cup-full  of  matter  waa  difcharged  from  the 
different  fmufes.    I  drefTed  the  hmb  as  before; 
cutting  holes  for  the  efcape  of  the  matter 
oppofite  to  two  of  the  chief  finufte.  I  defired 
the  patient  to  put  his  leg  to  the  ground,  in 
order  to  afcertain  the  efFe6i:  of  the  pei'pendi- 
cular  pofition  when  the  veffels  wtgrefupportedf 
and  he  experienced  no  inconvenience.     Tha 
feconddaypaffed,  as  the  former,  without  pain; 
and  as  the  matter  poured  into  the  linufes  readily 
eicaped,  he  had  no  uneafinefs  from  it's  deten- 
tion.    I  recommended  him  to  fit  up,  and  put 
his  leg  to  rfie  ground  fweral  times  in  the  day, 
in  order  to  accuftom  it  to  that  pofition.  After 
I  had  dreflcd  it  on  the'third  morning,  the  pa- 
tient ftobd  up,  and  took  two  or  three  fteps 
very  feebly  ;  but  this  was  rather  the  efFefl  of 
general  weaknefs  than  of  particular  infirmity 

L  2  in 


148      OK  ^Hff  COKBt^TUTIOKAL   ORI91V/ 

in  the  difeafed  limb.  I  now  advifed  him  to  go 
a  little  way  out  of  town  in  a  carriage.     The 
air  and  excrcife,  together  with  the  freedom, 
from  pain,  produced  a  very  beneficial  effect* 
He  began  tq  recover  his  appetite,  to  deep  at 
night,  and  acquired  fo  much  flxength,  that  he 
was  able  in  a  week  to  go  about  his  houfe^  and 
to  refume  his  attention  to  bufinefs.  The  dif- 
charge  from  the  (inufes  was  v^  trifling,  and 
the  fores  looked  much  better.     The  patient 
now  undertook  to  drefs   his    leg  himfelf^ 
and  hired  a  lodging  out  of  town,  fo  that 
I  only  faw  him  occafionally.     His  limb  was 
fo  much  amended  in  the  courfe  of  a  foitnight^ 
that  it  cauied  no  more  trouble  than  that  of 
daily  drefling.     But  his  health  was  not  good. 
His  countenance  had  the  fame  expreflion  of 
illnefs  as  when  I  firfl  faw  him ;  his  tongue 
was  white  and  diy  3  his  bowels  coftive ;  and 
the  fl:ools  of  an  unhealthy  colour.     I  there- 
fore recommended  him  to  take  again  the  fame 
medicines,  which  I  had  formerly  ordered  him. 
His  health  now  improved ;  his  tongue  became 
moifter,  and  lefs  furred ;  the  bowels  more  re- 
gular; and  the  faeces  coloured  with  a  more 
healthy  bile.     He  continued  recovering  tiU 

the 


AKX>  TRBATUEMT  OF  XOCAi.   IXt8£^AMS«   €4^ 

l}ie  middle  of  April,  when  he  began, to  conv* 
plain  of  the  trouble  of  applying  the  ftickingr 
plaifter,  and  ufed  the  calico  roller  alone.  I 
did  not  fee  him  for  three  weeks,  and  then 
found  him  in  a  very  defponding  flate.  He 
complained  of  the  ted^oufnefs  of  his  confine- 
ment, which  had  lafted  more  than  half  a  year, 
and  £aid  that  he  would  willingly  fubmit  to 
have  the  finufes  laid  open,  if  that  would  make 
him  well.  I  found  liis  leg  well,  excepting 
two  orifices  near  the  tibia ;  three  ulcers  whi(;^ 
formed  the  apertures  of  as  many  finufes,  had 
healed;  the  outline  of  the  bone  could  be 
diftinftly  felt ;  and  there  was  no  alternation  of 
it  in  form  or  fize.  I  was  unable  at  firft  to 
account  for  this  defpondency  under  fuch  fa-^ 
vourable  circumftances ;  but  I  fbon  difcovered 
that  it  was  the  effeft  of  hypochondiiacifin* 
For  his  tongue  was  much  furred  and  dry }  and 
at  the  fame  time  that  he  left  off  the  bandage, 
he  had  alfo  difcontinucd  his  medicines.  J 
urged  him  to  return  to  them  immediately ; 
and  called  on  him  again  in  ten  days,  y/hfin  he 
perceived  clearly  the  abfurdity  of  his  late  de* 
fpondency,  as  well  as  its  caufe.  He  called  on 
pie  on  the  loth  of  July,  with  a  new  fwelling 

L  3  jiear 


tSO        PK  THi   CQMSTITUTIONAJU  OHIOIV, 

near  tht  uppct  part  of  the  tibia,  which  thrcaflw 
isned  to  form  ah  abfcefs,  ilmilar  to  thoie 
Hvhich  had  formerly  taken  place.  I  covered 
the  limb  with  the^bandage  of  fticking-plaifter, 
as  at  iirft.  The  new  difeafe  difappeared  en- 
tirely }  and  the  old  ones  were  fp  much  bcnc- 
^ted  by  the  exaft  and  equal  pi^ffurc,  that  the 
patient  felt  no  difference  between  the  found 
^nd  the  afiefted  limb.  The  ulcers  gradually 
healed^  and  his  health  is  better  than  it  has 
been  for  fome  years :  yet  ftrU  there  is  ap  evi^ 
^dent  tendency  to  diforder  of  the  digeftiyg 
organs, 


CASP8. 


-ANJB  TRSATMPMT  AP  «)jp AJ'"WS*A«JP««    I^" 


CASES. 


SECTION  y. 

On  more  defined  Difeafes^  as  Carbuncle  and  Scrofula 
arifingfrom  Diforder  of  the  Conjiitution. 

IF,  upon  an  extenfive  and  accurate  exafnina- 
tion  of  the  fujbjeft,  it  were  to  appear,  that, 
many  very  peculiar  and  veiy  diffimilar  local, 
difeafcs  originate  from  a  common  caufe,  name- 
ly from  weaknels  and  irritability  of  the  fyf- 
tem  in  general,  our  enquiry  would  be  farther 
extended,  and  we  fhouldfeel  anxiovs  to  Joiow 
whether  fimilar  caufes  may  not  operate  in 
the  production  of  more  common  and  more 
frequent  local  disorders.     As  far  as  my  late 
obfervations  liav^  enabled  me  to  determine, 
that  ftatc  of  the  digellivc  organ5,  which  I 
confider  as  denoting  conflitutional  diforder, 
exifts  prior  to  the  formation  of  a  carbuncle  j 
and  is  exacerbated  during  the  progrefs  of* 
thatdifcafc.  This  opinion  indeed  will  appeajc 

/'  4  pro^ 


15^        ON  TRB  COKSTIT0TZONAL  ORIGIN, 

probable,  if  we  confider  the  kind  of  perfons 
who  are  attacked  with  carbuncles,  and  the 
conliderablc  derangement  of  health,  which 
even  a  trivial  local  difeafe  of  this  nature  occa- 
fions.  I  fhall  mention  but  one  cafe  in  fup- 
port  of  this  opinion,  though  I  have  made 
iimilar  remarks  in  feveral  other  inftances. 


CASE  XIV. 

I  attended  a  gentleman,  who  was  a^6te4 
with  carbuncles,  during  three  fucceffivc  at- 
tacks, at  the  interval  of  about  a  year  between 
each.  I  made  an  incifion  through  the  indu- 
rated fkin,  down  to  the  fubjacent  floughy 
cellular  fubftance,  and  thus  brought  the  local 
difeafe  to  a  crilis.  This  tieatmenf  was  fiif- 
ficient  in  the  two  firft  attacks ;  the  extenfion 
of  the  difeafe  was  prevented;  the  (lough$ 
feparated,  and  the  wound  healed.  The  pa- 
tient, whofe  mode  of  life  was  intemperate, 
had  cough ;  difficult  refpiration ;  fiiUnefs  and 
tendemefs  of  the  parts  fituated  in  the  epi- 
gaftric  region  ;  unhealthy  fecretion  of  bile ; 
and  in  fhort,  all  thofe  fymptoms  which  denote 
a  very  confiderable  degree  of  diforder  of  the 

digeftive 


AMI)  TRJBATMEKT  OF  LOCAL   DISEASES;    1 53 

digeltive  organs :  it  is  probable  indeed  that 
fome  organic  difeafe  of  the  chylopoietic  vif- 
cera  exifted.  ^  After  he  had  recovered  from 
the  carbuncle,  I  told  him  that  the  moft  im- 
portant difeafe  ftill  exifted ;  and  urged  him 
to  be  attentive  to  his  diet,  and  to  the  direc- 
tions of  his  medical  attendants.  He  ftill  how- 
ever continued  to  live  intcmperately,  and 
his  diforder  increafed.  He  was  indeed  nearly 
dying  from  difeafed  vifcera,  when  he  was 
attacked  with  carbuncle  for  the  third  time. 
The  divifion  of  the  parts  produced  a  tempo- 
rary ceffation  of  the  difeafe  j  but  it  began 
again  to  l][)read  in  every  direflion  froni  its 
prcumference,  and  he  died. 

It  will  not,  I  believe,  be  doubted,  that 
boils  are  a  (lighter  degree,  with  fome  varia- 
tion, of  the  fame  difeafe,  which  caufcs  an- 
thrax and  carbuncle  j  and  it  is  almoft  unne- 
ceffary  to  ranark,  that  fome  perfons  are  fub- 
je6l:  to  a  fucceflive  formation  of  very  large 
and  troublefome  boils  from  the  leaft  irrita- 
tion of  the  Ikin.  I  have  fcen  many  perfons 
thus  affefted ;  and  there  has  been,  in  every 
jnftance,  diforder  of  the  digeftive  organs,  the 

cor- 


\ 


154      ON  THB   CONSTITUTIONAL  ORIGIN, 

correftion  of  which  has  prevented  the  return 
of  thefe  vexatious  local  difeafcs.  One  gen- 
tleman, who  had  been  tormented  for  many 
yeai's  by  the  quick  fucceflive  formation  of 
boils  as  large  as  eggs,  has  been  free  from 
them  for  fome  yeai's ;  though  he  has  had 
other  diforders,  which  denote  fuch  a  condition 
of  the  conftitution,  as  it  has  been  my  object 
to  defcribe  in  this  paper. 

I  have  remarked  in  many  inftances  that 
difeafes  of  the  abforbent  glands,  fuch  as  are 
ufually  and  juftly  denominated  fcrofula,  0(C- 
currihg  in  adults,  have  apparently  originated 
from  the  diforder  which  I  have  defcribed.  In 
feveral  cafes  the  local  difeafe  was  of  long 
duration,  and  had  become  worfe  rather  than 
better  under  various  plans  of  medical  treat- 
ment J  yet  it  amended  regularly,  and  fome- 
times  even  quickly,  in  proportion  as  the  ftatc 
of  the  digeflive  organs  was  corredled.  J 
need  not  detail  any  cafes  on  this  occalion, 
fmce  every  furgcon  muft  know  them  fami- 
liarly. The  patient;s  are  commonly  fent  to 
the  fea-fide,  or  into  the  country ;  where  en- 
larged glands  fubfide,  and  thofe  which  have 

fup^ 


AND .  TRBATM^WT  OF  X.OCAL   X>IB£AS£|;.   I55 

fuppurated  and  ulcerated  heal ;  and  the  local 
difeafe  recovers,  in  pr<^ortion  as  the  health 
in  general  is  amended. 

There  are  cafes  of  fcrofiilous  diieaies  oc* 
curhng  fuddenly,  and  in  various  parts  o£ 
the  body  at  the  fame  time,  which  feem  to 
originate  in  that  ftate  of  the  conftitution 
which  is  occafioned  by  diforder  of  the  digct 
tive  organs^    I  have  chiefly  obferved  thcfe 
cafes  in  children;  and  they  have  followed 
foiAe  violent  febrile  afFeftion.     In  two  cafes 
which  I  lliall  particularly  mention,  the  iinall- 
pox  was  the  antecedent  difeafe.     I  have  al* 
ready  ftated,  that  when  the  health  has  been 
confiderably  difordered  by  fome  violent  dif^ 
cafe,  the  digeftive  organs  may  become  fubfe^ 
quently  afle£led ;  and  that  this  diforder  proves 
9  caufe  of  many  fecondary  difeafes. 


CASE  XV. 

A  child  of  two  years  <?ld  had  the  finally 
pox,  from  which  he  did  not  feem  to  recover, 
but,  on  the  contrary,  fell  into  a  vciy  bad  ftate 
f^f  ^ipaltji.  The'abforbent  glands  on  the  right 

fide 


156      OM   TH8    COMSTITUTIOMAL   ORIGtW, 

fide  of  the  nock  became  enlarged  in  fuccef- 
fion,  To  as  to  form  altogether  a  very  confi- 
derablc  tumour,  which  extended  down  to 
the  collar  bone.  The  axillary  glands  then 
became  aiFcfted  in  the  fame  manner;  the 
fwelling  was  unufually  great,  and  feemed  to 
extend  under  the  pectoral  mufcle,  elevating  it, 
and  forming  by  this  means  a  continuation  of 
tumour  with  the  glands  of  the  neck.  Thefe 
fwelUngs  had  partially  fuppurated,  and  had 
broken  in  two  places,  viz.  in  the  neck,  and 
about  the  margin  of  the  perioral  mufcle  :  but 
no  relief  followed  j  on  the  contrary,  the  mafs 
of  difeafe  feemed  to  be  rapidly  increafing. 
The  child  was  bowed  forwards,  fo  that  the 
fpine  was  much  cun'ed  in  the  loins  ;  the  left 
leg  appeared  paralytic ;  and  a  fwelling  was 
percdvedin  the  abdomen,  which  I  could  not 
but  afcribe  to  an  enlargement  of  the  external 
iliac  glands.  The  child  was  extremely  ema- 
ciated ;  his  fkin  felt  hot  and  dry;  his  tongue 
was  covered  with  a  brown  fur ;  and  the  ftools 
were  black  and  highly  ofFenfive.  As  there 
was  no  expeftation  that  he  could  furvivethis 
defperate  ftate,  thofe  medicines  only  were 
prefcribed  that  feemed  likely  to  correiV  the 
ftatc 


d 


AKD   TREATMENT   OF   LOCAL  DISEASES.*    I57 

ftate  of  the  digcftive  organs ;  fuch  as  occa- 
(ional  dofes  of  calomel  and  rhubarb,  A  ftri6t 
attention  to  diet  was  alfo  recommended. 
Under  this  treatment  the  ftools  gradually 
became  natural,  and  the  tongue  clean.  The 
difeafe  feemed  to  flop  immediately.  As  the 
health  was  reftored,  the  fwellings  rapidly 
fubfided ;  and  the  child  became  one  of  the 
healthieft  and  ftoutell:  of  the  family. 


CASE   XVI. 

A  female  child,  after  having  had  the  Jfinall 

pox,  got  into  bad  health  from  diforder  of 

the  digeftive  organs.     She  was  then  fuddenly 

attacked  with  a  fcrofiilous  afFe6tion  of  the 

Jknee  and  elbow  of  the  oppqfite  fides  of  the 

body.     Two  coUcftions  of  fluid  had  takepi 

place  beneath  the  fafcia  of  the  leg  and  thigh. 

The  joints  were  greatly  ehlarged,  and  the 

fwelling  was  appai^ently  caufed  by  an  increafe 

in  the  fize  of  the  bones.     Had  I  feen  either 

joint,  a$  a  fingle  cafe  of  difeafe,  I  (hould  have 

faid  that  it  would  leave  the  child  a  cripple. 

It  was  manifcft,  in  the  prefent  inftance,  that 

thefe  local  difeafes  were  the  confequence  of 

general 


\ 


1^8        OK  THE  CONdTITUTIOKAL  O&fom^ 

general  ill-health ;  and  that  the  firft  objcft 
was  to  correft  the  diforder  of  the  fyftem.  The 
funftions  of  the  digeftive  organs,  which  had 
been  deranged,  were  reftored  to  their  natural 
ftate  by  employing  the  fame  diet  and  medi- 
cines which  had  been  fo  fignally  fuccefsful  ii\ 
the  preceding  cafe.  By  thefe  means  the 
health  was  re-eftablifhed,  and  the  local  dif- 
cafes  gradually  difappeared, 

I  have  heard  it  remarked  by  furgeons  of 
great  experience,  that  patients  often  recovei* 
when  many  fcrofulous  difeafes  appear  at 
the  fame  time ;  although  fome  of  them  may 
be  (6  confiderable,  that  they  would  feem 
to  warrant  amputation  had  they  appeared 
fingly.  The  cafes  which  I  have  related 
afford  a  moft  clear  and  fatisfaftoiy  account 
of  the  mode  of  recovery.  General  irritation 
and  weaknefs  bring  on  difeafes,  to  which 
perhaps  a  pre-difpofition  may  exift,  in  feveral 
parts  of  the  body  3  thefe  ccafe  when  their 
exciting  caufe  is  removed. 

Of  late  indeed  I  have  beeil  equally  fur- 
prized  and  rejoiced  to  fee  fwellings  of  the 

abfor- 


Alio  TREATMEKT   OI'  LOCAL  DISEASES.  1^^ 

abfbrbent  glands  in  children  readily  difperfed 

by  that  medical  attention  to  corredt  errors  in 

the  funftions  of  the  digeftive  organs,  which 

I  have  defcribed.     Some  of  thefe  fwellings 

came  on  rapidly,  and  fome  flowly,  but  thefe 

were  fo  large  and  fo  much  inflamed,  that  if 

any  perfon  had  formerly  told  me  they  might 

be  difperfed  by  fuch  meafures,  I  fhould  have 

thought  the  afTertion  an  abfolute  abfurdity 

from  its  direft  contradiftion  to  my  former 

experience.     From  amongft    a  confiderable 

number  of  cafes  I  fhall  relate  the  following. 


CASE  XVIL 

The  fon  of  one  of  my  friends  had  gradually 
fallen  into  a  very  bad  ftate  of  health.  The 
child  was  about  fix  years  of  age,  and  had  been 
unwell  for  feveral  months ;  when,  in  con- 
clufion,  two  glands  in  the  neck  became  gra- 

* 

dually  enlarged,  till  each  had  attained  the  fizc 
of  a  large  walnut.  The  child's  tongue  was 
much  furred,  his  appetite  very  deficient,  and 
capricious ;  his  bowels  had  a  coftive  ten- 
dency j  his  ftools  were  never  of  a  proper 
colour.     His  flefh  was  wafted  and  flabby,  his 

4  counte- 


x6o      ON   THE   CONSTITUTIOKAL  ORIGIK, 

countenance  pale,   his  pulfe  feeble  and  frc^ 
quent;  and  his  general  demeanor  languid 
and  irritable.     I  told  his  father,  that  I  could 
advife  nothing  as  a  local  application  better 
than  bread  and  water  poultice  5  and  that  the 
chief  obje£l  of  attention  was  the  correftion 
of  that  diforder  under  which  he  had  long 
laboured,  fo  that  his  conftitution  might  regain 
its  natural  tranquillity  and  ftrength.     Upon 
this  fubjeft  I  promifed  to  fpeak  to  the  gentle- 
man who  had  hitherto  attended  the  child.  In 
about  two  days  a  deep  redncfs  came  over  tlic 
pioft  prominent  part  of  each  gland,  denoting, 
as  I  concluded,  a  difpofition  in  the  internal 
parts  to  fuppurate.     The  child  took  half  a 
grain  of  calomel  with  five  of  rhubarb  every 
fecond  night,  and  ten  drops  of  the  acid :  vi* 
triol :  dilut :  three  times  a  day.     In  about  a 
week,  an  evident  amendment  was  obfcrved  in 
the  appetite,  fpirits,  and  colour  of  the  excre- 
tions  from  the  bowels.     In  a  fortnight,  the 
fpirits  of  the  child  became^  to  ufe  the  words 
of  the  parents,  ungovernable ;  and  an  evi- 
dent amendment  of  the  health  in  general  took 
place.     In  a  month,  the  child  might  be  faid 
to  be  Vv  ell  s  though  he  flill  remained   thin. 


3  After 


AKD   T&BATMENT   Q9   LOCAL    1>I6SA8B8.    l6l 

After  another  fortnight,  he  difcontinued 
all  medicine^*  except  the  occafional  ufe  of 
the  powders,  for  at  this  time  all  veftiges 
of  enlargement  in  the  glands  had  difappeared^ 
I  do  not  relate  this  cafe  as  extraordinary,  for 
I  have  feen  feveral  worfe  cafes  cured  by  the 
fame  means  ;  and  as  I  have  faid,  fome  of  the 
fwellings  have  come  on  tardily  and  others 
rapidly*  It  is  related  merely,  fcecaufe  in  the 
fame  family  another  child  had  fuppuration 
of  the  glands ;  which  left  a  fore  that  healed 
flowly. 

It  cannot  indeed  be  proved  that  thefe  cafes 
would  have  been  llrumous  5  it  can  only  be 
faid,  that  to  all  appearance  they  were  the 
fame  as  others  which  I  have  formerly  feen 
fuppurate,  and  foim  fores  (low  in  healing, 
and  fuch  as  are  generally  denominated  kro 
fulous. 


CASE  XVUL 

A  flender  child  about  five  years  of  age  had 
five  fwoUen  glands  on  the  right  fide  of  the 
neckband  three,  on  the  left.    Their  magm« 

vox*.  I.  M  tudc 


l5l      OKTHX   CONSTITUTIONAL   OMCtHf 

tude  was  eonfiderable,  and  the  child's  ap^ 
pearancc  lickly;  and  the  diforder  had  fo 
threatening  an  appearance,  that  the  gentle-^ 
man  who  attended  the  family  requefted 
the  parents  to  take  fome  additional  opinioii 
on  the  cafe.  The  tongue  was  furred^ 
and  the  bowels  fa  habitually  coftive,  that 
fometimes^  a  week  elapfed  without  any  alvine 
evacuation.  As  the  child  was  feveriih,  he 
took  at  firft  fome  faline  medicines  in  a  ftate 
of  efFervefcence,  which  was  afterwards 
changed  for  the  diluted  vitriolic  acid.  He 
alfo  took  half  a  grain  of  calomel,  every  fecond 
nighty  which  gradually  Iwought  about  a 
regular  lecretion  of  healthy  bile,  and  in  about 
three  weeks  the  child  might  be  faid  tabc 
well,  for  his  bowels  a6led  regularly  when  no 
medicine  was  taken,  and  the  difcharges  from 
them  were  properly  tinftured  with  biles. 
The  ufe  of  calomel  was  now  only  reconq^ 
mended,  if  the  appearance  of  the  flools  va« 
ried  from  the  rhubarb  colour*  The  fwoUen 
glands  difappeared,  nothing  but  a  bread  and 
water  poultice  having  been  applied  to  them. 
The  bodily  powers  of  the  child  were  cooh 
fiderably  augmented,  and  his  a(pe£t  became 
healthy. 


AND  TRBATMEKT  OF  LOCAL   DISEASES*    163 


CASE     XIX. 

A  boy  between  feven  and  eight  years  of 
Age  had  a  lamenefs  about  the  hip,  which  was 
fo  confiderable  as  greatly  to  alarm  his  pa- 
rents.   There  was  no  tendemefs  when  the 
joint  was  comprefled  either  in  front  or  from 
behind.  The  tongue  was  furred,  and  he  had 
been'fubjeft  to  flight  paroxyms  of  fever,  re- 
fembling  an  intermittent.     I  recommended 
lialf  a  grain  of  calomel  with  a  few  grains  of 
rhubarb  every  other  night.     In  a  fhort  time 
ihe  lamenefs  fo  entirely  cUfappeared,  that  I 
-vmB   no    further    confulted    on  liis   cafe. 
About  eight  months  afterwards,  however,  I 
ivas  deiired  to  fee  him  with  three  confider- 
^bly  enlarged  abforbent  glands  on  one  fide 
of  his  neck,  and  two  on  the  other.    They 
had  for  many  days  continued  to  increafe. 
Jle  was  at  that  time  feverifli,  and  I  now  be- 
came more  acquainted  with  the  flate  of  his 
'health  in  general.    I  learned  that  he  eat 
rather  voracioufly,  and  could  not  be  reflrain- 
td  from  taking  very  highly  feafoned  food ; 
that  though  his  bowels  regularly  enough 

M  2      -  cvacu- 


164       ON  THB  CONSTITUTIONAL  OSilOIM', 

evacuated  the  r?fidue  of  the  food,  the  ftools 
were  of  various,  and  always  of  faulty  colours, 
and  very  oftbnfive;  that  he  pcrfpired  profufely- 
upon  the  flighteft  exertion.  His  ikin  was 
covered  every  where  with  fcurf  and  eruptions, 
and  his  hands  were  hard,  harfh,  and  chapped- 
He  took  the  medicines,  as  in  the  preceding 
cafe,  for  about  the  fame  length  of  time,  when 
the  glandular  complaint  was  welL  He  con- 
tinued the  half  grain  of  calomel,  however, 
for  thiee  months,  for  the  fecretion  of  bile 
had  not  even  in  that  time  become  healthy  in 
quantity  and  quality.  His  fkin  was,  how- 
ever, perfeftly  fmooth  and  free  from  erup- 
tions. His  hands  only  retained  in  a  flight 
degree  their  former  feel. 

I  have  alfo  feen  inflances  of  fores  ap- 
parently fcrofulous  left  after  the  fuppuration 
and  ulceration  of  difeafed  glands,  which  had 
continued  for  more  than  a  year,  heal  rapidly 
under  the  fame  kind  of  treatment.  I  have 
however  feen  other  inftances,  in  which  the 
fores  did  not  appear  to  be  amended  by  fuch 
conftitutional  treatment, 

I  have 


A>iD   Tt^SAtMB^T  OF  LOCAL  DIS&ASSS*    l6j 

I  have  alfo.  obferved  feveral  inftances  of 
.ftf  umous  afFeftions  of  the  fingers  in  children 
get  well  in  proportion  $s  the  general  healtli 
has  become  eftablifhed  by  correftingdifordert 
of  the  digeftive  organs.  I  need  not  howevef 
detail  them.  Thefe  difeafes  were,  in  my  opU 
hion,  ftriftly  fcrofulous.  The  nature  of  the 
difeafe  in  the  following  cafe  will  not  I  think 
be  doubted,  and  on  this  account  I  relate  it. 

CASE    XX- 

A  child  about  five  years  of  age,  after  hav* 
ing  had  the  meafles,  got  into  a  bad  ftate  of 
health,  and  had  feveral  fcrofiilous  abfcJeflei 
form  on  the  forej^arm*  They  became  fores  of 
various  fizes,  but  in  general  about  that  of  k 
ftiillirig ;  the  furrounding  Ikin  was  thickiened 
and  of  a  purplifh  hue.  The  fores  were  fou! 
and  without  granulations.  In  this  ftate  thtf 
were  when  I  firft  law  the  patient,  and  had 
continued  with  occafional^itmendment  and 
deterioration  for  twa  years-  Being  confulted 
on  the  cafe,  and  perceiving  the  child  appear-r 
ed '  out  ef  health,  I  examined  his  tongue, 
yfhich  -was  furred;  enquired  refpeftinghJi 

M  3  appetite^ 


l66       OV  TH£  COH8TITUTIOKAL  O&IOIK, 

appetite,  which  was  deficient,  and  the  ftate 
of  his  bowels,  which  were  coftive.  Th« 
fame  medicines  were  prefcribed  as  in  the  for- 
mer cafes.  In  about  fix  weeks  the  child  got 
kito  remarkably  good  health,  which  it  had 
not  enjoyed  from  the  time  of  its  firft  indiP* 
pofition,  and  the  fores  rapidly  and  fbundly 
healed. 

My  obfervations  have  led  me  to  believe^ 
t!hat  moft  local  difeaies  are  preceded  by  gene- 
ral indifpofition,  of  which  the  difordered  ftate 
of  the  digeftive  organs  is  an  evidence,  and 
may  have  been  a  cauie.  The  relief  arifiag 
from  the  correction  of  this  diforder  is  indeed 
furprifing,  and  the  general  knowledge  of  this 
fadt  I  have  deemed  my  duty  to  promote  to 
the  utmoft  of  my  power.  When  the  appe^- 
tite  has  been  deficient,  I  have  been  accuftoro^ 
ed  to  recommend  acids  as  medicines,  when  on 
the  contrary  it  has  been  good,  and  the  diges- 
tion difficult  and  imperfeCt,  I  have  reconip* 
mended  bitters  and  alkalies. 

I  mention  this  to  account  for  my  giving 
the  vitriolic  acid  in  thefe  cafes.    It  is  in  adr* 

dition 


AKB  TaSATMEKT  OF  LOCAL  DX8EA8£8.  iSj 

dition  to  its  medical  properties,  fo  pleafant, 
that  even  fpoiled  children  will  take  it  with- 
out a^tating  themfelves,  and  diftrefling  their 
parents.     It  pleafes  me  to  be  able  to  give 
proofs  of  its  utility ;  becaufe,  I  think,  they 
will  be  allowed  to  difprove  that  any  fpecific 
good  arifes  from  the  adminiitration  of  alka- 
lies.    Alkalies  may  be  ufeful  occafionally  in 
^iylpeptic  cafes  ;  but  that  they  have  no  fpeci- 
<£c  adtion  in  the  cure  of  fcrofula,  I  have  long 
thought  from  fome  experiments  which  I  madfe 
on  this  fubje6t  at  the  hofpitaL     In  cafes  of 
jcrofulous  glands,  I  gave  foda  in  doies  which 
Twre  gradually  increafed  till  they  affedled  the 
qualities  of  the  iirine,  without  percC&ving  any 
IxncSt  to  accrue  to  the  local  difeafe  from  their 
life.    The  pleafure  which.  I  feel  in  thus  en- 
^eavouring  to  difprove  the  fpecific  virtues  of 
alkalies  ariies  from  this  circumflance : — That 
if  I  am  right  in  my  notion,  that  they  arc 
-<hiefly  ufeful  by  their  operation  in  the  fto* 
mach  and  bowels,  it  fhews  how  much  better 
it  is  to  be  informed  of  what  ought  to  be 
done  for  the  cure  of  difeafes,  than  of  the 
means  by  which  it  may  occafionally  be  ac- 
complifheds  or  in  other  words,  it    ihews 

M  4  how 


1^68     OM  TBB   COHSTITVTXONAL  OUGIMf 

how  much  fupcrior  the  rational  is  to  the  cm-^ 
pirical  pra6lice  of  medicine. 

After  having  attempted  to  ftiew  that  many 
Bon-defcript  difeafes  arife  apparently  from 
the  ftate  of  the  conftitution,  and  that  car- 
buncle and  fcrofula  are  fometimes  confer 
quences  of  the  fame  caufe  5  it  may  be  en- 
quired, whether,  if  the  fame  general  diftur- 
bance  of  the  health  can  produce  fo  many  va* 
rieties  of  local  difeafe,  it  may  produce  many 
others,  and  even  every  variety.  Even  in 
cancer,  diforder  of  the  digeftive  organs  ap- 
pears to  be  antecedent  to  the  local  difeafe, 
and  aggravated  by  its  exiftence ;  but  whether 
this  diforder  be  the  efFeft  or  caufe  of  the 
conftitutional  diathefis  cannot,  I  think,  be  at 
prefent  determined. 


CASEa 


AND  TMATMSNT  OF  tOCAX  BUEAffSS*  xSq 


"C  A  S  E  S. 


SECTION  IV. 

Oh  Dj/iafes  of  various  Glands^  arifingfrim  Diforder 

of  the  Conjiitution. 

T  HAVE  alfo  obferved  that  difeafes  of  parti- 
•*'  cular  organs  feem  to  originate,  in  many 
iiiftances,  from  diforder  of  the  fyftem  in  gene- 
fal.  The  teftis  of  the  male  fubjeft',  and 
breaft  of  the  female,  have  furniflied  me  with 
examples  of  this  obfervation.  In  the  cafes 
to  which  I  allude,  the  tciles  were  alternately 
afFcfted,  enlarging  confiderably,  and  then 
^bfiding^.  I  have  met  with  numerdus 
and  intereftiris:  cafes  of  fuch  difeafes  of  the 
Breaft ;  however,  the  relation  of  a  few  wilj 
be  fufRcient  to  inform  the  reader  of  all  that 
I.  know  concerning  this  fubjeft. 

*  The  caufe,wjiich  excites  and  maintains  alternate  irri-» 
tation  and  difcafip  of  the  tefles,  generally  refides  in  tlie 
urethra ;  but  tlxere  was  no  difeafe  of  that  part,  in  the  cafes 
which  I  now  mention.  The  patients,  fitd  beca^ie  uzi» 
healthy,  and  diforder  of  the  teftes  followed.  Similar  a£} 
feQti^n^  are  not  uncommon  in  pfeudo-fyphilis. 

5  A  lady 


170        OK  THE  CQKSTITUTIOKAIi  OtiOlNt 

.CASE    XXI. 

A  lady  came  to  London,  to  flibmit  to  the 
removal  of  a  difeafed  breaft,  if  it  fhould  be 
judged  neceflTary.  The  difeaie  had  exiiled  for 
more  than  two  years.  The  brcaft  of  the  af- 
fb£bed  fide  was  one  third  larger  tlian  the 
other;  indurated  in  feveral  parts;  and  fo 
much  enlarged  and  hardened  in  one  place, 
that  this  might  have  been  taken  for  a  diflind: 
tvunour  on  a  hafly  and  inattentive  examina-^ 
tion  *.  This  part  was  fituated  near  the  mar- 
gin of  the  perioral  mufcle.  The  difeaie  bad 
refifted  the  various  means  employed  with  a 
view  to  difperfe  it,  fuch  as  leeches,  lotions, 
mercurial  ointment,  &c.  It  was  occafionally 
painful,  and  caufed  the  patient  fb  much 
mental  anxiety,  that  the  ilirgeon,  who  attend^ 
ed  her  in  the  coimtry,  thought  it  fhould  be 
removed.     The  mammary  gland  of  the  op-* 

*  It  may  not  be  improper  to  obferve  here,  for  the  inftmc* 
tion  of  the  younger  part  of  the  profei&on,  that  if  a  breaft 
containing  a  portion  which  is  particularly  indurated  be  ex* 
amined  with  the  points  of  the  fingers  placed  circularly^ 
the  difeafe  will  feel  like  a  feparate  tumour  \  but  if  die  fiat 
furf ace  of  the  fingers  be  moved  over  itj  its  true  nature  wiJt 
become  manifeft. 

po(ite 


iiKD  TMATllKKr  OV  LOCAL   DI8BAt|K8.  I7I 

pofite  fide  was  far  from  being  in  a  perfeftly 
healthy  date ;  which  circumftance  appeared 
to  forbid  an  operation^  fince  the  fame  difeale 
might  take  place  afterwards  in  the  oppoiite 
breaft  The  patient's  general  health  was 
Bmch  impaired^  her  tongue  was  furred^  her 
appetite  deficient,  her  digeftion  impcrfeft; 
the  biliary  fecretion  was  difordered,  and 
the  bowels  coftive.  I  ordered  her  to 
take  a  compomid  calomel  pill  every  other 
night,  five  grains  of  rhubarb  half  an  hour 
iidfiore  dinner,  and  the  infufion  of  gentian 
with  fenna,  fb  as  to  procure  a  fufiicient  eva» 
cuationof  the  bowels  daily.  Linen  moifi:<- 
cned  in  water  was  applied  to  the  part  in  the 
evening,  or  when  it  felt  painful  and  heated* 
This  plan  of  treatment  induced  the  bulk  of 
the  difeafed  gland  by  at  leail  one  third  in  the 
courfe  of  a  fortnight.  The  patient  went 
afterwards  into  the  country,  Hill  employing 
the  fame  medicines ;  and  was  entirely  free 
from  the  difeafe  in  three  months,  though  fhc 
&lt  occafionally  fhooting  pains,  which  pro- 
bably indicated  that  her  health  was  nbt  com- 
pletdy  re-eftabUfhed. 

CASE 


tyZ       OK  TR6   COKSTITUTIONiU.  OKICIIT, 


r 


CASE    XXI& 

>  A  lady  confulted  me  on  account  of  a  con^ 
fiderable  fwelling  of  the  breafl,  attended  with 
much  pain.  It  had  come  on  fuddenly,  and 
had  been  painful  about  a  week;  but  fhc 
thought  that  a  lump  had  exifted  previous  to 
this  time.  The  principal  tumour  was  on  the 
iide  next  the  fternum,  and  was  as  large  as  aiX 
hen's  egg ;  it  feemed  to  be  diftinfl^  yet  there 
was  a  general  fwelling,  with  partial  indu£a»r 
tion  of  the  fubftance  of  the  gland.  The  tongue 
was  furred,  the  bowels  coftive,  and  the  pulie 
frequent;  and  (he  was,  to  ufe  hci?  own  c»- 
preflion,  very  nervous.  I  directed  her  to  ufe 
the  fame  means  as  were  mentioned  in  the 
preceding  cafe.  Small  dofes  of  mercury  a£t 
beneficially  on  the  bowels,  by  inducing  regu- 
lar and  healthy  fecretions ;  and  I  know  no 
better  method  of  adminiftering  it  as  a  difcu- 
tient.  The  general  induration  of  the  breaft 
an4  tumefaction  of  the  integuments  fubfided 
quickly  under  this  treatment,  and  left  the 
lump  in  the  fame  ftate  which  I  fuppoied  it 
to  have  been  in  before  the  attack  of  general 

fwelling 


AND  TREATMENT   OF   LOCAL   DISEASES.    I7J 

fwelling  and  pain.  In  another  week  this  ap-^ 
parently  diftinft  tumour  was  flattened  on  its 
furface,  diminiihed  in  fize,  and  confufed  with 
the  fubftance  of  the  mammary  gland.  Its 
form  varied  each  fucceflive  week  y  it  firft  be- 
came oblong,  and  afterwards  feemed  to  fepa- 
Tate  into  two  parts;  but  in  lefs  than  fix 
weeks  no  trace  of  it  could  be  felt. 

CASE    xxin. 

A  medical  man,  who  refides  in  the  countiy, 
l)rought  his  daughter  to  town  for  advice. 
She  had  apparently  a  tumour  in  her  left 
breaft,  between  the  nipple  and  the  axilla  j  in 
which  part  fhe  had  felt  a  good  deal  of  pain. 
The  fwelling  was  of  very  confiderable  fize, 
and  the  breaft  fo  tender,  that  I  could  not 
exaftty  make  out  whether  it  arofc  from  dit- 
tin£l  tumour,  or  from  a  partial  enlargement 
of  the  mammaiy,gland.  Want  of  time  pre* 
vented  the  patient's  father  from  fhewing  the 
cafe  to  another  furgeon.  I  could  only  give 
him  this  opinion  j  that  in  the  prefent  cir* 
cumfVances  no  one  would  think  of  an  opera- 
tion. I  recommended  the  application  of  the 
lotio  ammon.  acetat.  when  the  part  felt  heat- 
ed ;  and  as  the  patient  liad  diforder  of  th? 

fto- 


\ 


j74       ^^  "^^^  CONSTITUTIONAL  CRiail^^ 

ftomach  and  bowels  to  a  great  degree,  that 
the  chief  attention  fhould  be  paid  to  the  date 
of  thefe  organs.  A  grain  of  calomel  was  di- 
refted  to  be  taken  every  fecond  night  j  rhu* 
barb  before  dinner,  and  infuf.  gentian  and 
fenna,  if  ncceffary. 

About  two  months  afterwards,  having  oc* 
cafion  to  be  in  that  part  of  the  country  where 
the  patient  redded,  I  called  on  her.  Her 
father  then  told  me  that  the  fwelling  had 
fubfided  confiderably,'  after  his  daughter's 
return  in  the  country ;  and  that  of  late  he 
had  not  examined  the  complaint,  as  {he  told 
him  (he  felt  no  unealinefs  fronr  it. 

When  I  now  examined  the  bread,  I  could 
not  perceive  any  difference  between  it  and 
the  other.  No  veftige  was  left  of  a  diforder, 
which  had  been  of  fuch  a  magnitude,  as  to 
occafion  confiderable  alarm  -,  a  circumftancc 
that  excited  the  greateft  furprize  in  the  mind 
of  her  father,  who  was  a  practitioner  of  much 
cxpeiience  *. 

*  I  have  alfo  known  cafes  of  induration  and  fuppuratioa 
of  die  falivary  glands,  apparently  caufed  by  the  fame  gene« 
111  diforder,  and  cured  by  the  fame  treatment. 

14  before 


AIlD  TItEATMBNT  OF   LOCAL   DISEASES.  I75 

Before  I  had  paid  attention  to  thofe  com- 
plaints which  arife  from,  or  arc  aggravated 
by  conftitutional  caufcs,  I  could  not  havic 
believed  that  fuch  confiderable  local  difeafcs, 
after  refifting  various  topical  and  general 
means,  fhould  give  way  fo  readily  and  com- 
pletely to  fmall  dofes  of  medicine.  It  is  only 
by  confidering  the  manner  in  which  this 
effeft  is  produced,  that  the  fubjeft  can  be 
placed  in  a  proper  point  of  view.    ' 

An  attention  to  the  ftate  of  the  bowels 
is  indifpenfably  neceflaiy,  even  in  the  com- 
mon practice  of  furgeiy.     A  fimple  cut  of 
the  finger  frets  into  a  bad  phagedaenic  fore, 
which  refifts  every  local  remedy  fo  long,  that 
amputation  is  at  laft  propofed.     This  is  the 
confequence    of   bad   health,   which  in  its 
turn  is  aggravated  by  the  irritation  of  the 
lore.     The  patient  has  a  furred  tongue,  with 
other  fymptoms  of  difordered  digeftivt  organs. 
An  attention  to  this  diforder  correfts  the 
painful  ftate  of  the  fore,  which  now  heals 
pidly  under  fimple  dreflings. 

A  patient  has  a  diforder  in  the  urethra, 

almoft 


176       ON   THE    CdNSTITUTIONAL  OKWWi 

almoft  too  trivial  for  furgical  attention  5  yet 
producing  much  inconvenience*  The  func* 
tions  of  the  digeftive  organs  arc  impaired, 
and  he  is  hypochondriacal*  He  confults  a 
phyfician,  under  whofe  care  his  general 
health  is  amended,  and  he  no  longer  feels  or 
thinks  of  the  local  difeafc. 

An  eryfipelatous  inflammation  of  the  leg 
is  imputed  to  fome  trivial  caule ;  as  for  in- 
ftance  a  gnat- bite.  It  becomes  worfe  under 
the  common  remedies.  The  health  has  been 
long  declining,  and  the  chylopoietic  vifcera 
are  obvioufly  deranged.  The  eryfipelas  is 
quickly  cured  by  medicines  prefcribcd  for 
that  diforder. 

A  patient  has  a  trivial  fore  on  his  leg  which 
the  furgeon  finds  a  difficulty  in  curing  by 
the  ufual  methods.  The  patient  feels  indiC* 
pofed,  and  has  a  manifell:  diforder  of  his  di- 
geftive organs.  The  fore  begins  to  Hough, 
and  becomes  veiy  painful.  The  diforder  of 
the  ftomach  and  bowels  is  augmented ;  fb 
great  is  the  indigcftion,  that  the  fmall 
quantity  of  food  v.  hich  the  patient  thinks  it 

neceflary 


1 


AND   TIIEATMEMT  0?   LOCAl.   DtSEASSS.  177 

neceflkry  to  fwallow  for  fuftenance,  feels 
weighty  and  uncomfortable  in  the  ftomach  j 
and  the  vegetable  food  becomes  almoft  cor- 
rofively  acid.  Opium  fails  to  procure  fleep, 
or  even  to  give  eafe.  When  the  mortifica- 
tion has  fpread  fo  as  to  occupy  almoft  one 
fourth  of  the  integuments  of  the  leg,  feveral 
very  copious  pultaceous  ftools  of  a  greenifli 
brown  colour  are  difcliarged  from  the  bowels 
in  the  courfe  of  the  night,  and  the  patient's 
Feelings  undergo  an  entire  revolution.  Before 
this,  the  ftools  procured  by  medicine  were 
watry  and  dark  coloured.  The  patient 
now  fleeps  like  one  long  harafled  by 
pain  and  watching ;  his  ftomach  is  tran- 
quil and  willingly  receives  aliment,  which 
now  produces  no  uneafy  fenfations.  The 
ikin  which  had  been  hot  and  dry,  becomes 
moiftened  with  a  gentle  perfpiration,  and  the 
pulfe  beats  with  its  natural  frequency,  and 
in  a  tranquil  manner.  The  effeds  of  this 
favourable  crifis  being  maintained  by  medi- 
cal treatment,  the  floughs  are  thrown  off  and 
the  fore  heals  with  a  rapidity  indicative  of 
confiderable  vigour  of  conftitution,  and  fur- 
tha:  demonftxative  of  the  floughing  not  hav-* 
VOL.  I.  N  ing 


4 

1 


IjrS       ON   THE   COMSTITUTIONAL   OUGIH, 

ing  been  tlie  effeft  of  vafcular  weaknefs,  I 
of  nervous  irritation.  I  could  relate  numer- 
ous cafes  of  eryfipelatous  inflammation  ter- 
minating in  floughing,  in  which  the  difeafe 
arofe  horn  a  ftniilar  conftitutional  caufe. 


A  patient  fuppofes  that  his  knee  is  ftrained ; 
for  pain  and  inflammation  of  tlie  joint  fud- 
denly  come  on,  with  depofition  of  fluid  into 
the  articulai"  cavity ;  this  attack  is  attended 
with  fever,  furred  tongue,  and  unnatural  dis- 
charges from  the  bowels.  Leeches,  cooling 
wafhes,  and  poultices ;  in  Ihort,  all  topical 
appHcations  are  unavailing.  It  is  a  cale  of 
rheumatic  inflammation,  for  wliich  a  phyfi- 
cian  is  confultcd.  Five  or  fix  weeks  elap{e 
without  any  abatement  of  the  difeafe,  the 
patient  being  almoft  unable  to  ftir  in  bed. 
An  alteration  in  the  health  fuddenly  takes 
place  i  the  tongue  becomes  clean,  the  bowels 
regular,and biliary  fecretion healthy;  and  there 
is  no  longer  any  pain  in  the  knee.  All  the 
fluid  is  abforbed  from  the  joint  in  two  days» 
and  the  patient  walks  about  his  chamber. 
Or  there  may  actually  have  been  fomc  local 
injurj' ;  but  the  confequences  are  very  coti- 
8  fiderablc 


1 


AVa  TRKATMENT  OP   LOCAL   DISEASES.    179 

fiderable  and  violent,  and  quite  incommen- 
furate  to  the  caufe.  Such  occurrences  can, 
only  be  explained  by  imputing  the  effefls  to 
the  ftate  of  the  health  in  general  *. 

A  cafe  like  that  defcribed  in  the  preceding 
Iketch  would,  I  believe,  be  acknowledged  by 
every  one  to  be  dependent  on  the  ftate  of  the 
conftitution  in  general}  but  I  could  bring  for- 
ward a  great  number  of  initances  of  chronic 
affedions  of  joints,  incurable  by  local  mea- 
fures,  which  were  evidently  cured  by  corre6t- 
ing  thofe  errors  in  tlie  ftate  of  the  digeftivc 
organs,  which  were  the  caufe  or  efFei5t  of 
genei-al  diforder  of  conftitution.  In  difeafes 
of  joints,  we  find  three  diftinfl  kinds  of  cafes. 
Firft  a  fcrofiilous  difeafe  of  the  bones,  which 
ultimately  affefts  their  articular  furfaces ; 
fecondly,  an  inflammatory  affeftion  of  the 
joint,  producing  effufion  of  fluids  into  its 
cavity  and  ulceratiwi  of  the  cartilages  and 
ligaments  ;  and  in  this  cafe,  the  moft  perfe6t 
reft,  and  moft  ftrenuous    efforts    by  local 

•  As  operations  are  injuries,  to  we  ought  not  to  per- 
form them,  if  it  can  be  avoided,  when  the  conflitutioa  u 
inucb  difordered.  I  could  relate  feveral  iiiRaiices  of  the 
wounds  made  in  operations,  afliuning  difeidcd  actions  from 
iiich  a  ftate  of  the  coaftitucion. 

N  2  means 


l80      •N  THE  CONSTITUTIONAL  011)^117, 

means  to  put  a  flop  to  inflammation  are  re- 
quiiite;   and  thirdly,  an  inflaimmation  de* 
pendejjt  on  conftitutional  cauies.     This  in-* 
flammation  is  fometimes  of  an  a£live  and 
painful  nature,  and  fometimes  of  a  more  in- 
dolent  and  chronic  charafter;  but  whatever 
form  it  may  aflume,  it  is  Icfs  prone  to  injure 
the  ftru6hire  of  the  joint,  and  little  fufceptible 
of  cure  by  local  meafures,  whilft  it  yields 
to  thofe  means  which  tend  to  improve  the 
health  in  general.     Wheii  a  difealed  joint  is 
fo  fituated  as  to  become  an  objeft  of  examina- 
tion, thefe  circumftances  will  be  fufficiently 
evident.     I  am  .induced  to  mention  them 
chiefly  on  account  of  fuch  variety  of  affec- 
tions occurring  equally  in  the  hip,  as  wdl  as 
in  the  other  joints,  in  which  cafe  the  be- 
nefit accruihg  from  different  modes  of  ti'eat- 
ment  is  lefs  demonflrable  to  the  fight  and 
touch  *. 

*  As  I  know  of  no  treatife  on  difeafes  of  the  hip  in 
which  the  diftinf^ion  of  cafes  is  made  \  and  as,  from  what 
I  have  feen,  I  cannot  but  confider  the  fubjeft  to  be  very 
important ;  fo  I  think  I  fhould  do  wrong  to  forego  the 
prefent  opportunity  of  relating  as  fuccin^ilyas  poffible  tw» 
of  \t  confiderable  number  that  have  come  under  n^y  obfinr* 
VHtioUi  is  order  to  excite  attention  to  this,  fubje^ 

CASE 


AKD  tRBATMENT  OF  LOCAL  DI^fiAS£S.   x8f 

CASE   L 

A  boy  about  twelve  years  old  was  fent  from  fchool  to 
Londdn^  being  fuppofed  to  have  a  lumbar  abfcefs*    There 
was  a  confiderable  colle£lion  of  fluid  beneath  the  fafcia  o£ 
die  thigh ;  but  it  received  no  impulfe  when  the  patient 
coughed.    The  boy  limped  in  walking  as  if  he  had  a  dif« 
eafed  hipi  fcarcely  bearing  on  the  afTed^ed  joint*'    When 
preflurewas  made  on  the  front  of  the  orbicular  ligamentf 
it  gave  him  acute  and  confiderable  pain.     He  was  kept 
perfe^y  quiet  it),  bed,  blood  was  taken  by  leeches  rje*  ^ 
peatedly  from  the  integuments  oppofite  to  the  inflamed 
joint,  and  linen  wet  with  diluted  aq:  ammon:  acet:  con- 
stantly applied,  tiU  preflTure  no  longer  occafioned  pain.   A 
blifter  was  then  applied  over  the  joint,  and  the  cuticle  being 
removed,  the  fore  furface  was  dreflied  with  favine  cerate* 
Tins  drelfing  produced  confiderable  inflammation  and  ul- 
ceration beyond  the  bliftered  part,  and  caufed  the  furface 
of  the  {kin  which  had  been  deprived  of  its  cuticle  to  mor- 
tify.    Near  a  month  elapfed  before  the  fore  healed.     At 
this  time  no  fluid  was  difcoverable  beneath  the  fafcia ;  no 
uneafinefs  was  felt  when  the  joint  was  comprefled ;  and 
the  boy  could  not  be  prevented  from  getting  up,  becaufe 
he  felt  as  competent  to  walk  about,  as  before  the  occur- 
rence  of  his  difeafe.     He  went  to  fchool  again  in  the 
country,,  and  after  two  years  was  put  into  a  merchant's 
employ ;  in  which  fituation,  he  was  obliged  to  be  con- 
ftantly  walking  about  the  town.     He  then  again  became 
lame  in  the  fame  manner,  but  not  to  the  fame  degree. 
There  was,  however,  no  effiifion  of  fluid  beneath  the  faC^ 
— cia  of  the  thigh.     A  month's  reft  with  fimilar  treatment 
feemed  to  have  cured  this  relapfe  ^  and  I  then  told  his 
father  that  he  muft  change  the  employment  of  his  fon  t 
•bfinrviflg)  that  though  the  joint  might  recover  fufficiently 

H  3  to 


iSl      ON  THE   CONSTITUTIONAU  ORIOINf 

to  endure  common  eserc'ife,  without  injury,  it  was 
not  to  be  expefted  that  it  -would  ever  be  able  to  fufl^n 
violent  exertions  with  impunity.  I  urged  hin^^  alfo, 
to  Ut  me  know  immediately  if  there  was  any  return 
of  limenefs.  About  three  months  afterwards,  I  met  the 
fcther  and  his  fon  in  the  ftreet,  and  obferve  J  that  the  youth 
limped  in  walking  very  much.  I  aiked  why  I  hid  not 
been  informed  immediately,  as  I  had  requefted,  of  return 
of  lamenefs  i  and  further  enquired,  whether  the  boy  ftill 
continued  in  the  fame  fituation.  Being  told  thathe  did  fo, 
I  felt  fo  much  hurt  at  the  cruel  and  abfurd  conduct  of  hig 
father,  that  I  declared  I  would  no  longer  interfere  .in  their 
concerns,  nor  was  I  atked  to  do  fo. 

All  that  I  can  further  relate  of  this  cafe  is,  that  a  largs 
abfcefs  formed  and  broke  behind  the  trochanter,  and  that 
I  once  afterwards  faw  the  poor  lad  lying  in  St.  Bartholo- 
mew's hofpital  with  his  thigh  bone  diflocated  in  confe« 
quence  of  the  deftruition  of  the  ligaments  of  the  joint. 


CASE    II. 

A  young  lady  of  a  delicate  and  fufceptihle  conflitutiotii 
who  had  fufTered  much  unealinefs  of  mind  on  account  of 
fome  of  her  friends,  became  fo  exceffively  lame  in  the  left 
liip  that  fhe  could  not  move  a  few  fteps  without  fupport. 
PreiTure  on  the  front  of  the  joint  occafioned  confiderable 
pain.  Her  tongue  was  much  furred,  and  her  bowels 
greatly  difordered,  and  (he  had  fits  of  agitated  and  diffi- 
cult refpiration.  I  recommended  notliing  but  tepid  fo- 
mentations to  the  hip,  and  explained  to  her  phylician  what 
I  thought  would  be  right  fo  be  done  with  regard  to  the 
ftale  of  the  digellive  organs, 

As  ftie  became  better  in  health,  her  power  of  moring 

about  incrtafed,  and  ftie  went  to  tjie  fea-lide.     After  two 

Jiesrt 


AVn  TRSATMSNT  OF  LOCAL  BISSABK.    fSj 

jears  there  ftill  remained  fome  tendemefs^  when  the  iup 
joint  was  comprefled  and  fome  thickening  of  ^  parts 
which  covered  it.  She,  however,^  eTentually  got  well^ 
though  no  local  applications  of  any  moment  were  made 
to  the  difeafed  parts.  I  need  fcarcely  add^  that  the  0»eans 
employed  in  the  firft  cafe,  with  fuch  ftriking  fuccefs, 
would  have  been  prejudicial  in  the  latter,  whilft  tbofe 
which  were  ferviceaUe  in  the  kft  cafe,  would  have  been 
futile  and  nugatory  in  the  former. 


H  4  CASES': 


tftf.    «1C<  TBI  C0M8VI'rvTieRA&  OMOWy 


CASES. 


«ECnONV. 

« 

Dif orders  of  Parts  which  have  a  Continuity  of  Sur^ 
face  with  the  alimentary  Canal. 

I  HAD  formerly  obferved  fpafinodic  ftruc- 
tures  of  the  cefophagus  to  difappear  under 
various  modes  of  treatment,  in  a  manner 
which  I  did  not  underftand.  Mercury  feem- 
cd  to  efFeft^the  cure  in  three  inftances.  Many 
cafes  have  occurred  to  me  lately,,  in  which 
the  irritation  in  the  cefophagus  feemed  to 
be  firft  excited  and  afterwards  maintained 
by  diforder  of  the  digeftive  organs.  It  will 
be  readily  allowed,  that  fpafinodic  ftri6hires 
of  the  cefophagus,  when  long  continued,  may 
caufe  a  thickening  in  the  affefted  part  of  the 
tube,  and  thus  the  ftrifture  may  become  per- 
manent. One  inftance  will  be  fufficient  to 
illuftrate  and  verify  this  view  of  the  fiib- 

CASE 


AHJO  TRBATMEKT  OF  LOCAL  DISBASS8.    1^5 

CASE    XXIV. 

A  lady,  who  had  been  in  bad  health  for 
many  years,  and  was  fuppofcd  by  her  medi- 
cal attendants  to  have  a  ilridture  of  the  cefo- 
phagUS)  became  at  lail  incapable  of  fwallow- 
ing  any  food,  except  in  very  fmall  quantities ; 
ihe  was  even  then  obliged  to  drink  fome 
fluid  after  each  morfel,  to  facilitate  its  defcent 
into  the  ftomach.     Some  mucus  aiid  blood 
rofe  into  the  mouth  after  vomiting,  which 
very  generally  followed  the  taking  of  food. 
Under  thefe  circumftances,  I  was  requefted 
to  pafs  a  bougie,  in  order  to  afcertain  the  ftate 
of  the  oefophagus ;  but  I  declined  this  exami- 
nation, on  account  of  the  diforder  wliich 
exifled  in  the  ftomach.     The  tongue  was 
greatly  furred;  the  parts  in  the  cpigaftric 
region  very  tender :  the  bowels  much  difor* 
dered;  the  fecretion  of  bile  either  very  un- 
healthy, or  entirely  wanting;  every  fymptom, 
in  fhort,  which  indicates  an  aggravated  form 
of  diforder  of  the  digeftive  organs,  exifted 
in  a  ftriking  degree.     The  ftomach  and  bow- 
els were  brought  into  a  better  ftate  by  fuch 
medical  attentions  as  I  have  already  fo  o£|m 
'ddcribcd;    and  the  cefophagus  partook  of 

this 


1 86        ON  THE  CONSTITUTIONAL  OMdnr^ 

this  amendment :  for  moderately  (ized  mor- 
fels  of  food  could  now  be  fwallowed  with- 
out the  neceffity  of  wafhing  them  down  by 
liquids.  The  general  health  alfo  improved, 
imd  (he  became  fat.  But  the  diibrder  of  the 
digeftive  organs,  which  had  been  of  long 
continuance,  wa^  not  completely  fubdued; 
Ihe  was  ftill  fubjeft  to  relapfes,  and  in  fome 
of  thefe  the  difficulty  of  deglutition  again 
occurred  *» 

The  throat  and  mouth. are  the  parts  next 
in  order ;  but  it  is  unneceflary  to  relate  addi^ 
tional  cafes  under  this  head:  fome  of  the 
inflances  already  recorded  will  be  fufficient 
to  confirm  my  fentiments  on  this  fubje£t, 
and  the  propriety  of  the  praftice  which  X 
have  recommended. 

• 

That  difeafes  of  the  nofe  may  be  caufedt 
or  aggravated  by  irritation  arifing  from  the 
ftomach  is  a  propofition,  which  will,  I  thinic, 
be  readily  granted.  Indeed  it  feems  furpri- 
fing  that  the  operation  of  this  caufe  has  been 

♦  This  patient  has  now  for  more  than  four  years  been 
free  from  this  diforder. 


AND    TREATMENT   OF   LOCAL    DISEASES.    1S7 

To  little  adverted  to  in  books  of  furgeiy ;  fincc 
the  phaenomena  which  prove  the  fa£l  are  ib 
well  known.  Are  the  monftrous  nofes,  caafed 
by  exceflive  drinking  of  vinous  and  fpiritu- 
ou's  liquors,  to  be  otherwiic  accounted  for, 
than  by  irritation  arifing  from  the  Itomach  f 
And  do  not  worms  in  children  caufc  a  teazing 
ienfation  in  the  extremity  of  the  nofe  ?     I 
had  fcen,  in  private  pra^ice,  feveral  cafes  of 
irritation  and  fwelling  of  the  end  of  the  nofc, 
in  feme  inftances  accompanied  with  fmall  ul- 
cerations of  the  pituitai7  membrane.  In  thcfe 
cafes,  the  Ikin  over  the  nofe,  which  was  tumid, 
became  rough  and  dilcoloured :  the  middle 
cf  the  difcoloured  part  became  found  ;  wbilft 
the  circumference  retained  its  morbid  aftions, 
the  difcafe  there  fpread  in  a  fmall  degree.    In 
thefe  cafes  the  tongue  was  furred  ;  and  there 
were  evident  indications  of  diforder  in  the 
ftomach  and  bowels.     The  difeafe  was  check- 
ed, and  cured,  by  attention  to  this  diforder. 
I  was  ftioTigly  imprelTetl  with   the  opinion, 
that  if  thefe  cafes  had  been  neglefted,  tliey 
would  have  terminated  in  that  herpetic  ulce- 
ration, which  fo  often  aiie^ts  the  end  of  the 
pofe,     I  have  alfo  iccn  feveral  inftances  of 

that 


H  grams 


188      ON   THE    CONSTITUTIONAL  ORIGIN, 

that  herpetic  ulceration  in  its  confirmedllatc 
more  materially  benefited  by  medical  atten- 
tion to  correft  the  diforder  of  the  digeftive 
organs  than  by  any  local  application :  and  I 
fcel  confident  that  it  may  be  frequently  cured 
by  fuch  endeavours. 

I  have  obferved,  in  all  the  cafes  of  that 
noifome  and  intraflable  difeafe,  ozgena,  which 
have  come  under  my  care  lately,  that  the 
ftomach  and  bowels  have  been  difordered ; 
and  more  benefit  has  been  obtained  by  endea- 
vouring to  bring  thefe  organs  into  a  healthy 
ftate,  than  by  all  the  local  application,  which 
had  been  previoufly  tried.  I  ftated  to  a  me- 
dical friend  my  opinions  refpefting  one  pa- 
tient, who  came  from  the  countiy,  and  beg- 
ged to  know  the  effeft  of  the  treatment  which 
I  had  propofcd.  He  informed  me,  after  fome 
months,  that  he  had  not  been  able  to  fuccecd 
in  corretfllng  the  vifceral  diforder  ;  and  after 
relating  the  means  which  had  been  ufed,  he 
adds,  *'  The  patient  was  now  attacked  with 
a  bilious  diforder,  to  which  Ihe  had  formerly 
been  fubject,  and  for  which  I  gave  her  fix 
grains  of  calomel  in  a  bolus,  which  foon 


AND  TABATMEKT  OF  LOCAL  ni8SA4Sa«  1S9 

relieved  her.  During  thi$  attack  the  nofe 
feemed  well ;  there  was  no  fetor  in  the  djf- 
charge,  and  fhe  recovered  her  fenfe  of  finel- 
ling."  However  the  difeafe  returned  after- 
wards as  before. 

I  have  known  fevcral  inflances  of  perfons 
who  have  for  a  long  time  been  fubj^£t  to 
polypi  of  the  nofe,  in  which  the  polypi 
ceafed  to  grow  after  fome  attention  had  been 
paid  to  correftadiforder  of  the  digeftive  organs. 

« 

In  farther  confirmation  of  the  opinion, 
that  difeafes  of  the  nofe  depend  much  upon 
the  flate  of  the  flomach,  I  fhall  mention  the 
cafe  of  a  woman,  who  .had  a  difeafe  of  the 
nofe,  which  I  expefted  would,  at  Icafl,  prove 
very  tedious  and  very  troublefome,  but  which 
got  well  fpeedily  under  fimple  dreflings,  in 
confequence,  as  appeared,  from  the  effedt  of 
intemal  medicines. 

CASE    XXV. 

This  patient  was  between  thirty  and  forty 
years  of  age ;  had  a  furred  tongue,  bowels 
alternately  coflive  and  lax,  and  the  difcharges 
difcoloured.     An  enlargement  of  the  left  ala 

14  nafi. 


nafi,  caufed  by  a  great  thickening  of  the  pirfl^ 
covering  and  lining  the  cartilage,  had  gradu-> 
ally  taken  plate.  The  ikin  wds  difcolourcd, 
ttnd  an  ulcer,  about  the  fize  of  a  fixpence,  had 
formed  on  the  under  furface  of  the  ala.  The 
fore  was  deep,  with  a  floughing  furface,  and 
uneven  and  fpreading  edges.  Spermacfeti  Ce- 
rate was  employed  as  a  drefling ;  and  the  ex* 
tcmal  fkin  was  frequently  bathed  with  Gou-^ 
lard's  waih.  She  was  ordered  to  take  inter- 
nally five  grains  of  rhubarb  an  hour  before 
dinner,  five  grains  of  the  pil.  hydrarg.  every 
iecond  night,  and  the  infufion  of  gentian  with 
fcnna  occafionally.  The  fore  ceafe^  to  fprcad^ 
the  fwelling  gradually  fubfided,  and  all  dif* 
cafed  appearances  were  removed  in  the  courfc 
of  a  month.  The  patient  alfo  found  her 
health  confiderably  amended. 

In  mofl  cafes  of  deafnefs,  there  is  probably 
a  ftate  of  irritation,  and  a  tendency  to  inflam- 
mation, throughout  the  pafTages  of  the  ear. 
The  external  meatus  may  be  unufually  fen- 
fible,  the  fecretions  being  either  fupprefTed, 
or  difcharged  in  an  unnatural  quantity.  The 
lining  of  the  euftachian  trumpet  is  thickened; 

and 


AMD  TRlKAtMEKT  OV  IX>CAL  t>ItaAftS.   tj|t 

and  hence  it  becomes  partially  obftrufted.  It 
muft  be  admitted  that  fuch  a  ftate  of  the  br- 
gan  is  likely  to  be  aggravated  by  a  caufe^ 
which  maintains  or  produces  irritation  in  the 
nofc.  When  dullnefs  of  hearing  alfo  depends 
on  a  torpid  ftate  of  the  nerves,  it  may  be 
caufed  by  the  fame  circumftance,  vrhich  is 
known  to  afFeft  the  fenfibility  of  other 
nerves. 

Indeed,  I  have  remarked  that  the  hearing 
of  many  perfons  has  confiderably  varied  with 
the  ftate  of  their  health  in  general ;  fo  that  I 
felt  no  ftirprife  from  the  oa:urrence  related 
in  the  following  cafe. 

A  gentleman  applied  to  me  on  account  of 
fome  pfeudofyphilitic  fymptoms,  which  I  told 
him  would  gradually  become  well.  I  advifed 
him,  at  the.  fame  time,  to  be  particularly  at- 
tentive to  the  ftate  of  the  digeftive  organs, 
whidi  were  generally  difordered  by  the  efFefts 
of  the  poiibn.  He  took  five  grain§  of  the  pilj 
hydrarg.  every  feccMid  or  third  night.  The 
dilbrders  for  which  he  had  confulted  me  were 
all  removed  in  the  courfe  of  two  months ; 

when 


t9>        OK  THE  CONS TITUTIOKAI-  ORIOIK9 

when  I  received  a  letter  from  him,  faying; 
that  he  thought  it  a  duty  he  owed  to  me  and 
to  the  public  to  inform  me^  that  the  lenient 
courfe  of  mercury,  which  I  had  recommend^ 
ed,  had  cured  him  of  a  confiderabie  degrioe  of 
habitual  deafnefs, 

I 

It  is  well  known  that  ophthalmy  frequents 
ly  arifes  from  conftitutional  caufes;  and  in 
(iich  cafes  the  digeftive  organs  are  generally 
deranged.  The  health  will  be  moft  ipeedily 
reftored,  and  the  local  difeafe  moft  effe^hially 
diminilhed,  by  correfling  the  diibrdered  ftatc 
of  the  abdominal  vifcera.  There  is  r^o  nc* 
ceffity  for  enlarging  upon  this  fubjeft ;  yet  it 
may  be  ufeful  to  ftate  what  I  have  obferved 
refpedting  thofe  ophthalmies,  wliich  take  place 
fubfequently  to  gonorrhoea,  and  which  have 
generally  been  afcribed .  to  a  retropulfion  of 
that  diforder,  or  to  the  accidental  application 
of  the  difcharge  to  the  furface  of  the  eye.  In 
the  worft  of  the  cafes,  which  I  have  fecn 
lately,  there  was  confiderabie  rednefs  and  irri- 
tability of  the  eye,  lafting  neai  iy  a  fortnight. 
The  digeftive  organs  were  deranged  in  all  the 
inftances,  to  which  I  allude  -,  and  I  attribute 

the 


AND  TI^SATMBNT  OF   LOCAL   DISEASES.     1 93 

the  comparative  well-doing  of  thefe  pa- 
tients to  the  attention  which  was  paid  to 
thdr  corre£Uon.  In  other  cafes,  which 
I  had  formerly  been  witnefs  to,  where 
evacuations  by  bleeding  and  purging,  &c. 
were  employed,  the  diforder  was  extreme- 
ly obftinate;  nay  feveral  patients  loft  their 
fight. 

The  cafes  of  ophthalmy  connefted  with 
gonorrhcea  appear  to  be  of  two  kinds.  In 
the  worft  cafe,  and  that  which  I  have  happened 
to  meet  with  moft  rarely,  there  is,  I  think, 
rcafon  to  fuppofe  that  fome  of  the  difcharge 
from  the  urethra  has  been  accidentally  ap- 
plied to  the  furface  pf  the  eye.  This  circum- 
ftance  may  be  infeired  from  the  copious  and 
puriform  difcharge  which  takes  place  from 
the  conjunctiva  which  is  continued  for 
about  three  weeks,  and  from  the  difeafe  not 
yielding  to  any  remedies  which  ufually  re- 
lieve other  ophthalmies.  The  milder  and,  to 
mc,  more  commonly  occurring  cafe,  feems  to 
be  the  refult  merely  of  irritability  of  confti- 
tution.  With  relation  to  this  fubjeft  I  may 
mention  that  I  know  a  patient  who  has  feve^ 

VOL.  u  o  ral 


194     <^^   THE   dOKSTITUTIOKAL  btLimHi 

ral  times  had  difcharge  from  the  urethra  ifid 
inflamed  eyes  alternating  with  each  other ; 
and  both  appai'ently  arifing  from  conftitu-; 
tional  caufes.  I  fhall  alfo  add  the  following 
ftriking  inftance  of  ophthalmy  conncftid 
with  gonorrhoea,  in  which  the  inflaminaticHi 
of  the  eyes  can  neither  be  fuppoied  to  be  the 
efFeft  of  local  contamination  nor  of  mctaf- 
tafis. 

CASE  XXVI. 

A  gentleman,  having  a  gonorrhoea  and  being 
in  a  remote  part  of  Scotland,  felt  himfelf  ob- 
liged to  go  to  the  weft  of  England  with  the 
greateft  expedition.  He  came  to  London  by 
the  mail  coach,  and  during  the  journey  his 
eyes  became  greatly  inflamed,  and  he  was 
much  tormented  with  dyfury ;  he  was  indeed 
fo  ill,  upon  his  arrival  in  town,  as  to  be  unable 
to  proceed  on  his  journey.  His  eyes  were  ex- 
ceedingly red  and  painful,  and  the  lids  tu- 
mid. He  had  frequent  and  urgent  delire  to 
void  his  urine.  The  difcharge  from  the 
urethra  was  veiy  copious.  His  tongue  was 
much  furred;  his  bowels  had  a  coftive  ten- 
dency; thellools  were  blackifh  and  offenfive; 

his 


lu$  pulfe  frequent,  and  neither  fUlI  nor 
ftrong^  his  ikio  hot  ^id  rather  dry.  He 
.  Hjad  that  formerly,  having  a  gonoi^l^oea,  he 
had  been  affected  .with  ophthahny  in  the  fape 
iDanner,  He  waB  directed  frequoitly  tp 
hathe  his  eyes  with  lukewarm  deco^ion  of 
poppies ;  but  the  chief  attention  was  paid  tp 
ih»  ilate  of  his  flomach  and  bowels.  He 
took  five  grains  of  the  pilul.  hydrarg,  every 
night,  and  other  medicines  to  procure  a  fuf- 
ficient  alvine  evacuation  daily.  On  the  third 
day  he  bad  fevere  rheumatic  pains  in  his 
fiioulder.  On  the  fourth,  his  knee  became  af- 
fe£ted  with  rheuma-tifm,  and  fo  Qiuch  fwoUen 
that  he  was  incapable  of  moving  about, 
though  his  eyes  were  much  better,  fb  that 
he  was  able  to  fit  up  and  bear  the  window 
ihutters  of  his  chamber  to  be  left  open,  which 
he  could  not  before  have  permitted.  On  the 
fifth  day,  though  better,  his  eyes  were  ftill 
much  inflamed,  his  dyfury  troublefomc,  and 
he  was  unable  to  walk  frpm  the  rheumatic 
afFe^on  of  his  knee.  The  difcharges  from 
the  bowels  had  been  regularly  obferved,  and 
they  ftill  continued  of  a  very  wrong  colour, 
till  the  evening  of  this  day,  Y^hen  he  had  a 

o  2  ftool 


196      ODT  THE   COMSTITXTTIONAL   OViWin, 

ftool  properly  tinftured  with  healthy  bile. 
He  now  felt  a  fudden  and  furprizing  amend- 
n'.ent,  which  appeared  equally  fo  to  othe0 
on  the  following  day;  for  I  found  him 
walking  about  with  very  little  lamenefs,  his 
eyes  requiring  no  further  attention  than 
wearing  a  green  (hade,  and  he  had  no  dy- 
fury.  In  two  days  he  purfued  his  journey, 
nor  did  he  experience  any  relapfc. 

There  is  a  chronic  ophthalmy,  which  is,T 
believe,  generally  confidered  to  be  venereal, 
probably  from  the  difficulty  of  curing  it, 
and  probably  from  mercury  being  frequently 
beneficial  to  it.  As  cafes  of  this  defcription 
evince  how  much  ophthalmies  are  likely  to 
depend  upon  conftitutional  caufes,  I  (hall 
briefly  relate  the  following  to  identify  the 
kind  of  difeafe  to  which  I  allude. 

CASE   XXVIL 

A  gentleman  had  for  more  than  two  years 
been  more  or  lefs  fubjeft  to  a  chronic  oph- 
thalmy. When  he  was  very  bad,  he  had 
twice  ufed  mercury  for  its  cure,  and  with 
temporary  fuccefe.  The  lafl  mercurial  courfc 

was 


AND  TR.SATMEKT   OF.  LOCAL   OlfEASES.    l^f 

was  a  coniiderable  one,  as  the  relapfe  of  his 
diforder  was  attributed  to  the  infufficiency 
^f  the  former  one.  The  ophthalmy,  how- 
ever, returned  with  as  much^  if  not  with 
more  feverity  than  formerly.  The  eye  was 
extremely  red,  very  irritable,  and  his  vifion 
very  imperfcft.  I  found  the  patient  fhut  up 
in  a  cloie  and  dark  chamber,  from  which  he 
rarely  ventured  to  ftir,  left  he  fhould  catch 
cold.  His  tongue  was  furred,  and  his  biliary 
iecretion  faulty.  I  dire£ted  fmall  dofes  of 
mercury  every  fecond  night,  merely  as  pro- 
bilious  medicines,  and  requefted  him  to  pay 
attention  that  his  bowels  were  kept  clear 
without  being  what  is  called  purged.  I  alfb 
~  urged  him  to  go  out  into  the  air  and  ufe. 
a^ve  exercife.  By  purfuing  thefe  meafures, 
the  ophthalmy  was  nearly  well  in  about  three 
weeks.  He  now  either  caught  cold  or  fan- 
cied that  he  had  done  fo ;  his  general  health 
became,  difturbed,  and  his  ophthalmy  return- 
ed. It  got  well,  however,  as  the  difturbance 
of  his  conftitution  wore  of,  and  though  he 
had  two  or  three  times,  during  a  year,  fome 
trivial  returns  of  ophthalmy,  yet  they  were 
always  induced  by  general  diforder,  and  rea- 

o  3  dily 


j:. 


198        OK  THCS  OOKSTirUTIONAL  OAIOIlff 

dlly  got  well  by  tneafures  dire£led  to  corredt 
difbrders  of  the  alimentary  canaL 

That  cutaneous  difeafes  *  are  much  con^ 
nested  with  the  ftate  of  the  ftomach^  is  genf^^ 
rally  known.  Hence  various  medicines  have 
beert  reccwimended  to  correft  difordcrs  of 
that  vifcus,  with  the  view  of  removing  the 
more  evident^  but  confequent  difeafe  of  the 
fkin.  The  account,  which  I  have  given  of 
diforders  6£  the  digedive  organs,  may  lead  to 
a  more'rational  and  lefs  empirical  treatment, 
ajid  to  the  more  juft  appreciation  of  the  value 

*  It  may  perhaps  be  right  to  advert  to  the  direft  and 
fudden  fympathy  which  ezifts  between  the  (kin  and  the 
ftomach.  In  affefiions  of  the  latter  organ,  the  flcin  is  dry 
and  cold,  moift  and  cold,  hot  and  dry,  or  moift  and  dry  | 
and  it  fuddenly  changes  from  the  one  to  the  other  condi- 
tion, as  the  ftate  of  the  (lomach  varies.  When  the  digef- 
tive  organs  are  difordered,  the  irritable  (late  of  thfe  (kin  is 
manifefted  by  the  cffe£ks  of  blifters  and  other  irritating  ap- 
plications^ A  Uiiler  produces  a  tormenting  local  difeafe^ 
and  even  a  Burgundy  pitch  plafter  caufes  extenfive  ery- 
thema. Indeed,  when  the  conftitution  is  irritable,  all  the 
modes  of  counter-irritation,  which  furgeons  employ  under 
other  circumftances  with  fuccefs  for  the  cure  of  local  dif« 
eafes,  are  likely  to  do  harm ;  and  thus  tliefe  curative  me- 
thods obtain  difcredit  in  confequence  of  jtheir  ill-timed  em^ 
ployment. 

>and 


AND    TMATMENT   OF   LOCAL   DISEASES.    I99 

and  mode  of  aftion  of  remedies,  which  arc 
ran(5liQned  by  experience.  It  is  almoft  fuper- 
^uous  to  relate  any  cafe  to  authenticate  (o 
well  known  a  fadl ;  the  following,  however, 
mgiy  he  found  intereiling  and  inftrudliye, 

A  patient  in  St.  Bartholomew's  hofpital 
had  an  herpetic  difeafe  of  the  fkin.  This  had 
healed  in  the  middle,  and  ipread  in  the  cir^ 
cumference  to  fuch  a  degree,  that  it  occupied 
nearly  the  whole  length  of  the  leg,  and  in- 
cluded two  thirds  of  its  circumference:     The 

■  * 

jflcin  had  recovered  a  moderately  found  date 
In  thie  centre.  The  difeafe  was  propagated  in 
the  circumference  by  an  ulceration,  which 
threw  out  a  projeaing  and  firm  fungus  of  a 
t^wiiy  colour,  of  about  half  an  inch  in 
breadth.  A  fmall  groove  or  channel  fcpa- 
rated  this  iimgus  from  the  furrounding  in- 
flamed Ikin,  which  had  not  yet  ulcerated.  A 
funilar  difeafe  occupied  the  back  part  of  the 
arm;  this  was  of  an  oval  figure,  and  refem- 
bled,  in  every  circumftance,  that  which  I 
have  already  defcribed  upon  the  leg.  Thefc 
difeafes  had  exifted  for  nearly  two  years,  and 
xpn^tinuod  to  ^read  in  oppofition  to  every 

o  4  mode 


200     ON   THB   CONStlTUTIONAL  OklOlK, 

mode  of  treatment.  Mercury  had  been  em- 
ployed, even  to  falivation,  without  any 
marked  alleviation  of  the  local  complaint; 
I  immediately  perceived  that  the  digeftivc 
organs  were  greatly  deranged:  upon  cor* 
refting  this  diforder,  the  fkin  furround- 
ing  the  difeafe  became  pale  \  and  all  difpo- 
fition  to  fpread  ceafed.  The  fungus,  how- 
ever, ftill  projected,  and  did  not  heal ;  ifwas 
therefore  drelFed  with  a  weak  folution  of  kali 
arfenicatum.  This  remedy  feemed  to  fub 
vert  the  difeafed  aftions,  which  had  produced 
the  fungus ;  fo  that,  in  lefs  two  months,  the 
patient  was  difcharged  from  the  hofpital 
perfedily  well, 

I  have  feen  fimilar  herpetic  difeafes,  of 
much  lefs  extmt,  fucceed  to  the  abforption  of 
matter  from  fores  upon  the  genitals.  Thcfe 
have  got  well  when  the  patient  has  gone  mto 
the  country,  and  appeared  again  when  he  has 
returned  to  town.  They  have  healed  under 
a  courfe  of  mercury,  and  broken  out  again 
when  it  was  difcontinued, 

.    In  this  review  of  diforders,  occurring  in 

14  parts 


I 
AUD  TRBATMSKT  OF  LOCAL   mMAHSff*  20I 

parts  having  a  continuity  of  (urface  with  the 

digeftive  organs,  I  have  traced  them  from  the 

ftomach.     Another  fet  of  difeafes  may  ori- 

^nate  from  the  fame  fource.     The  large  in- 

teftines  fufFer  more  in  advanced  ftages  of  thele 

diforders  than  the  fmaller  ones ;  hence  difbr- 

dcrs  of  the  reftum,  and  particularly  many 

irritable  difeafes  about  the  orifice  of  that 

bowtl,  are  deducible  froip  this  caufe.    I  fhall 

not,  however,  prolong  the  account  by  the 

relation  of  cafes ;  but  content  myfelf  with 

aflfuring  the  reader,  that  the  opinion  has  been 

derived  from  facls,  and  not  from  preconceived 

notions  of  the  opei  ation  of  fuch  diforders. 


SEC. 


^K»       <m  «Kf  ^0imiTVriQ^4i.  9V»lffp 


SECTION    V. 


rthis  Sc6Kon  I  fhall  mention  what  infor- 
mation I  have  obtained  by  diffeftion,  rela- 
tive to  the  caufation  of  other  difeafes  by  thoie 
of  the  digefHve  organs.  The  reciprocal  fym- 
pathy,  which  exilh  between  the  brain  and 
thedigeftive  organs,  is  generally  admitted ; 
but  the  Idnd  and  the  degree  of  the  effedi 
arifmg  from  this  iympathy,  is  not,  perhaps,  in 
general,  fufficiently  underftood.  Thefe  or- 
gans mutally  increafe  each  other's  diforder  ; 
till  the  afFeftion  of  the  fenforium  leads  to  the 
greateft  difturbance  of  the  nervous  fiinftions, 
and  even  thofe  of  the  mind. 

All  this  may  happen  without  any  vifiblc 
difeafe  of  the  brain.  Dr.  Kirkland  particu- 
larly direfted  the  attention  of  medical  men  to 
nervous  apoplexy ;  and  the  obfervations, 
which  have  been  made  fince  his  time,  have 
proved,  that  not  only  a  general  derangement 

of 


ANP  VltBATMlMT  Of  LOeJIX  tHnAttS.  00$ 

of  the  functions  of  the  nervous  iyfton  pro^ 
ducing  apoplexy,  but  alfo  partial  efFed:^  o£  a 
fimilar  nature  caufing  hemiplegia  and  para- 
lyfis,  may  take  place,  without  any  vilible 
change  of  ftru^ure  in  the  braki.    I  have 
met  with  numerous  inflances  of  this  kind:; 
but  could  not  determine  whether  the  affec^ 
tions  were  merely  nervous,  or  whether  they 
were  produced,  or  aggravated  by  diibrder  of 
the  digeftive  organs.     I  only  know,  that  the 
patients  died  affected   by  apoplexy,  hemi* 
plegia,  or  more  local  paralyfis,  without  any 
derangement  in  the  evident  ftruauie  of  the 
brain.     I  may  alfo  mention,  that  I  Ibrmerly 
examined  the  brains  of  three  perfons  who 
died  in  a  comatofe  ftate,  in  confequence  of 
€he  metaflafis  of  liieumatifin.     In  theic  eaies 
no  morbid  appearance  was  obferved  in  die 
brain,  except  fi>me  flight  marks  of  inflamma*- 
tion  of  the  pia  mater.     It  therefore  appears 
clearly  to  me,  that  diforder  and  a  confider* 
able  diminution  of  the  nervous  f un£tions 
may  take  place,  without  any  organic  afFeftion 
of  the  brain.     The  perfcfl:  recovery  of  pa- 
tients, which  fometimes  happens,  after  fuch 
difbrders,  may  aHb  be  confidered  as  additional 

evidence 


S04      car  THB  COK&TITUTIONAZi  ouoiir,    ^ 

evidence  of  there  having  been,  in  flich  in- 
ilances^  no  organic  diieafe  of  the  brain. 

There  can  be  no  doubt  but  that  epilepfy 
may  in  like  manner  take  place  without  any 
morbid  alteration  of  the  ftruftureof  the  brain, 
or  its  membranes.  Some  of  theperfbns  whofe 
heads  were  examined,  without  the  difcovcry 
of  any  difeafe  of  thofe  parts,  had  been  fubjeft 
to  attacks  like  thofe  of  epilepfy.     Dr.  Henry 
Frafer  has,  of  late,  publifhed  a  decifive  in* 
ftance  in  pr^of  of  this  fadt.     A  patient  died 
of  epilepfy,  and  his  brain  was  examined  with 
particular  attention  by  Mr.  Cooper,  without 
any  morbid  alteration  of  ftru£hire  being  dif* 
covered  *.     In  general,  however,  morbid  ap- 
pearances are  evident  in  the  brains  of  thofe 
perfons  who  die  of  epilepfy.     Tubercles  arc 
moft  frequently  met  with.     There  is,  how- 
ever,  a  difordcr  of  ftmdlure  which  I  wifh 
briefly  to  mention,  as  I  do  not  find  that  it 
has  been  noticed.     In  two  perfons,  who  died 
of  epilepfy,  I  found  the  medullary  fubftancc 
of  each  hemifphere  altered  from  its  natural 

♦  See  Frafer  on  Epilepfy,  page  39. 

ftrufture  j  • 


AMD  TRSATMBKT  OP  LOCAL  OISBASM.   dOJ 

ftru£hire;  it  had  loft  its  natural  firamefs,  and 
finoothnefs  of  furface,  and  appeared  like  thick 
curdled  cream. 

\ 

Now,  if  diforder  of  the  digeftive  organs 
is  capable  of  caufing  or  aggravating  nervous 
diforder,  even  to  the  produftion  of  thofe 
efFe6b  which  have  been  mentioned^  when 
there  is  no  alteration  of  ftrufture ;  it  rauft 
be  granted  that  fuch  a  ftate  of  irritation  of 
the  fenforium  may  lay  the  foundation  of  an 
excitement  of  the  vafcular  ftrufture  of  the 
l>rain,  and  thus  very  frequently  produce  organic 
^{eaie.  When  this  has  occurred,  it  will  ag- 
gravate and  eftablilh  the  nervous  afFeftion,^ 
^uid  thus  perhaps  render  it  infufceptible  of 
cure. 

Such  are  the  general  obfervations  which 
I  have  made,  by  means  of  anatomical  enquiry, 
relative  to  thefe  fubjefts.  With  refpeft  mott 
efpecially  to  the  inveftigation  of  my  prefent 
objeft,  1  have  examined  the  bodies  of  fix 
patients,  in  whom  difeafe  moft  certainly 
began  in  the  abdominal  vifcera,  and  was  con* 
tinned  JLti  them  to  the  conclufiou  of  thdr 

lives. 


2o6     OM  THE   CONSTITUTIONAL   OUGIW, 

lives.  Ncverthclcfs  the  patients  feeraed  to  die 
rather  of  nervous  dilbrdef,  than  of  difeafe  of 
the  parts  firft  affected.  One  of  the  patients 
died  affefted  with  apopIe6lic  fymptoms,  and 
five  with  hemiplegia. 

In  all  thefe  cafes  the  liver  was  greatly  dif- 
eafed,  and  the  bowels  alfo  exhibited  difeafed 
appearances.  In  three  of  the  ca(es  there  was 
conliderabic  inflammation  of  the  membranes 
of  the  brain ;  and  a  good  deal  of  water  in  the 
ventricles.  In  two  of  them  no  morbid  appear- 
ance of  the  brain  was  dil'covered.  1  have  alio 
examined  a  child,  who  was  fuppofed  to  die 
of  hydrocephalus,  accompanied  by  gi'cat 
diforder  of  the  ftomach  and  bowels.  In  this 
cafe  the  bowels  were  inflamed,  the  liver 
found,  and  the  brain  perfectly  healthy  in 
appearance;  yet  there  had  been  fo  great  a 
diminution  of  fenfation  and  motion,  as  to 
kave  no  doubt  of  the  exifl:ence  of  hydi-oce- 
phalus.  I  am  aware,  that  great  opportunities 
of  obfervation,  accurate  attention  to  the 
hiflory  of  difeaies,  and  anatomical  exami- 
nation of  fatal  cafes,  are  requifite  to  enable  us 
to  form  jufi  ootiuns  relative  to  the  prelent 
4  t'ubjeft. 


J 


AND  TiLAATICBHT  OF  IJOCAL  MSSAns.   ftO/ 

fobjeft.  I  thought,  however,  that  it  might 
not  be  improper  to  ftate  what  had  been  the 
refult  of  my  own  enquiries  by  difleftion,  in 
order  to  jM^omote  a  more  general  attenticm  to 
the  fubjeft. 

When  my  attention  was  ftrft  direfted  to 
the  fubjeft  of  fympathetic  affe6tions  of  other 
organs,  caufcd  by  diforder  of  thofe  con- 
cerned in  digeftion,  my  primary  ck^eB:  was, 
to  endeavour  to  afcertain,  by  difte^ion,  how 
for  pulmonaty  difeafes  originated  from  fuch 
a  fource.  1  have,  in  the  courfe  of  ray  en- 
quiries, had  feveral  opportunities  of  cxa- 
nuning  the  bodies  of  patients  who  apparently 
died  of  phthifis,  combined  with  difeafes  of  the 
digeftive  organs.  In  thefe  cafes  both  the  hif- 
tory  and  diffeftion  tended  to  prove,  that  the 
chylopoietic  vifcera  were  the  feat  of  the 
greateft  and  moil  eftablilhed  (hfeafe,  and  that 
tile  pulmonary  affeftion  yas  a  fecofndary  dif- 
order. The  liver  was  greatly  difeafed,  and  the 
lungs  were  aMb  befet  with  tubercles ;  yet  a 
coniiderable  portion  of  thofe  organs  was 
found.  But  diifeftibns  can  never  condufively 
afcert2Ut)i  the  truth  of  the  opinions  which  >  I 

have 


2o8        ON  THE  CONSTITUTIONAL  OHIOIN, 

have  flated ;  for  the  fame  diipofition  to  difeafe 
exifting  in  tlie  conftitution  may  equally  affefl 
both thcpulmonary and digertiveoigans.  Nay, 
obfervations  madj  m  diiicLlion  in  general, 
would  tend  to  difprove  the  opinions  alluded 
to ;  for  difeafes  of  the  kings  are  very  com- 
monly met  with  in  de;'d  boilies,  while  thofe 
of  the  liver  and  bowels  are  much  lei's  frequent. 
Yet  confiderable  diforder  of  the  digeftive  or- 
gans does  exift,  and  may  continue  for  many 
years,  without  any  organic  difeafc  being  appa- 
rent :  it  is  poffible,  therefore,  that  fuch  dif- 
order may  excite  dileale  of  the  lungs,  and  thus 
produce  a  worfe  difeafe  in  the  latter  organs, 
than  what  exifted  in  the  former.  In  fliort, 
the  opinions,  which  I  have  delivered,  cannot 
be  either  afcertained  or  refuted  by  anatomical 
refearches  alone. 


Accurate  attention  to  the  (late  of  the  digef- 
tive organs  may  determine  this  impoitant  fub- 
je£l,  and  lead  to  the  prevention  and  cm'e  of 
the  fympathetic  difeafcs  which  I  have  men- 
tioned. The  attention  alluded  to  is  not  of 
.  that  general  kind,  which  adverts  only  to  the 
quantity  of  the  ingefla,  and  the  periodical  ex- 
uliion 


pumon 


AND  TRBATMENT  OV  LOCAL  DISEASES.    209 

pulfionof  the  cgcfta,  but  one  that  moreflxiftly 
obferves  whether  the  vifccra  are  fnce  £rom 
irritation^  and  whether  their  iecretions  are 
healthy  or  otherwife.  My  opportunities  of 
acquiring  praaicalinformation  on  this  fubjeft 
muft  neceflarily  have  been  very'  limited ;  yet 
I  have  feen  many  cafes  which,  to  me,  ap^ 
peared  to  prove,  that  puhnonary  irritatiod 
fometimes  proceeds  from  disorder  of  the 
fiigeftive  organs.  In  cafes  of  furgical  dif- 
eafes,  accompanied  by  diforderof  the  digeftive 
oreans,  I  have  alfo  occafionally  obferved  a 
cough  attended  with  expeftoration  to  ceafe, 
\ipon  the  corrciflion  of  the  diforder  of  thoib 
organs. 

■ » 

A  cafe,  which  happened  about  five  years 

^go,  flrongly  impreffed  thefe  opinions  on  my 

-mind,     A  fervant  of  mine  told  me,  that  his 

wife  was  dying  of  a  confumption,  whi^h  had 

been  rapidly  increafing  for  fix  months,  and 

had  baffled  all  attempts  to  relieve  it.   Think* 

ing  that  I  could  procure  her  ibme  mediql 

affiftance  from  the  hofpital,  I  went  to  fee  her* 

The  cafe,  however,  feemed  paft  hope.     She 

was  extremely  emaciated  j  her  pulfe  beat  140 


I 


310      ON  THB   CONSTITUTIONAL  ORIGIN, 

In  a  minute ;  her  face  was  flufhed ;  (he  had  a 
moft  diftrefling  cough  5  and  fpit  up  more  than 
a  pint  of  muciis-/ mixed  with  pus  and  ftreaked 
with  blood,  in  twenty-four  hours.     The  cir- 
cumftancc,  however,  which  moft  difturbed 
-her  was  a  continual  purging  of  black  and  of- 
fenfive  matter.     She  told  trie  that  her  bowels 
were  firft  difordered ;  that  an  unhealthy  ftatc 
of  thofe  organs  had  preceded  the  pulmonary 
affeftion,  ^nd  was  indeed  habitual.  I  thought 
it  unnecelwry  to  trouble  my  medical  friends 
in  fo  hopelefs  a  cafe ;  and  ordered  fome  pills, 
containing  one  grain  of  opium,  to  be  taken 
in  foch  quantity  as  was  neceflary  to  ftop  the 
purging.     As  fhe  informed  me  that  the  dif- 
order  began  in  the  bowels,  I  added  to  each 
pill  half  a  grain  of  calomel.     By  thefe  means 
the  purging  was  fo  much  checked,  that  fhc 
did  not  find  it  neceflary  to  take  more  than  two 
pills  in  twenty-foiir  hours ;  and  when  fhe  had 
taken    twelve,    the    mercury,    very    unex- 
p6Etedly,  afFefted  the  mouth.     From  that 
period^  the  ftools  became  of  a  natural  co^ 
tetir  and  confiftence;   the   cough    and    ex- 
pefboration  ceafed;  and  Die  was  foon  fuf- 
ficiently  recovered  to  go  into  the  country; 

from 


AND  TRBATMBHT  QF  LOCAL  DISEASES,    ail 

from  whence  fhe  returned  apparently  in  gpod 
health. 

Now  if  it  were  to  be  afcertained,  that  pul- 
monaiy  irritation,  which  nxight  of  courfe  pro- 
duce pulmonary  difeafe,  fometiootes  arifesfroni 
difbrder  of  the  digeftive  organs*  5  it  woi^d  |>e 
right  to  enquire  further,  whether  it  produces 
fuch  eflFedh,  by  the  nervous  diford^r  it  occa- 
fions,  and  by  its  operation  on  the  health  in 
general ;  or  by  means  of  a  mojre  immediate 
lympathy  exifting  between  the  pulmonary 
and  digeftive  organs.  I  do  not  mean  to  in- 
iinuate,  by  what  has  been  faid,  that  pulmo- 

*  In  the  fecpnd  part  of  my  furgical  and   phyfiological 

s  in  which  I  related  experiments,  made  with  a  view 

afcertain  the  fun£lions  of  the  fkin,  I  mentioned  that  as 

i^     was  manifeft  the  (kin  and  lungs  were'  both  engaged  in 

iStx^  fun£tion  of  throwing  forth  carbonic  acid  gas,  it  fd- 

kyvred,  that  when  from  viciflitudes  of  the  atmofphere  pr 

.w^eaknefs  of  the  fanguifetous  organs,  the  circulation  az^d 

fecretion  of  the  fkin  were  much  diminiflied  the  lungs 

w-ouldbe  liable  to  plethora,  and  have  to  perform  more  than 

^eir  ordinary  duty,  which  circumltances  were  likely  to 

induct  irritation,  and  perhaps  confequent  difeafe  of  thofe 

^I'gans.    Thof^  experiments,  a^  they  are  not  pf  pra£li(^ 

^Pqr^nce,  I  Ihall  not  reprint. 

p  2  tiary 


^11       ON  THE  C6M8tlTUTlONAL 

tiiry  difeaies  do  not  afife  originally  and  idicv 
pathically ;  but  only  to  fugged  that  they  may 
ariie  fympathetically,  or  in  confequence  of 
•  diforder  of  the  digeftive  organs.  The  propor- 
tionate number  of  cafes,  in  which  they  origi- 
nate in  this  manner,  can  only  be  determined 
by  very  extenfive  experience.  That  the  fto- 
mach  and  bowels  are  diibrdered^  during  the 
progrefs  of  phthifis,  will,  I  conclude^  be  readily 
admitted ;  and  that  an  attention  to  corre£t 
fuch  diforder  is  requifite,  muft  be  adoiow- 
ledged,  from  what  has  been  faid  relative  to 
the  influence  of  fuch  treatment  upon  various 
local  difeafes. 

The  aftions  of  the  heart  feem  to  me  alfb 
to  become  difordered  from  fympathy  with 
the  ftomach.  That  palpitations,  and  feeble 
or  intermitting  aftions  of  that  organ  arife  front 
this  caufe,  is  proved  by  their  ceafmg,  whea 
the  ftate  of  the  ftomach  becomes  changed. 
The  palpitations  which  take  place  after 
eating,  in  cafes  where  the  heart  is  irritable, 
further  evince  the  fympathy  which  exifts  be- 
tween thefe  organs.  Surgeons  are  occafion- 
ally  confulted  on  cafes  of  palpitations  of  the 

14  heart; 


AKI>  TREATMENT  OF  LOCAL  DfSlASIS.  21% 

licart,  which  the  patients  miftake  for  aneu- 

xiiins ;  and  I  have  feen  many  inftances,  where. 

the  great  degree  of  palpitation  led  to  a  belief, 

tiiat  foipe  organic  affe6lion  exifted,     Tjiis 

lias  ceafed  on  an  amendment  of  the  general^ 

liealth,  apparently  arifmg  from  an  amejip*: 

ration  of  the  ftate  of  the  digeftive  organs^ 

and  the  patients  have  continued  in  perfeft. 

liealth.     I  have  not  colle6led  any  a^curat^^ 

xiarratives  of  the  cafes  that  I  have  feen :  none 

at  Icaft  which  I  could  properly  prefent;to 

^he  public  as  a  proof  of  the  faft.     There  iy 

nothing,  however,  of  which  I  am  more  per-. 

feftly  convinced;  for  I  have  felt  it  to  b^ 

triie  in  my  own  perfon.     After  confiderable 

^d  unufual  fatigue,  I  was  feized  with  pain^ 

and  a  fenfation  of  coldnefs  in  the  region  o^ 

the  ftonpiach.     I  had  no  appetite,  ,an^, -thp 

Tnliary  fecretion  was  ftipprefled.    Whilft  thia 

^iforder  continued,  which   was  for  manj 

weeks,  my  pulfe  intermitted  very  frequently, 

and  I  was  diftreffed  with  hypochondriacai 

lenfations.     Upon  an  alteration  in  the  ftate 

of  the  digeftive  organs,  and  a  renewal  of  the 

I>iliary  fecretions,  which  happened  very  fud* 

€lenly  after  taking  five  graina  of  the  pil^ 

p  3  hydrarg. 


114       ^^  ^^'  CONfTXttrTIONAX.  0aiCfIK, 

hydrarg,  my  pulfe  became  perfectly  rcgulari' 
and  my  mind  tranquil. 

The  oblervatidns,  which  I  have  made  in 
ilirgical  cafes,  lead  me  alfo  to  attribute  many 
haemorrhages,  and  particularly  thofc  from 
the  hbfe,  to  a  fympathetic  afFeftioh  of  the 
heart  and  arteries,  excited  by  difordqr  of  the 
digeftive  or^ns. 

If  fuch  i*  fiate  of  the  fyftem  in  general,  as 
I  have  defcribed,  and  which  is  manifefled  by 
circumftances  denoting  the  digeftive  organs 
to  bfe  in  an  unhealthy  ftate,  and  the  nervous 
lyftem  to  be  likeWife  difordered,  may,  in 
fome  uiftances,  caufe  various  local  difeaies 
of  parts  not  eflcntial  to  life,  the  care  of 
<A^hich  cuttom  has  configned  to  the  fur- 
geoh ;  and  may,  in  other  inftances,  produgc 
diforders  of  organs  effential  to  our  exiftence, 
the  care  of  which  is  allotted  to  the  phy- 
ficiah  5  the  fubjeft  niuA  be  allowed  to  be  of 
the  higheft  importance.  Of  late,  indeed,  I 
have  been  inclined  to  confider  th'efe  circum- 
ilances  as  the  caufe  of  the  complicated 
difeafes  which  are  ttiet  with  in  iiian,   fo 

mvufh 


AKO  TREiV.TM9NT  Of   LOCAL   DISEASES.  SI^ 

much  more  frequently  than  in  animals,  la 
man  the  brain  is  more  fenfitive,  and  liable 
to  be  difordered  by  mental  afFeftions.  In 
man  the  digeftive  organs  are  liable  to  be  dif- 
ordered by  ftimulating  and  unnatural  diet. 
Sedentary  habits  and  impure  air  co-operate 
to  aggravate  thefe  diforder?.  .The  afFe6lio»s 
of  the  brain  and  digeftive  organs  mutually 
increafe  each  other ;  and  thus  a  ftate  of  coa« 
ftitution  arifes,  which  is  produ6tive  of  the 
moft  general  and  complex  difeafes.  But  even 
thefe  do  not  feem  to  me  to  be  the  moft  caldr 
mitous  terminations  of  fuch  caufes.  The  dis- 
order of  the  fenforiunji^  excited  and  aggr^va,^ 
by  the  means  which  have  been  defcribpdj  ft^ 
quently  afFefts  the  mind.  The  pperatiofls 
of  the  intelle6l  become  enfeebled,  peiplcxvi 
and  perverted;  the  temper  and  difpofition 
irritable,  unbenevolent,  and  defponding ;  the 
moral  charafter  and  condu6l  appeal's  even 
liable  to  be  affected  by  thefe  circumftances. 
The  individual  in  this  cafe  is  not  the  oriy 
fufferer,  but  the  evil  extends  to  his  connec- 
tions and  to  fociety.  The  fubjeft,  therefore, 
appears  to  me  of  fuch  ui4>ortance,  that  no 
apology  need  be  offered  for  this  impeiie6l 

attepipt 
^  4 


ai6      OK  TOE  eON8TlrXTTl<mAt  OUGlKy 

attempt  to  place  it  under  general  contem- 
plation *. 

I  have  endeavoured  to  fhew  in  the  intro- 
duftory  obfervations^  that  a  ftate  of 
nervous  difbrder  and  a  diforder  of  the  di- 
gcftive  organs,  may  reciprocally  produce  each 
other  I  and  that  when  both  occur,  they 
become  mutually  increafed,  and  thus  derange 
the  conflitution  in  general,  fo  as  to  prove 
the  exciting  or  predifponent  caufes  of  nume- 
rous diflimilar  and  important  local  afFe6tions. 
I  fliall,  in  conclufion,  for  the  reafons  men« 
tioned  in  the  preface,  offer  the  opinions 
which  the  confideration  of  the  foregoing  and 
iimilar  cafes  have  impreffed  on  my  mind* 
When  I  find  in  difeafes  that  the  fuh£tiont 

^  The  ancients,  who  formed  their  judgment  of  the 
nature  of  diforders  by  obferving  the  excretions,  denonu« 
nated  <m  irritable  and  defponding  ftate  of  mmd.  Hypo* 
chondriafis  $  and  when  a  more  fixed  and  irrational  de- 
jection took  place^  they  deem?d  it  an  atrabiliary  diforder^ 
and  called  it  Melancholia.  There  can  be  no  doubt  of  the 
correAnefs  of  their  obfervations  )  for  if  the  difofder  htm 
gan  in  the  nervous  fyftem,  it  would  generally  produce 
mnd  become  aggravated  by  that  diforder  of  the  digefttvc 
^rgans^  from  which  they  denominated  it* 

of 


AKB  TRIATHEKT  OF  LOCAL  DISEASES,  ^if 

of  the  digeftive  organs  are  impaired  and 

^ifturbed,    I  confider  this  diforder  as  the 

^caufe  or  efFecb  of  a  more  general  derange* 

xnent  of  the  fyftem  at  large.     When  it  feems 

-to  be  the  caiife,  and  when  it  can  be  fpeedilj 

-corre£bed  and  removed,  then  the  relief  and 

<ure  of  thofe  local  difeafes  which  may  have 

'taken  place,  is  in  many  inftances  fo  fudden 

^uid  furprizing,  that  I  think  it  impoffible  to 

confider  the  diforder  of  the  general  health 

and  the  local  difeafe,  in  any  other  reladoa 

but  that  of  caufe  and  effeft. 

The  cure  of  local  difeafes  by  means  that 
.cannot  be  fuppofed  to  a6t  othei-wife  than  by 
correfting  errors  in  the  funftions  of  the 
digeftive  organs,  incline  me  to  differ  in 
opinion  from  thofe  who  confider  the  local 
difeafes  alluded  to,  as  the  effeft  of  impurity 
of  flie  fluids,  and  to  coincide  with  others, 
ivho  confider  them  as  the  refult  of  general 
irritation,  frequently  induced  i$y  that  of  the 
abdominal  vifcera. 

When  I  fee  the  fame  local  difeafes  removed 
hj  the  fame  means,  though  more  •  flowly, 

I  do 


ftl8       OK  TH£  CONSTITUTIONAL  OUnUT, 

I  do  not  wonder  at  the  tardinefe  pf  the  Cure  j 
and  perceiving  that  the  amendment  of  the 
local  difeafe  is  proportionate  to  that  of  the 
health  in  general,  I  feel  warranted  in  forming 
the  fame  opinion  as  to  jthe  mode  iii  whidi 
the  cure  is  effefted.  When  I  fee  local  .di£- 
cafes  difappearing  and  re-appearing  as  the 
conftitution  in  general  is  tranquil  or 
difturbed,  I  feet  confirmed  in  my  opinion 
concerning  their  origin.  'T- 

If  the  aftions  of  any  part  of  the  body  be 
excited  and  increafed  by  accidental  caufes,  it 
may  reafonably  be  inferred,  that  in  a  ftate  of 
health  they  will  be  fimple  and  common, 
unlefs  the  ftimulant  be  of  a  peculiar  nature ; 
but  if  the  adtions  be  fpecific  and  difeaied, 
we  may  naturally  conclude  that  the  caufe 
of  their  becoming  fo  is  conftitutional.  The 
occurrence  of  fimilar  local  difeafes  indifferent 
parts  of  the  body,  furnifties  an  additional 
proof  tliat  the  caufe  of  fuch  difeafes  is  confti* 
^utional. 

It  muft  indeed  be  very  difficult  to  alcer* 
tain  the  c&ufes  of  the  peculiarities  of  local 

difeafes  ; 


AN0  T&SATMBMT   OF   LOCAL   DISEASES.  21^ 

difcafes ;  but  when  I  fee  fuch  a  variety  of 
them  cured,  fometimes  luddcnly,  by  means 
which  tpnd  onl]F  to  tranquillize  and  invi-» 
gorate  the  conftitution,  I  become  confirmed 
in  the  opinion  that  a  fimilar  ftate  of  health 
jnay  lead  to  the  production  of  diflimilai:  local 
diieafes^ 

I  have  further  obferved  with  refpeft  to 
this  fubjeft,  that  perfons  who  have  been  out 
©f  health,  but  with  no  other  diftinguifhable 
errors  in  their  conftitutions  than  fuch  as 
I  have  defcribed,  I  mean  nervous  weaknefs 
and  irritation,  with  a  marked  diforder  in  the 
functions  of  the  digeftive  organs,  have  been 
liable  to  a  fucceflion  of  diflimilar  local  dif- 
cafes. In  fuch  inftances,  I  have  {ten  in  fuc-r 
ceflion  enlargements  of  abforbent  glands, 
boils,  rheumatic  afFeftions  of  joints,  and 
dyfury :  yet  all  local  difeafes  have  ceafed  as 
the  health  became  re-eftablifhed,  by  atten- 
tion to  correft  the  difordered  funftions  of 
the  digeftive  organs,  I  have  feei)  alfo  in 
the  fame  patient  enlargements  of  aforbent 
glands,  rheumatic  difeafe  of  a  joint,  and 
an  eruptive  difeafe  of  the  Ikjn,  which  have 

all 


SSO        OK  THE   CONSTITUTXONAJL  ORXGIK, 

all  equally  got  well  as  the  general  health  itn^ 
proved,  by  fimilar  medical  attention,  .  Nay^ 
the  continuance  of  local  diicafes  in  ibme  in-r 
jlances,  after  the  diforder  of  the  ccHiftitution 
has  been  relieved  or  cured,  does  not  in  n>y 
opinion  invalidate. the  foregoing  conje6lures 
refpefting  their  origin.  Local  difeafe^,  how- 
ever induced,  m^y  have  become  eftablifhed 
by  habit,  ox  continued  frpm  that  ftate  of 
difordei  into  which  they  have  reduced  the 
part  that  they  have  attacked.  ^A  local 
difeafe,  however  excited,  may,  as  we  know 
from  experience,  be  of  fuch  a  nature  as  that 
its  actions  never  ceafe,  and  as  we  have  not 
fucceeded  in  curing.  I  allude  to  cancefi 
which  occurs,,  in  conclufion,  in  fuch  con* 
ftitutions  as  I  have  endeavoured  to  defcribc. 

It  has  been  faid  that  I  have  been  hafty 
in  drawing  thefe  cpnclufions.  Yet,  as  may 
be  feen  in  my  firft  publication,  I  mentioned, 
in  fpeaking  of  diforder  of  tlie  digeftive  organs 
as  exciting  or  aggravating  nei"vous  irritation, 
and  thereby  caufing  local  difeafes,  it  followed 
that  the  nervous  irritation  might  exift,  and 
produce  difeafe,  without  this  ufually  exciting 

caufe« 


AKD  TRBAtBIBNT  Ol^  LOCAL  DIdSASES.  S2< 

•  .  •  •        . 

caufe.  I  then,  too,  brought  forwards  in- 
fiances  of  local  difeafes  produced  by  locd 
caufes,  in  order  to  eftablifh  our  opinions  of 
the  independent  nature  of  local  difeafes.  I 
further  remarked,  that  conftitutions  difpofed 
to  local  difeafed  aftions,  might  naturally  be 
luppofed  to  be  liable  at  the  fame  time  to  a 
manifeft  diforder  of  the  nervous  fyftem  and 
of  the  digeftive  organs  5  and  from  thence,  as 
I  obfcrved,  might  have  arifen  that  connexion 
between  local  difeafe  and  general  difordCr, 
which  I  have  fo  continually  remarked.  I 
likewife  added,  that  though  the  cafes  related 
naturally  fuggefted  an  opinion,  that  there  is 
fome  conftitutional  caufe  for  the  produftion 
of  local  difeafes,  they  appeared  to  me  iniuf^ 
ficient  to  prove  it.  After  having,  however, 
drawn  the  opinions  which  I  offered  from  * 
very  confiderable  number  of  cafes,  and 
having  been  folicitous  to  ftate  both  IJdes  of 
the  queftion  as  fairly  as  I  was  able,  Aat 
the  reaaer  might  judge  of-  it  for  himfclf| 
I  truft  no  imputation  of  hafte  can  propSrTjT 
be  attached  to  my  conduft.  In  my  own 
opinions  I  place  very  little  confidence ;  yet 

it 


%2%       ON  TH£  CONSTITUTIONAL  OtL^OfNy. 

it  is  impoflible  to  avoid  forming  t}iem,  aii4 
I  think  it  proper  to  relate  tbem,  for  tjw 
reafons  which  have  been  dated  i^  the 
preface. 

That  fiicli  opinions  as  have  been  deliyerpd 

in  the  four  paragraphs  preceding  the  laft, 

are  deduced  from  a  partial,   though  mofjt 

commonly  prefenting  view  of  the  fuhjeft, 

I  now  readily  repeat;  becaufe  I  have  feen 

inflances  of  local  difeafes,  in  which  I  couJl^ 

jiot  trace  any  difturbance  of  the  nervou$ 

fyftem,  or  of  the  digeftive  organs,  apparently 

adequate  to  their  produftion^    With  refpedb 

to  fome  of  the  fbriking  cafes  which  I  have 

related,  wherein  the  fuddennefs  of  the  cure 

made  it,    I  think,   evident  that  the  local 

difcafe  was  the  efFeft  of  nervous  diforder, 

•induced  by  that  of  the  digeftive  organs  ;  it 

njay  be  further  enquired,  how  is  it  poffiblc, 

•that  a  fimilar  caufe  fhould  produce  fuch 

various  effefts?     Is   it  becaufe  a  ftate  of 

-weaknefs    apd  irritation    having  occurred, 

thofe  local  difeafes  enfue,  to  which  there 

is  a  predilpofition  in  the  conftitution  ? '  And 

are 


ANQ   TRBATMENT  OF  LOCAIr  DI8BA8SS.    tlj 

are  we  to  confider  the  general  diforder  of  the 
fyftem,  as  the  exciting  or  predifponent  caufq 
of  the  local  difeafe? 

Granting  it  were  afcertained,  tiiat  local 
difeafes  generally  arife  from  difturbance  of 
the  amftitution  at  large,  and  confequently^ 
(as  it  has  been  my  chief  objeft  to  ftate,) 
may  be  moft  readily  and  efFe^hially  cured  by 
meafures  which  tranquillize  or  invigorate 
the  conftitution,  ftill  it  would  be  very  im- 
probable, and  contrary  to  common  obfer- 
vations,  to  (iippofe  that  local  difeafes  might 
not  arife  without  any  material  conftitutional 
difturbance. 

Though  I  am  ftrongly  impreffed  with  the 
opinion,  that  the  primary  caufes  of  local 
difeafes,  are,  in  general,  fuch  as  I  have  re- 
prefented,  yet  I  think  it  probable,  that  there 
may  be  adjunft  circumftances  at  prefent 
but  little  underftood,  which  by  their  co- 
operation lead  to  the  peculiarity  of  fuch 
difeafes.  In  our  prefent  ftate  of  knowledge, 
therefore,  I  think  it  better  to  confider  the 
difturbance  of  the  fyftem  in   general,    as 

merely 


124      ON  THE   CONSTITUTIOKAL  ORIGIK, 

merely  the  exciting  caufe  of  local  diieafetf. 
With  this  view  of  the  fubjett,  the  cafes 
recorded  (hew  how  fuddenly  local  difeafes  arc 
frequently  cured,  when  the  exciting  caufe  is 
removed  j  how  generally  they  decline  in  pro- 
portion as  the  exciting  caufe  is  diminiftied  z 
and  thus  they  indicate  how  they  may  be 
prevented  by  a  timely  attention  to  mitigate 
and  remove  tliat  caufe. 


It  may  not  be  improper  ftlrtlier  to  ftate 
the  opinions  which  I  have  formed  refpedling 
the  origin  of  difeafes  of  partiailar  organs, 
and  which  may  be  confidered  as  local  dileafes, 
though  they  are  not  generally  alluded  to 
when  that  term  is  employed.  If  we  may  be 
able  to  trace  the  origins  of  difeafes  of  the 
abforbent  and  falivary  glands,  of  the  breaft 
and  teftes,  to  conftitutlonal  caufes,  why  may 
we  not  reafonably  expert  that  limilar  cir- 
cumftances  may  produce  difeafes  of  the 
lungs,  liver,  and  kidney  ?  It  feems  to  mc 
improbable  that  fo  complex  a  ftnuiture  as 
the  'human  body,  fhould  be  fo  corredlly 
formed,  as  that  every  pait  fliould  poflefs  it« 
due  proportion  of  vetTels  and  nerves,  en- 


dowed J 

I 


An2>  .tilbatmekt.-of  local  Dis£Asks.  225* 

tdo wed. with  an  exaft  degree  of  natural  and^ 
relative  ftrength;   or  in  other  words,  that, 
there  fhould  be  no  fuch  thing  as  comparative 
weaknefs  or  irritability  of  the  different  organs 
of  the  body,  fuch  as  flipuld  predifpofe  them 
to  diieafe. 

We  may  therefore  accdunt  rationally,  and 
in  conformity  to  acknowledged  fa6ls, '  for  the 
produftion  of  difeafes  in  vital  organs,   by 
fuppofmg,  that  a  ftate  of  general  weakneft 
and  irritability  being  induced,  the  naturally 
weak  parts  fufFer  in  the  greateft  degree,  and 
in  confequence  they  moft   readily  become 
the  fubje6ls  of  difeafe.     But  when  difeafes  of 
vital  or  other  organs  occur,  it  is  probable  that 
anotlier  caufe  contributes  to  their  produc- 
tion; that  is,  the  fympathy  which  each  organ 
has  with  the  diforders  of  another.     If,  then, 
the  organ  thus  fympathetically  afFefted  be  na- 
turally difpofed  to  difeafe,  its  ftrufture  may 
be  irremediably    fpoiled  in  confequence  of 
vafcular  aftions,  excited  through  the  medium 
of  nervous  irritation.    If  this   opinion  be 
corre6l,  it  is  highly  important,  as  the  me- 
dical indication  in  this  cafe  is  to  remove 

VOL.  I.  (i^  the 


i2d  ON  rnt  dOMStlTUTIOKAl  miGIKy  &c^ 

the  exciting  caufe,  and  our  attention  becomes 
direftcd  to  an  organ  in  which  perhaps  there 
is  but  little  mariifeftation  of  diforder,  or  if 
there  be,  which  is  likely  to  be  overlooked 
when  the  attention  is  fo  forcibly  attracted  to 
an  apparently  far  greater  evil  ♦. 

^  See  the  cafe  beginning  tt  page  209., 


<    a«7    > 


On  aneurisms. 

npHE  exposure  of  a  portion  of  an  artery,  and 
-^    tying  it  in  order  to  ftop  the  current  of 
blood  into  an  ancurifmal  fac,  as  propofed  by 
Mr.  Hunter,  may  be  faid  to  have  been  a  new 
operation,  at  leaft  in  modern  furgery.     It  is 
not  therefore  furprizing  that  errors  were  at 
iirfl  committed  in  the  mode  of  performing  it. 
*The  haemorrhages  which  took  place  after  the 
operation  in  the  firft  cafes  in  which  it  was 
j)erformed,  ai'ofe  from  the  ulceration  of  the 
artery  that  had  been  tied.  The  vefTcl  in  thei^ 
oafes  was  laid  bare  and  detached  in  fome  ^r 
^ee  from  its  furrounding  connexions,  and 
^he  middle  of  the  detached  portion  was  tied 
by  a  fmgle  ligature.    An  arteiy  thus  circum- 
ilanced  muft  neceffarily  inflame ;   which  it 
would  do  in  different  modes  and  degrees,  ac- 
cordingly as  the  flate  of  the  conflitution,  or 
of  the  part  was  more  or  lefs  healthy ;  and  this 
inflammation  produced  the  ulceration  of  the 
vefleL 

0^2  Tht 


t28  ON    ANEURYSMS. 

*■ 

The  occurrence  of  haemorrhage  ''led  fbme 
furgeons  to  adopt  a  practice  which  cannot 
but  be  confidered  as  injurious*  .  They  ap- 
plied a  fecond  ligature  above  the  other,  leav- 
ing it  loofe,  but  ready  to  be  drawn  tight  if 
the  firft  Ihould  not  anfwer.  The  fecond. 
ligature,  however,  muft  not  only  keep  a 
certain  portion  of  the  arteiy  detached  from 
the  furrounding  parts,  but  muft  alfo  giv0  ad- 
ditional irritation  to  the  inflamed  veflel; 
and  on  both  thefe  accounts  it  is  more  likely 
tQ  make  the  inflammation  end  in  fuppuration 
or  ulceration. 

ff 

The  mode  of  performing  the  operation 
fgr  the  aneqf  ifm,  which  Mr.  Hunter's  judg- 
ment and  experience  taught  him  to  adopts 
was  to  expofe  and  difl^irb  the  artery  as  little 
as  polfible,  and  affer  having  tied  it  to  bring 
.the  furrounding  parts  into  contaft  with  it 
again.  Though  an  experienced  and  ikilful 
operator  may  accomplifh  this  obje6t  with 
very  little  difturbance  of  the  artery  from  its 
natural  fituation  and  connexions  j  yet  I  can- 
not  but  fufpefk  that  furgeons  in  general  may 
not  be  fo  fuccefsful,  efpecially  in  cafes  when^ 

from 


Ji   V  .        ■  *.  "tf 


I 

f  • 


ON    ANEURISMS.  ^29 

from  the  deep  fituation  of  the  vefTel,  the  fur- 
rounding  it  with  a  ligature  depends  more  on 
feeling  than  on  fight  *.  Alfo,  though  when 
the  artery  is  found  and  the  conftitution 
healthy,  ulceration  may  not  enfue,  even 
though  the  artery  is  in  fome  degree  feparated 
from  its  furrounding  connexions,  and  tied 
by  a  fingle  ligature;  yet  it  is  furely  proper 
to  guard  againft  thofe  circumftances  which 
tend  to  produce  its  ulceration.  As  large 
artories  do  not  ulcerate  when  they  are  tied 
Aipon  thefurface  of  a  ftump  after  amputation, 
it.  occurred  to  me  that  it  would  be  right  to 
tie  them,  in  cafes  of  aneurifm,"  as  nearly  as 
poflible  in  the  fame  manner  and  under  the 
fame  circumftances.  The  large  veffels  on 
the  furface  of  the  ftump  continue  to  poflefs 
all  their  natural    furrounding   connexions,- 

*  It  can  neither  be  confidered  as  a  compliment  to  Mr. 
Hom/e,  nor  an  affront  to  any  other  furgeon,  to  fuppofe  that 
no  one  can  perform  the  operation  for  an  aneurifm  zh^t 
Mr.  Hunter's  method  better  than  he  does.  Yet  in  a 
fcries  of  cafes  publiflied  in  the  Second  Volume  of  the 
Tranfadions  gf  a  Society  for  the  Promotion  of  Medical 
and  Chirurgical  Knowledge,  hemorrhage  from  ulcera- 
tion of  the  artery  appears  to  have  been  a  frequent  occuxw 
rence. 

CL3  whilft 


^3^  OK  ANEURISMS* 

whilft  they  arc  left  in  a  lax  ftatc,  in  confc-* 
quence  of  their  divifion. 

To  accomplifh  this  objeft  in  cafes  of 
aneurifin,  I  propofe  that  the  operation 
Xhould  be  performed  in  the  following 
Inahner^  —  The  operator  fhould  divide 
the  immediate  coverings  of  the  artery, 
till  he  has  fairly  expofed  its  furface.  When 
lie  can  touch  the  bare  veffel,  he  will  not,  I 
believe,  find  any  difficulty  in  feparating  from 
it,  by  means  of  his  finger  and  thumb,  or  the 
blunt  edge  of  an  aneurifinal  needle,  the  cel- 
lular fubftance  that  connefts  it  to  the  coiv^ 
tiguous  parts.  This  part  of  the  operation 
is  not  painftil  and  fhould  be  performed 
flowly.  The  firm  fides  of  the  vefTel  enables 
the  furgeon  clearly  to  diftinguifh  its  furface, 
and  by  keeping  the  finger  in  exaft  contaft 
with  it,  a  paflage  may  be  made  completely 
round  the  artery.  Care  fhould  be  taken  not 
to  elevate  the  artery  more  than  can  be  poffibly 
avoided,  bccaufc  the  artery  would  be  flretched 
in  its  longitudinal  direftion  by  fo  doing;  and 
care  fhould  alfo  be  taken  not  to  injure  the 
(Contigudius    veins   or   nerves.     When  the 

2  operator* 


ON   ANEURISMS.  H^f 

operator  has  thus  gently  infinuated  lus  finger 
between  the  veffel  and  its  furrounding  con? 
nexionSy  fo  that  an  inch  of  its  furface  is  every 
where  expofed,  two  ligatures  may  be  put 
under  it,  one  of  which  is  to  be  carried  up- 
wards, and  the  other  downwards,  as  far  as 
the  artery  is  detached,  and  then  tied  as  firmly 
as  pofRble,  The  artery  Ihould  then  be  di- 
vided by  a  probe-pointed  bifloury  in  the 
interfpace  between  the  two  Hgatures,  but 
nearer  to  the  lower  ligature  than  to  the  up- 
per one. 

In  my  opinion,  large  arteries  fhould  always 
he  tied  with  moderately  thick  ligatures,  be- 
caufe  we  may  then  draw  the  noole  as  tightly 
as  poflible.  without  apprehenfion  of  cutting 
or  tearing  the  coats  of  the  vefTel,  or  of  breaks 
ing  the    ligature.     The    latter   occurrence 
would  in  many  cafes  prove  a  very  embar- 
raffing  circumflance,  and  it  might  be  very 
injurious  on  account  of  the  jerk  communi- 
cated to  the  artery  to  a  confiderable  diftance* 
Alfo,  when  an  artery  is  tied  with  a  thick 
ligature,  the  compreffion  made  by  it  is  not 
ib  great  as  to  produce  a  Ipeedy  mortification 
and  feparation  of  the  ei^  of  the  vefTel,  fo 

0^4  that 


\ 


232  •  ON   ANEURISMS*  ' 

that  the  ligature  remains,  in  general,  a  fort^ 
night  before  it  is  detached,  and  tbercforet 
time  is  allowed  for  the  confolidation  of  the 
fides  of  the  veflel  prior  to  its  feparation  *• 

When 

*  Doctor  Jones,  whofe  numerous  and  accurate  experi- 
ments have  thrown  much  light  upon  the  natural  means  by 
which  haemorrhages  are  fupprefled,  thinks  that  the  liga^ 
tures  fliould  be  round  and  firm  ;  becaufe  fuch  cords  are 
moft  likely  to  cut  the  internal  coats  of  th«  artery.  I  am 
iblicitous  that  they  fhould  be  ftrong  and  moderately  large; 
bocaufe  as  fiar  as  I  have  remarked,  large  ligatures  remain 
longefl:  on  the  arteries  before  they  are  detached  5  and  in 
examining  the  (lumps  of  patients  who  have  died  after 
amputation,  I  have  frequently  feen  the  fides  of  the  artery 
unclofed,  even  though  the  ligatures  have  fallen  off  froni 
them. 

Though  ligatures  when  applied  to  the  principal  arteries 
of  amputated  limbs  are  fcarcely  ever  known  to  flip  or  be- 
come proje£led  from  their  fituation,  yet  it  has  been  ap- 
prehended that  fuch  an  occurrence  might  take  place,  in 
cafes  of  aneur.fm,  from  the  greater  determination  of 
blood  into  tl>e  arteries  of  tlie  limb  in  fuch  cafes.  To  ob- 
viate fuch  an  effe£l,  Mr.  Henry  Cline  fuggefted  tlie  fol- 
lowing method  of  fecuring  the  ligature  in  its  fituation. 
His  fuggeftion  was  adopted  by  Mr.  Cooper,  who  thus  de-» 
(cribes  the  operation  in  which  it  was  inftituted ; 

«  An  inc  lion  beirg  made  on  the  middle  of  the  inner 
part  of  the  thigh,  and  the  femoral  artery  expofed,  the  ar- 
tery was  fcparated  from  the  vein  and  nerve  and  all  the 
furrounding  parts,  to  the  extent  of  an  inch,  and  an  eyed 
probe  armed  with  a  double  ligature^  (each  cord  of  which. 

wa% 


CN    ANEURISMS.  233 

When  an  artery  is  thus  tied  in  cafes  qf  an- 
curifin  it  poffeflcs  its  natural  furrounding 
connexions  and  fupport,  and  is  left  Ipofe,  in 
confequence  of  its  divifion.  It  appears,  in- 
deed, in  moft  refpefb  fimilarly  circumftanced 
tp  an  artei7  tied  upon  the  furface  of  a  ftump, 
and  as  I  never  knew  haemorrhage  from  ulcera-^ 
tion  of  the  veflel  take  place  after  the  opera- 
tion for  aneuiifm,  when  it  was  accomplifhed 
in  this  manner,  I  cannot  but  continue  to 
pra6lice  and  recommend  this  method  of  fe- 
curing  the  artery.  That  the  operation  for 
the  aneurifm  will  fucceed  when  only  a  fingle 
ligature  is  employed  has  been  proved  by  ex- 
perience ;  but  as  hssmorrhages,  independent 
of  ulceration  of  the  artery,  fo  frequently  arifc 
from  ah  inflammatory  aftion  of  the  veflels, 

was  armed  with  a  needle,)  was  conveyed  under  the 
artery  and  the  probe  cut  away.  The  ligature  neareft 
the  groin  was  firft  tyed ;  the  other  was  feparated  an  inch 
from  the  firft  and  tied  alfo  ;  then  the  needles  were  pafled 
through  the  coats  of  the  artery,  clofe  to  each  ligature,  ai^d 
between  them  \  the  thread  they  carried  was  tyed  into  the 
knot  of  the  ligatures  which  had  been  already  fecured- 
around  the  veflel  :  and  thus  a  barrier  was  formed  in  the 
artery,  beyond  which  the  ligature  could  not  pafs."  See 
(he  firft  number  of  the  Eighth  Volume  of  the  Medical 
^d  Fhyfical  JournaL 

every 


fi34  ON   AN£U|IISM8* 

every  thing  tending  to  produce  a  tranquil 
ftate  of  the  wounded  parts  cannot  but  deferye 
to  be  put  in  praftice,  and  the  relaxation  of 
the  artery  by  its  divifion,  muft,  I  think,  con- 
tribute to  this  efFeft, 

i 

The  cafes  of  aneurifins  which  I  am  about 
to  recite,  are  not  however  intended  to  illus- 
trate any  mode  of  conducing  the  operation, 
but  merely  to  fhew  the  powers  which  nature 
poffefles  of  carrying  on  the  circulation,  and 
niaintaihing  the  limb  in  its  priftine  ftate  of 
vigour  and  ftrength,  even  though  fo  large  an 
artery'  as  the  external  iliac  may  have  been 
tied,  and  thereby  rendered  impervious. 

CASE  i. 

Feb.  1796. — James  Lindfey,  aged  thirty- 
four,  about  a  year  ago  perceived  a  (welling 
beneath  the  calf  of  his  right  leg ;  and  foon 
afterwards,  whilft  walking,  he  fuddenly  felt, 
he  faid,  "as  if  he  had  been  ftruck  on  the  part 
**  by  a  cannon  ball,"  the  pain  being  fo  great 
that  he-  could  not  move  for  feveral  minutes. 
The  pain,  however,  gradually  abated ;  but  the 
Iwelting  of  the  leg  had  continued  to  increafe 

Iince 


ON  Aif£URisii^»  ajs 

iince  that  time.  The  whole  calf  was  now 
lifted  up  by  a  quantity  of  blood  cfFufed  bc- 
jieath  it.  The  mufcles  appeared  thin,  and 
were  fo  extremely  tenfe  as  to  occafion  great 
pain,  accompanied  with  confiderable  eryfipe- 
Jas  of  thie  whole  leg ;  lo  that  a  fpeedy  ulcer- 
ation and  floughing,  or  fudden  rupture  of  the 
diftended  part,  was  hourly  to  be  dreaded. 
Under  thefe  circumftances,  tying  the  artery 
above  the  aneurifm,  was  the  only  means  of 
relieving  the  patient  from  his  prefent  fuffer- 
ing,  and  of  preferving  him  from  fudden 
death.  But  what  was  particularly  difcou- 
raging,  both  to  the  patient  and  furgcon,  was 
the  difcovery  of  another  aneurifin,  fituated  in 
the  femoral  artery  of  the  oppofite  limb.  No 
preternatural  pulfation,  however,  could  be  felt 
in  any  other  part  of  his  body. — The  operation 
was  performed  by  Sir  Charles  Blicke  in  the 
following  manner :— An  incifion  about  three 
inches  in  length  was  made  through  the  inte- 
guments of  the  middle  of  the  thigh,  fo  as  to 
cxpofe  the  inner  edge  of  the  fartorius  mufclc 
and  the  fafcia  covering  the  arteiy,  which 
was  divided  to  the  extent  of  fomevvhat  more 
than  an  inch.  The  arteiy  was  feparated  from  its 

con- 


336  ON    ANEURISMS.  "**, 

conncclions  for  onfe  inch  of  its  length.  Twe 
ligatures  were  put  under  it,  and  finnly  tied, 
•and  the  artery  was  divided  in  the  intervrf 
•between  them.    The  lips  pf  the  wound  were 
then  brought  together  by  flips  of  fticking- 
plafter^    This  patient's  limb  was  for  fome 
time  much  coWer  than  the  other,  and  nearly 
three  days  elapfed  before  it  had  regained  its 
natural  degree  of  warmth  ;  but  the  tenfion, 
pain,  and  eryfipelatous  inflammation  quickly 
fubfided.     The  divided  integuments  united 
above  and  below  the  ligatnres,  but  not  be^ 
tween  them ;    and  there    was  alfo  a  large 
difcharge  from  the  wound :  which  eircum- 
ilance    was  probably    owing  to  the    ftate 
of  the    patient's    conftitution,    which  was 
much  reduced  in  point   of  ftrength.     This 
man,    however,    did  not   complain    of   the 
leart    throbbing,    tcnfion,    or    pain   in  the 
wounded   part ;    and  this  entire  exemption 
f  om  the  fuiTerings  of  other  patients,  I  could 
not  but  attribute  to  the  divifion  of  the  ar- 
tery.    The  upper   ligature  came   away  on 
the  tenth,  and  the   lower  on  the  fifteenth 
day ;  after  which  the  wound  healed  gradually, 
though  very  flowly* 

Abou^ 


ON    ANEURISMS.'  237 

About  five  weeks  after  this  operation,  the 
aneurifm  in  the  oppofite  thigh .  was  almoft 
ready  to  burft ;  the  tumour  having  acquired 
a  pyramidal  form,  and  the  ikin  covering  the 
apex  having  yielded  fo  much  as  to  form  a  kind 
of  procefs  from  the  tumour.     Indeed  the  in- 
teguments at  this  part  were  fo  thin,  that  we 
every  hour  expected  them  to  give  way.    The 
aneurifm  was  fituated  fo  high,  as  to  make  it 
probable  that  the  difeafe  extended  above  the 
place  where  the  arteria  profunda  is  fent  off. 
The  patient  liad  hitherto  refiifed  to  fubmit 
to  the  operation  ;  but  on  refledting  that  if  the 
tumour  ihould  burft  in*  the  night,  he  muft 
perifh  unlefs  the  bleeding  veffel  could  be  im- : 
mediately  fecurcd,  he  confented  to  let  me  tie 
the  artery  in  the  groin,   whilft  we  had  day* 
light  and  proper  afiiftance.-  The  tumour  ap- 
proached fo  near  to  the  groin,  as  to  prevent 
us  from  comprefling  the  artery  againft  the 
bone ;  for,  in  attempting  this,  the  comprefs 
occupied  the  place  where  the  incifion  ought 
to  be  made,  and  our  endeavours  to  make  a 
'  compreflion    ftill  higher  were    ineffeftual; 
they  wd&kened,  but  did  not  interrupt  the 
puliation  of  tlie  tumour.     As  the  artery  was 

13  '     io 


338  C    AMEtJRTEMS. 

fo  impcrfecHy  comprelTed,  haemorrhage  took 
place  during  the  operation,  which,  though  not 
dangerous  to  the  patient,  proved  extremely 
cmbarraffing  to  the  furgconj  for  in  attempt- 
ing to  lay  bare  the  fafcia  of  the  thigh,  1  di- 
vided, by  the  very  firft  incifion,  (b  many  iinall 
arteries  fupplying  the  inguinal  glands,  and 
alfo  fo  many  veins,  that  the  blood  which 
was  poured  forth,  completely  filled  the  fpace 
made  by  the  incifion,  and  overflowed  the  fides 
of  the  wound.  The  appfication  of  the 
fponge,  the  ufual  refource  on  thefe  occa- 
fions,  was  of  no  avail ;  for  the  wound  was 
xnflantly  filled  again,  ib  that  the  whole  ope- 
ration was  to  be  done  upon  parts  covered 
with  blood,  where  the  only  guide  in  its  per- 
formance was  the  feeling.  I  did  indeed  fee 
ibme  expofed  inguinal  glands,  and  found  that 
I  had  divided  two  of  them  in  trying  to  get  at 
the  fafcia  of  the  thigh.  As  foon  as  I  could 
diltinftly  feel  this  part,  I  made  a  finall  open- 
ing through  it,  and  introducing  my  finger,  I 
divided  it  upwards  as  far  as  Poupart's  liga- 
ment, and  downwai^ds  as  low  as  the  aneurif- 
mal  fac  would  allow  me.  The  puflation  of 
the  artei-y  now  ferved  as  my  guide,  Laying- 
aAde, 


OK .  ANBURISMfi;  tj^ 

afide,  therefore,  all  furgical  inftruments,  I 
made  way  with  my  finger  in  a  perpendicular 
diredlion,  till  I  could  touch  its  coats,  and 
then,  with  my  finger  and  thumb,  feparated  it 
from  its  connexions,  lb  as  to  be  able  to  grafp 
it  alone  between  them,  I  then  paflTed  two 
ligatures  under  it  by  means  of  an  eyed  probe, 
and  drawing  one  of  them  upwards,  and  the 
other  downwards,  as  far  as  the  fpace  would 
permit,  I  tied  them  firmly.  The  upper  li- 
gature was  about  half  an  inch  from  the  os  pu- 
bis, and  the  lower  one  the  fame  diftance  from 
the  *  arteria  profunda,  which  veflel  I  had  dif- 
tinftly  felt  before  I  tied  the  ligatures. 

There  are,  perhaps,  few  fituations  of  ancu- 
rifm  where  the  artery  can  be  tied  fo  fepa- 
rately  and  diftin6lly  as  here ;  the  pulfation  di- 
refts  the  furgeon  to  the  prccife  fituation  of 
the  veffel  -,  and  if  he  only  keeps  fufficiently 
clofe  to  its  fides  when  he  pafles  the  ligature 
round,  neither  the  vein  nor  the  nerve  can  be 
included.  I  did  not  divide  the  artery  between 
the  two  ligatures  j  it  was  fuggefted  that  itwerc 
better  not  to.doso;  and  I  knew  that  I  could  ob- 
tain all  the  advantages  of  a  relaxed  ftate  of  the 

vcflTel, 


t40  6n  ANFJURISlif. 

vcffel,  by  merely  bending  the  thigh  upon  the 
pelvis*  The  patient  did  not,  after  the  opera- 
tion, fufFer  any  kind  of  pain  from  the  wounded 

* 

parts ;  which,  I  think>  fhews,  that  the  artery 
did  not  inflame  much  in  confequencc  of  the  li- 
gature. The  fuppuration  was  moderate,  and 
every  thing  relative  to  the  wound  went  on  as 
well  as  could  be  cxpc6led.  The  limb,  and  par- 
ticularly the  foot,  was  colder  than  that  of  the 
oppofite  fide ;  but  in  about  three  days,  it  gra- 
dually acquired  its  natural  temperatufe ;  and 
it  all  along  retained  a  perfeft  flate  of  fenlibi- 
lity,  which  I  confidered  as  a  proof  that  it  was 
fufficiently  nourifhed.  To  prevent  the  heat 
from  being  carried  off  fafter  than  it  was  ge- 
nerated, the  limb  was  wrapped  in  flannel  j 
but  I  avoided  the  application  of  any  artificial 
wamith,  left  its  ftimulus  fhould  prove  inju- 
rious, by  exciting  action  when  the  powers 
of  life  in  the  part  might  have  been  confider^ 
ably  diminifhed. 

The  blood  in  the  aneurifmal  fac  did  not 
appear  to  have  coagulated  before  the  opera* 
tion ;  for  the  bulk  of  the  tumour  could  be 
greatly  leflened  by  prefTure,  whenever  the 

patieat 


ON   ANEURISMS  ^41 

patient  would  allow  the  attempt  to  be  made, 
fo  that  I  conclude  the  limb  had  received 
a  confiderable  quantity  of  blood  through  the 
femoral  artery,  until  that  veffel  was  tied.  The 
tumour  diminifhed  greatly  after  the  operation 
and  the  blood  contained  in  it  became  coagu- 
lated. This  redu6lion  of  the  fwelling,  I 
think,  was  owing  to  a  confiderable  part  of 
the  blood  paffing  onwards  through  the  femo- 
ral artery :  and  I  regretted  afterwards,  that, 
at  the  time  of  the  operation,  I  had  not  en- 
deavoured to  prefs  all  the  blood  from  the 
aneurifmal  fac;  which  experiment  would  have 
fhewn  how  far  it  was  fluid  or  coagulated. 

Every  thing,  with  refpeft  both  to  the  ftatc 
of  the  limb,  and  the  patient's  general  health, 
went  on  well  till  the  fifteenth  day,  when 
the  upper  ligature  feparated,  and  the 
blood  gufhed  in  a  full  ftream  from  the  open 
extremity  of  the  veflel.  This  fortunately 
happened  during  the  attendance  of  the 
furgeons  at  the  hofpital,  and  the  bleeding 
was  flopped  by  preflTure  until  their  arrivaU 

* 

The  ftream  of  blood  which  flowed  upon  any 

remiflion  or  wrong  application  of  the  preflTure^ 

VOL.  !•  R  was 


042  <}N    ANEURISMS. 

was  fo  large,  that  we  did  not  dare  to  remoTC 
the  patient  even  from  the  betl  on  which  he 
lay.  Mr.  Ramfden  undertook,  in  this  fitua- 
tion,  to  prevent  the  further  efcape  of  blood 
from  the  veffel,  whilft  I  proceeded  to  tie  the 
artery  above  Poupart's  ligament.  Accord- 
ingly, I  firft  made  an  incifion,  about  three 
inches  in  length,  through  the  integuments  of 
the  abdomen,  in  the  direction  of  the  artery, 
and  thus  laid  bare  the  aponeurofis  of  the  ex- 
ternal oblique  mufcle,  which  1  next  divided 
from  its  connexion  with  Poupart's  ligament, 
in  the  direflion  of  the  external  wound,  for  the 
extent  of  about  two  inches.  The  marginsof 
the  internal  oblique  and  tranfverfalis  mulcles 
being  thus  expofed,  I  introduced  my  finger 
beneath  them  for  the  protection  of  the  peri- 
tonxum,  and  then  divided  them.  Next,  with 
my  hand,  I  pufhed  the  peritonaeum  and  its 
contents  upwards  and  inwards,  and  took  hold 
of  the  external  iliac  artery  with  my  finger  and 
thumb,  fo  that  I  was  thus  enabled  to  com- 
mand the  flow  of  blood  from  the  wound.  It 
now  only  remained  that  I  fliould  pafs  a  liga- 
ture roxmd  the  artery,  and  tie  it;  but  this 
zt;quired'  caution,  on  account  of  tJic  conti- 


gtt^ 


OK   AKBURISMi.  S43 

guity  of  the  vein' to  the  artery.  I  could  not 
fee  the  veflels ;  but  I  made  a  reparation  be- 
tween them  with  my  fingers.  Having,  how- 
ever, only  a  common  needle  with  which  to 
pafs  the  ligature,  I  feveral  times  withdi-ew 
the  point,  from  the  apprdienHon  of  wound- 
ing the  vein  *.  After  having  tied  the  artery 
about  an  inch  and  a  half  above  Poupart's 
ligament,  I  divided  that  part,  and  thus  lud 
the  new  and  the  former  wound  into  one.  I 
traced  as  well  as  I  could  with,  my  finger, 
the  continuation  of  the  artery,  from  the 
place  where  the  ligature  was  now  made,  to 
that  where  it  was  formerly  applied.  I  wilh- 
cd  to  have  divided  the  artery,  and  to  have 

*  It  woitH  he,  I  think,  an  ufqful  iddidon  to  our  furgical 
inftmments  for  fuch  purpofes,  to  have  iiee<Uei  made  with 
haixUet  of  pure,  and  confequently  flexible,  ClTer,  and  wiA 
fteel  points  that  have  edges  juft  (harp  enough  to  pafs 
diToagh  the  cellular  fubftancc}  but  neither  (b  pointed  nor 
fo  flurp,  as  to  endanger  the  wounding  any  parts  of  confe* 
quence  that  may  be  contiguous  to  thofe  round  which  they 
arepafled.  When  the  points  of  thefeinftruments  wertcmce 
pafled  underneath  the  relTel,  the  furgeon  could  bend  their 
handles  fo  as  to  accommodate  them  to  the  fpace  they  have 
to  turn  in,  and  thus  avoid  an  incouTenience  which,  I  be- 
.lieve,  moll  furgeons  muft  have  experienced ;  I  mean,  the 
great  dtfficulty  of  turning  a  common  needle  in  a  deep  and 
tianow  wound. 

R  2  fuffered 


244  ON   ANEURISMS. 

fufFered  it  to  retraft  behind  the  peritonaeum : 
but  I  found  it  fo  attached  to  the  fiirrounding 
parts,  as  to  render  fuch  divifion  difficult,  and 
perhaps  not  advifable. 

The  lips  of  the  wound  were  brought  toge- 
ther with  fticking-plafter,  and  one  future 
only  was  made,  oppofite  to  the  natural  iitua- 
tion  of  Poupart's  ligament.  The  peritonaeum 
was  preffed  back  into  its  place,  and  the  pro- 
tufion  of  it  reftrained  by  bringing  together 
the  integuments  with  ftraps  of  fticking- 
plafter. 

No  perceptible  alteration  occurred  in  the 
ftate  of  the  limb  after  this  fecond  operation; 
but  the  patient's  health  was  confiderably  re- 
duced, by  his  having  fufFered  from  the  com- 
plaint nearly  twelve  months,  by  having  un- 
dergone three  operations,  and  by  the  lols  of 
a  confiderable  quantity  of  blood.  No  adhe- 
-  fion  took  place  between  the  divided  parts ; 
the  edges  of  the  wound  were  open  and 
floughy ;  the  wound  was  painful,  difcharged 
a  great  deal  of  pus,  and  was  fo  eitremely 
tender,  that  he  could  not    bear   it  to  be 

touched. 


ON   AK£URISM8«  945 

touched.     Sill  no  greater  mifchief  appeared 
till  the  fifth  day  after  the  operation,  when  a 
haemorrhage  of  ^irterial  blood  took  place  in 
fuch  quantity,  that  there  was  no  doubt  but 
that  it  arofe  from  the  principal  artery ;  though 
the  ligature  with  which  it  was  tied  ftill  re- 
mained firm.     The  patient's  health  was  now 
fp  impaired,  and  his  weaknefs  fo  great,  that 
an  attempt  at  tying  the  artery  ftill  higher  up, 
wovild  have  appeared  like  torturing  him  with- 
out any  hopes   of  ultimate  fuccefs.     The 
wound  was  therefore  cleanfed  and  dreffed  j 
fome  comprefles  were  applied  upon  it,  and 
bound  down  by  the  fpica  bandage.     By  thi§ 
treatment  the  haemorrhage  was  ftopped;  and 
the  attendants  were  ordered  to  make  a  preflurc 
on  the  bandage  if  any  frefh  bleeding  ftiould 
occur.     The  comprefles  were  renewed  for 
three  fucceedjng  dayp ;  and  though  occafion- 
ally  the  wound  bled,  yet  it  was  not  profufely, 
or  in  fuch  quantity  as  to  deftroy  the  patient : 
his  ftrength,  however,  gradually  declined ;  a 
trpublefome  cough  occafioned  extreme  pain 
in  the  wound,  and  in  the  courfe  of  the  eighth 
4ay  after  the  laft  operation,  he  died, 

^  3  ^'f- 


246  ON.  AK£UR]£Mi« 

DiJfeBion. 

No  marks  of  difeafe  were  difcoverable  in 
the  aorta,  or  in  the  internal  iliac  artery.  The 
external  iliac  was  covered  by  a  great  number 
erf  lymphatic  glands,  which  prevented  it  from 
being  readily  diftingvdfhed ;  yet,  when  iepa- 
rated  from  thefe,  it  did  not  appear  difeafed. 
For  nearly  two  inches  above  the  part  which 
was  tied,  the  lymphatic  glands  covering  the 
artery  were  con(iderably  enlarged,  having 
no  doubt  become  additionally  fwoUen  from 
the  irritation  excited  by  the  ligature.  The 
external  furface  of  one  of  them  next  the 
wound,  had  ulcerated;  and  the  ulceration 
penetrated  through  the  gland,  and  conmiu- 
nicated  with  the  artery,  as  was  afterwards 
made  evident  by  flitting  open  that  veflfel.  It 
was  through  this  aperture  that  the  blood  had 
efcaped ;  for  the  ligature  ftill  remained  firm 
upon  that  part  of  the  artery  which  it  had  in- 
clofed.  From  this  ligature  to  the  place  where 
the  vefl'el  had  formerly  been  tied,  the  artery- 
was  fo  clofely  connefted  with  the  furround- 
ing  fubflance,  that  diffe6tion  was  required  to 
feparate  them.     The  parts  of  the  artery  from 

which 


ON  ANBURISMS.  247 

which  the  former  ligatures  had  ieparated, 
were  about  half  an  inch  afunder,  and  the  ca- 
nal of  the  vefTcl  appeared  perfeftly  open.  — < 
The  whole  of  the  veffcls  from  the  bifurcation 
of  the  aorta,  to  the  aperture  in  the  tendon  of 
the  triceps  mufcle,  were  now  removed,  and 
carefully  difleftedj  and  after  being  ftufFed, 
and  hardened  by  fpirits,  they  were  cut  open 
to  (hew  the  ftate  of  them  internally.  A 
coagulum  of  blood,  about  two  inches  long, 
was  found  above  the  part  where  the  laft  li- 
gature was  made.  At  what  time  this  coagu<«- 
lum  had  been  formed,  is  perhaps  difficult  to 
afcertain ;  it  did  not  feem  to  have  taken  place 
after  death,  for  above  it  the  arteiy  contained 
no  blood ;  and  if  it  had  occurred  immediately 
after  the  operation,  it  is  probable  that  it  would 
have  prevented  the  haemorrhage.  I  have  al- 
ready remarked,  that  the  man  did  not  bleed  for 
feme  time  previous  to  his  death ;  in  which  inter- 
val, pei'haps,  this  coagulum  had  been  formed.— 
Thculcerated  opening  from  the  artery  through 
the  difeafed  gland,  admitted  the  paiTage  of  a 
modcrate-fized  bougie.  The  ligature,  which 
ftill  firmly  inclofed  the  artery,  had  brought  its 
fides  in  contact,  fo  as  to  render  it  probable 
that  they  would  have  united.     All  the  other 

R  4  parts 


24S  OK   AKCURISMS; 

parts  of  the  femoral  arteiy  were  quite  open^ 
fo  that  a  large  bougie  could  be  paffed  from  the 
lower  end  of  it,  through  the  aneurifmal  fac, 
tp  the  place  where  the  ligature  now  remained. 
About  half  an  inch  of  the  artery  was  want-^ 
ing,  which  had  been,  as  it  were,  cut  out  by 
the  ligatures  in  the  firft  operation-  The  fides 
of  the  arteries  below  the  part  which  was  tied 
were  thicker  than  natural,  and  their  internal 
furface  was  rough,  and  of  a  yellowifh  white 
colour-  The  arteria  profunda  was  filled  with 
coagulated  blood,  and  had  become  reduced  to 
lefs  than  the  natural  fize.  The  fides  of  the 
artery  of  the  oppofite  limb  had  firmly  united 
at  the  part  where  it  had  been  tied.  No  coa- 
gulum  was  found  in  it,  and  it  had  not  di- 
jninifhed  in  fize  in  any  remarkable  degree 
above  the  part  which  was  clofed. 

It  may  be  enquired  in  this  cafe,  why  the 
artery  did  not  heal,  but  upon  the  feparation 
of  the  ligature  remained  widely  open.  That 
the  ligature  was  tightly  applied  is,  I  think, 
evident  from  its  supprefling  all  haemorrhage 
till  its  feparation  on  the  15th  day.  I  am 
inclined  to  attribute  the  want  of  imion  in 
the  artery  to  its  unhealthy  ftate,  which  opi- 
nion 


ON   AN£URISMS«  249 

nion  is  confirmed  by  the  difleftion,  which 
/hewed  that  even  the  lower  orifice  of  the  ar- 
tery had  not  healed,  whilft  the  artery  in  the 
other  limb  which   was  tied  much  furthCT 
from  the  anenrifin,  and  where  the  veffel  was 
likely  to  be  found  and  healthy,  had  be- 
ome  firmly  united.     The  event  of  this  cafe 
ould  induce  me  to  tie  the  artery  as  remote- 
;y  from  the  feat  of  ancurifm  as  could  with 
ropriety  be  done. 


In  this  firft  operation  of  tying  the  external 
i^liac  artery,  I  was  urged  to  perform  it  by  the 
mpulfeof  the  moment,  for  the  death  of  thepa- 
lient  would  otherwife  have  been  inevitable.  In 
:his  cafe  I  thought,  I  difturbed  the  perito- 
laeum  too  much,  and  tied  the  artery  higher 
:han  was  neceflary.     As  the  limb,  however, 
^id  not  appear  to  fuffer  materially,  I  felt  it 
^i  duty  to  perform  a  fimilar  operation  in  the 
following  cafe.     The  veflel  was  tied  lower 
down,  fo  that  it  was  brought  into  view  at 
tlie  time  of  the  operation.     It  was  tied  with 
two  ligatures  and  divided  in  the  interval  -,  it 
afterwards  firmly  united  at  each  extremity, 
and  the  ligatures  came  away  at  the  ufual 

I  z  time : 


^SO  ON    ANEURISMS. 

time :  neither  did  there  appear  any  deficiency 
in  the  nutrition  of  the  limb.  Thefe  cifcum- 
ftances  afford  reafonable  expectations  of  fuc- 
cefs  in  future  operations  of  this  kind,  yet  in 
theprefent  inftance  the  operation  appeared  to 
have  been  too  long  delayed,  and  the  patient 
to  have  died  from  an  event  which  was  not 
forefeen,  but  which  might  perhaps  have  been 
prevented. 

CASE    n. 

Wrungel,  a  German,  by  trade  a 


fugar-baker,  of  a  fickly  afpeft  and  (lender 
make,  about  5  feet  7  inches  high,  and  near 
40  years  of  age,  was  admitted  into  St.  Bar- 
tholomew's hofpital,  on  account  of  an  aneu- 
rifin  in  the  femoral  artery,  clofe  to  Poupart's 
ligament.     This    he   imputed    to  a  ftrain 
about  three  weeks  before.     The  tumor  at 
the  time  of  admiffion  was  of  the  fize  of  a 
iinall  orange,  and  the  blood  contained  in  it 
was  fluid ;  for  it  could  be  entirely  exprefled 
from  the  aneurifmal  fac.     At  a  confultation 
on  the  treatment  of  this  cafe,  I  faid  that  I  did 
not  think  a  furgeon  warranted  in  tying  the 
external  iliac  artery,  till  he  was  in  fome  mea- 
fure  compelled  to  it  by  the  progrefs  of  the 

difeale. 


ON   ANEURISMS*  25! 

diieaie,  for  the  following' reafons.  ift.  Aa 
aneuriiin,  in  proportion  to  its  increafe  and 
duration,  obftrufts  the  paffage  of  the  blood 
through  tlie  natural  and  principal  channels, 
and  obliges  it  to  circulate  by  other  courfes, 
which  are  enlarged  according  to  the  exigency 
of  the  cafe.  It  feems  highly  probable,  that 
in  proportion  to  the  fize  of  the  artery  which 
is  tied,  and  the  magnitude  of  the  part  to  be 
nourifhed  after  that  operation,  fo  will  be 
the  degree  of  previous  enlargement  in  thefe 
collateral  channels,  which  is  neccffaiy  to  en- 
iiire  its  fuccefs.  On  this  account  the  opera- 
tion (hould  be  delayed  longer  in  an  inguinal 
aneurifin  than  in  any  other. 

2dly.  The'operation  of  tying  the  external 
iliac  artery  muft,  in  the  prefent  ftate  of  our 
knowledge,  be  confidered  as  very  ferious  in  its 
nature,  and  uncertain  in  its  event.  I  had  then 
only  once  tied  this  veflel  when  a  man  would 
otherwife  have  bled  to  death  from  the  femoral 
artery ;  and  though  the  limb  was  nourifhed, 
the  artery  ulcerated.  The  operation  was  done 
a  fecond  time  in  London,  and  the  limb  mor- 
tified i  but  no  fair  practical  inference  can,  I 

am 


a^Z  ON  ANBURISMS^ 

am  told,  be  drawn  from  the  latter  cafe,  as  the 
operation  was  poftponed  till  mortification  was 
as  it  were  impending. 

3dly.  There  is  fome  chance  in  aneurifin^ 
of  a  cure  fpontaneoufly  occurring  from  the 
clofiirc  of  the  artery  above  by  the  coagulation 
of  the  blood.  To  cite  thofe  inftances  only 
which  have  come  within  my  own  knowledge, 
and  which  it  feems  right  to  mention,^  as  %t 
incrcafes  the  ftock  of  fafts  before  the  public  ; 
I  have  known  fuch  a  fpontaneous  cure  take 
place  twice  in  the  popliteal  artery,  once  in  the 
arteria  profunda  femoris,  and  once  in  the 
axillary  artery.  For  thefe  reafons  it  was 
agreed  to  poflpone  the  operation  in  the  cafe 
of  the  prefent  patient  till  circumflances  fhould 
appear  to  demand  its  performance*.. 

*  There  was  about  twelve  months  ago  a  foldier  in  the 
York  hofpital,  who  had  an  aneurifm  of  the  femoral  artery, 
but  the  external  tumor  had  fo  much  overlapped  Poupart*s 
ligament,  and  interpofed  itfelf  between  the  integuments 
smd  the  fafcia  of  the  external  oblique  mufcle,  as  to  render 
an  operation  very  difficult,  if  not  impoffible.  In  this  cafe 
the  integuments  mortifying,  occafioned  a  fimultaneous 
coagulation  of  the  blood  in  the  artery,  for  though  the  coa<» 
gula  came  out,  yet  there  was  no  frelh  haemorrhage^  and 
die  patient  recovered. 

Our 


ON    ANEURISMS*  ^53 

Our  poor  patient  therefore  lay  in  the  hos- 
pital dviring  two  months,  in  which  time  his 
difeafe  gradually  increafed,  and  his  health  dc- 
dined.     Towards    the    latter   part   of  the 
time  he  fufFered  a  great  deal  of  pain  in  the 
front  of  his  thigh,  which  deprived  him  of 
reft,  and  the  whole  limb  was  largely  oedemar- 
tons,    Thefe  fymptoms  would  naturally  arife 
from  the  prefTure  which  the  aneurifin  mufi: 
make  on  the  anterior  neives  and  abfbrbcnts 
of  the  thigh.     The  tumor  had  advanced  to- 
wards the  Surface,  and  the  ikin  had  become 
ilightly  inflamed,  yet  the  protruding  part  of 
the  tumour  was  not  of  greater  extent  thaa 
when  he  was  firft  admitted  into  the  hofpital, 
and  no  judgment  could  be  formed  of  that 
•part  which  was  more  deeply  fituated,  on  ac- 
count of  the  general  fwelling  of  the  thigh. 
The  blood  could  even  now  be  expreffed  from 
the  prominent  part  of  the  tumour,  and  I  felt 
anxious,  left  the  obftruclion  tothe  circulation 
in  the  main  artery  fhould  not  have  been  fuf- 
ficient  to  have  obliged  the  blood  to  circulate 
by  other  channels.     It  deferves  to  be  re- 
marked, that  the  aneurifin  may  extend  con- 
fiderably  beneath  the  fafcia  of  the  thigh, 

caufing 


^54  ON   ANEURISMS. 

caufing  pain  and  oedema  by  its  preflure,  and 
yet  that  part  which  advances  towards  the  fur- 
fece  may  be  of  no  great  magnitude. 

The  patient's  fufferings  increafed  confider- 
ably  during  the.  week  preceding  the  ope- 
ration, {o  that  he  declared  his  prefent  ft^te 
was  almofl  iniupportable,  and  folicited  that 
fomething  might  be  done  to  change  it  either 
for  the  better  or  the  worfe.  He  never,  how- 
ever, was  able  to  explain  the  caufe  of  this  unr- 
common  degree  of  anxiety  and  inquietude. 

The  operation  was  undertaken  on  Saturday 
the  24th  of  Oflober.  An  incilion  of  three 
inches  in  length  was  made  through  the  in- 
teguments of  the  abdomen,  beginning  a  little 
above  Pouparf  s  ligament,  and  being  conti- 
nued upwards  j  it  was  more  than  half  an 
inch  on  the  outfide  of  the  upper  part  of  the 
abdominal  ring,  to  avoid  the  epigaftric  artery. 
The  aponeurolis  of  the  external  oblique  mus- 
cle being  thus  expofed,  was  next  divided  in 
the  direftion  of  the  external  wound.  The 
lower  part  of  the  internal  oblique  mufcle  was 
thus  uncovered,  and  the  finger  being  intro- 
duced 


ON    ANEUillSliS.  ^55 

duced  below  the  inferior  maigin  of  it  and 
of  the  tranfverfalis  mufcle,  they  were  divided 
by  the  crookpd  biftoury  for  about  one  inch 
and  a  half.      I  now  introduced  my  finger 
beneath  the  bag  of  the  peritoneum,  and  car- 
ried  it  upwards  by  the  fide  of  the  pfbas 
mufcle,  fo  as  to  touch  the  artery  about  an 
inch    above  Poupart's    ligament.      I  took 
care  to  difturb  the  peritonssum  as  little  as 
pofnble,  detadhing  it  to  no  greater  extent 
than  would  fcrve  to  admit  my  two  fingers  to 
touch  the  veffeL     The  pulfations  of  the  ar- 
tery made  it  clearly  diftinguifhable  from  the 
contiguous  parts,  but  I  could  not  get  my 
finger  round  it  with  the  facility  which  I  cx- 
pe6ted.      This  was  the  only  circumflance 
which  caufed  any  delay  in  the  performance  of 
the  operation.  After  inefFeftual  trials  to  pafs 
my  finger  beneath  the  artery,  I  was  obliged 
to  make  a  flight  incifion  on  either  fide  of 
it,  in  the  fame  manner  as  is  neceflfary  when 
it  is  taken  up  in  the  thigh,  where  the  faftia 
which  binds  it  down  in  its  fituation  is  flrong. 
After  this  I  found  no  difficulty  in  paffing 
my  forefinger  beneath  the  artery,  which  I 
drew  gently  down,  fo  as  to  fee  it  behind  die 

ba^ 


9^6  ON    ANEURISMS. 

bag  of  the  peritonaeum-  By  means  of  an 
eyed  probe  two  ligatures  were  conveyed 
roimd  the  veffel ;  one  of  thefe  was  carried 
upwards  as  far  as  the  artery  had  been  de- 
tached, and  the  other  downwards :  they  were 
firmly  tied,  and  the  veffel  was  divided  in 
the  fpace  between  them.  Nothing  further 
remained  than  to  clofe  the  external  wound, 
which  was  done  by  one  future,  and  fbme 
ftrips  of  fticking-plafter.  The  threads  of  the 
upper  ligature  were  left  out  of  the  wound 
above  the  future  which  clofed  its  edges,  and 
thofe  of  the  lower  beneath. 

A  few  remarks  on  this  operation  may  be 
permitted.  To  divide  the  parietes  of  the  abdo- 
men, pufh  afide  the  peritonaeum,  and  tie  the 
external  iliac  artery  by  the  fide  of  the  pibas 
mulcle,  is  an  operation  more  formidable  in 
found,  and  on  its  firft  propofition,  than  it  is 
in  reality.  It  is  performed  almoft  without 
ihedding  blood,  fo  that  the  principal  circirai- 
ftances  of  it  are  very  evident.  When  I  for- 
merly performed  this  operation,  I  was  urged 
to  it  by  immediate  neceflity :  I  tied  the  artery 
much  higher  than  in  the  prefent  cafe,  dif- 

turbed 


.   OK   ANBURIlSMft*  Ajf 

turbed  the  peritonaeum  in  a  greater  degree, 

and,  contrary  to  my  own  principles,  I  did 

not  divide  the  artery*     In  the  prefent  cafe^ 

l:iaving  time  to  deliberate  upon  the  fteps  of 

^ihe  operation,  I  detached  merely  fo  much  of 

itlie  peritonaeum  as  enabled  me  to  reach  the 

su^ery,  as  far  as  I  conveniently  could  above 

oupart*s  ligament ;  but  not  fo  far  as  to  make 

X  difficult  to  afcertain  that  I  furrounded  the 

only  with  my  finger,  without  injuring 

ny  of  the  adjacent  parts,  nor  fo  far  but  that 

could  draw  down  and  diftinguifti  the  artery 

hich  I  included  in  the  ligature.     The  re- 

embrance  of  the  fwelling  in  the  external 

liac  glands,  and  of  the  ulceration  of  the  ar-» 

xry  in  the  former  cafe,  led  to  this  difference 

f  conduct. 

The  poor  man  was  greatly  exhaufted  by 

operation,  and  his  leg  which  had  been 

:hilled  by  expofure  during  the  operation, 

:ontinued  very  cold  for  a  long  time  after- 

'"Sii^fards.     It  was  wrapped  up  in  flannels,  to 

^  prevent  the  diffipation  of  its  own  heat;  but 

'^  1  would  not  apply  any  artificial  warmth  to 

'  xeilore  its  temperature  left  it  ihould  a£t  as  a 

Simulant. 

VOL.  I,  s  He 


258  ON   ANEURI&MS. 

He  could  not  compofe  himfclf  after  the 
operation,  nor  did  he  fleep  during  the  night, 
fo  thgit  on  the  following  day  his  ftate  was 
very  unpromifing.  His  pulfe  beat  1^60  in  a 
minute,  his  tongue  was  covered  by  a  dark 
brown  ftur^  he  looked  agitated,  and  a  purg- 
ing took  place,  which  was  not  reftrcdned  till 
the  following  night  by  a  cordial  and  opiate 
mixture.  Refpefling  his  pulfe^  it  is  proper 
to  mention  that  it  beat  120  moft  days  in  the 
week  preceding  the  operation • 

His  thigh  was  as  wann  as  tliat  of  the  found 
fide,  his  leg  cooler  than  the  oppofite  one,  and 
his  foot  many  degrees  colder.  He  had  how- 
ever perfeft  fenfation  in  his  toes,  and  power 
of  moving  them,.  The  leg  and  foot  were 
rubbed  with  oil  three  or  four  times  a  day,  in 
order  to  prevent  any  ftagnation  in  the  veins,, 
and  to  diminilh  perfpiration.  It  was  wcH 
jcovered  as  before  by  flannels. 

OnMonday,the  2d  day  (Oft.  26.)  thepulfe 
waslefs  frequent:  he  had  fleptagooddealdu?- 
ringthe  night,  and  feemed  ftupified  by  the  opi- 
um ;  but  was  on  the  whole  fo  little  better,  that 
I  concluded  he  would  gradually  fmk  in  con- 

jfequence 


ON  ANEURISMS*  2^9 

fequence  of  the  (hock  of  the  operation.   The 
temperature  of  the  limb  was  a  little  increafed. 
The  man  however  took  bread  and  milk  and 
other  food  in  modtt'ate  quantities,  whenever 
it  was  offered  to  him :  the  purging  having 
ceafed,  the  quantity  of  the  opiate  was  di- 
minifhed/    He  rither  improved^  in  the  even«^ 
ing,  and  refted  well  during  the  night  -,  fo  that 
on  (061.  27,)  the  third  day  after  that  of  the 
operation,  every  circumftance  wore  a  favour- 
able afpeft.     His  pulfe  did  not  exceed  loo, 
snd  was  moderately  firm  and  foil ;  his  appe- 
"tite  had  increafed:    the  temperature  of  the 
limb  was  a  good  deal  augmented,  fo  that  his 
foot  was  fcarcely  colder  than  that  of  the 
ibund  fide ;  and  the  oedema  of  the  limb  was 
<:onfiderably  diminifhed.     I  now  dreffed  his 
ivound,  in  which  he  had  not  complained  of 
3)ain,  nor  of  any  tendernefs,  when  the  fur- 
Tounding  parts  were  compreffed.     The  in- 
^ifion  appeared  but  as  a  line,  except  at  the 
"laeighbourhood  of  the  ligatures,  where  it  was 
a  little  open,  and  from  whence  there  ifTued 
a  moderate  quantity  of  as  healthy  pus  as  I 
had  ever  feen.     The  furrounding  parts  were 
perfeftly  natural  both  in  appearance  and  fen- 

s  2  fation. 


%6o  OK    ANbUtllSMS. 

fation.  On  the  fourth  day  {0£t.  28.)  he  was 
ftill  better ;  his  pulfe  90 ;  his  appetite  good ; 
his  fleep  found ;  and  his  limb  lefTenlng  in 
fize,  and  increafing  in  warmth.  The  ftu- 
dents  at  the  hofpital  had  dreffed  the  wound 
before  my  arrival,  and  reported  that  the  dif- 
charge  was  tinged  with  blood. 


'^^ 


On  the  fifth  day  (0£t.  29.).  he  was 
better,  his  pulfe  being  but  80  when  1 
counted  it.  The  wound  and  contiguons 
parts  looked  remarkably  well,  but  a  bloody 
(anies  was  difcharged,  which  I  felt  unabl^o 
account  for. 


On  the  fixth  day  (061.  30.)  the  ftate  of 
his  health  and  limb  continued  as  well,  if  not 
improving.  The  bloody  difcharge  however 
had  increafed  in  quantity,  infomuch  that  it 
ran  through  the  coverings  of  the  wound  and 
foiled  the  bed ;  it  had  alio  become  foetid. 
From  the  firft  occurrence  of  this  bloody  dil- 
charge  -I  felt  confiderable  uneafinefs  refpeft- 
ijig  it.  I  could  not  believe  that  a  healthy 
wound  would  fecrete  fuch  a  fanies,  and  I  felt 
apprehenfive  left  the  woimd  ihould  fpread 
from 


OV  ANEURISMS. 

from  difeafe.     Nothing  however  took  place 

to  confirm  thi^  idea.    It  feemed  probable  alfo 

that  if  the  aneurifmal  fac  were  not  entire, 

feme  of  the  blood  being  expofed  to  the  air 

might  tinge  the  difcharge  from  the  wound, 

and  grow  putrid.     I  frequently  preffed  on 

the  tumour,  but  could  prefs  no  blood  from 

the  wound.     In  this  ftate  of  uncertainty  it 

Was,  however,  plealing  to  obferve,  that  the 

patient's  health  continued  in  every  refpeft 

Ibetter  than  could  reafonably  have  been  ex- 

J>e6led. 

The  circumftances  of  the  cafe  remaihed 
'v-ery  much  the  fame  during  the  feventh  and 
.^dghth  days  after  the  operation.  On  the 
nnoming  of  the  ninth,  (Nov,  2.)  when  I 
crame  to  the  hofpital,  I  met  Sir  Charles 
^licke,  who  told  me  that  the  poor  Gerthati 
^i^vas  dying;  intelligence  which  equally  fur- 
^riied  and  fhocked  me. 

He  was  indeed  in  a  dreadful  ftate,  appear- 
ing like  a  man  far  advanced  in  typhus  fever. 
Xiis  pulfe  was  1 50 ;  his  tongue  covered  with 
?x  brown  fiir  j  his  intelledl  wavering,  and  die 

S3  z&ton 


262  ON'  ANXURISMS. 

aftion  of  his  mufcles  tremulous.  On  exa- 
mining the  wound,  with  a  view  to  difcovcr 
the  caufe  of  this  grwt  and  fudden  alteration, 
and  prcffing  on  the  tumour  beneath  Poupart's 
ligament,  I  fprced  out  a  great  quantity  of 
blood,  rendered  fluid  and  highly  foetid  by 
putrefa^on,  infomu(:h  that  it  inftantly  blacfc-r 
ened  the  probe  wjth  wliich  it  accidentally 
came  in  cpntad. 

The  caufe  and  cirpumftanccs  of  the  bloody 
difcharge  were  now  made  clear ;  the  furfisice 
of  the  expofed  coagulated  blood  of  die  aneu-* 
rifin  had  at  firft  tinted  the  difcharge  from  the 
wound,  and  then  had,  by  gradual  diflblution, 
been  more  plentifully  commixed  with  it,  amj 
given  it  a  degree  of  putridity.  Till,  however, 
the  whole  mafs  had  become  putrid,  and  had 
been  converted  in  confequence  into  a  fluid,  }t 
could  not  be  forced  out  from  beneath  Poupait's 
ligament  when  preflure  was  made  on  the 
tumour  3  nor  did  it  till  that  period  excite  in- 
flaipmation  in  the  furrounding  parts  by  its 
acrimony,  or  derange  the  conftitution  by  its 
abforption. 

After 


OR    ANEITRISMS.  263 

After  entirely  exprcfling  the  putrid  blood 
I  wafhed  out  the  cyft  with  warm  water,  till 
it  returned  untinged.     The  relief  which  was 
by  thefe  means  afforded  to  the  poor  man  w« 
wry  ftriking  and  conliderable.     His  pulfe 
became  moderate,  his  intelleft  clear  i  he  had 
fbme  refrefhing  deep,  and  again  took  food  in 
moderate  quantities.     On  the  following  day, 
when  the  integuments  beneath  Poupart's  liga- 
ment were  comprefled,  a  confiderable  quan- 
tity of  foetid  difcharge  and  air  were  forced 
out.     It  was  not  however  at  all  tinged  with 
blood,  and  appeared  to  me  to  be  merely  the 
ion  from  the  cyft  which  had  contained 
blood.     I  direfted  that  this  difcharge 
^lould  be  preffibd  out,  the  cavity  fyringed, 
a  poultice  applied  three  times  a  day; 
ut  finding  a  confiderable  quantity  of  fetid 
aid  ftill  lodged  in  the  cyft,  I  thought  it  right 
X)  make  an  opening  into  it  beneath  Poupart's 
igament,  to  afford  it  a  more  ready  exit.     No 
batement  in  the  quantity,  or  alteration  in 
quality  of  the  difcharge,  was  however  re- 
x-narked ^  it  feemed  to  be  fuch  as  a  floughing 
Xbre  commonly  furnifties^ 

This  fever  came  on  on  the  evening  of  the 

s  4  eighth 


^ 


t64  ON   ANBUEIftMt. 

eighth  day  (Nov.  i.)  after  that  of  the  opera^ 
tion^  and  I  am  convinced  it  would  haye 
fpeedllydeftroyedthepatlent^  had  not  the  caufe 
been  ^etefted  and  removed.  The  powers  of 
his  conflitution  rallied  again  >  his  pulfe  was 
firm^  and  often  not  more  than  ioq  i  he  took. 
fufHcient  food,  and  flept  moderately  weU-. 
Butt  he  p^y  as  has  been  faid,  did  not  go  on 
well,  and  Teemed  to  prevent  any  increafe  of 
ftrength.  For  a  week  I  was  not  without 
hopes  that  fome  favourable  change  might 
happen,  but  afterwards  I  loft  all  fuch  expec- 
tations, as  his  already  much  reduced  powers 
were  ftill  further  declining ;  neveithelefs,  he 
held  out  more  than  another  week,  when  he 
died  on  November  16,  the  twenty- third  day 
after  the  operation.  A  few  days  before  iiis 
deatli  both  ligatures  came  away  with  the 
dreffings. 

DiJfeSlion. 

A  veiy  flight  adhefion  had  taken  place  bcr 
tween  the  figmoid  flexure  of  the  colon  and 
that  part  of  the  peritonaeum  which  was  oppo- 
fite  to  the  wound,  but  there  was  no  other 
appearance  of  that  membrane,  or  of  the 

bowels. 


bowels,  having  differed  any  inflammation  M 

xronfequence  of  the  operation.     The  peiitd^ 

nasum  was  feparated  from  the  loins,  andfrora 

the  poflerior  half  of  the  left  fide  of  the  dsst^ 

phragm,  by  a  confiderable  colleftion  of  bloody 

^^which  extended  downwards  to  Poupart's  ligai 

ment,  and  communicated  under  that  ligament 

l)y  a  fmall  aperture  with  the  aneurifmal  fac. 

This  opening  was  (ituated  in  the  direction  of 

^at  crevice  which  is  found  between  the  inteP-' 

3ial  iliac  and  pfoas  mufcles.  The  only  rational 

4:)rplanation  that  can  be  given  of  the  forma- 

lion  of  this  colleftion  is,  that  the  blood  ha:d 

l)urfl  its  way  from  the  aneurifmal  fac  iivthe 

vacancy  between  the  mufcles  jufl  mentioned; 

after  which  it  would  readily  and  extenfively 

feparate  the  peritonaeum  in  the  manner  dfe- 

fcribed.     I  am  inclined  to  attribute  to  this 

circumflance  the  undefinable  diflurbance  of 

health  which  the  poor  patient  fuffcred  during 

the  week  preceding  the  operation.     It  may, 

perhaps,  excite  furprife  that  this  colle6lion 

did  not  become  putrid. 

No  particular  account  can  be  given  of  the 
aneurifmal  fac  beneath  Poupart's  ligament^ 

fince 


y 


f$6  on  ANZUMSMS. 

fince  it  and  the  contiguous  parts  had  floughed 
in  confequcnce  of  the  irritation  of  the  putrid 
tikxxl.  A  fmall  aperture  had  been  made  by 
this  floughing  in  the  front  of  the  orbicular 
ligament  of  the  hip  joint,  and  a  fmall  extent 
of  the  thigh  bone  was,  by  the  lame  caufe^ 
deprived  of  its  periofteum. 

A  bougie  was  pafled  from  the  lower  end 
of  the  femoral  artery  into  the  fac. 

The  extremities  of  the  external  iliac  artery, 
which  had  been  divided  in  the  operation, 
were  united  together  by  a  firm  new-formed 
fubflance  >  the  fides  of  each  extremity  were 
perfectly  clofed,  and  a  fmall  plug  of  coagu- 
lated blood  was  found  in  each. 

Having  thus  given  as  brief  an  account  as 
I  am  able  pf  the  qircumftances  of  this  cafe, 
as  they  appeared  to  me,  I  cannot  conclude 
without  mentioning  the  obfervations  of 
others,  particularly  as  they  may  aflifl-in 
fuggefling  rules  of  conduft  for  future  ope- 
rations on  fimilar  cafes.  It  has  been  faid 
that  the  irritation  of  the  aneurifinal  bag  was 

pro- 


OK   ANEURISMS.  dfijf 

probably  a  fpontaneous  occurrence^  and  not 
the  efFeft  of  the  acrimony  of  the  piitrid 
bloody  But  the  fuddennefs  of  this  attack, 
the  manifeft  exiflence  of  a  cauie  fufficient  to 
produce  it,  and  the  total  abience  of  fuch  an. 
occurrence  in  all  other  cafes  of  aneurijGn, 
render  this  fuppofition  highly  improbable* 

It  has  alfo  been  imagined  that  part  of  the 
difcharged  blood  might  have  returned  from 
the  lower  end  of  the  artery.     This  latter 
opinion  is  veiy  improbable,  iince,  after  the 
complete  removal  of  the  blood,   none  re-' 
turned  by  that  channel :  and  in  the  &r&  cafe 
which  I  have  related,  none  returned  by  the 
inferior  part  of  the  artery,  though  the  area 
of  it  was  ftill  of  its  natural  dimenfions,  and 
unobftrufted.     This  latter  obfervation  had 
tended  to  diminifh  my  confidence  in  the 
powers  of  the  communicating  channels,  and 
made  me  wiih  to  defer  the  performance  of  the 
op.eration  as  long  as  poflible.     It  feems  evi- 
dent that  in  the  prefent  inflance  it  was  too 
long  delayed. 

It  would  be  defirable  in  future  to  perform 
the  operation  before  an  extenfive  difl^ifion  of 

7  blood 


^V  OK   AK£URISMIt. 

blood  had  taken  place;  indeed,  could  thd 
adequatcnefs  of  the  collateral  arteries  for  the 
fupply  of  the  limb  be  eftablifhed,  it  would 
be  proper  to  operate  at  an  early  period  of 
tfic  difeafe. 

It  dcferves  to  be  confidered  whether,  in  cafes 
where  it  is  probable  the  blood  is  become  diffii- 
fed,  itmight  not  be  right  at  the  time  of  the  ope- 
ration to  open  the  aneurifinal  bag,  and  remove 
the  blood.  I  iliould,  howeVer,  be  inclined  to 
poftpone  this  attempt;  for,  perhaps,  no  neccjp* 
fity  might  exift,  as  putrefaflion  might  not  take 
place.  A  few  days  will  determine  the  degree  of 
hfe  of  the  limb,  and  would  make  a  wound  lefs 
likely  to  ulcerate  or  flough.  Should  figns  of 
the  putrefaftion  of  the  blood  enfue,  or  the 
probability  of  fuch  an  occurrence  become 
evident,  I  fhould  think  it  neceflary  to  make 
a  fmall  opening  into  the  aneurifmal  bag  for 
the  removal  of  the  contained  blood.  This 
being  done,  if  no  blood  came  from  the  lower 
orifice  of  the  artery,  there  would  be  no 
ceffity  for  tying  it. 


CASK 


OH    ANEURISMS^  A€^ 

CASE   m. 

r 

Jane  Fidd,  aged  40,  who  had  been  in  the 
habit  of  drinking  to  excefs,  was  admitted  into 
St.  Bartholomew's  Hofpitai,  with  a  very  large 
femoral  aneurifin,  reaching  as  high  as  Ppu^ 
part's  ligament.  The  whole  limb  was  cede-^ 
matous,  but  in  no  very  confiderable  degree* 
Siie  was  quite  incapable  of  ufmg  the  leaft  ex^ 
ercife,  or  of  fitting  upright ;  and,  even  in  bed, 
ihe  fuffered  continual  pain,  which  was  much 
aggravated  duting  the  pulfation  of  the  aneu- 
rifm.  The  pain  was  fo  violent  as  to  preclude 
fleep.  She  had  no  appetite ;  her  pulfe  was 
feeble  and  frequent,  generally  exceeding  loo; 
but  her  tongue  was  not  furred;  and  her 
bowels  were  regular. 

On  Saturday,  nth  Oftober,  1806,  thd 
operation  was  performed  in  the  fame  manner 
as  in  the  laft  cafe.  Ah  incifion,  about  threi 
inches  in  length,  was  made  through  the  inte-,^ 
gumcnts  of  the  abdomen,  in  the  dire£iion  of 
the  artery,  beginning  juft  above  Poupart's  li-^ 
gamcnt.  Having  divided  the  fkin  and  aponeu^ 
rofis  of  tlie  external  oblique  mufcle,  I  ixu 

troduced 


troduced  my  finger  between  the  margin  of 
the  internal  oblique  arid  tranfverfe  mufclcs 
tod  the  pcritonseum.     I  then  divided  their 
lower  edges  upwards,  in  the  dire6lion  of  the 
external  wound,  to  the  extent  of  an  inch  and 
a  half,  with  a  probe-pointed  biftoury.     Hav- 
ing thus  made  room  for  the  admiffion  of  my 
finger,  I  put  it  down  upon  the  artery,  felt  its 
puUations,  and  gentjy  infinuated  it  beneath 
theveflel  J  and  then,  withtheaneurifmalneedl<^ 
pafled  under  it  two  moderately  thick  ligatures^ 
carrying  them  upwards  and  downwards,  as 
far  as  the  detachment  of  the  artery  permitted^ 
and  tying  them  as  firmly  as  I  could.     I  next 
divided  the  artery  in  the  interval,  but  much 
nearer  to  the  lower  ligature  than  to  the  upper 
one.     The  wound  was  afterwards  clofed,  in 
the  itiiddle  by  a  ligature,  and  in  other  parts 
by  fticking-plafter.     Upon  removing  the  pa- 
tient to  bed,  fhe  complained  of  great  pain  in 
the  wound,  and  in  her  head ;  and  was  very 
reftlefs  and  ungovernable.     She  wifhed  for 
fomething  to  procure  fleep,   and  I  gave  her 
twenty-five  drops  of  laudanum.     This,  in- 
ftead  of  having  the  defired  efFe61:,  made  her 
much  more  reftlefs ;   fhe  was  continually 

changing 


ON   ANEITRISM^.  1/1 

changing  her  pofition  in  bed,  and  complain* 
ing  of  violent  headach.  At  night  fhe  be* 
came  more  tranquil.  The  one  foot  waS 
much  colder  than  the  other ;  but  the  limbs 
at  the  knees  were  nearly  of  an  equal  tem- 
perature. 

Sunday,  12th,  I  vifitcd  her  early  in  the 
morning,  and  found  that  fhe  had  been  mode-^ 
rately  quiet  during  the  night ;  that  fhe  had 
fufFered  much  pain  in  her  foot,  but  none  iij 
the  wound.  The  pain  in  the  limb  fhe  de- 
fcribed  as  having  firfl  attacked  the  thigh, 
next  the  leg,  and  afterwards  the  foot,  which 
lafl  pain  had  now  ceafed.  The  foot  was 
warmer  than  it  was  the  preceding  evening, 
and  in  a  flate  of  perfpiration :  it  was  four 
degrees  of  heat  lower,  by  Fahrenheit's  fcale, 
than  that  of  the  healthy  limb.  The  fuper- 
ficial  veins  of  the  leg  were  filled  with  blood« 
Her  pulfe  was  96.  She  had  no  appetite.  I 
left  her  with  a  promife  to  vifit  her  again  at 
night,  recommending  her  to  lie  quiet,  and 
take  fome  fimple  nourifhment.  About  noon, 
one  of  the  drefTers,  obferving  that  her  fkin 
was  hotj  and  ^e  tongue  dry,  gave  her  fbmc 

faline 


a/^  ON   ANEtTRI8U»# 

ialine  medicine,  with  a  fmall  quantity  o^anti-^ 
inonial  wine,  which  occafioned  vomiting, 
and  fach  continued  naufea,  that  fhe  refiifed 
all  kinds  of  food.  The  limb,  at  night,  con* 
tinued  in  the  fame  ftate  as  in  the  morning. 
She  was  free  from  pain  ;  her  pulfe  120.  As 
(he  was  without  an  evacuation,  I  gave  her 
a  pill,  containing  two  and  a  half  grains  of 
///.  aloet.  e  myrrh,  with  the  fame  quantity  of 
€xtra£t  of  colocynth,  ordering  it  to  be  re*- 
peated  in  the  morning,  if  neccffary. 

Monday,  13  th.  The  foot  was  nearly  of  the 
fame  temperature  with  the  other.  She  had  had 
two  ftools,  and  felt  much  more  comfortable^ 
Still, however,  fhe  had  an  averfibn  to  all  kinds 
of  nourifhment.  Her  pulfe  was  150  and 
1 60,  at  different  times  of  the  day.  I  may 
here  mention,  that  every  fubfequent  day,  fhe 
had  one  or  more  flools,  without  having  re- 
courfe  to  opening 'medicine;  and  whenever 
(he  was  more  irritable  or  difturbed  than 
uiual,  fhe  had  a  tendency  to  purging.  In 
the  evening  of  this  day,  I  inquired  if  fhe  had 
a  wifh  for  any  particular  kind  of  nourifh- 
ment; and,  at  her  fuggeflion,  gave  her  half 
-       .  I  a  pint 


ON    ANEURISMS. 


373 

'  and  toaft- 


si  pint  of  porter,  with  fome  ginger  3 
*^d  bread.  This  feemed  to  agree  with  her 
f^omach,  as  fhe  flept  the  whole  night,  and 
^woke  much  refreihed  the  next  morning. 
DHer  tongue  was  then  clean  j  fhe  took  fome 
^tea  and  mufHn  for  breakfaft,  and  broth  and 
l>read,  in  moderate  quantities,  in  the  courfe 
of  the  day.  Half  a  pint  of  porter  was  allow- 
ed her  at  dinner  and  fupper.  Her  pulfc  this 
«iay  (Tucfday)  was  95.  The  foot  warmer 
than  the  other.  The  wound  was  drefled  for 
■the  firft  time ;  it  appeared  well  clofed,  and 
«difcharged  but  little.  Wednefday,  pulfe 
■^bout  the  fame  number  1  had  flept  during  the 
flight,  but  not  fo  foundly  as  on  the  preceding 
«3ne.  The  wound  and  contiguous  parts  wertf 
"lender ;  there  was  a  confiderable  difcharge, 
'^hich  was  fetid ;  the  lower  ligature  came  off 
"^he  artery.  The  artery,  as  I  have  mentioned, 
"■vras  divided  veiy  near  to  the  lower  ligature ; 
and  it  is  probable,  that,  in  the  reftleifnefs  of 
~<he  patient  fublequent  to  the  operation,  the 
amotions  of  the  limb  had  drawn  the  ai'tery 
from  out  of  the  ligature  *. 

Thurfday, 

•  I  have  never  made  ufe  of  the  expedient  fuggefted  by 

Mr.  Henry  Cline,  for  fecuring  ligature!  upon  aneries 

VOL.  I.  T  Cnce 


2;r4  0^    ANEURISMS. 

Thurfday,  The  wound  veiy  tender,  and 
the  Ikin  had  inflamed  very  much  3  pulfe  84, 

Friday;  The  difcharge  from  the  wound  lels 
in  quantity,  and  more  puriform ;  pulfe  the 
fame  in  number,  but  very  feeble. 

Saturday,  The  patient  had  been  feized  in 
the  middle  of  the  night  with  fevere  headach 
and  fhivering,  and  in  the  mommg  fhe  could 
cat  no  breakfafL  Her  tongue  was  rather  dry, 
and    flightly    covered  with   a  brown  fur; 


fince  I  never  felt  its  neceflity  ;  and  becaufe  I  have  always 
thought  it  right  to  tie  a  large  artery  with  fo  thick  a  liga- 
ture, that  it  would  have  been  unfuitable  to  the  pradioe 
which  he  has  recommended.  One  advantage  arifing  froniL 
tying  a  large  artery  with  a  thick  ligature  is,  that  it  may  be 
drawn  as  tight  as  poflible,  without  apprenhenfion  of  cutting 
tlie  veffel,  or  of  its  fpeedily  coming  off  from  it.  Should  I^ 
in  any  future  indance,  think  it  right  to  oppofe  any  mechs^ 
riical  obftacle  to  the  ligature's  coming  off  the  veffel  which 
it  encitcles,  I  fliould  do  it  in  the  following  manner. 
Having  tied  a  large  knot  at  one  end  of  a  fmall  thread,  I 
would  pa&^it,  by  means  of  a  common  fewiog  needlef 
dirough  the  middle  of  the  artery^  in  front  of  the  ligature 
which  encircles  it  j  I  would  then  form  a  fecond  tliick  knot 
on  the  thread,  clofe  upon  the  furface  of  the  veffel.  Thefe 
two  knots  would,  I  think,  prefent  a  confiderable  obftacle 
to  the  flipping  of  the  circular  ligature  from  off  the  end  of 
the  artery. 

.     pulfe 


]pui{e  95,  and  feeble.     Half  a  pint  of  wine 

Was  allowed  her  in  fago,  in  addition  to  the 

. J>oi:i:er ;  and  fhe  took  the  infus.  mentb.  vitrioL 

of    the    hofpitalj    with    jTome    tin6lure   of 


Sunday,  She  was  much  better;  tongue. 
ttoill  and  clean,  and  her  appetite  much  im-- 
proved.  She  difliked  the  bittemefs  of  the 
medicine,  peppennint-water  was  therefore 
"ibfbituted  for  the  common  mint- water,  and 
"^e  tincture  of  gentian  was  omitted  j  pulfe 
Sa  ;  fkin  cool* 

Monday,  In  the  fame  Aate  as  yefterday ; 

Granulations  appeared  in  the  wound  below 

the  ligature,  which  clofed  it  in  the  middle. 

This  part  of  the  wound  is  now  about  an  inch 

m  breadth,  and  a  third  more  in  length.    The 

^ound  above  the  ligature  about  one  fourth 

*>t  an  inch  acrofs ;  and  the  new  flefti,  by 

^Hich  it  is  united,  of  a  tawny  colour,  and 

ft^bby  texture.     The  furface  of  the  ikin,  to 

^  Confiderable  extent  froin  the  wound,  red 

^nd  excoriated, 

T  2  Tuefday, 


1ij6  ON    ANEURISMS* 

Tuefday,  She  had  a  return  of  headaeh,  with 
lofs  of  appetite  -,  her  pulfe  96.  There  flowed 
from  the  woufijd  a  confiderable  difcharge,  of 
an  ofFenfive  fniell,  and  feemingly  irritating  to 
the  Ikin  over  which  it  pafled.  She  coift- 
plained  of  having  had  a  reftlefs  night ;  and 
obferved  that,  in  general,  (he  found  herfelf 
well  or  ill,  as  the  preceding  night  had  pafled 
comfortably  or  otherwife.  Thinking  it  pro- 
bable that  the  irritable  fliate  of  the  wound 
might  contribute,  in  a  great  meafure,  to  pre- 
vent her  from  deeping,  I  dreffed  it  with  aii 
aqueous  folution  of  opium,  and  fmearedthe 
excoriated  ikin  with  lard,  to  prevent  the  acri- 
monious difcharge  from  affeftihg  if.  All 
appearance  of  granulations  in  the  wound 
had  vanished.  I  ordered  her  fifteen  drops  of 
laudanum  in  lier  night  draught ;  and,  inftea:d 
of  the  infus.  mentb.  vitriol.  I  gave  her  docoSt. 
cinchon.'  l^y  with  5]  oi  tinSl.  card.  comp.  every 
four  hours. 

Wednefday,  She  had  a  Comfortable  night, 
with  much  deep ;  her  pulfe  80.  The  wound 
greatly  amencjed.  The  difcharge  puriform, 
lefs  fetid,  and  fmaller  in  quantity.     The  new 

flefh 


OK   ANEURISMS.  277 

flefh  above  the  ligature  florid  ;  and  granu- 
lations appeared  again  on  the  fides  of  the 
wound,  below  the  ligature.  The  fame  treat- 
ment was  continued. 

Thurfday,  She  had  not  refted  fo  well,  and 
complained  of  headach.  The  wound,  how- 
ever, was  rather  better  than  on  the  preceding 
day.  I  cut  out  the  ligature  which  clofed  the 
wound  in  the  middle,  thinking  it  might  tend 
to  keep  up  irritation.  She  attributed  the 
pain  in  her  head  to  the  opium  fhe  had  taken; 
to  afcertain  this  point,  I  ordered  the  dofe  to 
be  increafed  to  twenty-five  drops. 

Friday,  She  had  flept  well,  and  was  free 
from  headach  ;  her  pulfe  under  80.  This 
day,  the  ligature,  from  the  upper  part  of  the 
artery,  came  away  with  the  drefllngs.  The 
excoriated  ikin  had  healed  -,  the  rednefe  was 
inconfiderable.  The  wound,  in  every  part, 
had  a  healing  appearance.  It  feems  unne- 
cefiary  to  detail  particularly  the  fubfequent 
part  of  the  cafe.  She  was  kept  in  bed  to  the 
end  of  the  third  week,  when  flie  was  allowed 
to  fit  up,  that  her  bed  might  be  made.     I 

T  3  thought 


aj9  OH  ANEURISMSf 

thought  this  caution  requifite,  from  knowing 
that  ligatures  are  detached  from  arteries  b^ , 
fore  the  fides  of  the  veffel  are  united,  J  alio 
confined  her  to  bed  during  the  whole  of  the 
fourth  week;  but  advifed  her  to  move  the 
limb  about  frequently.  The  wound  healed 
liki?  a  healthy  wound ;  and  was  nearly  clofed 
in  a  month  after  the  operation,  During  the 
third  week,  when  the  wound  no  longer 
proved  a  fburce  of  irritation,  her  puUe  did 
not  exceed  y^  ftrokes  in  a  minute ;  it  was 
generally  lower,  and  once  I  found  it  to  be 
only  68.  At  the  expiration  of  the  montl^ 
fhe  got  up  daily,  and  walked  about  the 
ward  5  although,  on  her  admiflipn  into  the 
hofpital,  fhe  was  incapable  of  walking  at  all. 
There  was  not  the  leaft  oedema  of  the  limb* 
Its  circumference,  at  the  calf,  was  but  one 
third  of  an  inch  lefs  than  the  oppofite  fide. 
Having  walked  many  times  the  length  of  the 
ward,  fhe  became  tired,  and  thought  that  the 
limb  which  had  been  operated  on,  felt  more  fa-* 
tigued  than  the  other.  Theaneurifmaltumoux 
remains  at  this  time  of  a  confiderable  fize.  It 
is  certainly  more  than  one  third  lefs  than  at^ 
the  time  of  the  operation.     I  have  Velatect 

th^ 


ON   ANEURISMS.  279 

the  cafe  thus  particularly,  in  order  that  the 
reader  may  judge  of  it  for  himfelf.  To  me 
it  appears,  from  this  and  the  former  cafes, 
that,  in  an  advanced  ftate  of  femoral  aneu- 
rifin,  the  artery  may  be  tied  above  Poupart's 
ligament,  with  as  little  detriment  to  the 
circulation  of  the  limb,  as  in  other  cafes 
of  aneurifm,  where  the  operation  is  at- 
attended  with  very  conftant  fuccefs.  The 
fymptoms  immediately  fubfequent  to  the 
operation,  appear  to  me  to  have  arifen  entire-. 
ly  from  the  irritable  and  weak  ftate  of  the 
patient.  She  had  pain  in  the  head  fi'om  the 
operation  j  and  fo  (he  had  afterwards,  when- 
ever her  health  was  difordered  by  irritation. 
Her  pulfe,  prior  to  her  taking  the  medicine 
which  a£led  as  an  emetic,  was  96 ;  but  the 
fubfequent  day  it  was  150  or  160.  This 
appears  to  be  the  refult  of  the  ftate  of  the 
ftomach,  for  that  becoming  tranquil,  the 
pulfe  was  again  reduced  to  95  or  96,  In  a 
conftitution  fo  weak  and  irritable,  a  wound 
was  not  likely  to  heal  kindly ;  and  all  the 
fubfequent  circumftances  of  the  cafe  are  fatir* 
faftorily  explained,  as  the  efFefts  of  an  irri- 
table wound,  adting  upon  an  iiritable  confli- 

T  4  tution 


s8o'  ON  ANEHRISMSt 

.  ^  ,       ..... 

tution.  Upon  the  wound  becominjg  healjthy^ 
at  the  expiration  of  a  fortnight,  all  variations 
of  the  conftitution  ceafed.  I  cannot,  there- 
fore^ but  coniider  the  perplexing  circupi- 
fiances  that  fuccoeded  the  operation,  as  the 
cffeft  of  the  patient* s  peculiarity  of  conftity- 
tion,  and  not  as  arifing  fronj  the  operation 
itfelf,  or  from  the  ftatc  of  the  limb  confc- 
quent  to  fuch  an  operation.  A  fimilar  ope- 
ration has  lately  been  performed  by  IVJr.  Frere^ 
of  Birmingham,  with  fuccefs.  The  patiait 
being  healthy;  the  wound  healed  without 
difiiculty. 

Mr*  Tomlinfon,  of  Birmingham  aljfo,  per- 
formed a  fimilar  operation  with  equal  fuc- 
cefs, fo  that  it  feems  proved  that  the  external 
iliac  artery  may  be  tied,  in  the  cafe  of  a  femoral 
aneurifm,  with  as  little  detriment  to  the  limb, 
as  occurs  from  tying  the  femoral  artery  in  a 
cafe  of  popliteal  aneurifm.  I  lately  favyr  the 
woman  who  was  the  fubjeft  of  the  laft  cafe 
which  I  have  related,  and  there  is  no  diftin- 
gjiifhable  difference  in  the  fize  or  ftre^gth  of 
the  two  extremities. 

CASE 


ON  AN£URISM8#  tSt 


CASE  IV. 

}•  Peiterfon,  a  Swedifti  failor,  abouf  forty 
yeai"s  of  age,  was   admitted   into   St.  Bafr 
thplouiew's  hofpital,  on  accounjt  of  gin  aneigt* 
rifm  of  the  femoral  artery,  juft  below  the 
groin.     He  was  a  thin  man,  but  had  ftrong 
xnufcles.     He  had  a  languid  appearance ;  an4 
his  pulfe  was  fmall  and  feeble  3  his  appetite^ 
according  to  his  report,  moderate,  and  bowel$ 
regular;    his  tongue,  however,  was  mudi 
furred.     As  the  upper  and  moft  prominent 
part  of  the  aneurifmal  tumour  was  afcencjing 
above  Poupart's  ligament,  fo  as  to  make  ijt 
probable,  that  if  it  increafed  it  might  over- 
lap the  ligament,  and  render  the  operation 
difficult,  delay  was  inadmiflible,  and  the  opc^ 
ration  was  performed  on  Saturday,  25th  Fe- 
bruary, 1809.     It  was  accomplifhed  as  ia 
the  preceding  cafe.     I  put  my  finger  behind 
the  peritonaeum,  and  clearly  diftinguifhed  the 
cylindrical  fonn,  and  firmnefs  of  the  artery ; 
but  I  could  not  perceive  its  pulfation.     I 
prefled  on  the  veffel,  and  the  beating  of  the 
aneurifm  ceafed ;  I  remittted  the  prefliire,  and 
it  was  renewed.    Haying  thus  afgertained 

13  that 


a84  OV   ANEURISM8* 

and  not  fp  brown  or  incrafted.  His  pain^ 
alfo,  was  much  diminifhed,  though  the  epi- 
gaftric  region  was  ftill  tender.  His  faline 
^r^ughts  were  continued,  and  he  was  direfted 
to  tiake  ^ve  grains  of  the  pilul.  hydrarg,  each 
night.  The  next  day  he  was  ftill  better ;  his 
pulfe  90,  his  ikin  moift,  and  his  tongue 
cleaner  J  he  took  food  without  difguft:, 
though  not  with  much  appetite.  As  he  had 
no  evacuation  from  his  bowels,  a  little  open- 
ing ele£i:uary  was  given  him,  and  the  faline 
draughts  were  changed  for  the  infus.  menth. 
vitriol,  with  a  little  tinft.  cardam.  He  had 
a  ftool  in  the  night,  which  was  of  a  light 
pchre  colour ;  that  is,  a  ligjit  brown,  which 
dilution  would  not:  convert  into  a  yellow. 
He  continued  the  fame  medicines  till  the 
tenth  day  after  the  operation,  with  an  evi- 
dent amendment  in  his  health  ;  though  the 
alvine  djfchargcs  which  we  contrived  to  pro- 
cure daily,  were  ftill  of  the  colour  above 
defcribed,  though  fomewhat  deepcj. 

On  the  tenth  day,  after  obfervang  his 
tongue  and  pulfe,  &c.  thofe  who  law  him, 
joined  with  me  in  opinion,  that  he  was  in 

better 


ON   AN£URISMS#  zH^ 

feetter  health  than  when  he  was  admitted  into 
the  hofpitaL 

During  this  conftitutional  difturbanc^ 
the  upper  part  of  the  wound  became  open, 
and  the  difcharge  was  ofFenfive  and  irrita-^ 
ting,  and  excoriated  the  fkin  over  which  it 
flowed.  I  therefore  greazed  it  with  frcfh 
lard  at  each  drefling,  to  prevent  as  much  as 
poflible  the  difcharge  from  afling  upon  it* 
Some  fwelling  of  the  parts  on  that  fide  of  the 
wound  next  the  ilium  alfb  took  place.  Still 
there  was  nothing  very  materially  wrong,  and 
the  ftate  of  the  wound  gradually  amended  as 
the  patient's  health  became  tranquil. 

On  the  tenth  day,  the  ligatures  came  away, 
and  then  the  patient  firft  complained  of  a 
pain  on  the  infide  of  his  thigh,  juft  above  his 
knee. 

On  the  nth  day  he  repeated  his  com- 
plaints, and  faid  that  the  pain  difturbed  him, 
and  prevented  his  fleeping  during  the  night. 
I  knew  not  to  what  to  attribute  it;  I 
thought  it  might  indicate  fome  irritation  of 

the 


tti6  ON   AKBXjfBLlSRltf* 

the  anterior  crural  nerve;  however  as  thd 
patient  remained  pretty  well,  I  gave  no  di- 
rie6lions  refpedling  it* 

On  the  1 2th  day,  when  I  vifited  the  pa- 
tient, I  was  ftiocked  at  his  appearanccT*  His 
countenance  exprefled  great  anxiety  and  de- 
spondency 5  and  his  pulfe  was  more  than  1 20* 
His  tongue  was  covered  with  a  brown  fiir* 
He  had  miffed  his  regular  evacuation  from 
the  bowels.  Being  clear  that  the  calomel 
had  been  of  eflential  fervice  before,  I  gave 
him  two  grains  of  that  medicine,  and  ordered 
again  the  effervefcing  draughts. 

On  the  13th  day,  he  was  no  better;  but 
more  languid.  The  calomel  had  produced 
two  copious  loofe  ftools,  fcarcely  tinted  with 
an  ochre  colour.  I  requefted  Dr.  Roberts 
to  fee  him,^  who  directed  him  to  take  a 
grain  of  opium  at  night ;  ordered  him  (ago 
and  wine  for  food  ;  and  the  infufion  of  car- 
carilla  with  tini5l.  of  col  umbo. 

Fourteenth  day,  he  neither  feemed  better 
nor  worfe ;  he  had  llept  fom'  hours  in  the 

night 


•ON   ANEURISMS.  ttf 

night.  A  flight  blufli  of  the  Ikin  appeared 
on  the  infide  of  the  thigh,  fuch  as  indicates 
inflammation  of  the  abforbing  veflels.  Fo- 
mentations and  poultice  were  dire£led  to  this 
pait.  Dr.  R.  alfo  ordered  half  a  grain  of 
calomel,  with  five  of  cicuta,  to  be  taken  night 
and  morning. 

Fifteenth  day.  He  was  confiderably  better, 
though  his  leg  continued  painful ;  the'  pain 
however  was  diminifhed.  He  was  dirc6led 
to  continue  the  fame  medicines ;  and  to  infure 
a  good  night,  if  one  grain  of  opium  failed  to 
give  him  reft,  he  was  allowed  to  take  ano- 
ther after  four  hours. 

Sixteenth  day.  Not  quite  fo  well.  He  had 
had  no  evacuation  for  the  laft  twenty-four 
hours.  He  took  a  little  opening  eleftuary. 

Seventeenth  day,  He  had  a  ftool  during 
the  night,  and  was  better.  His  thigh  wats 
cedematous  but  not  painful.  The  pain  was 
defcending  towards  his  ancle.  Dr.  Roberts 
wifhed  him  to  take  the  blue  pill  in  preference 
to  the  calomel.  Five  grains  were  therefore 
given  each  night. 

High- 


Eighteenth  day,  He  was  better,  and  con- 
taiued  gradually  to  improve  till  the  twenty-* 
fourth  day,  when  he  declared  he  felt  quit* 
well,  and  had  had  fix  hours  comfortable  fle^. 
The  colour  of  the  ftools  had  been  gradually 
improving,  and  on  that  day,  whfcn  fuch  a 
marked  amendment  took  place,  the  ftool 
might  be  faid  to  be  nearly  properly  tin6hired 
with  bile,  and  of  a  proper  confiftence. 

During  this  time  an  abfcefs  had  formed  oii 
the  irifide  of  the  thigh,  a  little  above  the  knee, 
where  the  abforbents  of  the  limb  began  to  ki- 
fiame,  arid  the  matter  had  been  difcharged 
by  a  pun6ture  made  with  a  lancet.  Swelling 
in  the  ham  likewife  took  place,  and  was  ap- 
parently caufed  by  the  irritation  of  the  ab- 
forbents in  that  part,  but  no  matter  formed 
in  it,  and  the  leg  alfo  became  cedematous. 
The  wound  made  by  the  operation  had  heal- 
ed firmly  and  all  tumefadlion  about  it  had 
fiibfided.  As  the  patient's  bowels  afted  re- 
gularly, no  medicines  were  now  given  him. 

After  about  a  week  had  elapfed,  he  was 
feized  as  before  with  pain  in  the  epigaftric 

region. 


ON  AHBURI8BCS.  OSp 

region,  rheumatifm  in  the  right  (houlder, 
and  inability  to  move  the  right  arm.  His 
countenance  again  expreflcd  defpondency  and 
difturbance  ;  his  pulfe  was  frequent  and  his 
fkin  hot ;  the  abfcefs  alfo  was  painful  and  dis- 
charged copioufly,  and  became  diftended  with 
matter,  fo  that  it  Teemed  neceflary  to  enlarge 
the  aperture,  which  had  nearly  healed.  His 
tongue  was  much  furred,  and  his  ftools  had 
no  bile  in  them. 

He  again  took  calomel  at  firfl,  and  after- 
wards the  pilul :  hydrarg :  and  the  fecretion  of 
bile  was  gradually  renewed  and  increafed,  as 
in  the  preceding  inftances,  which  produced  a 
proportionate  amendment  in  his  general 
health.  His  limb  alfo  was  fo  much  improved 
as  to  enable  him  to  walk  about  the  ward, 
and  to  go  out  occafionally  into  the  air. 

Believing  that  living  in  a  better  air  would 
greatly  contribute  to  the  reftoration  of  his 
health,  he  was  foon  afterwards  difcharged 
from  the  hofpital  3  looking  as  well  as  he  did 
on  his  admiffion,  and  capable  of  walking  with 
but  little  infirmity.  He  was  advifed  to  take 
the  pilul :  hydrarg :  every  fecond  night,  till  the 

VOL,  I,  y  lecre- 


f9P  Olf  AHXtlMSAiS. 

fecretion  of  bile  was  right,  and  to  take  them 
afterwards  whenever  he  perceived  it  to  be 
deficient  or  faulty.  He  was  alfo  enjoined  to 
keep  his  bowels  regular  in  oth^r  refpe£ls. 

The  cafes  which  I  have  related  and  refor^^ 
red  to  fhew  that  the  current  of  blood  through 
the  external  iliac  artery  may  be  flopped, 
without  occafioning  any  material,  or  even 
evident  diminution  of  the  powers  of  the 
limb.  It  alfo  appears  to  me  that  this  oper- 
ation does  riot  difturb  the  conftitution,  in  a 
greater  degree,  than  a  fimilar  one  performed 
upon  arteries  of  lefs  magnitude.  It  is  true, 
that  confiderable  diforder  of  the  conftitution 
took  place  in  the  cafes  which  I  have  related, 
but  it  feemed  to  have  arifen  from  the  pecu- 
liarities of  the  ftate  of  health  of  the  patients, 
and  not  as  a  neceflary  ponfequence  of  the 
operation.  In  the  laft  cafe,  every  thing  went 
on  favourably  till  a  diforder  of  the  digeftive 
organs  occurred.  To  fuch  diforder,  it  can- 
not be  doubted  that  there  was  a  ftropg  pre- 
difpofition ;  and  of  which,  the  operation  by 
its  efFefts  on  the  mind  as  well  as  the  body, 
confinement  in  an  hofpital,  and  great  altera- 

tioi> 


lion  of  4iet  may  be  confidered  as  the  exciting 
cauies.  I  think  it  probabk  that  the  ftate  c^ 
the  conftitution  might  have  greatly  ccmtm 
butcd  to  produce  the  general  irritation  of  the 
abforbents  of  the  limb,  which  was  firft  ob* 
ierved  on  the  day  when  the  ligatures  came 
away,  I  cannot  doubt  but  that  the  inflam?^ 
nation  of  thefe  vefTels  did,  as  indeed  it  gene-« 
rally  does,  greatly difturb  the  conftitution  and 
aggi'avate  its  difordered  ftate.  Thefe  con^t 
jeftures  appear  to  me  to  be  verifid  by  the 
Jaft  occurrence  which  I  have  related.  When 
the  wound  was  healed,  and  the  limb  fo  well 
as  that  it  probably  could  impart  no  irrita- 
tion to  the  general  fyftem,  from  leaving  off  the 
mercurial  medicine,  diforder  of  the  digeftive 
organs  recurred  and  produced  the  efFefts 
which  I  have  defcribed. 

That  the  femoral  aneurifm,  when  it 
occurs  near  to  the  groin,  may,  like  other 
aneurifms,  fometimes  be  cured  by  th?  pro- 
cefles  of  nature,  is  proved  by  experience; 
yet  this  is  not  likely  to  be  the  common 
event  of  fuch  cafes.  I  knew  two  in- 
ftanccs  of  patients  dying  of    haemorrhage 

froi^ 


»gZ  OK  AKIU11I8M8# 

from  fuch  aneurifms.  The  fufferings  both 
of  body  and  mind,  in  thefe  cafes,  were 
ihocking.  The  patients  were  unable  to  move, 
and  the  diftenfion  of  the  integuments,  and 
prefTure  on  the  nerves  occafioned  great  paiii 
and  irritation.  The  patients  alfo  lay  apprehen- 
iive  and  uncertain  of  the  hour  when  ^eir  iiif- 
ferings  might  be  terminated  by  a  fearful  and 
fetal  haemorrhage.  I  think  myfelf  therefore 
fortunate  that  I  was  firft,  as  it  were,  com- 
pelled  to  perform  an  operation,  which  I  trufi^ 
may  be  found  to  diminiih  the  fufFerings,  and 
preferve  the  lives  of  thofe  afflifled  with  this 
difeafe. 


•^J?^ 


Stnhan  and  Prefton, 
Printers^Street,  Londoa. 


SURGICAL  OBSERVATIONS 


OM 


DISEASES  RESEMBLING  SYPHILIS  j 


AMD   ON 


DISEASES  OF  THE  URETHRA. 


BY  JOHN  ABERNETHY,  F.It.S. 

JfOKORARY    MSMBBR    OP   THB    ROYAL  MEDICAL  SOCIETT  Of 

EDINBUROHy   AND   OF    THE    MEDICAL    SOCIBTIBB 

OF    FARISy    FHILADBLFHIA,   &C. 

AISISTANT  SURGEON  TO  ST.  BARTHOLOMEW'S   MOSFtTAL, 

AND  TEACHER  OF  ANATOMT  AND  SURGERY. 


LONDON.' 


VDNTBD  TOR  LONGMAN,  HURST»  RBES,  AND  ORMBy 

FATERNOSTBR-ROW. 

l8lO« 


/ 


SURGICAL  OBSERVATIONS. 


afivwi 


On  the  Origin^  Symptoms^  and  Treatment  of  Difeafes 
produced  by  the  Abforption  of  morbific  Animal 
Matter  J  and  which  in  Appearance  frequently  refem^ 
ble  Syphilis. 

SECT.  I. 

INTRODUCTORY  REMARlCS. 

SINCE  the  publication  of  Mr.  Hunter's 
accurate  obfervations  on  the  Venereal 

Difeafe,  it  has  been  generally  admitted  that 
certain  modifications  of  animal  matter,  being 
applied  to  a  fufceptible  furface  of  the  body, 
will  in  many  inftances  excite  an  ulcerative 
difeafe,  in  which  the  difeafed  part  fecretes  mat- 
ter precifely  fimilar  to  that  which  had  excited 
it.  Thefe  kinds  of  infeftious  matter  Mr.  Hun- 
ter called  morbid  animal  poifons,  in  order  to 
diftinguifti  them  from  thofc  poifons  with  which 
fome  animals  are  furnifhed  for  purpofes  con- 
nefled  with  their  ceconomy.  Mr,  Hunter  fur- 
ther fhewcd  that  the  animal  matter  of  oneper- 
•  VOL.  II.  B  fon 


N 


1  ON   DISEASES 

•fon  might  induce  difeafe  in  another,  even 
though  the  pcrfon  from  whom  tlie  matter  was 
derivecl  had  no  difeaie*.  As  Mr.  Hunter's  opi- 
nions have  been  confirmed  by  the  fubfequent 
experience  of  other  pra6litioners,  and  appear 
to  have  obtained  pretty  general  affent ;  and  as 
fome  of  the  cafes  which  I  mean  to  bring  for- 
waid  feem  ftill  further  to  confirm  and  illuftratc 
thefe  opinions,  it  does  not  ajipear  neccflary 
for  me  at  prefent  to  enlarge  on  thefe  fiibjcfts. 

Infc6lious  matter  may  be  the  effeft  of  dif- 
eafe in  one  perfon  and  the  caufe  of  it  in  ano- 
ther, and  yet  it  would  appear  a  folecifm  were 
we  to  call  the  infeftious  matter  itfelf  diC- 
eafed  or  morbid.  Befides,  as  fome  kinds  of 
animal  tnajter,  which  are  not  the  produfts 
of  difeafe,  are  neverthelefs  capable  of  exciting 
it,  I  have,  in  the  firft  edition  of  this  book, 
called  all  kinds  of  infeflious  animal  matter, 
morbific  animal  poifons,  which  term  there 
appears  no  reafon  to  change. 

It  cannot,  I  think,  on  due  confideration  of 
the  fubje£t,  be  denied,  that  many  fores  are  in- 

♦  See  his  cafes  of  difeafes  indu(?ed  by  the  tranfpfanttl- 
tion'of  teeth,  and  the  fucUing  of  children^  in  his  work  on 
the  Y^e^eal  Difeafe,  -l.  . 

-  duced. 


RESEMBLIHO '  SYPHILIS,  3 

duced  on  the  genitals,  by  fexual  intercotirfe, 
which  are  not  the  effe<Ss  of  the  venereal  poifon, 
and  that  many  of  them  infcft  the  conftitu- 
tion,  and  produce  fecondary  fymptoms  refem- 
bling  t^ok  of  that  diforder.  It  may  be 
aflced,  however,  if  thefcttfcafes  be  not  vene- 
real, what  arc  they  ?  As  they  are  all  the 
confequence  of  fexual  intercourfe,  they  may, 
in  one  fenfe  of  the  word,  be  faid  to  be  vene- 
real. To  avoid  ambiguity,  therefore,  I 
{hall  in  thefc  pages  denominate  that  difeafe 
which  broke  out  at  the  fiege  of  Naples, 
and  which  Mr.  Ilu^jfer  has  defcribed  as  the 
venereal  difeafe,  byjjlie '  name  given  to  it  by 
nofological  writers,  that  is.  Syphilis ;  and  I 
ihall  call  ihofe  difeafes,  which  differ  from  it 
in  their  progrefs  and  mode  of  becoming  well, 
though  they  ftrikingly  refcmble  it  in  appear- 
ance, by  a  name  importing  thefe  circum- 
ftances,  tlut  is,  Pfeudo-Syphilitic  Difeafes. 

To  prepare  the  mind  of  the  reader  to  take 
an  impartial  furvey  of  thefe  fiibje£ls,  I  think 
it  will  be  ufeful  to  make  a  few  pr^limiHary 
■obfervatitMis  relative  to  the  probable  wigin 
of  plbvi^Qrfyphiliti^  Aifes^. 
•,  -r      -^  It  z  Celfus 


4  ON*    DISEASES 

Celfus  defcribes  eight  fpecics  of  fore* 
with  which  the  genitals  were  affefted  in 
confequence  of  fexual  i  intercourfe ;  and 
as  this  was  long  before  Syphilis  was 
known,  it  follows  that  there  muft  be  other 
caufes  producing  them.  Some  of  the  fores 
-defcribed  by  Celfus  are  not  unfrequently  met 
with  at  prefent,  and  they  are  not  fyphiUtic. 
Sores  aifo  frequently  form  upon  the  genitals 
of  females  in  confequence  of  that  irritation 
which  accompanies  difeafed  fecretions  from 
the  vagina.  Sores,  for  inftance,  very  fre- 
quently fucceed  to  gonorrhea  in  the  lower 
clafs  of  females,  who  pay;  little  attention  to 
cleanlinefs,  and  do  not  abftain  from  fexual 
intercourfe.  Sores  frequently  break  out  on 
the  prepuce  and  glans  of  the  male,  in  confe- 
quence of  the  irritation  which  gonorrhEea  or 
other  difeafes  of  the  urethra  produce  in  thefc 
parts.  Thefe  fores  generally  heal  without  the 
ufe  of  mercury,  frequently  without  inducing 
any  conftitutional  difeafe  :  and  when  they 
do  infect  the  conftitution,  the  difeafe  occa- 
fioned  by  them  is  not  fyphilitic.  I  merely 
mention  thefe  circumftances  at  prefent,  to  flievf 
that  it  is  poflible  foe  ulcers  to  form  which 

may 


1^ 


RESEMBLING   SYPHILIS. 


may  not  be  fyphilitic,  and  yet  the  difcharges 
from  t!iem  may  prove  morbific,  and  produce 
difeafe  in  others. 

Even  difcharges  from  the  genitals  of  one 
perfon,  where  no  ulcers  exift,  are  capable  of 
exciting  ulcers  in  another.  I  am  aware  that 
no  aigument  can  be  grounded  upon  the  ob- 
fervation  of  this  fa£t  in  common  cafes,  where 
the  parties  have  been  promifcuous  in  their 
'  intercourfe  with  others,  and  their  veracity 
cannot  be  relied  on.  But  I  have  known 
both  gonorrhiea  and  ulcers  occafioned  by 
connexion  with  perfons  who  had  no  fyphilitic 
difeafe,  where  the  veracity  of  the  parties 
might  be  relied  on,  and  where  no  promifcuoue 
intercourfe  could  be  fufpefted.  The  cafes 
of  fuppofed  gonorrhxa  arifmg  from  fexual 
intercourfe  with  perfons  who  apparently  have 
no  difeafe  are  fo  very  common  as  to  need  no 
exemplification.  I  think,  however,  it  will  be 
proper  to  adduce  fome  inftances,  in  which 
ulcei'S  have  taken  place  in  confequence  of  the 
application  of  irritating  matter  which  was 
not  of  a  fyphilitic  nature,  becaufe  cafes  which 
can  be  cited  in  proof  of  this  fa£l  muft  be  rare 
»  3  occur- 


4 


ON   IH^A6B5 


occurrences,  and  not  likely  to  be  met  with 
except  in  the  extenfive  pra6tice  of  a  large 
city. 

CASE  L 

A  gentleman  was  connefbed  witfa  a^femalc 
who  \vas  kept  by  another  gentleman,  and  dep- 
rived from,  fuch  connexion  feveral  very  irri- 
table and  foul  fores,  which  broke  out  on  the 
prepuce,  but  which,  however,  iiad  not  the  fy- 
philitic  charafters.  As  neither  the  woman 
nor  her  keeper  had  any  difeafe,  he  had  no  wifli 
to  tafcfe  mercury,  nor  had  I,  being  confulted  on 
his  cafe,  any  defune  to  recommend  it  to  him. 
The  foiies  did  hot  heai  until  bttween  two  and 
three  months,  though  a  variety  of  local  appli- 
cations were  employed.  He  at  length,  how- 
ever, became  perfeftly  well,  and  I  cautioned 
hira  not  to  be  again  conne6led  with  the  lame 
woman.  But  his  inclination  got  the  better  of 
his  prudence,  and  another  crop  of  fores, 
equally  irritable,  foul,  and  tedious,  took  place 
in  confcquence  of  a  fecond  connedtion .  Thefe 
^fores  were  treated  in  the  fame  mannei-  as  be- 
,  fore  and  flowly  healed.  After  fome  lapfe  of 
.'time,  he  aigain  erred  in  the  fame  'manner ; 
-and  again  received    »he  fame  punKhsnent. 

He 


RESEMBLIKQ   STPHILIS.  7 

He  had  no  conftitutional  difcafe  from  thefe 
ibres, 

CASE  II. 

A  gentleman  had  been  my  patient  with 
ftridlures  in  the  urethi^a,  which  were  iiearly, 
though  not  perfectly  well.  A  large  bougie 
could  be  pafTed  with  facility,  but  it.gaveibmc 
pain  on  pafling  thofe-  pacts  of  the  urethra 
where  the  ftriclures  had  been,  and'there  ftiM 
exifted  a  very  trivial  difcharge  from  that 
canal.  Under  thefe  circumftan<J€s  he  con- 
nefted  himfelf  with  a  female,  who,  there  was 
good  reafon  to  believe,  had  had  no  com- 
munication with  any  other  perfon/  She, 
however,  had  in  confequence  of^t^is  con- 
nexion, four  fores  which  formed  Aipon  the 
under  furface  of  the  labia  puderidi,  two  on 
each  fide.  Thefe  fores  were  veiy  irritable, 
and  became  larger  tl;ian  a  fixp^ice,  and  of  an 
oval  form.  They  threw  forth  exuberant  flefh 
of  a  livid  hue,  were  very  tender,  and  had  a 
great  deal  of  inflammation  furrounding  them. 
Various  dreflings  were  employed  without 
amending  them,  and  after  a  mdnth  had 
clapfe4  I  was  induced  to  recommend  from 

.  B  4  10  to 


ON    DISEABBS 


JO  to  15  grains  of  the  pU.  hydrarg.  to  be 
taken  daily.  After  another  fortnight,  as  no 
amendment  was  perceived,  and  the  mouth 
was  not  affefted  by  the  medicine,  the  patient 
rubbedin  2  drachms,  by  meafure,  of  mercurial 
ointment  every  fecond  night.  A  fecond  fort- 
night elapfed  without  any  amendment  in  the 
fores,  tliough  the  mouth  was  flightly  affefted. 
At  this  time,  the  uneafmefs  of  the  patient  and 
her  friend  induced  me  to  defire  they  would 
confult  another  furgcon,  who  thought  the 
fores  fyphiUtic,  and  wifhed  that  the  quantity 
of  mercuiy  ihould  be  increafed,  fo  as  more 
decidedly  to  affeft  the  mouth.  In  confe- 
quence  of  this  confultation,  the  patient  rub- 
bed in  the  fame  quantity  of  mercurial  oint- 
ment every  night,  and  difcontinued  the  inter- 
nal ufe  of  the  medicine.  At  the  conclufion  of 
another  fortnight,  the  mercuiy  fuddenly  af- 
fefled  the  gums,  and  produced  a  degree  of 
ptyalifm  which  prevented  its  further  ufe.  Still 
the  fores  were  not  amended,  and  on  the  abate- 
ment of  the  ptyalifm,  I  again  had  recourfe  to 
local  means  wjthout  refuming  the  ule  of  mer- 
cury, the  inefficacy  of  which  had  been  fully 
proved.     The  fores  now  healed  mpidly  under 

the 


RESBMBLIKO   SYPHILIS.  9 

the  local  ufc  of  a  fblution  of  cupr,  vitriolat. 
Wherever  mercury  has  been  ufed,  it  muft  be 
difficult  to  decide  whether  cafes  are  pr  are  not 
fyphilitic.  I  think  it  Very  clear,  however, 
that  the  cafe  juft  defcribed  was  not  of  that 
nature ;  and,  as  to  the  fores  healing  fuddenly, 
it  is  a  very  common  occurrence  when  no 
mercury  is  ufed.  For  fores  which  are  not 
affected  by  a  local  application  in  their  md* 
pient  ftate,  will  fometimes  heal  rapidly  if  the 
iame  application  be  made  to  them  in  an  ad- 
vanced ftate,  when  the  a6tivity  of  the  difeafe 
is  abated,  or  its  nature  changed  by  its  con- 
tinuance. 

Though  no  conftitutional  afFe£lion  fuc- 
cceded  to  the  fores  induced  in  the  foregoing 
cafes,  yet  that  the  fyftem  is  liable  to  be  con- 
taminated by  abforption  from  ulcers  of  this 
defcription  will  clearly  appear  from  the  cafes 
ri^l^t^  in  the  fubfequent  part  of  this  paper : 
and  at  prefent,  to  corroborate  this  feft  by  the 
teftimony  of  another,  I  fhall  relate  a  cafe 
which  was  communicated  to  me  by  an  emi- 
pent  and  accurate  furgeon  in  this  town« 

CASE 


lO  ,  oaf  ■  fHPBA%B9 


CASE  III. 

m 

A  gentleman  lately  maiTied  complained  to 
^lis  furgeon  of  a  running  from  the  urethra, 
which  {o  itrikingly  refemblcd  a  venereal  go- 
norrhaea  that  the  latter  could  not  but  afcribe 
it  to  infe6lion.  He  had  afterwards  a  fwelling 
of  tlie pepuce,  and  fores  on  that  part,  which 
confirmed  the  furgeon  in  his  opinion,  and  pro- 
duced a  kind  of  diffontion  between  his'^- 
tient  and  him,  the  one  affirming  that  the 
difeafe  was  venereal,  the  other  that  it  could 
not  poflibly  be  fo,  as  his  wife  had  no  difeafe, 
and  he  had  had  connexion  with  no  other  wo- 
man. The  effect  of  this  litigation  was,  that 
the  furgeon  would  not  urge  the  taking  of  mer- 
cuiy,  nor  would  the  patient  require  the  ad- 
miniftration  of  that  medicine,  though  a  bubo, 
forethroat,  and  eruptions  fucceeded,  which 
.could  not  be  diftinguifhed  from  (imilar  com- 
plaints of  a  fyphilitic  nature,  but  all  of  which 
fpontaneoufly  got  well. 

The  narrative  of  the  following  cafe  was 
lately  fent  to  me  by  Mr.  Watfon  of  S  tour- 
port.     It  is  an  inftance  of  the  nurfe  being  in- 

4  fefted 


RESEMBLING    SYPHILIS.  tl 

fefted  from  the  child,  and  fimilar  inftances 
in  this  refpeft  are  not  unfrequently  met  with. 
Yet  it  contains  fome  interefting  circumftances 
which  are  explanatory  of  my  prefect  fubjeft, 
and  I  therefore  take  the  liberty  of  in&rting 
it  in  this  place. 

I         - 

CASE  IV. 

Mrs.  F.,  aftct  fucklinga  nuiie  child  about 
four  mopths,  perceived  a  finall  ulcer  on  the 
breaft  near  the  nipple,  which  (he  believed  flie 
caught  from  the  child,  as  it  had  a  bad  nofe  and 
fore  lips.  At  this  time  the  ulcer  was  about 
the  fize  of  an  almond,  and  of  the  fliape  of  one. 
As  it  did  not  heal  from  fimplc  dreffings,  the 
furface  of  the  fore  was  rubbed  with  argent, 
nitrat.  and  a  wafh  of  calomel  in  lime  water 
was  aftei^wards  applied .  Under  this  treatment 
the  ulcer  healed,  and  a  gland  in  the  axilla, 
which  had  enlarged,  fubfided.  This  happened 
about  three  weeks  after  the  patieht'  had  firft 
confulted  me.  Two  months  afterwards*,  the 
patient  had  a  fevere  febrile  attack,  accom- 
panied with  fore  throat,  of  wliich  fhe  foon 
recovered.  To  this,  fufccecded  a  copper- 
colotii*ed  eruption  which  came  out  on  all 

parts 


IS  ON    DISEASES 

parts  of  the  body.  No  medicine  was  given 
at  firlt,  but  as  the  patient  became  uneafy,  fo  mc 
compound  calomel  pills,  with  fmall  dofea  of 
nitric  acid  were  direfted.  She  took  about 
12  pills  and  fmall  dofes  of  the  nitric  acid  for 
the  fame  length  of  timCj  when  they  were  dif- 
continued.  In  about  two  months  all  the 
eruptions  had  difappeared,  except  fome  white 
blifters,  which  had  lately  formed  about  the 
labia  pudendi,  and  which  gave  her  pain,  when 
ihe  walked.  This  complaint  was  removed 
in  a  few  days  by  a  folution  of  fulphat  of  zinc. 
About  a  week  aftei-wards,  her  hufband  lh'."w- 
ed  me  a  fore  on  the  penis,  covered  by  a  black 
fcab.  It  was  about  the  fize  of  a  fixpcnce, 
the  furrounding  ikin  was  much  inflamed, 
but  the  bafe  of  the  fore  was  neither  hard  nor 
thickened.  In  a  few  days,  a  fecond  fore  ap- 
peared in  the  courfe  of  the  abforbents  between 
the  firft  and  the  groin.  The  inguinal  glands 
now  became  enlarged,  and  one  of  them  fup- 
purated.  In  about  three  weeks  from  the  fiiil 
appearance  of  the  fore  on  the  penis,  the  patient 
was  attacked  with  feverirti  fymptoms,  which 
were  followed  by  an  eruption,  different  from 
that  which  his  wi&  had  been  affe£led  with, 

but 


put  I 


RESEMBLIKC  SYPHILIS*  I3 

but  very  fimilar  to  the  erythema  papulatum 
fyphiliticum,  reprefented  by  Do6tor  Willan. 
The  fores  on  the  penis  fpread  rapidly  for  fbme 
days,  but  did  not  penetrate  deeper  than  the 
Ikin,  and  after  being  twice  touched  with  ar- 
gent, nitrat.  they  foon  healed  with  the  ufe  of 
calomel  in  lime  water.  The  abfcefs  in  the 
groin  was  opened  by  a  lancet,  and  the  wound 
ulcerated  confiderably,  but  afterwards  healed 
by  the  fame  means,  that  had  been  ferviceablr 
to  the  other  fores. 

This  patient  never  took  any  mercury,  ex- 
cept once,  when  fome  calomel  was  given  witjh 
ether  aperients,  as  a  purge. 

It  may  be  rationally  fuppofed  iSat  the  dif- 
charges  from  fuch  fores  as  I  ha^  defcribed, 
as  well  as  the  difcharges  from  fccreting  fur-- 
feces  not  in  a  ftate  of  ulceration*  may  prove 
morbific  and  excite  local  diieafes,  or  if  ab« 
Ibrbed  may  contaminate  the  conftitution. 
Cafes  which  render  thefe  opinions  probable, 
are  fo  frequent,  that  every  furgeon  mull,  I 
think,  have  remarked  them.  In  confequence, 
however,   of  his  preconceived   opinions,  he 

might; 


1(4  OH   DiSEASHS 

might  diftruft  the  veracity  of  his  f>atient«^ 
and  treat  the  difeafe  as  if  it  were  fyphilitic, 
and  thc'confequences  of  fuch  conduft  will  be 
difplayed  in  the  fubfequent  part  of  this 
paper. 

I 

After  thefe  preliminaiy  obfervations,  which 
are  defigned  to  fhew  how  fores  on  the  geni- 
tals may  arife  from  fexual  intercourfe  at  pre- 
fent,  as  they  did  even  in  the  time  of  Celfus ;  I 
may  further  remark  that  from  the  time  of  the 
breaking  out  of  the  lues  venerea,  it  is  probable 
luch  fores  continued  to  occur,  and  were  con- 
founded with  the  fores  induced  by  that  difeafe : 
thus  we  may  account  for  the  opinions  de- 
livered by  old  authors,  of  even  fyphilis  getting  ' 
v/ell  fpontaneoufly,  or  by  the  adminiftration 
of  medicines  of  acknowledged  inefficacy^ 
Every  furgeon  muft  have  feen  cafes  of  fyphilis 
getting  progreffiyely  worfe,  till  corrected  by 
mercury,  and  regularly  yielding  to  tlie  effeft 
of  that  medicine,  and  being  permanently 
cured  by  one  adequate  mercurial  courfe;  fo 
that  his  obiervations  v/iil  induce  him  to  ad- 
mit the  accuracy  and  juftnefs  of  the  defcrip- 
tion  of  that  difeafe  which  J\Ir.  Huijter  has 

given,  ^ 


given,  in  a  great  number  of  inftances.    Fur- 
ther,  when   from    the    infenfitwlity  of   the 
conftitution  to  the  operation  of  mercury  it 
has  been  difficult  to  excite  its  fpecific  efFeft, 
liow  numerous  are  the  eafes  of  chancres, 
ulcers  in  the  throat,  and  nodes,   that  have 
remai^d  ftatio-na^  and  unvarying  under  a 
long  ufe  of  mercury,  and  yet  have  yielded 
and  become  perfectly  well,  when  by  more 
energetic  meafures   the  conftitution  has   at 
length  been  affefled  by  this  medicine.     To 
identify  what  I  confider  as  true  fyphilis,  and 
to  excite  the  reader's  attention  to  that  difeafe, 
fo  that  he  may  contraft  it  with  thofe  which 
make  the  fubjeft  of  the  prefent  publication, 
I  Ihall  here  infert  a  cafe  which  was  related  in 
the  fir  ft  edition  of  my  furglcal  and  phyfiolo- 
gical  eflays,  to  fhew  the  efficacy  of  mercurial 
fumigations   in    afFefting    the  conftitution, : 
^hen  other  modes  of.adminiftering  mercury 
had  failed  to  produce  its  fpecific  effb6t*, 

CASE 

•  It  is  not  my  intention  to  republifli  the  cafes  in  proof . 
^f  this  faft,  becaufe  I  think  that   the  prefent  one  Is  fuf- 
tcient  to  evince  its  truth.     It  feems,  however,  right  to 
iKlention,  that  my  opinions  on  thi?  fubjeft  are  unalt^red^ 

and 


Ar'       *'    ^  1 


itf  OK  f^UZABU 


CASE    V- 

A  young  man  had  a  chancre  by  the  fide  of 
the  frsmumpreputii)  which  had  all  the  charac* 
tcrs  of  true  fyphilis.  It  was  of  a  circular  form, 
with  a  thickened  edge  and  bafe  j  there  were  no 
granulations,  and  matter  adhered  to  the  fur- 
fece.  For  this,  he  took  mercurial  pills  in  large 
quantities,  which  never  affected  his  mouth, 
though  occafionally  they  produced  griping 
pains,  and  made  him  feel  very  unwell.  He 
was  obliged  at  this  time  to  travel  pretty  con- 
ftantly,  fo  that  he  could  not  conveniently  rub 
in  mercurial  ointment.  When  the  mercury 
was  taken  in  fuch  quantities  as  to"  make  him 
feel  ill,  and  to  diforder  his  bowels,  the  fore 

and  to  repeat,  that  I  have  found  mercurial  fumigations 
employed  in  the  manner  recommended  by  the  Chevalier 
Lalonette,  a  phyfician  in  Paris  in  1776,  to  be,  in  the  ma- 
jority of  inflances,  a  more  powerful  and  innocent  means 
of  producing  a  mercurial  affe£tion  of  the  conftitution  than 
in  un£tion  or  the  internal  ufe  of  mercury,  and  equally  cer- 
tain of  radically  curing  the  difeafe  for  which  It  has  been 
thus  adminiftered.  The  fumigating  powder  which  I  have 
ufed  inftead  of  Lalonette's  is  calomel  wafbed  in  wateri 
containing  a  fmall  quantity  of  ammonia. 

5  looked 


RESSMBLIKa  SYPHILIS.  tf 

looked  red  on  the  furface,  and  feemed  dif- 
pofed  to  heal,  but  when  he  diminiihed  the 
quantity  of  the  medicine  the  fore  aiTumed 
its  former  difeafed  characters.  After  the 
chancre  had  continued  for  two  months,  a 
finall  bubo  formed,  iuppurated  and  burft. 
By  perfevering  in  the  internal  ufe  of  mer- 
cury to  the  greateft  extent  that  he  could  do, 
the  chancre  healed  and  the  bubo  got  well 
about  the  fame  time.  This  happened  four 
months  after  the  occurrence  of  the  chancre, 
and  fix  weeks  after  the  breaking  of  the  bubo. 
As  at  laft  having  got  the  chancre  to  heal  by 
puihing  the  ufe  of  mercury  to  an  extent  that 
made  him  feel  very  uncomfortable,  and  much 
indifpofed,  he  left  off  the  medicine  fooner 
than  he  ought  to  have  done.  In  two  months 
more,  his  former  occupations  ceafing,  he  re- 
turned to  London,  where  he  afterwards  re- 
mained. Shortly  after  his  return,  which 
was  in  September  1788,  one  of  his  tonfils 
ieemed  a  little  enlarged,  indurated,  and  ten^ 
der,  fo  as  to  occafion  a  difficulty  in  degluti- 
tion. In  the  courfe  of  a  week  it  ulcerated, 
and  the  ulcer  acquired  by  degrees  all  the 
charaders  of  fyphilis.  It  was  of  an  oval 
\OL.  II.  c  form 


4S  ON   DISEASES 

form,  excavated,  without  granulations,  and 
with  matter  adhering  to  its  furface.  The 
lame  circamftances  took  place  in  the  bppo- 
fite  tonfil  and  an  exadlly  fimilar  fore  formed 
in  it.  As  the  hiflory  as  well  as  the  appearances 
*  of  the  primary  chancre  left  no  doubt  of  its 
nature,  and  as  the  fecondary  fymptoms  were 
equally  unequivocal,  he  immediately  began 
a  mercurial  courfe:  being  healthy,  and 
his  bowels  not  eafily  difturbed,  he  took, 
on  an  average^  from  two  to  three  grains  of 
calcined  quickfilver,  or  calomel  joined  with 
opium,  every  day  for  three  months;  and 
^fa  ufed  mercurial  ointment  during  the  fame 
period,  beginning  with  two  drachms,  and  gra- 
dually increafmg  it  to  an  ounce  daily :  befides 
which,  he  had  for  a  fhort  time  taken  a  folu- 
tion  of  hydrargyrus  muriatus.  Yet  all  this 
Scarcely  produced  any  forenefs  of  his  gums, 
or  caufed  any  vifible  amendment  in  the  ulcers 
of  his  throat;  the  only  effeft  it  had  being  that 
of  preventing  them  from  becoming  worfe. 
His  bowels  indeed  were  occafionally  difturbed 
by  the  medicines,  but  were  cafily  quieted  by 
opium.  To  rub  in  the  quantity  of  mercurial 
ointment  ufed  towards  the  latter  part  of  the 

courfe^ 


kCSEMBLINO    SYPHILIS.  I^i 

Courfe,  the  patient  fpeat  nearly  an  hour  and 
half  every  night  and  morning ;  but  as  he  be-* 
came  weaker,  he  perfpired  confiderably  in 
confequence  of  this  exercife,  which  tended  to 
fruftrate  his  endeavours,  by  preventing,  or  at 
leaft  greatly  diminifhing,  the  abforption  of 
the  medicine. 

No  ground  being  gained  by  purfuing  this 
plan,  Sir  Charles  Blicke  recommended  mer- 
curial fumigation  according  to  Lalonette's 
method,  which  he  had  occafionally  employed 
with  fuccefs,  and  which  would  not  only  re- 
lieve the  patient  from  the  fatigue  of  rubbing 
in  tlie  ointment^  but  prevent  any  farther  ir- 
ril;ation  of  his  bowels,  by  fuperfeding  tlie  in- 
temal  ufe  of  mercury.  The  patient  was  ac- 
cordingly expofed,  for  half  an  hour  each 
night,  to  the  fumes  produced  from  half  an 
ounce  of  the  powder  j  by  which  means, 
in  lefs  than  a  fortnight,  his  conilitution  and 
mouth  became  properly  afFedted  by  the  mer- 
cury ;  the  ulcers  healed  foon  afterwards ;  and 
in  about  a  month  he  was  permitted  to  dit 
continue  the  remedy. 

c  z  In 


to  ON    DISEASES 

In  this  cafe  the  difeafe  in  all  its  ciiruff 
ftances  piecifely  agreedwit  h  the  defcription  c 
fyphilis  given  by  Mr.  Hunter.  It  was  ui> 
cliangeable  in  its  charaftersj  it  regularly  1 
and  progrefllvely  got  worfe  when  no  mercunf 'I 
was  employed,  it  was  ftationary  when  oppoftxJ  J 
by  that  medicine,  and  it  was  permanently  j 
cured  by  an  adequate  mercurial  affeftion  <rf  j 
the  conftitution. 


Having  been  educated  in  the  old  fchool, 
under  profefliors  who  prided  themfclves  in 
poflefling  the  Taflus  and  Vifus  eruditns,  I 
was  anxious  to  obtain  that  happy  difcrimi- 
nation  of  colour  that  fiiould  enable  me  to 
pi-onoimce  from  the  copperiih  tint  of  an 
ciiaption  that  it  was  undoubtedly  venereal. 
But  my  endeavours  were  ineffectual ;  and 
much  was  I  gratified  by  the  publication  of 
Mr.  Hunter's  book,  which  fumiflied  me  witli 
a  clue  to  guide  me  through  the  labyrinth  in 
which  I  had  been  bewildered.  AH  my  ob- 
ferations,  while  a  ftudent,  correfponded  with 
Mr.  H.'s,  and  when  I  experienced  as  well  as 
witnefled  the  perplexities  of  practice  in  Acfe 
difeaies»  I  faw  nothing  contiai'y  to  his  de- 


i 


s 


fail 


RESEMBLING   SYPHILIS.  a  I 

(cription .  I  faw  cafes  of  tnie  fyphilitic  dif- 
cafc,  which  had  been  regular  in  their  progrefs 
and  increafc,  when  no  mercury  was  ufed,  re- 
gularly and  permanently  cured  by  that  medi- 
cine. I  alfo  faw  difeafes  refembling  the 
venereal,  which  were  neither  regular  in  their 
progrefs  nor  cure.  Each  year  additional 
fails  prefented  themfelves  to  eftablifli  thefe 
opinions,  and  none  appeared  to  contradict 
them.  The  following  cafe  in  particular,  of 
a  medical  ftudent  of  the  hofpital,  made  b, 
itrong  impreffion  upon  my  mind. 

CASE   VI. 

This  gentleman  thought  that  he  had  in- 
fefted  a  (light  cut  on  his  hand  (which  wa§ 
fituated  in  front  and  juft  below  the  little 
finger)  with  the  difcharge  from  a  bubo  in 
thp  groin  that  he  had  opened.  The  wound 
fretted  out  into  a  fore  about  the  fize 
q£  a  fixpence,  which  he  (hewed  me,  and 
which  I  aflHrmed  had  not  the  thickened  edge 
and  bafe,  and  other  charafters  of  a  venereal 
chancre,  I  therefore  recommended  him  to 
try  the  e(Fe6t  of  local  means,  and  not  to  u(e 
jnercuiy, 

c  3  In 


•ft  OK    DISEiNSES 


In  about  a  month  the  fore,  which  had 
jpread  a  little,  became  again  contradled  in  its 
dimenfions,  and  aflumed  a  healing  appear- 
ance«  At  this  time  pain  was  felt  extending 
up  the  aim,  and  fuddcnly  a  confiderablc 
tumour  arofe  over  the  abforbing  veffels, 
which  proceed  along  tlie  inner  edge  of  the 
biceps  mufcle.  This  tumour  became  nearly 
as  big  as  a  finall  orange.  As  the  original  fore 
feemed  now  difpofed  to  heal,  and  as  there  - 

was  no  furrounding  induration,  I  could  not  :3 
believe  it  fyphil;tic,  and  therefore  recom-  — 
mended  him  ft  ill  to  abftain  from  mercuiy^  ^-^ 
and  apply  leeches,  and  linen  moiftened  in  the  ri^e 
aq :  lithaig  :  acct :  comp  :,  to  the  tumour  "ix  4' 
foiinedover  the  inflamed  abforbents. 

Under  this  treatment  the  tumour  was  dif — ^if- 
cufTed,  and  tlie  fore  at  the  fame  time  healed.  P:^. 
About  three  weeks  afterwards  the  patientr  i^^t 
called  on  me,  and  faid  that  there  were  ven^ 
real  ulcers  in  liis  throat ;  and  in  each  tonff 
there  was  an  ulcer  deeply  excavated,  with  ir- 
regular edges,  and  with  a  furfacc  covered  b^ 
adhering  matter;  ulcers,  in  fliort,  wh 
cvsiy  ilirgeon,  who  dcj)€nds  on  his  fight  a. 

hi 


RESEMBLING  SYPHILIS.  23 

his  guide,  would  have  pronounced  to  be  fy- 
philitic.  Shortly  after  alfo,  fome  copper-co- 
loured eruptions  appeared  on  his  face  and 
breaft.  He  fhewed  his  difeafes  to  feveral 
Jfurgeons,  on  whofe  opinion  he  relied,  who, 
without  hefitation,  affirmed  that  they  were 
fyphilitic,  and  that  the  mercurial  courfe  had 
been  improperly  delayed* 

Whilft  the  patient  was  looking  out  for 
lodgings,  in  order  that  he  might  go  through 
the  mercurial  procefs,  a  circumfcribed  thick- 
ening and  elevation  of  the  pericranium  cover- 
ing the  frontal  bone  appeared ;  it  was  of  the 
circumference  of  a  half-crown  piece;  and 
was,  in  (hort,  what  every  furgeon,  who  is 
guided  only  by  his  fight  and  touch,  would, 
without  hefitation,  have  called  a  true  corona 
veneris.  I  now  told  the  patient  that  I  was  ftill 
more  inclined  to  believe  his  difcafe  was  not 
fyphilitic,  from  the  fudden  and  fimaltaneous 
occurrence  of  this  node  \yrith  the  fore  throat, 
&;c.  Other  furgeons  thought  differently ;  and 
I  believe  this  very  fenfible  and  amiable  young 
man  imagined  that  his  health  would  become 
a  facrific^  if  he  any  longer  attended  to  my 

c  4*  ppinioa* 


04  <>^   DISEASES 

opinion.  He  was  preparing  to  fubmit  to  a 
mercurial  courfe,  when  very  important  con- 
cerns called  him  inftantly  into  the  country. 
He  went  with  great  reluftance,  taking  with 
him  mercurial  ointment,  &c. :  and  after  a  fort- 
night I  received  a  letter  from  him,  faying  that 
he  found  his  complaints  benefited  by  his 
journey,  that  bufinefs  had  prevented  him 
from  beginning  the  ufe  of  mercury  for  a  few 
days,  that  he  now  found  it  waB  unneceffary, 
for  his  fymptoms  had  almoft  difappeared,  and 
Ihgrtly  afterwards  he  became  well. 

At  the  time,  and  ever  fince,  I  confidered 
this  cafe  as  meriting  publication,  as  being  a 
moft  unequivocal  inftance  of  a  difeafe  occur- 
ring, which  could  not  from  appearance 
be  diftinguiflied  by  furgeons  of  the  greateft 
experience  from  fyphilis,  and  which,  how- 
ever, was  undoubtedly  of  a  different  nature ; 
and  I  believe  that  there  is  no  one,  who  would 
not  have  decided  on  this  cafe,  as  thofe  did 
who  declared  it  to  be  fyphilitic,  unlefs  they 
had  had  an  opportunity  of  watching  its  pro- 
grefs  very  attentively.  This  cafe  probably 
made  me  more   fcrupulous    than  I  fhould 

other-i 


HESBMBLIKO   SYPHILIS.  ^5 

othei^wife  have  been  in  admitting  difeafes  to  be 
fyphilitic,  till  their  unabating  progrcfs  efta- 
blifbed  their  nature  beyond  the  pollibility  of 
doubt ;  and  from  this  hefitation  in  deciding 
I  have  been  enabled  to  prove,  that  a  great 
number  of  cafes,  in  which  mercury  would 
have  been  employed,  have  got  well  without 
the  ufe  of  that  medicine. 

In  the  courfe  of  praftice,  I  frequently  met 
with  cafes  of  a  nature  fimilar  to  the  fore- 
going.   In  thcfe,  I  had  opportunities  of  trac- 
ing conftitutional  fymptoms  from  the  pri- 
mary fores  which  had  caufed  them,  a  circum- 
ilance  which  cannot  frequently  be  done  in 
hofjpital  praftice.     I  faw  that  the  primary 
fores  had  not  the  charafler  of  fyphilis,  not- 
withftanding  the  fecondary  fymptoms  often 
ftrongly  refembled  thofe  of  that  difeafe.     As, 
however,  I  did  not  meet  with  other  furgeons 
who  thought  as  Mr.  Hunter  did  on  this  fub- 
jeft,  and  as  my  obfervations  lb  ftriftly  coin- 
cided with  his,  I  thought  it  right  in  the  firft 
volume  of  my  Surgical  Obfei-vations,  pub- 
Uftied  1804,  to  excite  the  public  attention  to 
^efe  cafes  by  laying  before  it  the  following 

Effay, 


a6  ON   DISEASES 

Eflay,  but  previoufly  I  enquired  of  the  beft 
furgeons  in  London,  whether  conftitutional 
fymptoms  of  fyphilis  do  ever  fpontaneoufly 
^mend  ?     To  this  enquiry  no  one  decidedly 
replied  in  the  affirmative,  whilft  all  without 
hefitation  agreed  that  they  were  generally,  if 
not  conftantly,  progreffive,  unlefs  checked  by 
the , operation  of  mercury.     In  confequencc 
of  this  opinion,  fo  concurrent  with  Mr.  Hun- 
ter*s  defcription  of  the  difeafe,  I  was  induced 
to  puhliih  the  following  cafes  and  remarks* 


RESEMBLING   SYPHILIS.  $/ 

I 


SECTION  n. 

On  Pfeudo'fyphilitic  Difeafes  becoming  well  fpontOm 

neoujly. 

Ty/TR.  Hunter,  in  his  excellent  Treatife  on 

the  Venereal  Difeafe,  has  related  feveral 

cafes   fuppofed  to   be  fyphilitic,   and  fome 

of  which  vyere  certainly    not   fo,  as  they 

got  well  without  mercury ;  but  in  the  greater. 

number  the  employment  of  thi?   medicine 

rendered  their  nature  doubtful.    Mr.  Hunter 

alfo,  who  was  as  cautious  in  drawing  conclu- 

fions  as  he  was  accurate  in  making  obfeiva- 

tions,  expreflbs  himfelf  in  many  inftances  {o 

diffidently  on  the  fubje6l,  as,  in  my  opinion, 

not  fufficiently  to  imprefs  the  minds  of  his 

readers  with  the  certainty,  importance,  and 

frequency  of  fuch  fa6ls.     He  concludes  his 

obfcrvations  by  intimating  "  that  undefcribed 

difeafes,   refembling  the   venereal,   are  very 

numerous,  and  that  what  he  has  faid  is  rather 

to  be  conficjered  as  hints  for  others  to  profe- 

cute  this  inquiry  further,  than  as  a  complete 

account  of  the  fubjefl."     As  it  has  occurred 

to  me  very  frequently  to  meet  with  fuch 

cafes, 


lS  ON    DISZAEES 

cafes,  and  as  the  neceffity  for  difciiminating 
them  from  fyphilitic  difeafes  appears  to  me  of 
the  higheft  importance,  I  fhall  profecute  the 
fubje6l  by  relating  fome  unequivocal  cafes  of 
difeafes  ftrikingly  refembling  fyphiUs,  but 
which,  however,  were  difordcrs  of  a  different 
natm"c,  provided  it  be  admitted  that  fyphilis 
does  not  fpontaneoudy  get  well  without  the 
aid  of  Inedicine. 


The  necefHty  for  difcrimination  between 
thefe  difeafes  will  appear  upon  a  flight  con- 
fideration  of  the  fubjeft.  If  a  furgean,  who 
does  not  fee  that  extent  of  practice  which 
occurs  in  a  metropolis,  admiiiifters  mercury  in 
one  of  the  difeafes  refembling  fyphilis,  he  finds 
perhaps  that  the  fymptoms  yield  flowly ; 
and  even  after  a  confiderable  and  debilitating 
courfc  of  that  medicine  they  may  recur. 
They  are  then  counterafted  by  a  ftill  more 
fevere  ufe  of  mercury,  till  they  perhaps  fpon- 
taneoufly  ceafe,  which  may  not  happen  till  the 
patient's  conflitution  is  fo  enfeebled,  that  if  it 
do  not  fall  into  other  ftates  of  difeafe  it  very 
flowly  regains  the  ftandard  of  health.  Such 
eafcs  would  induce  the  furgeon  to  confider 

thQ 


RESEMBLING   SYPHILIS. 


«9 


the  venereal  difeafe  as  peculiarly  difficult  of 
cure,  and  liable  to  recur  on  the  remiflion  of 
even  a  fevere  courfe  of  mercury.  The  con- 
fequence  of  this  opinion  is,  that  he  employs 
mercury  to  an  unneceiTary  and  injurious  de- 
gree in  his  general  practice. 


I  do  not  mean,  however,  by  thele  remarks 
to  imply,  that,  in  my  opmion,  fyphilitic  dif- 
eafes  are  equally  fufceptible  of  cure  in  every 
inftance  by  mercury ;  nor  am  I  an  advocate 
for  what  has  been  termed  an  alterative  courfe 
of  this  medicine.  Cafes  which  frequently 
occur  have  con\'inced  me  that  it  requires  a 
very  confiderable  mercurial  effeO:  to  cure 
fypliilis  in  forae  inftances ;  and  that  this 
cfFe6t  mult  be  continued  for  a  confiderable 
time  in  order  to  infure  a  cure.  Mr.  Hun- 
ter probably  wifhed  the  fubjeft  of  difeafcs 
refembling  fyphilis  to  be  profecuted,  in  hopes 
that  fome  diftindive  characters  might  be 
difcovered  as  pecuUar  to  them  j  but  rfic 
following  cafes  ihew  that  thefe  difeafes  cnfuc 
from  primaiy  infei5ted  fores  of  very  diffimilar 
appearances,  and  foinetiraes  arife  without  any 
primary  fore  having  been  oblerved. 

' Whilft 


30  OH   DISEASES 

Whilft,  then,  the  primary  fymptoms  zrd 
thus  variable,  and  fueh  as  may  perhaps  in  the 
greater  number  of  cafes  be  diftinguifhed  from 
thofe  of  fyphilis,  the  fecondary  or  conftitu- 
tional  fymptoms  often  fo  ftrikingly  re- 
femble  thofe  of  that  difeafe,  as  not  to  be 
difcriminated  from  them  by  fight,  though  m 
general  they  may  be  by  their  progrefs. 

I  have  kept  no  particular  account  of  the 
numerous  cafes  which  I  have  met  with,  but 
the  five  following  inftances  happened  in  my 
own  private  practice  within  a  few  months, 
and  the  circumftances  of  them  are  ftill  frefh 
in  my  memoiy.  The  cafes  are  drawn  up 
frotn  narratives  which  I  requefted  the  pa- 
tients themfelves  to  make  out  of  their  own 
difeaies. 

CASE  VII. 

A  gentleman  had  a  fore  on  the  lower  part 
of  the  prepuce  near  the  froenum,  which  was 
much  irritated  by  travelling  from  the  country. 
When  he  came  to  town  there  was  a  good 
deal  of  furroundiiig  inflammation,  and  a 
thickening  adjoining  the  edges  of  the  fore 

which 


RESEMBLING   SYFMILIS.  31 

which  were  irregular,  and  feemingly  difpofed 
to  fpread*     An  appearance  of  granulations 
had  taken  place  on  the  furface  of  the  ulcer^ 
which  was  at  this  time  as  large  as  a  (hilling. 
I  gave  him  the  pilulae  hydrargyri,  whilft  I 
tried  by  local  means  to  quiet  the  irritation  of 
the  fore,  and  of  the  furrounding  parts.     As 
the  fore  appeared  to  heal  flowly,  and  feem^ 
ingly  in  proportion  to  the  quantity  of  mer-i 
cury  taken,  the  patient  rubbed  in  at  the  lame 
time  fbme  mercurial  ointment,  and  continued 
to  do  fo  till  after  the  fore  was  well,  which  was 
in  about  a  month.     In  three  weeks  after  he 
had  left  off  thefe  medicines,  this  patient  ap- 
plied to  mc  on  account  of  an  ulceration  on 
the  velum  pendulum  palati,  and  on  the  fur- 
face  of  one  tonfil ;  and  foon  afterwards  ulcers 
took  place  on  the  edges  of  the  tongue,  and  oa 
the  infide  of  the  lips  and  cheeks.     Copper- 
oloured  fpots  alfo  came  put  on  his  arms  and 
^s,  and  all  over  his  body.     They  were  very 
umerous,  but  none  appeared  on  his  face^. 
y  waiting  and  watching  the  progrefs  of  the 
feafe,    I   found  that  fome  of  the  ulcers, 
lended  fpontaneoufly,  aod  that  the  palate^ 
t  well,   I  therefore  exhorted  to  to  refrains  "^ 

40  ^^ 


59  OK  dUeases 

from  mercurial  medicine,  an4  he  went  into 
the  country.  A  medical  gentleman,  whom 
^e  patient  confulted,  was  very  anxious  to 
try  Ibmething  to  cure  this  difeafe,  when  his 
patient  was  feized  with  a  fevere  febrile  com- 
plaint, during  the  continuance  of  which  all 
thefe  doubtful  fymptoms  difappeared,  and 
there  has  not  been  any  return  of  difeale  fmce 
that  time. 

CASE  vni. 
A  gentleman  had  a  fmall  fore  on  the  pre- 
puce, at  a  littk  diftance  behind  the  corona 
glandis,  which  did  not  appear  like  a  venereal 
chancre,  and  therefore  no  mercury  was  uied. 
After  about  a  fortnight,  during  which  time  it 
could  fcarcely  be  faid  to  be  better  or  worfe, 
k  fuddenly  became  confiderably  indurated  in 
its  circumference,  and  the  furrounding  parts 
became  inflamed.     The  hardnefs  was  fo  con- 
fiderable  that  it  refembled  one  of  thofe  indu- 
ratqd  chancres  which  fo  frequently  occur ; 
and  in  confequence  of  this  ftriking  refem- 
bUmce,  another  furgeon,  whom  the  patient 
confulted  at  this  time,  infifted  on  his  con- 
fining himfelf  to  his  chamber,  and  ufing  mer- 
cury attentively. 

The 


RESEMBLUm  &YPHJLIS.  33 

The  quietude  of  thp  patient,  ,with  Some 
little  attention  in  regard  to  local  applications, 
foon  removed  the  inflammation  and  bardnefp, 
and  the  patient,  who  was  controlled  by  no- 
thing but  his  fears,  difcontinued  his  medicine 
after  thrice  ufing  .forae  mercurial  omtment, 
and  returned  to  his.fcwmer  mode  of  life. 

Aboutamonth  afterwards,  he  called  on, nje 
with  an  ulcer  in  each  tonfil,  one  of  which 
was  deeply  excavated,  with  irregular  edges, 

■  and  covered  by  adhering  matter.  Shortly  af- 
terwards, copper-coloured  fpots  appeared  on 
his, body,  -but  tliefe  difeafes  all  difappeaw^iii 
about  a  month,  without  ufing  mercuiy.  , 
CASE  IX. 

A  gentleman  applied  to  me  with  a  very  UtI- 
tablefore,  or  rather  excoriation,  extending  it- 
felf  over  the  left  half  of  the  corona  glandis.  It 
was  unlike  a  fyphilittc  fore,  as  may  be  fup- 
pofed  from  this  defcription,  yet,  as  the  pa- 
tient was  young  and  healthy,  I  advlfed  him. 
to  take  fome  of  the  pilulae  hydrargyri  to 
guard  againft  the  poflible  confequences  of  ab- 
Ibrption,  and  to  bathe  tlie  parts,a&£tedwith 

-    '-VOL.  II.  D  the 


34  ON    BISEASBJ 

the  aq.  litharg.  acct.  comp.  c.  opio,  and  ttf  ap- 
ply folded  linen  moiftened  witli  the  waih 
round  the  penis.  The  prepuce  foon  became 
Iwoln  and  inflamed,  fothat  he  was  unable  torc- 

■-tra£l  it,  and  the  attempt  gave  him  great  pain. 

[  fHe  was  therefore  diiefted  to  cleanfe  the  part 

by  injefting  frequently  the  dcco(fHon  of  white 

poppy  heads   of  a    lukewarm   temperature. 

'After  a  week  he  tried  a  very  weak  folution  of 

I  Arjtriolated  zinc,  aad  other  metallic  ialts,  but 

they  all  increafed  his  pain,  and  he  was  obliged 

V  -to  return  to  the  ufe  of  the  anodyne  wafh. 

-When  he  had  perfevered  in  this  courfe  three 
weeks  without  any  c\'idcnt  amendment,  he 
confulted  another  furgeon,  who  recommcndetl 
the  difcontinuance  of  the  mercurial  medicine, 
and  in  lieu  of  it,  the  free  ufe  of  the  bark. 
This  medicine  he  took  for  a  week  without 
any  amendment ;  he  then  tried  'the  nitrous 
acid  for  ten  days,  and  afterwards  took 
cicuta. 

In  about  two  mohths  he  was  able  to  retra£l 
the  forelkin,  and  then  the  folution  of  vltrio- 
lated  zinc  appeared  to  leflen  the  irritability, 

ajid 


^ 


HESEMBLINO   SYPHILIS.  35 

and  contribute  to  the  fkinning  pf  the  fore, 
which  was  merely  on  the  fnrface,  not  having 
been  attended  with  any^  lofs  of  fubftance« 

Afterwards  the  penis  being  ilil:ye£bd  to 
feme  accidental  irritation,  the  fame  kind  of 
forenefs  fpread  over  the  other  half  of  the 
corona  glandis ;  but  this  diie^e  was  not  ac- 
companied with  fo  much  tenderpefe  as  the 
former  one,  and  got  well  in  lefs  than  a 
month.  As  foon  as  it  was  well,  the  patient 
had  an  ulceration  of  the  velum  pendulum 
palati,  round  which  the  cuticle  afTumed  a 
whitifti  colour ;  the  ulceration  ipread  acrofs 
the  palate,  but  it  was  evident  that  the  part 
iirft  afFefted  got  better,  whilft  the  ulcer  be- 
Jcame  worfe  in  the  parts  laft  afFefted.  Two 
or  three  ulcers  took  place  upon  each  edge  of 
the  tongue,  and  fbme  on  the  infide  of  the 
lips.  At  the  fame  time  many  copper-coloured 
i^pots  appeared  on  the  face,  breaft,  arms,  and 
lower  extremities ;  they  came  out  in  fuccef- 
fioh,  were  of  an  oval  fhape,  about  the  fize  of 
a  fixpence,  and  had  a  ftrikingly'  fyphilitic 
afpea. 

p  2  Believing 


^  OK  DiS)»AM« 

Bdieving  :^t  the  piimary  fymptcmis  c^ 
this  difeafe  were  not  fyphilitic,  and  obierving 
that  fome  part  of  the  ulcer  on  the  palate  heal* 
ed,  and  that  fome  of  the  fores  on  the  tongue 
and  lips  got^better,  whilft  nevsr  ones  brc^e  out, 
I  recommended  the  patient  to  ufe  no  mercury. 
He  went  into  the  country,  where  all  thefe 
maladies  gradually  difappeared,  and  in  about 
a  month  he  was  perfeftly  well. 

CASE  X. 

A  perfon,  whofe  irregular  habits  of  life 
gave  reafon  to  fufpeft  the  exiftence  of  fyphilis 
in  the  conftitution,  had  ulceration  of  the  ton- 
fils,  not  fuperficial,  but  deep.  Thefe  were 
accompanied  with  copper-coloured  fpots  on 
the  face  and  breaft,  and  eruptions  on  the 
head  aipidft  the  hair,  accompanied  with  a 
.great  deal  of  fcurf.  Thefe  got  well  by 
anointing  the  head  with.ung.hydrarg.nitrat. 
mixed  with  fimple  ointment,  which  made  me 
doubt  whether  the  other  difeafes  were  really 
fyphilitic,^  and  caufed  me  to  delay  the  ufe  of 
'mercury.  The  complaints  did  not  amend, 
nor  did  they  get  materially  worfe.  There 
was  attending  thefe  difeafes  a  good  deal  of 

general 


RBSEMIbm^.  SVtHILIS.  Jf 

general  indispofition ;  the  appetke'fmleci^  and 
no fleep took  place  tidlthe morning;. 

At  this  time  a  tfendernefs  and  thickening 
of  the  periofteum  of  the  tibia  took  plac&i 
Though  other  medicines  did  not  appear  to  be 
of  any  fervice  1  fttll  was  averfe  to  the  u(e  of 
mercury.  Tired  of  delay,  the  patient  ego* 
(lilted  another  furgeon,  who  declared  the  dii^ 
eaie  to  be  veneral,  and  defired  that  mercurial 
ointment  might  be  ufcd*  The  patient  ao^ 
cordingly  rubbed  in  two  or  three  nights  with«- 
out  feeling  any  efled^  from  the  medicine,  and 
then  fet  off  on  a  party  of  pleafure  to  Bright 
ton,  where  all  the  difeafes  gradually  di^p* 
,peared  without  any  further  ufe  of  mercury* 

CASE  XI, 

A  gtotieman  had  an  enlargement  of  a  glknd 
in  thtf  git>in,  probably  fr6m  the  abfbrption  of 
fbme  infe£tious  matter,  though  he  was  not 
confcious  of  having  had  any  fore.  A  fecond 
and  a  third  g^and  became  enlarged^  the  ixlte* 
^cients  became  thickened' arid  infiamcds^  and 
flLrvery  large  bubo  formed;  It  fbppuiratied  and 
Jpmtt  in  thtfoe  platen.    Thrgputr^  tiimefifKh 

D  3  tion 


$9  ON  DX«EASES 

tion  fubfided,  but  by  no  means  dilpcrlcd, 
and  finufes  remained  where  the  abcefTes  had 
been.  About  this  time  I  faw  the  patient^ 
which  was  two  months  after  the  firft  appear- 
ance of  thedifeafe* 

Shortly  after  this,  he  had  an  ulceration, 
which  fpread  over  the  velum  pendulum  pa- 
lati,  and  except  that  it  was  more  fuper- 
ficial,  much  refembled  a  fyphilitic  ulceration. 
It  continued  fo  long  without  amendment,  that 
I  began  to  think  it  was  fyphilitic.  Bark  was 
jiow  given  plentifiiUy,  arid  the  ulcer  evidently 
amended.  The  patient  went  afterwards  to 
the  fea-fidc,  where  the  bubo  gradually  diC- 
perfed :  many  months  however  elapfed  before 
it  entirely  difappeared.  The  ulcerations  of 
the  velum  pendulum  palati  alfo  healed  flowly; 
and  ulcers,  which  afterwards  appeared  in  the 
back  part  of  the  pharynx,  got  well  Ukewile 
without  mercury. 

Thefe  cafes  arc  not  related  as  being  rare  or 
curious,  but  becaufe  they  all  occurred  to 
me  within  the  fpace  of  a  few  months,  and 
becaufe    fufficient   time   has.   ekpfed  'fince 

thcif 


i 


RESEMBtINO    SVPHILI8.  3^ 

iteir  occurrence  tp  fl;iew  that  there  is  no 
probability  that  there  will  be  any  recurrence  of 
thefe  or  fimilar  fymptoms.  It  muft  be  allowed 
that  they  are  inconteftable  inftances  of 
difcaTcs  getting  well  witliout  mcr-cury, 
which  could  not  be  diftinguilhed  by 
mere  infpeftion  from  fimilar  diieafes  truly 
fyphilitic.  For  though  mercury  was  employ- 
^  in  fome  of  the  cafes,  it  was  ufed  at  fuch  % 
time,  or  in  fuch  quantity,  that  it  cannot  in 
the  leaft  influence  our  decifion  as  to  this 
point.  For  inftance,  in  the  firft  cafe  though 
mercury  was  employed  for  the  cure  of  the 
primary  ulcer,  and  did  apparently  contribute 
to  it}  yet  the  fecondary  fymptoms  got  well 
without  mercury,  which,  according  Jo  the  opi- 
nions now  prevailing  among  furgeoos,  is  a 
proof  that  neither  was  fyphilitic.  it  may  in- 
deed be  fuppofed  that  the  fyphilitic  poifon. 
may  be  modified  by  certain  f onftitufions,  and 
its  effeds  fpontaneoufly  difappear;  and  fome 
may  queftion  if  the  fecondary  fymptoms  were 
the  confequences  of  the  fores  or  abforption  to 
jvhich  I  attribute  them.  What  I  have  written 
^s,  I  believe,  in  conformity  to  prevailing  opj- 
p  4  nions, 


4»  <H«    DlitfJtsVV       -     - 

iiionS,  and  I  forbear  to  enter  into  uncertiam 
difcufllons. 


Thefeinftances,  however,  though  not  fe- 
,  lefted  for  the  purpofe,  fhew  that  the  primary 
infcfted  fores  which  are  capable  of  producing 
fefcondai7     fymptoras,     ftrikingly    i-cfemb- 
ling  thofe  of   fyphiUs,    do  not  themfelves 
■^offefs  any  uniform  characters.     In  the  firft 
cafe  the  ulcer  had  no  uncommon  appearance ; 
if  was  of  the  iize  of  a  fliilling,  with  fretful 
,  'edges,  and  eveiy  where  covered  with  granu- 
lations.     In  the  fccond  there  were  no  appa- 
■ftnt  granulations,  and  a  great  degree  of  indu- 
ration fuddcnly  furrounded  it,  giving  it  a 
ilriking  refemblance  to  the  indurated  vene- 
I'real  chancre.     In  the  third,  the  fore  furface 
I'was  extremely  irritable ;  but  though  the  di^ 
r  eafe  exifted  for  a  long  time,  the  ulcenative 
^  procefs  did  not  eat  into  the  part ;  and  at  1^ 
'tonclufion  of  the  cafe  there  was  no  loft  of 
^'iflibftance.     In  the  fourth  and  fifth  cafts,  the 
'  abforption  of  the  matter,  which  caufed  the 
''fecondaiy  fymptoms,  either  took  place  with- 
out any  breach  of  fnrfacc,  or  the  prirtiary 
fores 


J 


RESSMB1.IMO   SYPHILIS.  4^ 

I 

fores  were  too  infignificant  to  excite  attend 
tion.  I  lately  attended  a  gentleman  vfho  had 
an  ulcerated  throat,  and  eruptions  on  thp 
head^  which  broke  out  between  the  fecond 
and  third  month  after  the  appearance  of  a 
fore  on  the  prepuce,  which  fore  healed  in  4 
few  days  With  no  other  treatment  than 
foatiiing.  it  with  a  folution  of  acetated  lead^ 
and  applying  to  it  a  piece  of  lint  moiftened 
with  that  litjuor.  This  circumftance  made 
him  difregard  the  primary  fore,  but  he  was 
afTured  by  a  forgeort,  whom  he  confulted, 
that  the  fecondary  fymptoms  were  fyphilitic^j 
they  however  got  well  without  mercury. 

It  is  probable,  that  the  morbific  poifons 
which  producepfeudo^fyphilk  may  be  abforbed 
without  any  evident  ulcer,  or  from  a  trivial 
ulcer,  which  may  heal  fpontaneoufly,  much 
more  frequently  thari  the  fyphilitic  poifon  >  and 
if  the  confcquent  oonftitutional  fymptoms  aj» 
confidered  as  the  effefts  of  the  latter  difeifc 
^and  treated^  as  fuch^  I  need  not  fay*  what 
coiiifulion  muft  be  pjrodoced  in  the  mind 
of  the  forgeoh  who  purfoes  this  condu^,  and 
how  bewiklered:  Ms  opiniona  muft  be  repe£t<* 

5  ing 


4ft  ON    DISEASES 

ing  venereal  difeafcs.      If,  for  mftance,  in 

■■  the    eleventh   cafe,     a  fuigeon  had    conii- 

dered    the    fecondary  fymptoms    as  fyphi- 

litic,     and   employed   mercury   fuccefsfully 

for  their  cure,  he  would  fet  this  down  as  a 

cafe  of  syphilitic  bubo  occurring  without  a 

I  previous  chancre,   and    be   inclined  in  his 

[  general  practice  to  ufe  mercury  in  all  cafes 

[  i)f  buboes  without  chancre,  left  conftitu- 

rtional  difeafes  fhould  enfue.     There,  how- 

r'ever,  does  not  appear  any  thing  that  ihould 

I  txempt  the  glands  of  the  groin  from  en- 

I  iargement,  and  difeafes  to  which  other  abforb- 

[  cnt  glands  are  fubjefl,  whilft  they  are  pai-ticu- 

r  larly  liable  to  irritation  and  confequent  difeaie 

"from  diforders  of  the  urethra  and  other  parts» 

to  which  they  are  connefted  by  means  of  their 

vefiels.  Theufeof  mercury  as  a  fpecific,  there- 

fbre,   in  enlargement  of  thefe  glands,  unlefs 

they  have  been  preceded  by  a  chancre,  muft,  I 

think,  be  confidered  as  improper. 

I  have  met  with  many  fimilar  cafes  fince 

thofe  five   that  have  been   related,  and  of 

which,  from  their  fuddcn  and  almoft  fimul- 

taneous  occurrence,  I  was  induced  to  take  a 

written 


J 


RESEMBLING  SYPHILIS*  4J 

written  account :  within  thefe  two  months^  I 
have  feen  two  cafes  of  eruptions  and  three  of 
fore  throats.  The  eruptions*took  place  par^ 
ticularly  about  the  hands  and  feet :  in  one 
cafe,  the  patient  has  been  falivated  for  them ; 
the  difeafe,  however,  recurred,  and  afterwards 
got  well  without  the  ufe  of  mercury.  In  the 
other,  there  were  warts  and  fores  on  the  pre- 
puce, and  buboes  in  the  groin,  which  fuppur 
rated  and  burft  :  the  eruptions  fo  ftrikingly 
refembled  thofe  of  fyphilis,  that  all  the  me- 
dical men,  who  accidentally  faw  the  patient, 
pxchimtd  that  they  were  fo,  with  a  confi- 
dence proportioned  to  their  profeflional  Ikill 
and  accuracy  of  obfervation.  Indeed  in  this 
cafe,  and  in  others,  I  have  been  almoft  im- 
pelled to  ufe  mercury,  in  confequence  of  tj^ 
opinion  and  wiihes  of  the  patient  and  tlifljf 
of  his  friends.  The  hiftory  however  of  this 
difeafe  did  not  accord  with  that  of  fyphilis  -, 
the  warts  had  preceded  the  fores;  fomp 
fores  healed,  and  others  broke  out ;  and  at 
laft,  fome  of  the  eruptions  began  to  get  well, 
and  the  reft  gradually  difappeared.  The 
third  patient  had  a  fore  throat  for  which  he 
had  been  £divated;  it  afterwards  recurred 

when 


44  .       oir.  DnsASsr 

^heh  it  got  wdr  without  mercury.  Thci 
fourth  aiid  fifth  had- ulcers  in  the  throat  and  oil 
the  lips  and  tongue:  they  all  got  well  with«» 
out  mercury.  One  of  the  patients  who  had 
the  £>re  throat  had  been  falivated,  but  the 
difeafe  recurred.  In  the  other  two  I  forbore 
to  u&  mercury,  and  I  have  reafon  to  fay 
they  will  do  well  without  it*  In  one  of  the 
latter  cafcr  there  were  ulcers  on  the  tongue 
:^d  the  infide  of  the  lips* 


If,  then,  the  occurrence  of  fuch  cafes 
frequent,  and  the  neceHity  of  difcriminating 
them  from  thofe  of  fyphilis  be  of  great  inl- 
portance,.  we  may  fblicitoufly  enquire  by 
jifhat  circumftances  we  are  to  diftinguifh  be* 

feen  difeafes  fa  fimilar  in  appearance,  *  but 
different  in  their  nature,  Mr.  Hunter 
ieemcd  to  wifti  the  profecutioaof  this  fubjeft, 
probably  from  the  expeftation  that  fomc  ch^ 
rafters  appropriate  to  thefe  difeafes  might  be 
dete6ted :  I  have  not,  however,  been  able  to 
difcover  any ;  the  fi£fit)ous  difeafe  in  appeai'- 
ance  fo  exaftly  referables  fyphilis  that  no  ol>- 
fcrvation,  however  acute,  feems  to  be  capable 
of  deciding  upon  its  natuite.  Although  the  ul<* 

cer5 


RESSMBLIKG  BYFHILIS.  45 

cers  in  thefe  ambiguous  cafes  generally  fpread 
more  extenfively  along  the  furface  of  the  part 
which  they  afFe6^,  yet  this  does  not  conftantLy 
happen,  as  is  (hewn  in  the  eighth  cafe 
In  this  cafe,  however,  the  induration 
which  furrounded  the  chancre  occurred  fud* 
denly,  and  went  away  as  rapidly.  The  pro- 
grefs  therefore,  of  the  two  difeafes  was  vcny 
diflimilar  *.     It  muft  alfo  b*  remarked,  that 

*  On. the  fttbjed^  of. induration  fiirrounding  chancres il 
think  it  may  be  ufeful  to  selate  the  following  cafe,  ;^nd.fo 
mention  that  I  have  known  fimilar  ones  in  a  lefs  degree : 

• 

A  ftudent  in  furgery  {hewed  n^  an  indurated  ghapcr^^ 
for  the  cure  of  which  he  had  ufed  a  great  quantity  of 
mercury,  which  had  affeAed  his  mouth  for  a  long  time^ 
tbpugh  not  feverely*  The  foire  So  exa£lly  refembled  a  bad 
.indurate^  Teoeral  chancre  that  I  did  not  hefitate  to  recom- 
mend him  to  remain  at  home,  and  rub  in  fo  as  to  product 
a  0ight  falivation.  But  as  no  amendment  was  perceiirAl 
after  a  fortnight's  confinement,  and  under  a  confideiable 
.affe&ion  of  the  mouth,!  was  induced  to  enquire  m9re 
.ftri&ly  into  the  local  treatment  of  the  fore,  which  I  foHiyt 
be  was  conftantly  irritating  by  various  ftimulating  applied 
tions.  He  alfo  affirmed  that  the  hardnefs  had  fereral  timet 
gone  away  and  returned  again*  By  bathing  the  part  wi^ 
milk  and  water,  and  dreiling  it  only  night  and  morning 
with  mild  falve,  the  hardnefs  quickly  abated,  and  though 
h%  defifted  from  the  mercurial  courfe  it  foon  became  per- 
\feGdj  well. .      .  J 

true 


I  havebeen  upon  the  watch,  and  becaufe  they 

jiave  occurred  in  patients  in  whoin  I  h^ve 

deen  the  .primary  lores,  the  appear^ce  an^l 

^'j^G^refe  of  which  have  excited  niy  fufpiciflii 

^  4o  their  nature.    I  have  ilated  the  rule  ^ 

^-gttieral,  but  not  imivecial ;  for  .1  cpi^myiq^ 

-cdate  cafes  of  difeafes,  in  which,  from  ^ 

great  abatement,  and  .'Cven  dii^ppQar^uice  <)f 

fymptoms,  I  have  concluded  the  difeafe  was 

tiot  fyphilitic;  yet,  from  the  dvur^tion  of  the 

,^ifbr<ier,  or  from  the  fubfequoit  a^pa^ticm 

of  its  fymptoms,  the  patient  has  ^(yf^  and^ 

•have  recommended  the  ufe  of  nier<:ury,  and 

*the  dileafe  has  been  fuccesfully  treatje^  ?^f}!g^- 

-tic  without  its  real  nature  being  oic^ained. 

The  rule  which  has  been  mendoned  relates 
to  the  conftitutional  fymptoms  of  the  vene- 
real difeaie,  ibr  the  primary  ones,  chancres^ 
'do  fometimes  heal  fpontaneoufly,  generally^ 
liowever,  though  not  conftantly,  leaving  a. 
4ihickening  or  induration  of  the  afFe£):ed  part^ 
They  may  alfo  be  induced  to  heal  by  topicaL 
.mesms,  without  mercury,  with  fimilar  events^ 
Some  enlargements  of  glands  in  the  groin, 
will  alio  in  like  manner  fubfide. 

It 


RESEMBLTNd   SYPHILIS*  49 

It  may  be  fairly  fuppofed  that  if  fome 
chancres  heal  fpontaneoufly,  conftitutional 
diieaies  arifing  from  the  fame  caufe,  may, 
in  like  manner,  fometunes  get  well  with- 
out  mercury.  The  queftion  can  only  be 
iblved  by  experience.  Delay  will  I  am  fure ' 
frequently  en?ible  a  furgeon  to  decide,  that 
the  difeafe  is  not  fyphilis ;  but  there  are  cafes 
in  which  no  amendment  takes  place,  and  the 
furgeon  is  as  it  were  forced,  from  the  pro- 
grefs  of  the  difeafe,  to  employ  mercury, 
though  doubtful  of  its  nature. 

In  recommending  prudent  delay  and  atten- 
tive obfervation,  I  hope  and  believe  that  I  am 
not  recommending  any  thing  likely  to  be  of 
<langerous  confequences.    The'V(fiicreal  dit- 
cafe  is  generally  foon  checked  by'  tRe  ufe  of 
»iercury ;  and  in  conftitutions  where  much 
3nedicine  is  required  to  counteraft  its  efFefts, 
that  medicine  may  be  given  with  freedom. 
By  delay  and  obfervation  we  perhaps  may 
perceive    that  eruptions  and  fore  throats, 
which  could  not  from  appearance  be  diftin- 
guiihed  from  venereal,  fpontaneoufly  amend : 
that  fome  eruptions  fcale  and  become  well, 

VOL.  II.  js  and 


5Q  Oi(  DXiBAS£8 

and  the  probability  will  of  courfe  be  that  rfitf 
reft  will  do  fo  likcwife :  or  that  an  ulcer 
mends  in  one  part  though  it  may  fpread  in 
another,  when  the  natural  inference  is,  that 
the  difeafed  aftions  in  the  fore  will  gradu- 
ally ceafe,  and  health  return  fpontaneouily  > 
and  that  what  has  occurred  in  one  part  of 
an  ulcer  will  fucceffively  take  place  in 
the  others. 

In  recommending  delay  it  cannot,  I  fiip- 
pofe,  be  thought  that  I  would  advife  any  one 
to  wait  till  an  ulcer  deftroyed  the  velum  pen- 
dulum palati,  or  did  material  injury  tp  any 
important  part.     There  are  cafes  where  the 
progrefs  of  the  difeafe  obliges  the  furgeon  to 
ufe  mercury,,  even  though  he  may  befufpicious 
that  it  is- not  fyphilitic.     The  efFeft  of  ex- 
citing a  mercurial  affeftion  of  the  conftitu-^ 
tion,  where  we  feel  ourfelves  under  the  nc- 
ceflity  of  employing  that  medicine^  in  dif^ 
eafes  refembling  fyphilis   is,    as  far  as  mj 
obfervation  enables  me  to  determine,   very 
various.     It  fometimes  cures  them  very  fud- 
denly,  and  veiy  differently  from  the  gradual 
amendment  which  it  produces  in  truly  Typhi-- 

iitic 


RESEMBUKO   SYPHILIS.  $1 

9 

litic  difeafes.  Sometimes,  however,  thefe 
difcafes  yield  more  flowly  to  its  operation, 
Jlnd  arc  cured  permanently.  Sometimes  the 
difeafes  recur  in  the  fame  parts  after  a  fe- 
vere  courfe  of  mercury ;  fometimes  mercury 
merely  checks  the  difeafe,  and  can  fcarcely  be 
faid  to  cure  it ;  in  which  cafe  it  feems  impor- 
tant to  fupport  the  ftrength  of  the  conftitu- 
tion,  and  to  keep  up  that  mercurial  effeft 
which  controls  the  difeafe,  and  can  be  borne 
without  material  derangement  of  the  confti- 
tution  for  a  great  length  of  time.  Some^- 
times  alfo  the  ufe  of  mercury  aggravates  thefe 
difeafes. 

Again,  in  fome  conftitutions,  fyphilitic 
difeafe  may  affume  unufual  charafters,  and 
be  veiy  difficult  of  cure.  It  muft  then  be 
fcarcely  poffible  to  difcriminate  between  thefc 
anomalous  cafes  of  fyphilis  and  thofe  of  diC 
eafes  refembling  it,  unlefs  fome  new  diftinc  - 
tions  are  difcovered. 

But  I  fupprefs  any  further  obfervation  on 
the  fubjeft,  having  accomplifhed  the  inten- 
tion of  this  paper,  which  was  to  depi6l  a 

E  2  kind 


5^  ON   DI8IA9E9 

land  of  cafes  which  very  frequently  occurs  in 
this  metropolis,  and  which  is,  I  believe,  too 
commonly  treated  as  fyphilitic,  but  which 
may  be  diftinguifhed  not  to  be  fo  by  a  little 
prudent  delay  and  attentive  obfervation.  The 
frequent  cafes  of  fuch  difprders  which  I  have 
recently  met  with  has  fuggefted  the  idea  that 
they  are  increafing  of  late  j  nor  is  it  impro- 
bable, fmce  they  are  like  fyphilis,  propagated 
by  promifcuous  intercourfe  from  fccretions> 
or  fores  not  fo  readily  curable  .by  mercury  a^ 
thofe  that  are  fyphilitic,  and  fome  of  which, 
are  not  from  their  nature  fo  prohibitory  of 
that  intercourfe. 

It  is  now  years  fmce  this  paper  was 
drawn  out  as  a  fubje6l  for  difcuflion  at  a  me- 
dical  fociety ;  and,  after  fuch  an  interval,  the 
chance  of  any  of  the  diforders  which  arc 
defcribed  in  it  returning  is  diminiftied  almoft 
to  nothing.  I  have  fince  met  with  confider- 
able  numbers  of  fimilar,  difeafes,  which  give 
confirmation  to  the  opinion  that  they  are  fre- 
quent occurrences.  In  fome  later  cafes,  when 
the  difeafe  has  been  long  protrafted,  and 
the  patient  very  anxious  to  get  rid  of  it,  I 

have 


RZSEMBLINO   SYPlTlLIS.  55 

have  given  a  little  calomel  for  that  purpofe, 
but  not  fo  as  to  invalidate  the  opinion  that 
the  difeafe  was  not  fyphilitic.  Having  waited, 
for  inftance,  four  months  from  the  occur- 
rence of  a  fore  throat  with  eruptipns,  and 
being  affured  by  the  progrcfe  of  the  dif- 
orders  that  they  were  not  fyphilitic,  I  have 
direfted  that  the  compound  calomel  pills  * 
Should  be  taken  in  fuch  dofes  as  to  control 
the  difeafe  without  weakening  the  conftitu- 
tion,  which  generally  difpofes  the  fores  in  the 
throat  to  heal,  but  I  have  taken  care  to  remit 
the  ufe  of  even  this  fmall  quantity  of  mer- 
cury if   it  feemed  to  heal   the  fores   too 
Ipeedily ;  for  it  feems  to  me  better  to  let  the 
difeafe  exhauft  itfelf  than  fuddenly  to  cure  it, 
as  in  the  latter  cafe  it  is  very  likely  to  return,- 
In  confirmation  of  this  opinion  I  may  men- 
tion, that,  about  five  years  ago,  a  gentleman 
appHed  to  me  to  undergo  a  falivation  for  the 
cure  of  a  fore  throat,  for  which  he  had  been 
ialivated  three  times,  once  in  each  fucceeding 

• 

f  The  pill,  as  prefcribed  in  the  pharmacopeia  of  St. 
Bartholomew's  Hofpital,  contains  i  grain  of  calomel,  i 
grain  of  the  precipitated  folphur  of  antimony,  and  2  grains 
^  powdered  gum  guaiacum. 


54  OM    Z>iSBA$I8 

year.  I  need  fcarcely  fay  that  it  was  one  of 
thofe  ulcerated  throats  which  have  been  de-f 
fcribed.  All  medicine  was  abftained  from ; 
and  in  between  three  and  four  months  the 
fores  fpontaneoufly  became  well,  and  have 
never  fincc  recurred.  The  whole  of  this 
paper  has  been  written  upon  the  prefumption 
that  difeafes  which  fpontaneoufly  get  well  are 
not  fyphilltic,  which  is,  I  believe,  the  general 
opinion,  Jt  may,  perhaps,  be  queftioned  by 
fome,  whether  the  jdifeafes  here  recorded  may 
not  be  modifications  of  the  venereal  difeaie. 
The  pra6lical  rules  of  conduft  will  not,  how- 
ever, be  altered  evpn  if  fuch  a  fuppofition  were 
verified,  fo  that  it  does  not  feem  neceflary  tq 
difcufs  this  point :  it  may  however  be  right 
to  remark,  that  there  are  cafes  which  would 
induce  the  belief  that  ulcerated  fore  throats, 
eruptions,  and  nodes  on  the  bones,  fimilar  to 
thofe  defcribed  it  this  paper,  may  occur  from 
a  general  diflurbance  of  the  conftitution, 
without  the  abforption  of  any  infeftious 
matter. 

The  obje^  of  this  paper  beipg  fijnply  to 
excite  attention  to  fuch  cafes  as  are  recprded 

in 


RESEMBLING   SYPHILIS,  55 

in  it,  I  did  not  think  it  neceflaiy  to  enlarge 
much  upon  a  circumftance  which,  however, 
is  a  ftrong  evidence  of  the  neceffity  of  difcri- 
tninating  between  fuch  difeafes  and  true 
fyphilis.  The  circumjftance  to  which  1  al- 
lude is,  that  though  a  courfe  of  mercury  may 
at  the  time  remove  all  the  fymptonjs  for 
which  it  has  been  employed,  yet  it  will  not 
cure  the  conftitutional  difeafe ;  for  the  fymp- 
tOTfis  will  recur  when  the  medicine  has  been 
difcontinued  after  repeated  and  fevere  courfes 
of  mercury,  as  will  be  fully  (hewn,  by  cafes 
which  I  fhall  afterwards  relate. 

Having  written  the  forgoing  account,  I 
intended  here  to  conclude,  having,  in  my 
own  opinion,  accomplifhed  my  purpofe, 
which  was  to  profecute  in  fome  degree  the 
fulgeft  which  Mr,  Hunter  deemed  worthy  of 
inveftigation,  and  to  depift  the  circumftance$ 
of  difeafes  which  I  believe  very  frequently 
pccur,  and  which  are  often  confounded  with 
cafes  of  fyphilis,  to  the  detriipent  of  patients, 
and  the  difcredit  of  our  profeifion.  But 
having  requefted  the  opinions  of  two  of  my 
picdical  friends  on  the  foregoing  paper,  one 

K  f  of 


5^  OK   DISEASES 

of  thcm^faid,  that  he  thought  the  publication 
of  it  would  be  injurious,  as  it  might  induce 
the  younger  furgeons  to  abftain  from  the  ufe 
of  mercury,  to  the  prejudice  of  their  pa- 
tients; the  other  gentleman  faid,  that  he 
thought  more  explicit  defcriptions  fhould  be 
l^ven  of  the  cafes  in  which  mercury  ihould 
be  withheld  or  employed.  In  confequcncc  of 
thefe  opinions,  I  am  induced  to  take  a  clofer 
comparative  view  of  the  difeafes  that  are,  and 
of  thofc  that  are  not,  fyphilitic. 

I  undertake  the  tafk  reluctantly,  becaufe 
the  brevity  with  which  I  muft  fpeak  of  thefe 
Aibjefts  may  render  my  opinions  liable  to  miC- 
apprehenfion,  and  becaufe  I  do  not  feel  com- 
petent to  its  proper  performance.  Yet,  by 
this  means,  I  think  I  fhall  do  away  the  obr 
jeftion  of  one  of  my  medical  friends  j  for  I 
believe  that  I  am  myfelf  more  likely  to  err  in 
reconmiending  the  too  free  than  the  too 
fparing  adminiftration  of  mercury  in  difeafes 
of  this  nature.  Any  furgeon  who  has  ob- 
fei'ved  the  ruinous  confequences  of  repeated 
mercurial  fourfes  in  fome  conftitutions  would 
probably  err  in  the  fame  planner  3  and  hfs 

2  diflike 


RESEMBLING   SYPHILIS.  ^f 

diflike  to  diforder  the  conftitution  by  mercury 
would piobably  lead  him  even  to  ufe  it  more 
freely  than  might  be  abfolutely  neceflary: 
,tliis  he  would  do  in  cafes  clearly  fyphilitic, 
in  order  to  prevent  the  poffibility  of  the  re- 
currence of  difeafe,  and  a  repetition  of  a  mer- 
curial courfe.     In  doubtful  cafes,  which  are 
cured  by  exciting  the  mercurial  aftion  in  the 
conftitution,  he  would  adopt  a  fimilar  mode 
of  treatment,  in  order  to  fupprefs  the  difeafe 
for  fo  long  a  time  as  to  make  it  lefs  likely  to 
recur  5   or  if  any  fubfequcnt  difeafe  fhould 
take  place,  to  render  it  highly  probable  that 
this  was  not  fyphilitic,  fince  it  had  broken  out 
after  fuch  a  courfe  of  mercury  as  muft  be 
confidered  to  be  adequate  to  the  cure  of  al- 
moft  any  difeafe  of  that  nature.     By  under* 
taking  this  talk  I  fhall  perhaps  comply  with 
the  wifhes  of  my  other  friends,  in  ftating  more 
explicitly  the  circumftances  which  fhould  in* 
duce  a  furgeon  immediately  to  ufe  or  ab- 
flain  from  the  adminiflration  of  mercury, 
and,  at  the  fame  time,  contribute  .my  mite 
of  obfervation  to  thofe   already  offered  ori 
tl^s  ftiU  obfcure  futjeft  of  venereal  difeafes. 

The 


58  OK    DISEASES 

The  mofl:  clearly  marked  fyphilitic  chan*' 
^c  has  been  excellently  dcfcribed  by  Mr, 
Hunter,  The  ftriking  charaders  of  the 
difeafc  are,  an  ulcerating  inflammation  with- 
out any  reparation,  attended  with  indura- 
tion of  the  furrounding  parts.  The  defcrip- 
tion  is,  a  fore  of  a  fomewhat  circular  form, 
excavated,  without  granulations,  with  mat* 
tcr  adhering  to  the  furface,  and  with  a 
thickened  bafe  and  edge. 

There  is  anotlier  fpecies  of  chancre  iij 
which  the  difpofition  to  ulcerate  is  lefs  than 
nfual,  and  the  difpofition  to  indurate  is 
greatci';  fo  that  the  ulcerated  furface  may 
heal,  and  leave  an  indurated  knob  or  tu- 
bercle  in  the  afFefted  part. 

There  are  befides  fome  chancres  in  which 
the  difeafed  aftion  feenis  to  be  very  inert ;  ir> 
thefe  tlie  ulcer  is  fupeiiicial,  the  thickening  of 
jhe  furrounding  parts  flight,  and,  after  fome 
time,  the  ulcerated  furface  acquires  a  ftate  of 
health,  and  cicatrizes,  without  producing  any 
perceptible  granulations.  I  conclude  that 
the  truly  fyphilitic   chancre  fometimes  af- 

fume; 


RESEMULtNO   SYVRILIS.  59 

fumes  the  appearances  juft  defcribed,  becaufe 
I  have  repeatedly  confidered  the  conftitu- 
tional  fymptoms  which  fucceedcd  to  fiich 
fores  as  truly  fyplulitic,  yet  I  may  have  bam 
deceived,  for  reafons  which  I  (hall  after- 
wards explain. 

But  it  is  impoffible  to  dejift  by  words  the 
various  fores,  fome  of  which  are  of  a  very 
irritable  nature,  that  are  produced  by  sexual 
intercourfc,  and  through  the  medium  of 
.which  the  conftitution  becomes  contami- 
nated;  neither  is  it  poffibic  to  know  from 
local  circumftances  whether  they  be  fyphi- 
litic  or  otherwife.  It  is  from  their  eflFefts 
upon  the  conftitution  alone,  that  we  can 
judge  whether  they  were  fyphilitic  or  not. 
Many  we  know  are  not  fo,  fince  they  do  not 
produce  the  conftitutional  cfFefts  of  fyphilis. 
The  fubjeft  can  alone  be  decided  by  future 
experience  derived  from  watchful  obferva- 
tipn  made  by  unbiafled  men.  Mr.  Hunter 
thought  that  fyphilitic  poifon  might  pro- 
duce a  fore  which  might  be  modified  by  the 
diftafed  propenfities  of  the  conftitutibn  and 

the 


6o  ON   DISSASXS 

the  pait,  and  thus  lofe  its  diftinctive  cha- 
rafters. 

Influenced  by  this  belief,  he  (peaks  but 
briefly  on  the  fubjeft  of  chancres.  I  have 
alio  feen  cafes  of  conflitutional  difeafe,  which 
I  confidered  as  fyphilis  originating  from  pri- 
mary fores  which  had  not  the  ufual  charafter 
of  fyphilis :  the  more,  however,  that  I  fee  of 
the  fubgeft,  the  more  I  am  inclined  to  doubt  the 
correftnefs  of  my  opinions  on  this  point,  and 
of  this  I  am  certain,  that  the  greater  mmiber 
of  the  confl:itutional  difeafes  originating 
from  fores,  which:  have  not  the  fyphilitic 
charafter,  differ  materially  in  their  progrefs 
and  mode  of  getting  well  from  thofc  which 
are  the  confequences  of  true  fyphilis,  and  that 
they  require  a  proportionate,  peculiarity  of 
treatment. 

However,  if,  according  to  the  opinion  of 
Mr.  Hunter,  the  action  of  a  fyphilitic  chancre 
may  be  fometimes  fo  modified  by  the  difeafed 
propenfities  of  the  conftitution,  or  pait,  as 
to  form  an  ulcer  f^arccly  cognizable  at  a 

fyphilitii; 


RESEMBLINO  SYtHILIS.  Sf 

fyphilitic  one,  it  follows,  as  a  general  rule  of 

condu6t  in  praftice,  that  furgeons  are  not 

to  confide  in  their  powers  of  difcrimination, 

but  in  all  cafes  of  ulcers  arifing  from  impure 

intercourfe,  to  aft  as  if  the  fore  was  fyphilitic, 

to  give  fufficient  mercury  (lightly  to  affeft 

the  conftitution,  in  order  to  guard  againft  the 

confequences  of  abforption,  and,  by  local  and 

other  general  means,  to  cure  as  quickly  as 

poflible  the  local  difeafe,  and  thus  remove 

the   fource  of  contamination,  and  the  nc- 

ceffity  for  the  continuance  of  medicine.    The 

quantity  of  mercuiy  neceflary  for  the  cure  of 

a  fyphilitic  chancre  will  never,  I  believe,  be 

found  to  be  fo  confiderable  as  materially  to 

difturb  the  conftitution.    We  may  therefore^ 

without  hefitation,  employ  it  in  almoft  all 

caies  of  primary  ulcers,  and  be  guided  as  to 

its  continuance  or  ceflation,  its  increafe  or 

diminution,  by  the  cfFefts  which  it  produces 

in  the  fore  or  conftitution.      Mercury  in 

small  dofes  inclines  other  fores  to  heal,  as 

well  as  thofe  which  are  fyphilitic;  it  may 

therefore  aft  beneficially  when  the  difeafe 

is  not  fyphilis,  and  by  contributing  to  the 

healing  of  the  fore  remove  the  fource  of  con* 

taminatioa 


tamination  and  the  ncceflity  for  the  continu- 
ance of  uaedicinc.  It  is  furely  an  object  of  im- 
portance to  get  the  local  drfeafe  well  as  fbon 
as  pofiible,  and  topical  applications  often 
greatly  contribute  to  this  defirable  event; 
yet  they  fhould  not  be  of  a  very  irritating 
nature,  for  fuch  means  frequently  aggravate 
the  difeafe,  as  may  be  feen  in  fome  of  the 
cafes  which  are  related  j  nor  fliould  our  ap- 
plications be  of  an  aftringent  nature,  fince  by 
checking  difcharge,  they  incline  the  difeafe 
to  become  indurated,  and  it  requires  a  longer 
continuance  of  mercuiy  to  remove  a  fmall 
induration  than  to  heal  a  large  fore.  This 
obfervation  applies  equally  to  fores  of  a  fyphi- 
litic  nature  and  to  others,  Whilft  there  re- 
mains an  induration,  we  can  never  be  furc 
that  it  may  not  ulcerate  again,  upon  leaving 
off  the  ufe  of  mercury,  nor  can  we  be  affured 
that  it  may  not  contaminate  the  constitu- 
tion. Indeed,  in  the  fyphilitic  chancre,  it 
feems  beft  to  ufe  none  but  the  fimpleft  drefs- 
ings ;  for  when  it  heals  by  the  effect  of  mer- 
cury on  the  conftitution,  we  are  aflured  of 
the  adequatenefs  of  the  quantity  which  is 
employed  to  the  intended  purpofe,  and  we 

5  have 


HESEMBLlNd^   SYPHILIS.  63 

have  reafon  to  believe,  that  the  conftitutional 
mercurial  affection  which  has  fubverted  the 
local  actions  of  the  difeafc,  will  have  prevented 
its  contamination   by  any  matter  that  may 
have  been  imbibed  from  it.     If  then  we  may^ 
for  the  reafons  above  ftated,  employ  mercury 
without  hefitation  in  primaiy  infected  fores, 
being  governed  with  refpect  to  the  degree 
and  duration  of  its  ufe  by  its   effefts,   we 
ought,  as  has  been  (hewn  in  the  preceding  part 
of  this  chapter,   to  purfue  the  reverfe  con- 
duCt  with    refpeft  to  conftitutional  fymp- 
toms.    Here  we  are  required  to  hefitate,  tha^ 
we  may  learn  the, nature  of  the  difeafe  pre- 
vious to  attempting  its  cure.     It   has  ap- 
peared to  me,    that   a  longer  and  more  ac- 
tive operation  of  mercuiy  on  the  fyftem  is 
neceflary  for  the  permanent  cure  of  con- 
ftitutional fymptoms  in  true  fyphilis,  than 
for  that  of  the  primary  chancre.     Here,  if 
we  ufe  mercury  unhefrtatingly,  we  may  em- 
ploy it  to  an  injurious  degree,  where  it  is 
not  wanted,  and  we  generally  fail  in  pre- 
venting a.  recurrence  of  fymptoms.     Thefe 
are,  I  believe,  the  general  rules  of  praftice 
adopted  by  the  beft  furgeons,  and.they  appear 

to 


64  OK  DISEASES 

to  mc,  in  the  prefent  ftatc  of  our  know« 
ledge  of  thefe  difeafes,  to  be  judicious^  One 
advantage  refults  from  this  plan  of  conduct, 
which  is,  that  if  conftitutional  fymptoms 
follow  from  a  fore  treated  in  a  manner  that 
ought  to  have  prevented  contamination  of 
the  habit  had  the  fore  been  fyphilitic,  our  fut- 
picions  are  excited,  and  by  attentive  obfer- 
vation  we  may  perhaps  difcover  that  the 
fymtoms  are  of  another  nature. 

In  cafes  of  anomalous  fores  it  may  be  en- 
quired, if  in  thofe,  where  the  event  renders 
it  probable  that  they  were  of  a  fyphilitic  na- 
.ture,  the  difeafe  deviates  materially  from  its 
common  chaiafters,  that  of  an  ulcerative 
procefs  without  reparation,  and  extending 
in  every  direftion.  Do  thefe  fores  enlarge 
by  floughing,  or  produce  granulation  or 
fungus  ?  do  they  fpread  otherwife  than  nearly 
equally  in  their  whole  circumference  ?  does 
the  ulceration  extend  in  them  only  in  parti- 
cular direftions  ?  do  they  heal  in  one  part 
and  fpread  in  another  ?  or  do  they  fuddenly 
amend  atid  become  worfe  without  an  ade*- 
quate  mercurial  influence  to  produce  fuch 

changes 


RKSEMfiLlNO  8YPHILII.  6$ 

Thofc  infcdted  fores  which  arc  not  fyphi- 
litic  have  fuch  peculiarities^  as  have  beea 
fhewn  in  the  firft  part  of  this  paper,  and  as 
they  are  fo  very  various/  it  becomes  necef^ 
iary  to  diftinguifh  them  from  thofe  which 
are  fyphilitic,  by  accuratdy  noting  the  pro- 
grefs  of  anomalous  cafes  of  the  latter  dUeaie. 
It  is  extremely  difficult  to  form  any  correft 
opinions  on  this  fubje£fc  on  account  of  its  in« 
tricacy,  and  die  almoft  impoffibility  of  ab- 
ftaining  from  the  ufc  of  mercury  j  but  it  is 
a  fub^6l:  highly deferving  enquiry,  and  whicl^ 
never  can  be  fairly  inveftigated  till  it  be 
known  that  the  fecondary  fymptoms  anfing 
from  fores  may  not  be  fyphilitic,  though 
their  appearances    cannot  be  ^ftinguilhed 
from  fuch  difeafes  by  fight  alone. 

With  refpeft  to  fores  that  are  not  fyphilitic 
the  difficulties  of  inveftigation  are  greatly 
multiplied.  If  a  defcription  cannot  be  given 
of  fyphilitic  fores,  it  feems  almoft  abfurd  to  fay 
any  thing  of  thofe  multiform  fores  produced 
1^  infectious  matter,  the  qualities  of  which^ 
it  is  probable,  may  be  varioufly  modified, 

VOL.  II.  p  and 


66  ON   DISEASBI 

and  the  cffcfls  of  which  appear  equally  liable 
to  modification  from  pecuHarities  of  conftitu- 
tion.  Yet  in  this  intj  icate  fubje£t  there  are 
certain  fafts  which  can  be  diftindWy  obferved» 
and  deferve  attention.  Some  of  thefe  fores 
fpreadby  ulceration,  and  fame  by  floughing, 
of  which  inftances  are  related  in  the  firit  fcc- 
tion  of  this  paper.  Even  Celfus  has  defcribed 
feveral  fpecies  of  fores  which,  as  Dr.  Adams 
has  obferved,  we  are  acquainted  with  in  the 
prefent  day.  I  have  never  feen  that  phage- 
djenic  ulcer,  which  fuddenly  floughs,  affeiSt 
■  the  conftitution ;  neither  do  I  believe  that 
furgeons  in  general  have  remarked  it ;  thofe 
who  regard  all  thefe  fores  as  fyphiliticattributc 
the  abfence  of  lecondary  fymptoms  to  tlic 
chancre  having  been  removed  by  the  flough- 
ing  of  the  furrounding  parts.  Yet  in  the 
cafe  related  by  Mr.  French  in  Mr.  Hunter's 
Treatife  on  t!ie  Venereal  Difeafe,  fecondary 
fymptoms  did  occur  from  a  fore  of  this  kind, 
and  got  well  without  mercury.  It  may  there- 
fore, perhaps,  be  doubted  whether  this  diJeafe 
be  not  an  aggravated  foj*m  of  the  fore  wliich 
floughs  more  flowly,  and  from  which  the  con- 
ftitution 


■ 


RESEMBLIKO    STPHILIS. 


67 

ftitution  is  much  more  frequently  afFe6ted. 
Though  Dr.  Adams  has  reftrifted  the  term 
Phagedena  to  one  kind  of  deftruftive  fore, 
yet  I  feel  more  inclined  to  leave  it  as  a 
generic  term  for  all  thefe  deftruftive  fores, 
and  to  divide  them  mto  fpecies  according 
to  their  peculiar  chara£lcrs.  Then  we  may 
defcribe  them  as  ulcerating  phagedenic 
fores,  and  fores  which  fpread  by  flough- 
ing.  Again,  the  ulcerating  or  lloughing 
proccfs  may  extend  not  in  all  but  in 
particular  dircftions,  and  the  floughs  may 
take  place  from  the  edges  or  from  the  whole 
furface.  As  Dr.  Adams  has  treated  thefe 
fubjefts  at  large,  I  refer  the  reader  to  his 
book  i  but  I  will  tak«  upon  me  to  dcferibe 
fome  fpecies  of  fores  which  frequently  occur, 
and  are  treated  generally  as  fyphUitic,  but 
which  I  am  convinced  axe  not  lb. 

The  fores,  in  one  fpecies  alluded  to,  generally 
break  out  in  fucccflion,  and  fometimes  after 
confiderable  intervals  of  time;  which  circum- 
ftance,  if  remarked,  would  render  it  improba- 
ble that  they  arofe  from  infection  of  tj&c  ulce- 
rated part,  fmce  fuch  fores  would  probably 


4 

4 


£S  ON    DISEASKd 

be  contemirorary.  The  ulcer  is  at  firft  in- 
flamed, and  fpieatls  ordinarily  to  the  fizc  of 
the  finger  nail :  its  circumference  is  thickened ; 
it  tluows  out  new  flefli,  which  riles  above  the 
fiHTOunding  Ikin  ;  fometimes  there  Is  an 
appearance  of  feveral  little  cells  or  fpaces  in 
die  interftices  of  the  granulations,  if  they 
may  be  called  fo,  owing  to  the  whole  ulcer 
not  producing  new  flcHi  in  an  equal  degree. 
The  edges  of  tlie  fore  generally  retain  their 
difeafed  ftate  after  the  middle  has  become 
healthy  ;  from  this  caufe,  the  healing  of  the 
fore  is  retarded.  Tliefe  fores  are  flow  in 
healing  under  any  mode  of  treatment,  and 
they  generally  get  well  in  tlic  fame  fuccef- 
fion  as  they  broke  out.  They  Ibmetimts 
form  in  a  circle  round  the  orifice  of  the 
prepuce,  and  caufe  a  contraftion  in  that 
part  aftei'  they  have  healed.  I  do  not 
mean  to  fay  that  all  If^res  occupying  this  fitu- 
ation  are  not  fyphilitic,  but  merely  to  ftate, 
that  fometimes  after  a  gonorrhoea  of  the  pre- 
puce, cither  originally  occurring  there,  or 
having  happened  by  a  mctaftalis  of  difealc 
from  the  urethra,  fores  do  break  oujt  in  ttus 
.fttuation  at  a  remote  period  from  the  reception 


A 


^f  the  infeftion,  which  arc  rtbt  iypliilitic. 
The  fores  which  I  am  endcavourihg  to  dc- 
fcribe,  feem  to  be  the  confequence  of  an  ini- 
tated  ftate  of  the  prepiKe,  from  which  there 
is  fometimes  a  flight  general  difehaige,  like 
that  whkh  takes  place  when  the  gonorrhaea 
fhifts  its  fituation  from  the  mouth  of  the 
urethra,  and  becomes  the  gonorrhea  of  the 
prepuce.  The  glands  in  the  groin  fometimes 
fwell  from  irritation  in  diefe  cafes,  and  gene-^ 
rally  fubfide  again,  though  I  have  known 
them  fuppurate :  but  I  never  faw  any  fecon- 
dary  fymptoms  (iicceed  to  this  fpecics  of  ulcer. 

In  the  earlier  part  of  my  praftice,  in  con- 
formity to  general  rules,  I  ufed  to  give  mer- 
cury in  thefe  ulcers  to  fecure  the  conftitution 
againft  infection,  whilft  I  tried  to  heal  the 
fores  as  fpeedily  as  I  could  by  topical  appli- 
cations. S  lightly  deftroying  the  furface  with 
the  argentum  nitratpm  ^very  fecond  day^  and 
drefling  with  the  icdution  of  zincum  vitriola* 
turn,  were  tl>e  local  means  which  feemed  to 
be  moft  fuccefsfiiL  An  attention  to  the  his- 
tory of  the  difeafo,  and  frequent  applications 
for  advice  from  pericxis  who  had  been  ^ 

F  3  verely 


ym  OM   DISSASB8 

verely  and  unavailingly  falivated  for  the 
cure  of  this  ipecies  of  fore,  fbon  embol- 
dened   me    to    abftain    from   the    uie  of 

■ 

mercury,  and  I  have  never  found,  though 
J  have  met  vtrith  a  confiderable  number 
of  inftances,  that  I  have  in  this  refped  a&ed 
wrong. 

I  (hall  mention  the  circumfVances  of  a 
cafe  which  occurred  to  me  no  long  time 
ago.  A  gentleman  had  a  flight  irritation 
in  the  urethra,  and  after  a  few  days,  foun4 
the  prepuce  a  little  fwollen,  with  a  fmall 
difcharge  from  beneath  it.  This  was  checked 
by  a  weak  folution  of  zincum  vitriolatum  ; 
and  afterwards  three  fores,  fuch,  as  I  have 
defcribed,  broke  out  in  fucceffion,  for  which 
he  ufed  mercuiy  fo  as  to  affeft  his  mouth. 
The  fores  flpwly  healed,  but  two  new 
ones  made  their  appearance,  and  the  mer-r 
curial  courfe  was  perfevered'  in.  Thefe 
fores  alfo  healed  flowly,  and  a  running  came 
on  from  the  urethra,  nq  new  fpres  haying 
appeared.  The  mercury  was  left  off,  the 
gentleman  came  to  town,  and  was  much  dif^ 
^effed  to  find  that  three  other  fores,  exaftly 

like 


MSSMBLIKO  SYPHILIS.  fl 

like  the  former  ones,  now  broke  out,  but  the 
difcharge  from  the  urethra  had  ceafed.  At 
this  period  he  applied  to  me,  and  gave  me 
the  foregoing  narrative  of  his  diforder,  with 
an  aflurance  that  he  had  expofed  himielf  to 
no  new  rifk  of  infedlion.  I  employed  biily 
local  means  for  their  cure,  being  fatisfied  by 
the  hiftory  as  well  as  the  appearance  of  the 
fores  that  they  were  not  fyphilitic.  Near  a 
month  elapfed  before  any  confiderable  amend- 
ment took  place,  when  a  fwelling  appeared 
in  the  groin,  and  the  fores  healed  fuddenly 
in  a  few  days.  Leaches  and  Goulard's  wafh 
were  employed  to  difperfe  the  bubo,  but  in 
rain  ;  it  fuppurated,  and  formed  a  very  un- 
healthy abcefs.  There  was  a  great  deal  of 
iurrounding  eryfipelatous  inflammation,  the 
cuticle  feparated  from  the  furface  of  the 
bubo,  the  fkin  became  livid,  and  gave  dif. 
charge  to  the  matter  by  a  partly  floughing 
and  partly  ulcerating  procefs.  This,  how- 
ever, proved  the  crifis  of  the  complaint :  the 
abfcefs  having  thus  broken  filled  up,  and 
healed  in  the  courfe  of  about  three  wdeks, 
fince  which  the  patient  has  had  no  return  of 

F  4    '  difesUe. 


y%  OH   DISEASES 

difeafe.  This  gentleman  was  liable  to  have 
fores  break  out  fpontaneoufly  on  the  pre- 
puce :  they  got  well  readily  by  bathing  them 
with  a  weak  folution  of  zincum  vitriolatum ; 
and  I  believe  that  perfbns  who  have  naturally 
an  irritable  ftate  of  the  prepuce  are  moft  ob- 
noxious to  fuch  afFe£lions.  We  muft  not, 
however,  impute  the  occurrence  of 'thefe  pe- 
culiar fores  to  Jtnere  irritability,  but  to  fomc 
ipecific  contagion, 

^  The  dilcharge  from  the  urethra  in  fuck 
cafes  is  not  confiderable,  nor  attended  with 
much  inflammation  or  chordee,  nor  does  it 
increaie  in  violence;  it  may  therefore  be 
cafily  diflinguifhed  from  common  gpnorrhaea 
and  its  varieties. 

Sometimes,  in  a  common  gonorrhaea,  the 
difeafe  fhifts  its  ground  and  attacks  the  fore- 
flkin,  and  fores  form  about  the  orifice  of  this 
part.  Thefe  are  of  a  different  nature  from 
the  fores  which  I  have  been  defcribing :  their 
furface  is  generally  glofly,  not  producing  ex- 
uberant new  flefh,  and  their  colour  is  xm- 

'hcaltby. 


RESEMBLINO   SYHIILIS.  \J^ 

licalthy.  They  generally  get  well  as  the^di^ 
eafe  returns  to  its  originad  fitiuiticHi  ia  t^ 
urethra.  I  merely  mention  thefe  cir^m- 
ftances  to  induce  attention,  and  to  previet^ 
furgeons  from  confounding  the  fores  whicji 
I  have  been  deicribing  with  any  other  fitaf- 
larly  (ituated,  but  different  in  their  nature  / 

I  wifh  alfo  to  excite  attention  to  another 

fpecies  of  fores   which   I  have"  frequentljf 

met  with,  and  which  differ  confiderably  in 

their  progrefs  from  thofe  truly  fyphilitic. 

The  firft  appearances  of  the  fores  are  various, 

but  in  their  progrefs  a  thickening  in  the 

Surrounding  parts  takes   place,  whilft  the 

centre  is  foft  and  lefs  difeaied  than  the  €tr-<r 

cumference.    I  have  feen  the  furrounding 

parts  much  elevated,  and  an  opening  leading 

,  into  a  cavity  in  the  middle.  I  have  feen  f  heiB» 

on  the  contrary,  heal  with  a  flat  furfiice 

and  acquire  a  circular  hardnefs,  the  middle 

being  quite  foft,  and  the  area  of  the  circle 

gradually  increafe.     I    have   known    lores 

heal  apparently  well  and  fmoothly,  and  after<<» 

wards  the  edge  has  acquired  a  circular  hac4t 

neis  like  a  ring  of  fome  firm  fubflance. 

In 


OK  DISBASES 

'  In  all  thefe  fores  I  have  given  mercury 
in  dofes  fliort  of  producing  a  tendemefs  of 
the  gums,  and  the  difeafe  has  gradually  but 
flowly  got  well.  In  the  greater  number  of 
cafes  no  conftitutional  afieftion  has  eniiied. 
'  In  fome,  however,  it  has,  but  it  has  got  well 
.without mercury,  or  with  fuch  fmall  dofes 
as  would  certainly  not  have  cured  fyphilis. 
So  that  thefe  obfcrvations  concur  with  the 
hiftory  of  the  difeafe,  in  inducing  me  to 
believe  that  fores  of  this  defcription  are  not 
fyphilitic. 

m 

Under  this  head  of  fores  which  occur  on 
the  genitals,  and  which  are  not  fyphilitic,  I 
may  mention  one  fpecies  that  I  have  feveral 
times  feen  on  the  fide  of  the  penis,  which  is 
herpetic,  afFefting  new  parts  whilfl  thofe  firfl 
atFefled  get  well ;  fo  that  the  fore  may  exift 
a  long  time,  and  be  very  troublefome,  though 
its  fituations  may  have  varied  confiderably. 

I  have  alfo  fiben  a  circle  of  fmall  fores,  like 
what  takes  place  in  tinea,  occur  on  the  out- 
fide  of  the  prepuce  in  confequence  of  fomc 
acrimonious  fecretions  being  applied  to  it  in 


HESEMBLING   8TPHILY|^  75 

fexual  intercourfe.  Some  di&a&s,  whatever 
may  be  their  primary  nature,  do,  after  a  time^ 
{Extend  themfelves  between  the  integuments 
and  the  fubjacent  parts.  I  have  known  many 
difeafes  whi?h  burrow  in  this  manner  treat* 
ed  as  fyphilitic,  and,  as  the  event  of  the 
^afes  has  proved,  improperly.  Indeed^  the 
progrefs  of  fuph  diiea&s  is  fo  different  from 
that  of  fyphilis,  that  it  is  natural  to  difcredit 
their  being  fo.  Difeafes  which  proceed  in  this 
mamier  feem  to  be  of  an  irritable  nature,  and 
to  affeft  mpfl  thofe  parts  which  have  leafi: 
powers  of  life,  which  appears  to  be  the  caufc 
of  theh*  peculiar  mode  pf  extending  them* 
felves. 

*  *  • 

To  corroborate  this  remark,  that  fores 
^hich  burrpw  are  not  likely  to  be  fyphilitic, 
I  may  niention  the  cafe  of  a  gentleman  of  the 
inedical  profeflion,  who  had  a  fore  of  this 
defcription,  which  began  on  the  dorfum 
penis,  near  to  the  pubes,  for  which  he  ruh- 
.  bed  in  two  months,  and  had  his  conflitution 
ppnfiderably  affected ;  neverthelefs,  the  fore 
fpread  and  burrowed  under  the  integuments 
pf  the  pubes,  and  the  mercuiy  was  left  off. 

The 


\ 


76  '•«   OIMASES 

The  difeafe  became  communicated  to  a 
confiderable  diftri6l:  of  the  integuments  Gif 
the  bottom  of  the  belly,  and  to  thofe  «f 
the  fcrotum.  The  afFe£ted  parts  ibmetimeB 
ulcerated,  and  fometimes  heal<Kl.  A  great 
variety  of  local  and  general  remedies  were 
tried  without  benefit.  No  mercury  was  ufed 
except  in  very  trivial  quantity.  The  canities 
braeath  the  (kin  were  in  ibme  parts  laid  open^ 
at  di^i^ent  periods  of  the  diieafe  i  but  wi^out 
much  advantage.  After  two  years  and  a 
half  the  difeafe  became  well,  when  nothing 
but  fimple  dreflings  were  applied,  and  when 
he  took  nothing  but  decoction  of  ffu'fapariUa 
and  fmall  dpfes  of  rhubarb. 

I  have  in  the  foregoing  pages  endeavoured 
to  reprefent  briefly  the  circumftances  of  the 
primary  ulcers  of  difeafes  which  are,  and 
of  thofe  which  are  not,  fyphilitic,  and  to  ftate 
the  general  rules  for  the  adminiftration  of 
mercury  5  and,  at  the  fame  time,  I  have  de- 
fcribed  fome  fores  which  have  not,  as  far  as  I 
know,  been  diflinguifhed,  and  which,  in  my 
opinion,  are  not  fyphilitic,  though  they  are 
generally  treated  as  fuch.    To  take  a  fimilar 

compa* 


f  RXSEMBLINO  SYPHILIS.  y^ 

comparative  vievir  of  conftitutional  ^difeaics 
aiifing  from  thefe  various  (ores  would  render 
tMs  paper  too  prolix.  I  hope  it  will  be  leeti 
that  I  do  not  prefume,  nor  do  I  fee  caufe,  tc^ 
deviate  from  the  eftablilhed  rules  of  prac- 
tice foimded  on  the  general  experience  of 
furgeons.  It  would  indeed,  in  my  opinion, 
be  prefumptuous  in  an  individual  to  form 
general  rules  drawn  from  his  fcanty  e)cpe« 
rience ;  I  may  be  allowed,  however,  to  re-  > 
mark,  that  individuals  of  the  profeflion  are 
likely  to  err  by  inferences  drawn  from  their 
own  {M-aftice  %  and  it  spears  to  me  that 
fome  profeflional  men  at  preient  are  inclined 
to  believe  all  fores  arifing  from  impure  con* 
nexion  to  be  fyphilitic,  whilA:  others  may  be 
too  icrupulous  in  expelling  all  fyphilitic  fores 
to  pofiefs  their  common  chambers.  The 
truth  probably  in  this,  as  in  other  caies^ 
lies  between  the  extremes.  Much,  however, 
it  muft  be  acknowledged,  rmuuns  to  be  af« 
certained,  and  I  think  that  thoie  forgeon^ 
would  do  eifential  fervice  to  fcience,  who 
would  give  an  accurate  account  of  the  ir^ 
regularities  of  the  venereal  diieafe.  But  fudi 
an  account  never  can  be  given  by  one,  who 

efteems 


78  OK   DISEASES 

efteems  all  difeafes  fyphilitic,  which  refcmbic 
them  in  appearance.  The  foregoing  cafes 
will,  I  think,  at  leaft  prove  this  to  be  iact  -, 
and  it  was  a  principal  incitement  to  tlidr 
publication,  that  if  this  faft  were  gene- 
rally admitted,  it  might  excite  that  fcinipu- 
lous  attention  and  impartial  cbfei'vation  of 
fyphilitic  difeafes,  which  would  probably 
lead  to  accurate  diftinftions,  and  the  removal 
of  that  obfcurity  with  which  they  have 
hitherto  been  furrounded.  I  have  fupprefied 
many  obfervations  of  my  own  on  this  fub- 
jcft,  from  a  belief  that  it  is  better  to  fay 
nothing  than  to  offer  opinions  not  fully 
confirmed  by  fa£ls.  The  idea  that  fyphilis 
is  a  moft  variable  and  Proteus-Uke  difeafc, 
has  probably  arifen  from  thofe  irregular 
difeafes  which  I  have  defcribed  in  the  firft 
feftion  of  this  paper  having  been  confounded 
with  it.  The  opinion  is  however  prejudicial, 
as  it  checks  attentive  oblei-vation  by  declaring 
its  inutility.  If  it  fhould  be  in  our  power, 
as  I  fhould  hope  it  may,  by  dire£ting  our 
attention  to  the  hiftory  rather  than  to  the 
appearances  of  thefe  difeafes,  to  diftinguilh 
fyphilis  from  other  complaints,  then  we  may 

alfo 


RESEMBLINO  SYPHILIS^  f9 

alfo  be  able  to  defcribe  the  irregularities  of 
this  difeafe,  and  to  inform  others  when  it 
aflumes  deceptive  characters,  and  purfuey 
an  unufual  track,  what  difguife  it  puts  on^ 
and  what  courfes  it  follows. 


•i 


it 


k  • 


i    '■  :         J  .  ;  '  ;     / 


,» 


« 


'I  ,  ii    r , 


ii:w  ; 


VOL.  II. 


♦l.    8 


#0  *  6k  onsASBt 


SECTION  rxi. 

Oh  tyconJUtutional  Origin  of  Pfeudd-SypU^ 

litic  hifeafe^. 

f  N  Order  further  to  clucidaitc  the  nature 
of  pfeudo-fyphilitic  difcafcs,  I  publifhed 
fomc  cjtfes  in  which  they  originated 
fpontaneoofly^  or  without  there  being 
any  reafotiable  ground  for  fuppofing  that 
morbific  animal  matter  had  been  intbibed  to 
« contaminate  the  conftitution.  The  cafes  in^ 
eluded  in  this  fe£tion  were  firft  publifhed, 
amongft  others  which  were  deftgned  to  fhew 
the  importance  of  corns^ing  difwders  of  the 
digestive  organs  in  attempting  to  cure  local 
difeaies.  A  diforder  of  thole  organs  con- 
iVantly  exists  in  thefe  cafes ;  and  produces, 
or  at  leail  aggravates  and  procrafts  a  ftate  of 
weakness  and  irritability  of  conftitntion ;  to 
which  the  origin  c^  the  difeaie  muft  unr^ 
doubtedly  be  referred. 

CASE   XH- 

A  gentleman  refiding  in  the  country,  who 
had   been  ihany  years  married,  and  whofe 

moral 


RESEMBLING .  SYPHILIS.  Sc 

motal  chai'a£ter  prevented  any  fufpicion  of 
his  having  expofed  himfelf  to  venereal  infec- 
tion, had  an  ulcer  in  the  right  tonlil,  pofleffing 
every  character  of  a  truly  fyphilitic  fore.  The 
figure  of  the  ulceration  was  oval;  it  had  ex- 
tended  itself  deeply,  and  prefented  a  furiace 
cdvei*ed  with  adhering  matter,  and  without 
the  least  appearance  of  granulations.  It  had 
contmued  three  months  without  amendment, 
adthough  various  medicines  had  been  employ* 
ed  during  that  period.  Thefe  circumftances 
imprefledthe  minds  of  the  medical  attendants 
with  an  opinion,  that  the  diieafe  was  fyphi- 
litic. On  me  they  had  a  contrary  effect.  I 
thought  that  a  fyphilitic  ulcer  would  have 
become  materially  worfe  in  that  time,  as  mer- 
cury had  not  been  ufed  to  arrest  its  progrefe. 
Finding  that  the  patient  had  a  furred  tongue, 
and  diforder  of  the  digestive  organs,  I  recom- 
mended, as  the  first  obje6t  of  attention,  the 
correftion  of  that  derangement  of  the  fto- 
mach,  from  which  the  fore-throat  had  pro- 
bably originated.  The  patient  went  to  the 
fea-fide,  where  his  throat  was  alternately 
better  and  worfe;  but  the  dimenfions  of 
the  ulcer  were  not  wlarged.  Three  month$ 
TOL.  11.  G  elapled 


si  OK   blSKAS£9 

elapfed  before  I  faw  the  patient  a  fccoiu! 
tfane;  when  I  told  him  that  my  argument 
againft  the  complaint  being  fyphilitic  was 
greatly  ftrengthened.     It  was  manifeft  that 
the  dilbrder,  to  which  I  had  imputed  the 
fore,  ftill  exifted.     Being  unwilling  however 
that  the    refponfibility  ftiould   reft  entirely 
upon  my  felf,  I  advifed  him  to  confult  anothw 
furgeon,  who,  judging  of  the  nature  of  the 
fore  from  its  appearance,  (which  indeed  was 
ftrikingly  charafteriftical  of  fyphilitic  difeafe,) 
recommended  a  courfe  of   mercury.     The 
patient  underwent,    in  confequence  of  this 
advice,  a  regular  mercurial  courfe ;  during 
which  the  fore  got  well/    Between  two  and 
three  months  afterwards  another  fore  formed 
in  the  palate,  which  had  the  characters  of 
a  fyphilitic  ulcer,  in  a  ftill  more  ftriking  de  • 
gree,  if  poflible,  than  the  former.     It  was 
fituated   just    where    the    foft  palate  pro- 
ceeds from  the  bone.     It  was  of  a  circular 
figure,  and  fo  deep  as  to  expofe  the  bone^ 
The  circumference  of  tlie  ulcer  was  tumid 
and  inflamed  i;  its  edges  were  not   fmooth, 
hut  liad  A  tejjbflency  to  ulcerate.     There  was 
no=  appewariCB.  of  granulations,  and  the  dif? 
'  .L.      '-  change 


i 


charge  adhered  to  the  furfacc  of  the  ulcen  • 
The  patient  now  applied  to  me  again ;  when 
I  repeated  my  original  opinion^  that  thefe 
fores  depended  on  the  ftate  of  the  health  in ' 
general.    He  confulted  another  furgeOn,  who 
recommended  the  ufe  of  the  Lifbon  Diet^ 
Drink,  with  the  application  of  the  oxymfel 
aeruginis  to  the  part ;  under  which  treatment 
the  ulcer  healed;  and  no  other  complaint 
has  fince  occurred,  though  two  years  have^ 
elapfcd. 

CASE  XlIL 

A  gentleman,  who  was  habitually  fubjefl 
in  a  great  degree  to  diforder  of  the  digcftive 
organs,  had  an  excoriation  of  the  prepucd, 
which  had  Continued   tiix)ut  three   weeks/ 
when  coppers-coloured  eruptions .  tanie  out 
all  over  his  body,  fo  ftrikingly  finiilar  to 
thofe  which  are  venereal^  that  fome  of  his 
medical  attendants  recommeiided  tht  iffitne-* 
diatt  ufe  of  mercury.  It  was  however  iagree?f 
0  delay  the  mercufialcourfe'foi'  a  littlef  tiftid  j 
and  to  give  the  patient  half  a  graifi  of  Calofflef, 
with  three  grains  of .  hemlock  tAght  and' 
morning,  and  a  fblutldhof  ifia^nefia  ^trtelattT 

Q  2  jjft 


^4  on  DISBASX8 

in  mint-water,  fo  as  to  keep  the  bevels 
freely  open*  The  fpots  began  to  die  away 
almost  immediately,  and  foon  difappeared 
altogether.  The  patient  then  mentioned  that 
he  had  feveral  times  had  the  fame  kind  of 
eruption,  which  had  diiappeared  in  like  man- 
ner upon  taking  fome  openii>g  medicines. 

In  calling  the  reader's  atttention  to  those 
difeafes  of  the  bones  which  refemble  fyphi- 
litic  affections,  I  Ihall  not  pretend  to  rdate 
any  cafe  in  detail ;  for  furgeons  can  feldom 
trace  the  progrefs  of  thefe  difeafes  for  them- 
felves,  but  are  obliged  to  rely  on  the  doubtful 
hiftory  given  by  their  patients.  I  fhall  en- 
deavour to  Iketch  the  principal  parts  of  the 
fubject,  referring  to  particular  cafes^  merely 
to  shew  that  the  picture*  is  not  drawn  from 
fancy,  but  is  copied  from  nature. 

I  have  been  frequently  confulted  on  account 
of  fuppofed  venereal  afFe6tions  of  the  bones ; 
where  the  periofteum  has  be«i  thickened  and 
tender,  and  the  bone  enlarged,  and  the  con- 
comitant pains  have  been  fo  much  aggravated 
at  night  as  to  deprive  the  patient  of  reft.  The 

hiftory 


S.ESSMBLIKO  S7PHILIS*  ts 

hiftcry  of  the  cafe  has  removed  all  fufpicion 
of  a  venereal  origin  j  while  general  indifpo- 
fition,  a  ftirred  tongue,  lofs  of  appetite,  and 
other  attendant  fymptoms,  have  clearly  indi- 
cated great  diforder  of  the  chylopoietic  vifccnu 
By  attending  to  the  ftate  of  the  digeftive  or- 
gans in  thefe  cafes,  the  patient's  health  is 
amended ;  the  general  rheumatic  pains  are  di- 
minifhed  s  fleep  is  procured ;  and  the  difeafe 
has  receded  almoft  entirely.  After  fbme  time 
has  elapfed,  the  bone  may  again  fwell,  tht 
^veiling  may  again  be  checked,  and  return  no 
more.  Perhaps  (imilar  difeafes  may  take 
place  in  other  bones,  at  times  very  remote 
from  the  firft  occurrence  of  the  diforder.  If 
mercury  be  not  employed,  there  are  deciiive 
circumftances  in  the  hiftory  of  the  cafe, 
which  proves  that  it  is  not  iyphilitic.  Some- 
times fuppuration  takes  place,  and  expofcs  the 
bone :  this  occafionally  proves  a  kind  of  crifis 
to  the  difeafe  at  that  part.  But  the  circum- 
ftances of  thefe  afFe6lions  are  fo  variable  as  to 
preclude  a  complete  enumeration  of  their 
Symptoms. 

J  fhall  briefly  mention  the  cafes  of  two  pa- 

0  3  tients. 


9^  .  ^PJ«.,DJS»A«W. 

tients^  by  whom  I  was  ponfulted  about  the 
j&niptijue,  in  order  ^  identify  the  difcaflcs  to 
wldch  I  allude.     9oth  thefe  gentlemen  had 
been  iriarried  for  many  years  i  and  ther«  was 
not  the  least  reafon  to  fuppoie  that  ^uiy  mor-r 
bificpoiibn  had  been  imbibed.     They  bcr 
came  generally  indi^poTed,  had  relief?,  nights, 
pain^  ic^  the  head,  and  about  the  flioulders  ^ 
and  a  painful  thickening  of  the  poiofteum 
of  the-  tibia,  with  enjargement  of  the  bone, 
took  place.    The  chylopoietic  vifccra  were 
,^ifordered  in  both  thefe  cafes.     One  gentle- 
man had  ufed  npiercury  repeatedly  to  a  con- 
iiderable  extent,  which  produced  a. temporary 
alleviation  of  his  difeafe }  but  his  fufferings 
feemed  to  be  augmcnt;ed  upon  the  ceflation  of 
the  merqurial  excitement.     The  other  patient 
never  ufed  any  mercury.     They  both  experi- 
enced a  confiderable  mitigation  of  pain  from 
thofe  medicines,  which  correfted  the  ftate  of 
the  chybpoietic  organs.     Their  difeafes  were 
checked,  and  never,  became  again  fo  bad  as 
before  attention  had  been  paid  to  the  state 
of  the  vifcera.      Both  thefe  patients   wer^ 
better  or  worfe  as  the  ftate  of  the  bowels  va- 

riedj 


rccovcredi.  :•  .'  -^loii  ■.         ,  ..  .,.  i..;r  / 

V    .  •• t      tT^^  c*    "i  ■  h**"   ■-'-■■         ,  •  -     •• 

1 . ;  Similar  difeaies  'ftre  h  coQHnon^  that  I  bc(- 
iiffive  every  futgeoix  oE.expf&rionce'wiii  adtbiit 
thatafFe^lions  of  the  bencs,  with  wandenx^ 
p^ns,  often  occur  from  geaei^al  difbrder  ofthe 
iDcalth.  I  have  ^bever  feen  ihefe  cafes  xmac- 
companied  by  difiirder  of  the  chylopoietic 
organs ;  and  I  have  always  found  them  mtiSt 
laenefited  by  whatever  ha$  tended  to  re£iify 
the  fun£tions  of  thefe  organs* 

There  was  no  reafon,  in  any  of  the  cafis 
alluded  to,  to  fuipedl  the  abibrption  of  poifon. 
J  will  add  another,  to  corroborate  this  ftato^ 
ment.  A  gentleman,  who  had  been  marrie<i 
about  eight  years,  and  had  no  venereal  difeafe 
during  that  period,  was  feized  with  a  violent 
fever.  Shortly  after  his  recovery,  a  thicken- 
ing of  the  periofteum  on  the.  paricbil  bonte 
took  place.  The  fcalp  was  alfo  much  fwoUen, 
fo  as  to  threaten  fuppuration.  He  was  at  this 
time  in  ill  health,  and  hid  gf  dat  derangement 
•df  the  digeftive  organs.  By  attention  to  this 
letter  diforder,  the  fwellirig  fubfided,  and  no 

6  4  trace 


8S  air  MUASi$ 

trace  of  it  retnained.  The  patient  afterwards 
went  into  the  country,  where  his  health  was 
ftili  more  amended.  In  about  twelve  mcmths 
he  had  icveral  tumours  cf  the  ikme  kind  in 
different  parts  of  the  cranium;  one  alone 
threatened  to  fiippurate :  for  theie  he  under^ 
went  a  mercurial  courfe,  which  relieved  them^ 
ib  as  to  induce  him  to  perfevere  in  it  to  an 
extent,  which  almofi:  confbantly  cures  venereal 
difeafe.  His  health,  during  the  latter  part  of 
thcf.  mercurial  courfe,  being  much  diibrdei*ed 
by  the  medicine,  his  d^feafes  became  pio^ 
portionally  aggravated ;  he  therefore  defifted 
from  the  ufe  of  mercury ;  at  which  time  his 
complunts  were  but  little  better  tlian  at  their 
commencement.  Thefe  difeafes,  however, 
gradually  got  well  in  the  fpace  of  little  more 
than  a  year ;  flill  the  patient  continued  in  a 
bad  ftate  of  health,  the  fymptoms  of  which 
were  a  furred  tongue,  indigeftion,  and  faulty 
biliary  fecrction. 

I  add  another  cafe,  which  came  under  the 
obfervation  of  Dr.  Baillie.  A  ftudent  of  me- 
dicine, who  attended  the  leftures  in  Windmillr 
ftreet,  was,obferved  to  look  veiy  much  out  qf 

health 


RSSBMBLIH^  SYPHILIS*   ^  Sf 

health  ;  and,  on  enquiry,  it  was  found  that 
he  had  nodes  upon  his  fhins,  which  fo  exadjj 
reiembled  thofe  that  are  venereal,  that  no 
doubt  was  entertained  of  their  bdng  of  that 
nature.  It  was  therefore  eameftly  recooii-^ 
mended  to  him  not  to  delay  the  mercunal 
courie,  which  (eemed  requifite  for  the  cure. 
He  was  rery  rduftant  to  comply  with  this 
advice,  and  declared  upon  his  honour  that  he 
had  (imilar  fwellings  before  he  had  had  airf 
jexual  conne£tion.  This  declaration  made 
this  propofal  to  be  laid  afide ;  and  the  nodes 
got  well  by  a  flrong  deco6Hon  of  fariaparilla. 
without  a  (ingle  gi-ain  of  mercury  bdng  eov 
ployed.  Now,  if  this  account  be  accurate,  it 
(hews  that  difea(es  like  (yphilis  can  ari(e  from 
diforder  of  the  health,  even  without  any  fexua} 
intercour(e. 

All  furgeons  of  experience  will,  I  believe, 
admit  that  difcafes  refembling  fyphilis  occur 
from  di(brder  of  the  health  in  general.  In  all 
the  caies  whieh  I  Have  inftanced,  thei'e  was 
not  the  leaft  rea(bn  to  fuppofe  that  any  mor« 
bific  poi(bn  had  been  imbibed  to  produce  the 
difeafes  which  exiAed.    I  wi(h  much  to  have 

this 


thits  point  afcertaified  of  refuted  by  the  gener^ 
dcperience  of  furgeons.  The  cafes^  which 
would  tend  toeftftbUfhit,  miiftbeof  rareoccurr 
Xi^ef;  Mpft  of' the  u;iil:ancesv  to  which  I  have 
aflodrd,  occurred  m  knen  who » had  bean  long 
inanicd^iand  on  Wiioie  veracity  *  I  could  rely. 
.l^buereiiiaUb)  in  isiy  opinion^  fufficient  intiiniic 
CYidelrce  in  each  cafe  to  prove  that,  the  difeaie 
aifar.ttDtivenereaL  It  was  this  kind  of  cafes 
iifi^di  I  had  in  view  in  my  lafl  publication, 
ibf,  difcufHng  tlie  queflion  whether  thoie  di£- 
cflEfes,  which  may  be  denominated  pfeudo^fy-* 
piuHtic^:  arife  from  fome  modification  of  the 
^vcDereal  poifon^  oc  from. a  peculiaiity  of  coni- 
ilitation  in  the  patkjats,  who  are  expofed  to 
ihe  .afticxa  of  truly /fyphilitic  virus,  I  have 
there  feid>  that  f  *  it  deferves  to  be  obferved 
that  difeafes  refembling  fyphilis  do  occur^ 
without  any  reafon  to  fuppofe  that  any  mor- 
bific poifon  has  been  admitted  into  the  fyftem/* 
I  have  been  induced  to  dwell  upon  this  fub- 
je£l,  which  may  perhaps  be  confidered  more 
ipeculative  than  ufeful,  becaufe  if  the  opi- 
nion were  verified,  ii  would  explain  the  oc- 
currence of  pfeudo-fyphilitic  difeafes  in  a  very 
striking  and  fatisfactoi^  manner.     If  local 

4  difeafes 


R£S£MBI«lMO   SYPHILIS.  9t 

difeafes  refembling  fyphilis  may  take  place 
in  the  throat,  ikin,  and  bones,  from  a  certain 
ftate  of  weaknefs,  *and  irritability  of  conftitu-; 
tion,  then  various  modifications  <^  animal 
matter  being  abforbed  mly  (o  diford^r  the  ge- 
neral health  as  to  induce  fuch  a  ftate  of  weak- 
ness and  irrk^ion,  as  is  likely  to  produee 
thofefymptoiAs,  andliK^h  iymptoras<are  rallier 
to  be  regarded  as  ariitng  from  the  |>ropenfities 
'of  the  conftitution,  than  from  the  peculiar 
propertiies  of  the  matter  which  ha;s  been  im^ 
bibed.  It  is  fhcwn  in  my  former  publication, 
that  the  poifon  which  produces  pfeudo^fjrphi- 
litife  fymptoms  is  fometimes  abforbed  without 
an  ievident  breach  of  furface  in^  the  Ikin  j 
fometimes  from  a  tribal  fore  which  foon 
heals ;  whilft,  in  other  cafes,  it  produces  local 
fores  of  various  and  diflimilar  characters. 


«        V        A 


92  OK  DI6SAi£8 


SECTION  IV. 

On  the  Rffedis  of  Mercury  in  Pfeudo-^Sypbilitit 

Difeafes. 

TjAviNo  thus  by  the  publicatioa  of  the 
**  •*  coics  related  in  the  two  preceding  fee- 
tions,  endeavoured  to  excite  a  general  inves- 
tigation of  a  fubjeft  which  I  think  every  ono 
^U  adimt  to  be  highly  important,  I  proceed 
to  relate  fome  additional  cafes  of  diieaies 
which  I  coniider  a$  pfeudo-fyphilitic,  and  in 
which  mercury  was  employed  for  their  cure, 
in  order  to  ihew  the  effefts  refulting  from 
its  ufe.  I  was  neceffarily  precluded  from 
bringing  forward  fuch  cafts  in  my  firft 
attempt  to  elucidate  this  fubjeft,  because 
my  objeft  at  that  time  was  mercly  to  fhew, 
that  difeafes,  which  could  not  by  fight  be 
diftinguifhcd  from  fyphilis,  yet  differed  from 
it  in  the  primary  fores  from  which  they 
originated,  and  alfo  in  their  progrefs ;  for 
they  got  well  without  the  adminiftration  of 
mercury,  and  generally  recurred  after  the 
fevereft  courfe  of  that  medicine.  The  lat- 
ter 


RESEMBUNG    SYPHILIS.  93 

tei*  fa6l  will,  indeed,  be  more  ftrikingly  ma- 
nifefted  by  the  fucceeding  cafes.  I  was  alfb 
prevented  from  relating  cafes  of  this  defcrip- 
tion,  becaufe  the  adminiftration  of  mercury 
may  be  fuppofed  to  render  the  nature  of  the 
fubfequent  fymptoms  amb]guous ;  fince  they 
may  be  confidered  as  the  efFeft  of  that  dis- 
order of  the  conftitution,  which  the  poifbn 
and  the  antidote  have  conjointly  produced* 

As  the  tide  of  public  opinion  feemed  at 
that  time  to  run  ftrongly  againft  me,  I  men* 
tioned,  that  any  experienced  furgeon,  who 
regarded  the  cafes  in  queftion  as  anomalous 
cafes  of  fyphilis,  would  do  a  moil  elfential 
fervice  to  fociety,  if  he  would  lay  down 
pra6tical  rules  for  the  treatment  of  fuch  dif« 
cafes.  As  no  one  has  undertaken  this  tafk,  I 
fhall  endeavour  to  accompliih  it ;  for  I  think, 
that  the  cafes^  which  I  ihall  relate  will  at 
Icaft  Ihew  what  mercury  will  do,  and  what 
it  will  not  do,  in  thefe  difeafes.  An  attempt 
to  eftablifh  rules  for  the  treatment  of  thcfc 
difeafes  appears  to  me  of  great  importance ; 
becaufe  difcordance  of  opinion  is  both  dif- 

^  creditable 


94  <^  DISEASES 

creditable  to  the  profeflion>  and  injurious  to 
patients. 

Before,  however,  I  relate  the  fafls  from 
which  I  mean  to  deduce  the  pfaftical  rules 
of  treating  thefe  difcafes,  I  wifh  briefly  to 
recapitulate  the  reafons  which  induce  me 
to  think  that  they  are  not  fyphilitic  j  and 
alfo  to  advert  to  the  arguments  which  I 
have  heard  brought  forward,  by  thofe 
who  entertain  a  contrary  opinion.  I  wifh, 
alfo,  to  confider  the  effefts  likely  to  be  pro- 
duced on  the  conftitution  at  large,  by  the 
afcforption  of  morbific  animal  poifons ;  and 
to  difcufs  the  probable  efFefts  of  mercury, 
adminiftered  in  different  degrees ;  bccaufe  I 
think  it  necelTary,  that  all  thefe  circum- 
ftances  fhould  be  borne  in  mind,  whilfl:  the 
reader  perufes  the  cafes,  in  order'  that  he 
may  form  a  proper  judgment  of  the  nature 
and  treatment  of  thefe  perplexing  difeafes, 

I  concur,  then,  with  Mr,  Hunter  in 
opinion,  that  thefe  diieafes  are  the  efFe<?ks  of 
kinds  of  animal  poifon  different  from  that 

which 


HESEMBJLXNO  fiYl>RILt8.  ^Jp 

y^hkh  produces  fyphilis,  firfl:,  bccaufe  they 
may  be  contra6led  from  partde^  who*  have  nai 
fyphilitic  difeafc;  and  that  I  pcrcdvc  hovr 
they  may  be  contraftcd  at  prcfeirty  is  they  * 
were  in  Rome,  .during  the  time  of  Celfus*^ 
Secondly,  becaufe  I  fee  fuch  difeaJes  accor^ 
ring  in  per6)ns .  whofe  conftitution  i;  difor^ 
deresl,  but  where  there  is  no  reaibn  to  &ip-^ 
{ofe  tliat  any  poiibn  has  been  imbibed^. 
Thirdly,   becaufe  thefe  difeafes  differ  from 
fyphiUs;  in  often  getting  well  without  mer-* 
cury,   ajdd  in  recurring  after  the  fevcrcft 
courfes  of  that  medicine:^.    Yet  I  wifli^  as 
a  .comment  on  the  latter  claufe,  to  obferyCy 
that  though  it  may  be  regarded  as  a  general 
rule,  it  is  not  abfolutely  without  exceptions* 
We  have  fometimes  rccourfe  to  the  ufe  of 
mercury,  on  account  of  the  dcftru6tiye  pi»» 
grefa  of  difeafes,  which  we  have  the  0:rongeft 
reafims  ta  beHeve,  are  sK>t  fyj^ilitic;  ami 
mercury  femetimes  cures  thefe  difeafes^  witbt^ 
cm  rekpfe.     It  is  indeed  not  improbable, 
...  *  ■-> 

*  See  the  cafes  related  in  tli^  prelimiAary  remaxlcs* 
f  See  the  cafes  related  uj  the  3d  fe£Hon«       .1.  .; 

j:  i^ee  the  c:^es  related  in  the  2A  f^l&ion. 

th'a't 


.»<  J 


^  ON   DISIASES 

that  the  alteration,  which  mercury  produce* 
in  the  ftatc  of  the  conftitution,  may  occa- 
fionaliy  cure  a  diforder  which  is  not  fyphi- 
Htic.  Formerly,  when  I  met  with  a  cafe  in 
which  the  conftitutional  fymptoms  were  re- 
gularly progrefilve  till  mercury  was  em- 
ployed; if  they  jnelded,  and  were  cured  by 
an  adequate  courfe  of  this  medicine,  I  con- 
cluded that  the  difeafe  was  fyphilitic,  and  I 
regarded,  therefore,  any  deviations  which  1 
might  have  obfeived  in  the  progrefs  of  tlie 
primary  fore,  as  the  efteft  of  fome  peculiarity 
in  the  patient's  conftitution.  Of  late,  how- 
ever, I  have  thought  this  inference  to  be 
erroneous. 


I  fliall  next  advert  to  the  arguments  of 
thofe  who  think  differently.  Firft,  it  is 
faid,  that  the  fpontaneous  cure  of  thefe  dif- 
cafes  is  no  proof  that  they  are  not  fyphilitic. 
Secondly,  the  peculiarity  of  the  difeafe  is  ac- 
counted for  by  peculiarity  of  the  patient's 
conftitution,  whitli  may  not  only  contribute 
to  modify  the  difeafe,  but  alfo  to  prevent 
'tis  ordinary  cure  by  mercury;  tJecaufe  the 
Conftitution  may  be  incapable  of  bearing  at 
once 


-L 


HESEMBLIKO  SYPHILIS*  gf' 

orice;  fo  much  mercury,  as  is  ncceflSuy  for 
its  cure.     Cases,  however,   (land  in  direft 
oppofition  to  thefe    opinions.      For  thefe 
dileaies  may  be  contraftcd  by  perfons  of 
very  htalthy  confutations ;  and  I  have  known 
patients,  who  have  contrafled  pfeudo-fyphi- ' 
litic  difeafes,  contraft'  alfo  real  fyplulis,  both 
a  (hort  time  before  and  after  the  pfeudo- 
lyphilitic'afFeftion,    Further,  in  many  per-' 
fons,  who  are  the  fubjcfts  of  pfeudo-fyphi- 
litic  difeafes,  the  difeafe  recurs,  without  the 
intervention  of  any  new  exciting  caufc,  even 
though  a  mercurial  courfe  has  been  fub- 
mitted  to,  greater  in  degree  and  longer  in* 
duration,  than. is  necefiary  for  the  cure  of 
true  fyphilis,  even  though  the  mercury  has 
alfo  afted  on  the  patient's  conflitution,  in 
the  mofl  regular  and  complete  manner.     It 
is  indeed,  highly  probable,  and  accordant 
to  g<}ncral  dbfervation,   that  thefe^  difeafes 
^11  be  greater  aiid  more  obflihate  in  weak 
^nd  irritable  confFitutions,   than  ;  in  thofe' 
■^at  are  healthy,  and  this  dr cuhiftance  has 
3)robal51y  given  rife  to  the  preceding  fiip^ 

3)ofitions. 

,"  •     .  ■«  •  •  • 

<VOL.  IK  H  I  Wiftl 


) 


I  wifli  alfo  to  confider  the  probable  cffeftj 
which  would  be  produced  on  the  conftitu- 
tion  from  the  admilTioti  of  morbtHc  animal 
matter  into  the  circulation.  Such  infec- 
tious  matter  is  likely  to  produce  irritalnlity 
or  weakncfs  of  the  nervous  fyftem,  and  con- 
ftqucnt  general  difordcr.  The  nervous  dis- 
order is  likely,  more  efpecially,  to  difturb 

I  die  fun£Uons  of  the  digeftivc  organs,  and 
by  their  rc-a£tion  to  become  prolonged  and 
aggravated.     In  almoft  every  cafe  of  pfeudo- 

I  fyphilis  a  diforder  of  the  digelHvc  oi^ans 
is  manifeft>  and  in  many,  moft  evident  bc- 

I  nefit  is  derived  from  correcting  tliis,  as  far 
as  we  are  able. 


It  is  probable,  that  the  difoider  of  the 
I  nervous  fydcm,  and  conftltution  in  general, 

will  be  more  tranfient  in  fome  conftitutions 
.  tiian  in  others }  and  is  likely  to  be  prolonged 

by  every  thing  that  induces  debility,  and 
I  irritability.  Indeed,  if  we  have  no  fpccific 
I  remedy,  or  means  of  counterafting  the  ef- 
\  fe£ls  which  the  poilbn  has  produced ;    the 

rational  indications  of  treatment  would  be 

to  tranquillize  and  ftrengthen  the  fyftem, 

in 


RISEMBLIMO  lyHIILII. 


H 


in  the  expcdlation,  that  the  cfFefts  refult- 
ing  from  the  a6tion  of  the  poifon,  will 
gradually  fubfide.  Analogy  would  lead  us 
to  expert,  that  the  diforder  of  the  nervous 
iyftem,  induced  by  the  operation  of  the 
poifon,  would,  as  it  declined,  become  Inter- 
mittent, and  recur  in  paroxyfms.  I  have 
premifed  thefe  obfervations,  that  the  reader 
may  bear  them  in  his  mind,  during  the 
perufal  of  the  cafes,  afTuring  him  at  the 
fame  time,  that  they  are  the  refult  of  practi- 
cal remarks. 


I  wifti,  alfo,  to  explain  my  ideas  refpec- 
ting  the  operation  of  mercury.  Firft,  fmall 
dofes  of  that  medicine  do  not  feem  tp  afFeft 
the  conftitution  in  general,  but  merely  to 
aft  upon  the  digeftive  organs ;  yet,  by  this 
operation  they  are  often  produftive  of  the 
inoft  important  benefit,  as  has  been  ihcvm 
by  cafes  recorded  in  the  firft  volume  of  thcfe 
obfervations.  As  in  difcafcs  produced  by  the 
abforption  of  morbific  poifons,  the  digeftive 
organs  are  difordcred,  in  confequence  of 
nervous  irritation,  and  in  fome  patients,  in 
a  moft  remarkable  degree,  owing  probably 


200  C*t  hiitASM       ' 

to  a  pre-difpofition  to  diforder  in  them^  (o 
an  attention  to  keep  thefe  organs  in  as  cor- 
reftly  natural  a  ftate  as'poffible,  is  an  objc6t 
oF  primary  importance.     Secondly,  mercury 
exhibited  in  larger  dofes,  exerts  an  influence 
on  theconftitutlotl  in  general,  though  fcarcely 
perceptible  by  its  cfFeft  upon  the  pulfif  or 
fecrctions ;    bat  by  affefiling  the  ntriroxii 
fyftem,  in  a  peculiar  manner,  aftd  by  in- 
ducing a  fpecific  ftate  of  conftituticm,  it  coun- 
teracts that  morbid  irritation  which  has  be^ 
fore  prevailed,\and  is  the  efFeftof  th6  poi-* 
fon.      Thus  mercury   relieves  many  other 
difbrders,  as  well  as  thofe  whicli  affc  fyphi- 
Kticl     The  dofe  which  is  neceflary  to  pro- 
duce fvtch  effefts,   muft  vary  in  different 
perfons.     Such  a  ftate  of  mercurial  excite^ 
ment,  or  aflion,  as  is  neceflary  to  produce 
thefe  effefts,  may  alfo  be  kept  up  without 
inducing  debility;  — on  the  contrary,   pa^^ 
ticnts  frequently  become  ftrongcr  and  more 
healthy  under  its  influence,  becaufe  it  con- 
trolls  the  irritation  attendant  on    difea(e« 
Thirdly,  a  jgreater  meicui'ial  efieft  upon  the 
conflitution  produces  an  acceleration  of  the 
pulfe^  renders  the  conftitution  in  general 

r  irritable 


RESEMILINO   SYPHILIS.  lOI 

irritable  and  weak,  and  produces  a  more 
evident  and  confiderable  diforder  of  particu- 
lar  organs.  Such  an  affeftion  cures  com- 
pletely  and  radically  fyphilitic  difeafes }  whilft 
others^  which  had  been  checked  apd  cured 
by  a  flight  mercurial  afFeftion,  often  increafe 
jmd  break  out  again,  under  that  which  is 
greater  in  degree.  This  violent  station  of 
mercury  never  fails  to  weaken  and;  diforder 
the  conftitution.  ii^  general ;  and  thus,  with 
Its  powers  impai;:ed,  and  its  fun£lions  de- 
railed,, it  has  ftill  to  endure  the  cqntinuance 
of  the  difeafe.     . 

•  J* 

The  qdes,  which  I  ihall  now  brijig  for- 
war4|  are  fele£led,  becaufe  I  tiiink  they 
^ew  as  great  a  variety  of  cirairaftances 
incidental  to  tl^eie  difeafes,  as  could  b^  dif^ 
played  in  an  equal  number  of  examples.  I 
could  h^ve  crowded  the  book  with  inftai>ces, 
tending  more  direftly  to  illuflrate  and  con- 
finn  the  opinions  delivered  in  it.  My  object 
has;  however,  beeUj^  not  to  reprefent  the 
jr^\)jeft  as  more  clear  than  it  will  -appear 
•  inpraaice,  ,.     '  ^ 

'  •  H  3  CASE 


etf   DISKAtIB 


CASE  XIV. 

A  medical  ftudent,  had,  without  any  pre- 
vious chancre,  an  indolent  bubo,  wliich 
had  increafed  in  the  courfe  of  two  months,  to 
the  fize  of  a  fmall  egg,  at  which  time  I  firft 
faw  Mm.  After  about  three  weeks,  it  inflamed 
and  fuppurated.  The  inflammation  was  of 
an  unhealthy  nature,  and  the  bubo  ulcerated, 
forming  a  foul  ulcer,  about  three  inches 
and  a  half  in  length,  and  two  and  a  half  in 
"breadth.  During  this  procefs,  he  was  much 
difordered  in  his  health,  and  he  confined 
himfelf  to  his  bed.  Lint,  moiftened  with  a 
watery  folution  of  opium,  was  applied  to 
the  fore;  it  was  covered  by  a  drefling  of 
fpermaceti  cerate,  and  linen  moiftened  in 
fome  wafli  was  applied  over  all,  to  regulate 
the  temperature  of  the  part  Under  this 
treatment  tlie  fore  granulated,  cicatrized, 
and  had  contrafted  into  a  fmall  compals, 
when  the  patient's  heahh  again  became  dif- 
ordered, and  an  ulcer  formed,  on  the  upper 
furface  of  the  velum  pendulum  palatl.  He 
fnufflcd  in  fpeaking,  and  blew  from  one 
noftril  thick  mucus,  Ibme  matter,  and 
cKcafionally  blood.  Fain  extended  in  the 
courfe 


KESEMBLINO   9YPHILI3f  I03 

courle  of  the  euftachiati  trumpet  towards 
the  ear. 


His  difordcr  was  fo  troublefome  at  night 
as  to  preclude  fleep,  and  his  tituation  was 
altogether  fo  uncomfortable  as  to  induce 
him  to  have  rccourfe  to  mercury.  He  ac- 
cordingly rubbed  in  two  drachms  of  mercurial 
ointment,  for  ten  fuccefflve  nights.  In  this 
time  the  mercury  produced  a  flight  effef*- 
upon  the  gums,  and  relieved  him  fo  much, 
that  he  determined,  notwithfl:aiiding  my  re- 
monftrances,  to  difcontinuc  it,  feeling  hira- 
felf  perfectly  well.  In  about  fix  weeks  fub- 
fequent  to  this,  he  had  a  painful  affection 
of  the  upper  part  of  the  tibia,  attended  with 
a  coUcftion  of  fluid  under  the  Jafcia.  He  was 
fcverifli  at  night,  and  had  but  little  fleep ;  his 
ftomach  and  bowels  were,  during  the  whole  of 
the  difordcr,  affefted  in  the  manner  I  have  dc- 
fcribed  in  the  firft  paper ;  he  had  no  appetite, 
and  when  he  was  moft  indifpofed,  his  tongue 
was  extremely  furred.  He  again  ufed  mercury, 
but  after  having  rubbed  in  about  fix  times 
he  difcontinued  it,  as  he  found  himfclf  worfe, 
which  he  attributed  to  the  ufe  of  the  mcr- 


4 
4 


»«♦ 


cury 


104  ON  I>I$EA&£8 

cury.  The  diforder  of  his  kg  did  not  In- 
.  creafe,  but  after  fome  little  time  diminilhed; 
ftill,  however,  it  prevented  him  from  walk- 
ing about,  and  he  had  occafionally  fits,  of 
pain  in  it,  which,  after  continuing  for  a 
few  days,  abated,  fo  as  to  leave  him  com- 
paratively cafy.  Thus  his  leg  cpntinuedj 
from  about  February  to  June,  when  he  took 
lodgings  in  the  country.  He  had,  about  a 
montKafter  the  affeftion  of  his  leg,  a  fimilar 
attack  in  the  elbow,  the  progrefs  of  which 
>yas  ajfo  fimilar. .  His  health  was  improved 
^>y  his ,  refidence  in  the  country,  and  he  was 
foofi  able  to  walk  abojat,  which  contributed 
to  his  recovery.  He  for  a  few  days,  took 
ia  little  Jiydrarg:  muriat:  in  deco6l:  farfae,  but 
left  it  off  by  my  defire,  as  I  was  convinced 
that  his  difeafe  was  not  fyphilis ;  and  as  the 
fymptoms  were  declining  fpontaneoufly. 
He  was, once  or  twice  induced  to  befinear 
the  fkin  with  mercurial  ointment :  but  ex- 

r 

cepting  this,  he  ufed  no  mercury,  and  by 
the  autumn  of  the  year,  all  local  difeafe 
had  left  him.  His  health,  however,  was 
not  corrc6lly  right,  his  tongue  remaining 
furred,  and  his  bowels  irregular.    He  paffcd 

^  h  through 


RXSEMBLING  8TBHILIS.  'iQ^ 

through  the  wmter  without  any  relapfe.  In 
about  a  year  afterwards  he  had  fome  rheu* 
matio  complaints,  from  which  he  foon  re- 
covered,  and  has  continued  well  fince,  except 
that  he  has  been  fubje61:  to  occafion^  returns 
of  rheumatifin  *• 

CASE  XV. 

.    A  gentleman  about  thirty  years  of  age, 

-  of  a  healthy  robuft  habit,  had  a  fpre 
l)chind  the  corona  glandis,  which  I  faw  on 
the  :  third  or  fourth  day  after  its  appearance* 

-  Xt  was  then  nearly  as  large  as  the  n^  of  the 
finger,  and  fo  deep  as  to  defc^nd  to  the  liga- 
jnetitous  fubftance  of  the  corpus  cavemo- 
fum  penis.    It  was  indurated  in  its  circum- 

*  The  chief  circumftances,*  which  .feem  to  me  to 
detsrve  attention  in  this  cafe,  are,  that  probably  infe£);ious 
matter  Was  abforbed,  without  any  evideht  breach  of 
furface  or  primary  tore ;  that  the  jconftiti^tional  fymp« 
toms  were  at  firft  fuddenly  cured  by  a  (mali  quantity 
of  mercury ;  that  afterwards  the  ufe  of  mercury  rather 
aggravated  them,  in  confequence  of  which  it  was  dif- 
'continued;  that  the  diforder  of  the  conftitution  after« 
wards  gradually  fubfided;  and  that  the  whole  of  the 
mercury  employed  feems  quite  infufficicnt  for  the  cure 
of  fyphilis*     . 

ference. 


:f06  CN   DISIAUI 

fcrence,  and  there  was  no  appearance  of  any 
new  growth  from  its  furface.     This  ulcer 
appeared  to  me  to  have  been  too  rapid  in  its 
progrcfs  to  be  fyphilitic  ;  however,  as  it  had 
moft  of  the  charafters  of  fores  of  that  nature, 
1  recommended  the  patient  to  take  fifteen 
grains  of  the  piluf :  hydrargyr.  daily,  to  bathe 
with  milk  and  water,  to  be  veiy  gentle  in 
■the  application  of  mild  dreflings,  and  to  keep 
the  penis  furrounded  by  fomc  linen,  moift- 
ened  with  a  cooling  lotion.     After  a  fort- 
night had  elapfed,   an  enlargement  of  the 
glands  in  the  right  groin  took  place ;  and 
-as  the  fore  had  not  fprcad,  I  recommended 
-him  to  rub  two  drachms,  by  meafure,  of  mer- 
-curial  ointment,  into  the  right  thigh  every 
night,  wifliing  to  produce  an  evident  mer- 
\ :  curial  afFeftion  of  the  coniHtution,  with  a 
^  view  to  difcover  what  efFeft  it  would  ha\'e 
[,-t>n  the  fore.     In  about  a  week,  the  confti- 
litution  was  aifected  by  the  mercury,  and  tlie 
J- gums  were  (lightly  tender  and  fwollenj  the 
nfore  was,  however,  rendered  worfe;  it  be- 
'i-came  enlarged,  and  inflammation  took  place 
round   it.     The  inunction    was    therefore 
omitted,  but  the  pills  were  continued.    As 
w-  the 


RESEMBLING   SYPRILM.  lOJ 

the  mercurial  initation  fubfided,  the  fore 
became  tranquil,  and  the  bubo  ftationary. 
In  about  five  or  fix  weeks  from  the  begin- 
ning, granulations  appeared,  and  the  fore 
began  to  heal,  fo  that  by  the  feventh  week 
it  was  quite  well.  In  healing,  that  edge 
which  was  next  the  body  got  well  firft, 
while  the  other  rather  fprcad,  fo  as  to  en- 
croach a  little  on  the  back  edge  of  the 
corona  glandis.  The  bubo  gradually  fubfided. 
When  the  fore  was  healed,  {the  patient  ftUI 
continuing  the  mercurial  pills,)  he  wasfeized 
with  difficulty  of  fwallowing,  and  uncafy 
fenfations  on  the  upper  part  of  the  foft 
palate,  caufing  him  to  Ihuffle  in  fpeaking, 
and  to  blow  his  nofe  frequently.  I  advifed 
him  to  defift  wholly  from  the  ufc  of  mercury^ 
that  thefe  confVitutional  fymptoms  might 
go  on  unchecked  by  that  medicine,  obferving 
at  the  fame  time,  that  if  they  were  fyphilitic, 
and  required  the  ufe  of  mercury,  it  might 
be  ufed  with  more  freedom,  and  perhaps 
effeft,  in  confequencc  of  this  fufpenfion.  The 
difordcr  rapidly  increafed,  and  it  was  much 
worie  in  the  night,  when  the  fenfations 
were  fo  diAurbing,  that  the  patient  could 
obtain 


.<  • 


toi  *        OK  DISEASES         -« 

obtain  no  reft,  '  The  pain  extended  to  the 
car,  and  matter  and  blood  were  fometimes 
blowii  from  the  nofe. 

The  health  of  the  patient  was  much 
difordered ;  and,  as  he  faid  that  no  courfe 
of  'mercury  could  harafs  and  weaken  him 
fo  much  as  the  continuance  of  this  difeafe, 
it' was  agreed  in  confultation,  *tl»t  he  fhould 
Begin  a  mercurial  cdurie^  and  that. the  dif? 
teafe  ihould  be  treated  as  fyphilitic.  The 
padent  confined  himfelf  to  his  chamber, 
and  rubbed  in  two  drachms,  by  meafur^^  of 
mercurial  t)intment  every  night.  In  the 
courfe  of  a  week  the  difeafe  was  much  mitir 
gated;  in  a  fortnight,  at  which  time  the 
gums  were  fwoUen  and  tender,  it  was  well. 
The  mercury  was  continued  (fo  as  to  keep 
the  gums  as  fore  as  they  could  be,  without 
producing  that  ftate  pf  difeafe  which  would 
have  obliged  us  to  defifl  from  the  ufe  of  it) 
for  three  weeks  more,  when  a  new  occurr 
rence  took  place.  The  left  tonfil  became 
fomewhat  enlarged,  and  an  ulcer  was  formed 
upon  its  furface.  This,  another  furgeon 
who  was  confulted^  attributed  to  mercurial 

irritation, 


RESEMBLIKG   SYPHILID.  I09 

irritation,   Whilft  I;  on:  the  contrary,  fell; 
affureil  that  it  was  the.  cffe6t  of  the  dife^o 

.'I 

breaking  out  anew  under  the  full  effcSt  of 
mercury.  As  the  courfe  of  mercury  tvas 
deemed  pcrfeftly  adequate  to  the  cure,  of 
fyphilis,. .  it  was  now  difcontinued.  The 
uker  howqyer  continued  to  fpread^  nor  ^dii 
it  ceafe  till  it  had  entirely  deflxoycd  the  ton** 
fil,  when  it  healed.  About  three  weeks  af^ 
terwards,  and  fix  weeks  after  the  difufe  of 
mercury,  a  fimilar  ulcer  formed  on  the  dppo-. 
fite  tonfil,  whicl^  pairfiied  exaftly  th^  fame 
courfe,  sin4  ended  m  the  fame  ^'manner* 
After  aboiit^  three  weeks  piorc  an  ulder  ap- 
pea^*ed  to  have  formed,  iipon  the  upper  fur- 
lace  of  the  velum  pebiduliom  palati^  in  a  fitii- 
a1ic^>  corrcfponditjg  to  the  firft,  but  on  the 
<^ppfite  ii^e.  It  was  attended  with  ^  the 
iame  difHculty  of  deglu];;ition,  alteration  ia 
the  voice,  occafional  difcharj^  of  pus  and 
blood  from  the.nofe,  *and  tormenting  pain, 
extending  to  the  cuftachian  trumpet.  It 
ieemed  .^n  yain  to  ufe  niorcury,'  and  I  felt 
^reat  apprehenfibn  ^hat  this  ulcer  might  d^ 
^oy  the  foft  palate*  ,  It /forf unajtely  hi^ 
opened  other^ife ;  fbr  (aftcffircontinuiisig  .£«: 

atojt 


no  ON   DI9KASZS 

about  a  fortnight  to  fpread,  Co  t 
could  be  diftinftly  feen  on  the  margin  of 
the  velum  palati,  and  left  fide  of  the  uvula), 
it  healed,  leaving  no  greater  imperfeftion 
than  what  was  produced  by  an  adhefion  of 
the  left  fide  of  the  uvula  to  the  foft  palate, 
which  took  place  duiicg  the  healing  of  the 
ulcer.  After  this  complaint  was  well,  va- 
'  rious  eruptions  appeared  on  different  paits 
of  the  body,  many  took  place  on  the  head, 
forming  fores  which  were  flow  in  healing, 
I  and  many  fores,  which  were  formed  in  like 
I  manner  on  the  trunk  of  the  body,  became 
\  herpetic,  healing  in  one  part  and  fpreading 
in  another.  An  inflammation  and  indura- 
,  tion  of  the  coverings  of  the  lower  part  of 
the  right  tibia  alfo  took  place,  which  fub- 
fided,  fo  as  to  leave  but  little  appearance  of 
any  diforder  having  exifted.  During  these 
occurrences  the  patient  took  the  deco<5l. 
farfEe.  and  Lifbon  diet-drink,  nitric  acid, 
cicuta  and  bitters,  and  was  as  attentive  as 
poffible  to  keep  his  bowels  regular,  which 
was  difficult,  as  his  digeftive  organs  were 
throughout  the  whole  of  the  complaint  dif- 
ordered.    He  had  alfo  lived  a  good  deal  in 

the 


RESEMBLING   STfHILIS.  Ill 

the  country,  and  made  occafional  excurfions 
to  the  fea-fide,  and  ufed  the  tepid  falt-watcr 
bath.  Upon  his  return  from  one  of  thefc, 
about  fix  months  after  the  difconttnuance  of 
mercui7,  he  felt  himfelf  fo  perfeftly  well, 
that  he  indulged  himfelf  in  dining  with  Ills 
friends,  and  undertook  a  journey  into  the 
country  on  bufinefs.  The  exertion  attend- 
ing this  undertaking  feemed  to  have  operated 
in  re-inducing  difeaie,  for  he  was  foon  laid 
up  with  a  rheumatic  affe^ion  of  the  right 
foot,  and  one  of  the  teftes  became  enlarged 
to  a  confiderable  degree,  but  it  was  indolent. 
Nodes  alfo  appeared  on  the  middle  of  either 
tibia,  which  regularly  increafed.  The  en- 
largement of  the  teftis  fubfided,  when  the 
other  became  afFefted  in  the  fame  manner. 
For  between  two  and  thiee  months  after  the 
patient's  return  to  town  he  confulted  various 
furgeons,  who  knew  nothing  of  the  hillory 
of  his  cafe,  and  they  fo  uniformly  concurred 
in  affirming  it  to  be  fypliilitic,  that  the  pa- 
tient was  even  anxious  to  ufe  mercury  again. 
As  the  nodes  did  not  abate  as  the  other 
fymptoms  had,  and  as  they  did  not  yield  to 
the  application  of  leeches,  evaporating  lo- 
tions 


lions,  or  bandages,  I  thought  an  alternative 
Courfe  of  mercury  at  this  period  even  advis- 
able, to  fee  if  it  would  controU  this  local 
afFeftion.  The  nodes  were  not  like  venereal 
nodes.  TKey  were  elevated  and  bony,  and 
there  was  a  finall  quantity  of  fluid  beneath 
the  periofteum.  I  would  have  divided  the 
periofteum  at  firft,  but  I  was  reftrained  by 
the  apprehenfion  d(  the  wounds  becoming 
fores,  and  of  exfoliation  taking  place  and  aug- 
menting the  patient's  already  distrefsful  fitu- 
ation.  He  now  rubbed  in  fmall  quantities  of 
mercurial  ointment,  without  confining  him- 
felf.  This  courfe  was  attended  with  manifest 
benefit ;  infomuch  as  to  imprefs  his  mind  with 
an  opinion  that  a  more  liberal  ufe  of  mer- 
cury would  now  cure  him.  In  this  opi- 
nion he  was ,  confimied  by  fome  furgcons 
whom  he  had  confulted,  and  he  therefore 
refolved  to  ftay  at  home,  and  rub  in  every 
night  till  his  conftitution  was  affefted  by  mer- 
cury. By  the  accomplifhment  of  this  objeft, 
however,  he  was  made  materially  worfe.  His 
pains  were  tormenting,  the  nodes  inflamed, 
and  threatened  to  ulcerate.  The  mercury  was 
left  off,  and  I  divided  the  periofteum  to  the 

extent 


RSSXBfBUKO   SYPHILID.  IIJ 

extent  of  an  inch  and  a  half  on  the  furface 
of  one  node,  and  let  out  fome  ferum  mixed 
with  pus*  The  knife  in  pafling  down  garted 
againft  different  portions  of  bone,  which  were 
heaped  up  to  a  confiderable  height  above  the. 
level  of  the  tibia.  The  node  was  no  longer 
painfiiL  The  wound  hoaled,  and  pain  oc- 
curred again  in  a  flight  degree  and  gradually 
increafed.  The  fame  treatment  was  purfued 
with  refpcft  to  the  node  on  the  other  fhin, 
and  the  confequences  were  the  fame.  After 
the  wounds  had  healed  the  pain  gradually  re- 
turned,  and  in  about  a  month  he  found 
himfelf  pearly  in  the  fame  flate  as  before  his 
confinement.  Under  thefe  circumflances  he 
again  began  to  take  diet  drink,  with  fome 
mild  mercurial  pills,  which  never  perceptibly 
affeded  his  conflitution,  and  uqder  the  ufe 
of  which  he  became  mufcular  and  fat,  and 
by  this  treatment  the  pains  left  him,  and  in 
the  courfe  of  thre^  months  he  was  well^« 

CASE 

^  The  principal  circtimftances  worthy  of  remark  in  this. 
cafe  are,  diat  the  prhnary  fore  though  refembling  fyphilis 
in  mxtif  refpefls  differed  in  others.  It  was  aggravated 
^  die  free  ufe  of  mercury,  and  it  healed  on  one  fide 

TOl..n.  ji  whilft 


1 14  ON   DIS£AS£8  ^ 

CASE  XVI. 

A  gentleman  between  twenty  and  tlrirty 
years  of  age,  refiding.  in  the  country,  had  an 
ulcer  in  the  prepuce,  which,  to  ufe  the 
words  of  his  furgeon,  had  more  the  appear- 
ance of  excoriation  than  chancre  >  it  was  foe- 
ceeded  by  a  bubo  and  ulcerated  throat.  For 
each  of  thefe  difeafes  he  ufcd  mercury  fo 
freely  as  to  convince  fome  of  his  medical  at* 
tendants  that  the  difeafe  could  not  be  ^{y^ 
philitic;  his  furgeon  faid  enough  to  cure 
twenty  fyphilitic  patients.     The  ulcers  in  his 

t  * 

turhilft  it  fpread  on  the  other;  The  conftituti6nal  (jmp^ 
toms  were  fpeedily  cured  by  a  flight  mercurial  afiedionj 
but  they  broke  out  again  under  a  fevere  courfe  of  mer-r 
cury.  Many  conftitutional  fymptoms  got  well  without 
the  ufe  of  mercury,  and  when  at  laft  it  was  employed 
again  on  account  of  the  ftubborn  nature  of  the  nodes, 
thefe  difeafes  yielded  to  a  flight,  and  were  aggravated  by  a 
fevere  courfe  of  mercury.  The  difeafe  laftly  yielded  to 
an  alterative  courfe  of  msrcury,  fo  flight  as  not  maivi- 
fcftly  to  aflPect  the  conftitution,  and  daring  which,  the 
patient  got  mufcular,  fat,  and  healthy.  The  fubje£l 
of  tliis  cafe  was  a  remarkable  healthy  man,  and  had 
before  contracted  fyphilitic  difeafes,.  which  were  re^^ulas  in 
in  their  progrefs  and  cure.  Mercury  alfo  affe£led  his 
conftitution  in  the  mode  which  is  confidered^  mod  de- 
iirable  for  tlie  cure  of  fyplulis.  ;  ; 


RESEMfiUKO   SYPHILIS.  II5' 

throat  were  fbmetimes  better  and  fometimes 
worse,  both  during  the  continuance  and  after 
the  ceflation  of  the  mercurial  courfe.  After 
about  a  year  and  a  half  from  the  commence- 
ment of  the  difeafc  I  firft  law  the  patient, 
and  informed  his  furgeon,  that  in  my  opi- 
nicMi  pfeudo-fyphilitic  difeafes  generally  gave 
way  to  in  alterative  courfe  of  medicine,  con- 
joined to  decoftion  of  larfaparilla. 

About  nine  months  afterwards  the  patient 
came  again  to  town;  his  throat  was  not 
ulcerated,  but  His  nofe  was  greatly  difeafed. 
Some  adedlion  of  that  part  had  taken  place, 
when  I  firft  faw  him,  which  had  encreafed 
to  fuch  a  degree,  that  he  was  almoft  conftantly 
blowing  from  his  nofe  tough  mucus  and  pus, 
mixed  with  blood.  The  (kin  covering  the 
the  ofla  nafi  was  alfo  very  red,  fo  as  to 
threaten  the  giving  way  of  the  arch  of 
nofe.  He  was  much  emaciated  and  feeble, 
and  had  a  chlorotic  appearance. 

Under  thcfe  circumftances,  I  defired  him  to 
xirink  a  pint  of  deco6bion  of  farfaparilla  daily, 
Co  keep  his  bowels  ftri£bly  regular,  and  to  take 

I  2  five 


Il5  ON   DISEASES 

five  grains  of  the  pilul:  hydrargr  every  nighty 
defiring  to  fce.him  at  the  expiration  of  a  week* 
After  that  time^  when  he  called  on  me,  he  fsaA 
he .  could  perceive  no^  difference  whatever  in 
lus  difeafe.  Thinking  that  perhaps  in  ano- 
ther week  the  mercurial  effeft  would  be  in- 
creafed,  (o  as  to  affect  the  conltitution  and 
eontrQll  the  difeafe,  I  made  no  alteration 
in  the  quantity  of  the  medicine  5  but  when  at 
the  expiration  of  that  time,  I  found  the 
difeafe  undiminifhed,  L  recotnmeiided  him 
to  take  five  grains  of  the  piluh  hydtarg:  night 
and  morning.  After  the  expiration  of  aitdther 
week,  wlien  he  called  upon  me,he  iaid  thatthc 
difea&  of  bis  nofe  feemed  gone,  though  when 
he  blew  it  fbme  purulent  difcharge  {till  took 
place.  The  mercury  had  no  effeft  upon  his 
gums,  and  he  looked  more  healthy  and  felt 
ftronger  than  he  had  done  before  he  began 
the  mercurial  courfe.  Finding  the  difbrder  fa 
completely  fubdued  by  this  quantity  of  mer^ 
cury,  and  wifhing  above  all  otlier  confidera*** 
tions,  that  the  patient  fhould  acquire  fbme 
mufcular  flrength  and  vigour  of  conflitu- 
tion,  I  advifed  to  take  but  one  pill  daily  for 
the  future,  and  to  obferve  whether  the  fyxtipi^ 

.    1 1  toma 


R£S£MBLING   S7PHIL16.  >       fiy 

toms  fubfided  or  increafed  under  its  ufe.  In 
one  week  more  there  was  no  difcharge  from 
his  nofe,  even  when  the  air  was  forcibly  diivea 
through  iL  And  alter  three  weeks  ha4 
clapfed,  ot  at  the  end  of  fix  weeks,  he  had  be- 
come fo  mufcular,  fat,  and  healthy  looking 
as  to  produce  the  greatcft  aftonifhment  in 
all  who  had  feen  him  before,  and  faw  hirn 
after  that  fhort  interval  of  time. 

This  furprizing  recovery  mufl:  be  afcribcd 

to  the  youth  and  ftrength  of  his  conilitution 

relieved  from  diforder.     I  mention  it  partir 

<:ularly,  to  fliew  that  the  quantity  of  mercury 

that  controlled  the  difeafe  did  not  weaken 

'  the  conilitution.   When  the  patient  returned 

into  the  country,  I  recommended  the  con«- 

tiiiuance  of  the  pills  eveiy  other  night  fof 

ibme  time,  to  prevent  any   relapfe^  but  I 

was  informed  that  he  foon  left  them  off,  and 

has  fince  had  no  diforder  *. 

CASE 

^  When  a  diTeafe  Eefenskling  fyphilis  'attacks  the  nof* 
txHSf  we  aie  almofl:  compelled  to  ufe  mercury,  fince  we 
xsnnot  fee  the  charafter,  extent,  and  progrefs  of  the 
iplcer ;  yet  extenfive  experience  demonftr^tes  in  a  man* 
ner  horrible  to  obibnrey  how  many  fuch  difeafes  purfue  a 
jnoft  deflxuSlive  courfe  uncontroulei>  nay,  often  aggra- 

1 3  vated 


tlS  OK   BISBASBS 

CASE  xvn, 

A  gentleman  had  a  trivial  fore  upon  the 
prepuce,  and  being  engage4  to  many  in  the 
courfe  of  a  few  months,  he  underwent  what 
was  ponfidered  as  a  more  than  adequate 
courfe  pf  mercury,  for  the  cure  of  the  d^feafe. 
After  he  h»d  married,  hpwever,  his  throat 
ulcerated.  His  furgeon  hefitated  in  pro- 
nuncing  it  to  be  fyphilitic,  and  its  progiefs 
contra-indicated  that  fuppofition,  for  one 
fore  healed  and  another  broke  out,  or  ulcera* 
tion  again  enfued  in  the  fame  place.  One  of 
the  teftes  afterwards  became  confiderably  en- 
larged without  pain,  and  fores  broke  out  upon 
the  fcrotum,  which  "was  much  thickened,  and 
in  the  perinaeum.  Six  or  more  months  palled 
during  the  progrefs  of  the  difeafe  to  this 
ftate,  when  I  was  firft  confulted  on  the  cafe. 
It  was  in  the  fpring  of  the  year,  and  we  agreed 

■  III!  ■  "  I  .  I     ■  ■  ,  I    I  ■       ■  — ,^„ 

rated  by  the  mod  powerful  efFeSs  of  mercury.  The 
cafes  above  recited,  I  therefore  deem  worthy  attention, 
as  they  ihew  that  difeafes  refeqibling  fyphilis  may  occur 
in  the  nofe  as  well  as  elfewhere  ;  and  that  our  pra^^ice 
(hould  be  regulated  by  the  fame  principles  in  treatii^ 
thefc,  as  in  other  fymptoms  of  venereal  difeafes. 

that 


RESEMBLING   SYPmLIS,  1 1^ 

tfeat  he  fhould  fpend  the  fummer  at  the  fea- 
lide.  During  this  fummer  the  fores  on  the 
fcrotum  healed,  and  it  regained  its  natural 
ftate.  The  fwelling  of  the  teflds  fubfided. 
His  throat  occafionally  ulcerated  and  healed  y 
but  a  kind  of  difeafe  feemed  to  fpread  along 
the  alveolary  procefs  from  behind,  for  the 
teeth  loofeiied  and  came  out,  and  in  fome 
parts  the  gums  ulcerated.  This  happened 
on  the  left  fide  of  the  mouth,  and  it  ad- 
vanced as  far  forwards  as  the  firft  fmall 
grinder,  which  ftill  remained  firm.  In 
November  he  remarked,  that  whenever  his 
ftomach  and  bowels  were  difordered,  his  com- 
plaintis  were  aggravated ;  and  by  the  means 
which  were  fuggefted  for  regulating  thofe 
prgans,  he  paffed  through  the  winter  with^- 
out  any  increafe  of  diforder.  In  the  fuc<r 
ceeding  fummer  fores  broke  out  again  on 
the  perin£um>  and  by  the  fide  of  the  rectum, 
which  healed  under  dreffings  of  red  pr^^cw 
pit^te  ointment.  He  had  alfo  a  flight  en- 
largement of  the  teftis,  which  foon  got  welU 
Jn  the  fucceeding  autumn  the  difeafe  in  the 
alveolary  procefTes  feemed  to  trouble  him, 
^4  there  w^s  a  Aigh^  difcharge  from  the 

I  4  n^fc 


t20  cm  DISEASES 

nofe.  I  had  recommended  him-  to  abfhtin 
from  the  life  of  mercury,  while  liis  difor« 
ders  were  ftationary  ;  but  fearing  that 
there  might  be  an  increafe  of  difeafq  in 
this  part,  I  adviied  him  to  to  take  the  com- 
pound deco£lion  of  far{aparilla  and  one  of 
Plummer's  pills  night  arid  morning.  Under 
this  treatment  he  foon  recovei^ed,  without 
any  perceptible  efFeft  of  mercury  on»  Ids  con-» 
ftitution,  and  has  ismain^  well  iince. 

Though  I  feel  pretty  confident,  for  the  rea-^ 
fons  flated  in  the  preliminary  obfervations^  at 
well  as  thofe  contained  in  the  thitd  fe£ti<my 
thi^t  many  difeafes  which  refemble  fyj^ilis^ 
do  not  originate  from  that  poifon,  I  am  by 
no  means  equally  certain,  that  none  of  the 
cafes  which  I  am  now  promifcuouily  re^ 
lating,  might  not  have  ar^en  from  that 
fource.  Such  an  aflertion  would  be  to  de^ 
ny  the  poflibility  of  the  cffefts  of  fyphilitie 
poifon  being  modified  by  the  difeafed  pro-i 
penfities  of  the  conftitution,  It  would  be 
alfo  to  affirm  that  there  is  only  one  kind  -of 
fyphilitie  chancre,  and  one  kind  of  conflit«* 
tional  fyphilitie  difeafe^  whi<;h  is  fea^  firof^ 

feeing 


HESEMBUNO  SYIWIUS.  tt| 

being  my  intention,  I  meifely  ftate,  that  when 
the  primary  fores  differ  materially  from  thq 
ordinary  charadbers  and  progrefs  of  lyphilitic 
chancres,  that  they  may  fairly  be  fuipe^ei 
to  be  of  a  different  nature ;  and  that  in  ge-* 
jieral  the  conftltutipnal  fymptoms.  will  b? 
found  equally  to  deviate  from  the  progrefs  of 
fyphilis,  and  confequently  to  require  a  di^ 
fererrt  mode  of  treatanent. 


I  proceed  to  relate  fome  cafes  of 
delcription,  and  to  give  an  account  of  the 
conftitutional  lytoptoms  fubfequent  to  thefe 
kinds  of  fores,  in  a  few  cafes,  that  the 
r^dcr  may  judge  of  them  for  himielf^ 

CASE  xvm. 

On  ifurrowing  Sores. 

A  gentleman  forty  years  of  a^  who  had 
lived  very  freely,  in  the  month  of  July  1806^ 
«ontm£hed  a  Sort  between  the  prepuce  zxA 
glans  penis,  near  the  frsnum,  which  he  be- 
Sieved  to  have  originated  &om  fome  aaimonj' 
sa  tiie  iacretions.  This  probably  was  the 
i^inion  of  hss  fui^geon,  as  He  merely  recom« 
lOsended  cleanlixiefs,  and  ia  poultice,  until  the 
^(sadiiig  of  tj)e 'ibre  induced  him  to  uie 

mercury* 


Ill  ON    DISEASES 

mercury.     A   confiderable  fwelling  of  tlie 
prepuce  was  occafioned  by  the  irritability  of 
the  fore,  which  continued  to  fpread  by  ul- 
ceration forwards,   fo  as  to  extend  over  the 
whole  of  the   lower  half  of  the  glans,    to 
within  the  eighth  of  an  inch  of  the  urethra, 
and  backwards  between  the  integuments  and 
lower  half  of  the  body  of  the  penis  for  more 
than  half  way  to  the  fcrotum.     It  did  not 
prevent  him  from  denuding  the  glans,  and 
cleanfing  away  the  difcharge  in  fome  degree, 
•but  the  extent  of  the  fore  backwards  could 
3iot   he  feen.      It  had  continued  to  Ipread 
gradually  for  more  than  two  months,  al- 
though the  mouth  was  affefled  by  the  ufe  of 
a  great  deal  of  mercury.     His  conftitution 
was  much  enfeebled,    in   a  great   meafure 
I  ^wing  to  the  mercury  he  had  ufed.     In  this 
I  »ftate  he  came  to  London,  and  confulted  me. 
'Tearing  that  the  fore    might  continue   to 
I'ipread  if  the  mercury  was  laid  afide,  I  de- 
?  Ifired  him  to  rub  in  every  fecond  night,  fb  as 
irftill  to  keep  his  conftitution  under  the  influ- 
I'tnce  of  that  medicine,  while  I  endeavoured 
'to  correft  the  fore  by  local  means.     Various 
wafhes  were  tried,  for  inftance,  weak  folit- 


RE^EftfBLIKO   SYPfllLIS.  )k3 

tions  of  fulphate  of  zinc,  and  nitrate  of  filvcr, 
calomel,  and  muriate  of  mercury  in  lime 
^ater.  In  lefs  than  a  month  the  fore  was 
nearly  healed,  except  in  that  part  which  co-^- 
vered  the  urethra  about  half-way  below  the 
penis ;  and  here  the  ulceration  ieemed  kept  up 
by  the  efcape  of  fome  urine  from  the  canal^ 
and  he  had  at  this  time  a  frequent  prQpen* 
iity  to  void  his  urine.  It  appeared  probable, 
that  the  urethra  had  not  been  iti  9.  ibund 
ftate  prior  to  hi$  contra6):ing  this  complaint, 
and  that  it  had  derived  additional  irritation 
from  the  proximity  of  the  fore  to  the  mouth 
of  the  canal,  as  well  as  from  that  part  wherp 
its  ulceration  had  occafioned  an  opening* 
At  this  time  an  indolent  enlargement  of  the 
right  teftis  took  place,  and  fo  large  a  hydro* 
x:ele  was  formed,  that  I  was  much  inclined 
to  pun£hire  it,  to  relieve  him  from  the  in^ 
convenience  occafioned  by  its  weight*  The 
patient,  however,  was  anxious  to  return  into 
the  country,  where  he  was  directed  to  con- 
tinue the  fame  mild  mercurial  courfe.  In 
January,  1807,  he  returned  tp  town,  and  dur- 
ing the  interval,  the  hydrocele  difappeared, 
though  fome  enlargement,  of  theteftis  itiU 

co^t^^ 


ff4  ON  OI&BASBft 

continuecL  The  apeftiue  of  the  urethnt 
had  inflamed  and  ulcerated,  lea^ng  an  exter- 
nal  fonc.  The  other  part  of  the.  penis 
which  had  been  ulcerated,  contiaued  firmly 
healed.  His  healthy  however,  was  much 
bordered.  He  had  a  rheumatic  fwelling 
of  the  finger,  and  a  node  upoa  one  Ihin^ 
^urith  rheumatic  pains  in  vaiious  parts  of  his 
body.  Finding  conftitutional  fymptoms  ap* 
parently  oiiginating  from  a  fore, .  for  whidi 
'£rom  its  commencement  n^ercury  had  been 
nied  unremittingly,  I  advifed  him  to  dif^ 
jcontmue  rubbing  in,  and  he  went  to  Bath  in 
purfuance  of  the  recommendations  of  ibme 
of  his  friends.  I  previoufly,  however,  intro* 
duced  a  bougie,  and  found  feveral  ftridhire^ 
in  the  urethra,  which  had  probably  exifted 
before  he  had  contracted  the  other  com«> 
plaint.  As  a  bougie  of  a  moderate  fizc 
paffed  through  tlie  urethra,  I  merely  adviied 
local  warm  bathing.  During  a  month's 
refidence  at  Bath,  he  fuffered  much  from 
pains  in  the  tibia,  but  the  nodes  had  not 
increaded  during  that  period.  An  ulcer  larger 
than  the  furface  of  a  ihilling,  with  thick- 
ened inflamed  and  ^reading  edges;  deep  in 

the 


R£S£MBLIKO   8VPHILIS*  I25 

the  middle,  and  without  granulatiohs,  had 
formed  near  the  outer  angle  of  the  orbit  of 
the  eye.  Some  ibres  ofthe  fame  nature,  but 
lets  in  degree,  took  place  alfo  on  the  anni. 
Wifhing  to  know  if  thefe  fymptoras  were  truly 
fyphilitic,  I  detenxuned  to  try  if  they  would 
get  well  without  mcrctuy.  A  poultice  o£ 
bread  and  water  was  applied  to  the  fore  on 
the  face  at  night,  and  a  drefOng  of  fimple 
cerate  in  the  day*  The  edges  of  it  were  oc- 
caiionaily  touched  with  argent,  nitrate  to 
contfoul  their  fretful  difpoiition,  and  under 
this  treatment  the  ulcer  healed.  The  pa^ 
tient  was  anxious  to  return  into  the  countryjr 
and  as  I  thought  his  health  might  be  better 
than  in  town,  he  returned  to  his  own  houie 
with  ian  in^an^Hon  not  to  ufe  mercury  if.it 
could  be  avoided,  and  there  his  pams  in  a 
meafure  fubfided.  After  fome  time,  how^ 
ever,  the  nodes  on  the  (hin  became  more 
prominent,  though  lefs  painfiil.  Thenoi:* 
trils  aUb  became  very  much  afie&ed  by  the 
difeaie^  Hei>Iew  ft-om  them  pus  in  a  flnid 
form,  and  concrete  lumps  refembling  (to 
ius  own  words)'  •*  the  internal  parts  of  'the 
noiinls,  b^t  this  "  he  continues^  **  gradually 

went 


lafl  OH   DISEASES 

went  off,  leaving  the  noftrils  as  clear  as  be- 
fore.     My  general  health  now   improred, 
and  encouraged  by  this  circumftance,   I  was 
induced  to  make  a  journey  to  London  in  the 
month  of  June,  wlierc  I   lived  more  freely 
r  than  before  and  took  frcOi  cold.     Upon  my 
I  return  home,    I  had  a  recurrence  of   the 
I  pain  and  fwelling  in  my  fhin  bones,  and  the 
ain  of  the  legs  to  fo  great  a  degree,  that  it 
[  was  cfteemed  prudent  to  confult  a  phyfician, 
who  recommended  nitrous  acid,  two  mer- 
L  curial  and  an  opiate  pill  at  night.     Milk 
[  diet  was  alfo  recommended,  which  confti- 
I  tuted  my  principal    food.     The   acid  was 
r  continued  a    fortnight,    the    pills  about  a 
month,  but  little  relief  from  pain  was  expe- 
I  rienced.     The  nodes  gradually  Icflcned,  but 
tbe  pains  were  unabated,  and  occupied  my 
knees  and  ancles  as   well  as   fhiiis  -,     they 
continued  during  the  night,  and  remitted  in 
the  morning."     On   the  weather  becoming 
very  cold,  he  was  recommended  to  pafs  the 
}  winter  in  fome  warmer  place  than,  the  fitua- 
I  tion  in  which  he  refided.     He  came  to  town 
and  confulted  Dr.  BailUe  as  well  as  me.    He 
was  advifed  to  take  the  detoctioa  of  {hrfa>> 


1 


RESCMBLma  SYPHILIS.  lOif 

parilla,  with  a  fmall  quantity  of  hydrargonu* 
riat:  and  to  controul  the  night  pains  with 
extraft  of  henbane.      This  plan  anfwered 
very  well,  and  he  returned  into  the  country, 
where  he  faid  his  flomach  was  fo  much  nau- 
ieated  by  the  medicine,  that  he  was  obliged 
to  leave  it  off.     He  came  to  town  again  in 
the  ^beginning  of  January,    1808,  in  a  vei-y 
emaciated  and  crippled  ftate,  owing  to  rheu:^ 
matifm.  His  nights  were  palTed  in  great  pain,- 
and  this  terminated  in  pix)fuie  perfpiratidn 
in  the  morning,  fo  that  he  feldom  rofe  tilt 
paft  noon  on  the  following  day.     He  was 
fcarcely  able  to  walk,^  and  dreaded  the  leaft 
expofure  to  air,  which  confiderably  aggra- 
v^^  his  pains.     Some  fores  had  agaiifl  bro^ 
ken  out  upon  his  face,  and  one  .of  the  largeft 
was  fituated  on  the  front  of  the  ear,  extend  * 
ing  over  the  tragus,  the  difcharge  from  which 
generally  filled  the  concha,  and  this  obftruo 
tion  together  with  the  irritatibny  made  him 
very  deaf,     I  had  often  exprcffed  ta  the  pa-^ 
tient  my  convi£iion  that  an  alterative  and 
undelvlitating  mercuric  courfe  would  tem<^ 
poraurily  cure  his  difeafe,  but  wifhed  to  fee 
him,  when  that  medicine  was  employed,  that 
..-  .-^j  I  might 


I  might  obferve  its  efFe6ts«    He  'now  took  a 
pint  of  decodtion  of  farfap:  daily,  and  five 
j^i'ains  of  the  pil:  hydrarg:  every  night>  and 
in  about  a  fortnight  he  was  fo  much  reco* 
vered  that  he  v^as  able  to  ride  out,  which 
he  did  as  often  as  the  weather  permitted* 
At  the  end  of  the  third  wdek,  he  went  ilito 
the  country,  a  fhort  diftance  from  town,  to 
i^nd  a  week,  from  whence  he  rdde  at  the 
expiration  of  that  time,  eighteen  miles  with- 
out flopping.     His  rheumatic   pains  had 
nearly    left   him,     and    the  lores   on  lu3 
face  were  healed*    In  fhort  the  cefiation  of 
the  difeafe  was  ias  {biking  and  as  rapid  at 
in  almofl  any  cafe,  that  I  had  feen,  but  he 
was  not  reftored  to  perfeft  health.    Though 
comparatively  mufcular  and  flrong,  he  did 
not  acquire  that  flrcngth  which  hp  had  poC- 
feUed  prior  to  the  occurrence  of  the  difeafe^ 
nor  did  he  look  healthy.     He  continued 
in  town,  taking  the  fame  medicine  a  fort, 
night  longer,  during  which  time  he  com- 
mitted,   in    confequence  of  the  liberty  he 
had  acquired,  fcnne  little  irregularities,  &ich 
as  fitting  up  late,  and  eating  and  drinking 
too  much.     The   effect  of  this  alterative 

courie 


RESEMBLINQ   SYPHILIS.  1 29 

Courfe  of  mercury,  which  did  not  produce 
any  evident  mercurial  a6lion  in  the  confti* 
tution,  and  under  which  the  patient  ao- 
quired  a  furprizing  degree  of  ftrength  and 
and  apparent  health,  fully  equalled  and  cvett 
furpaffed  my  expectation.  Inferring  the  pro^ 
bability  of  a  relapfe,  and  that  half  the  dofe 
of  the  medicine  was  not  likely  to  be  in  any 
degree  prejudicial  to  the  conftitution,  I  recon« 
mended  him  to  return  into  the  country,  and 
to  continue  the  fame  medicines,  taking  the 
mercurial  pill  every  fecond  night  only.  The 
patient,  however,  did  not  profecute  the  plan 
laid  down,  and  his  health  has  continued 
greatly  difordered  ever  fince  this  period.  He 
has  been  fubje£l  to  various  local  difeafes,  but 
their  nature  was  fuch,  that  I  believe  no  un- 
prejudiced perfon  could  conlider  them  as 
fyphilitic*  He  has  had  fevere  rheumatifm, 
but  it  never  produced  a  local  attack  on  a 
bone,  fo  as  to  refemble  a  fyphilitic  node.  He 
bias  had  gout  to  which  he  had  formerly 
been  fubjedt. 

He  had  a  great  degree  of  inflammation  and 

induration  of  both  his  legs.     He  had  violent 

YOL.ii.  K  pain 


130  ON   DISKASKS 

p^  about  the  firft  joint  of  the  great  toe,  and 
matter  feemed  to  have  formed  beneath  the 
periofteum,  for,  upon  the  abcefs  brealdng, 
the  bone  was  denuded.  He  has  a  rednefs^ 
•thickening,  and  tendency  to  ulceration^  of 
the  integuments  of  the  als  nafu 

The^  patient  had  formerly  lived  very  freely, 
afld  the  alteration  in  his  ordinary  modes  of 
life,  with  the  cffeft  of  mercury  on  his  con- 
ftitution  when  employed  freely,  at  firft, 
for  the  cure  of  the  primary  fore,  feem 
conjointly  to  have  produced  this  deplorable 
derangement  of  his  conftitution* 

Under  thefe  circumftances,  he  fometimes 
took  the  compound  calomel  pill  in  the  dofc 
of  one  grain  of  calomel  each  night,  and  it 
generally  appeared  to  be  of  fervice  to  him. 
Sometimes  he  took  no  mercury.  His  local 
difeafes  did  not  (eem  to  be  much  afFe£led 
either  by  the  ufe  of  mercury  in  this  degree, 
or  by  its  difcontinuance. 

When  once,  without  my  knowledge,  he 
took  the  compound  calomel  pill  more  freely, 

it 


ABSEMBLIKO  SYPHILIS.  23 1 

it  evidently  was  injurious  both  to  his  health 
in  general^  and  to  his  local  difeafes« 

CASE  trs. 

A  gentleman  had  a  fore  between  the  pre- 
puce and  corona  glandis,  which  was  treated 
as  a  fyphilitic  chancre.  After  a  time  it  be« 
gan  to  fpread  in  the  cellular  fubftance, 
between  the  integuments  and  body  of  the 
penis  towards  the  pubes.  In  proportion  as 
the  fore  became  worfc,  the  quantity  of  the 
mercury  adminiftered  for  its  cure  was  in- 
creafed ;  fo  that  he  had  gone  through  a  very 
confiderable  courfe  of  mercury,  which  had 
made  his  mouth  very  fore,  and  had  greatly 
imp^ed  his  ftrength.  The  fore,  however, 
was  not  amended,  but  when  I  firft  iaw  him 
was  extending  itfelf  ftill  nearer  to  the 
pubes  and  more  round  the  penis.  I  dire£led 
him  to  clean  away  the  difcharge  by  fre- 
quently injedting  a  warm  deco£lion  of 
poppy  heads,  and  to  keep  a  bread  and  water 
poultice  round  the  penis.  After  fome  time 
the  Ikin  of  the  dorfum  penis  ulcerated,  and 
gave  an  outlet  to  the  difcharge  in  this  di- 

K  2  redion. 


l^Z,  on   DISEASJM 

reflion.  The  degree  of  difeafe  which  took 
place  feemed  to  have  been  prejudicial  to  the 
front  of  the  prepuce,  for  it  became  very  cede- 
matous,  and  the  ulceration  fpread  rapidly 
forwards  fo  as  to  divide  it,  leaving  the  glans 
and  body  of  the  penis  projecting  above  the 
feparated  and  tumid  fides  of  the  prepuce. 
The  fore  gradually  got  well  without  any 
other  medical  treatment  than  what  appeared 
neceflary  to  regulate  the  a£lions  of  the 
bowels.  He  took  indeed  occafionally  ibme 
decoction  of  iarfapadlla  and  fome  nitric 
acid.  The  patient  had  no  fubfequent  con- 
fiitutional  difeafe. 

Refpecting  thefc  fores,  which  I  have  called 
burrowing  fores,  I  may  obferve,  that  only 
a  few  of  them  begin  to  burrow  in  the  firft 
inflance.  It  is  generally  an  after  procefs^ 
and  may  be  confidered  in  the  greater  number 
of  cafes  as  the  efFeft  of  a  new  a6lion  taking 
place  in  the  fore.  It  is,  however,  fo  dif- 
cordant  to  the  progrcfs  of  true  fyphilis,  that  I 
cannot  believe  it  to  be  an  effeft  of  that  dif- 
eafe. If  we  have  any  doubt  we  mufl  look 
to  the  tonflitutional  fymptoms  which  fuc* 

cecd 


RESEMBLING   SYPHILIS.  I33 

^eed  to  them,  and  thefc  we  find  to  partake 
more  of  the  nature  of  pfeudo-fyphilis  than 
of  true  fyphilis.  Some  burrowing  fores  do 
not  fo  affeft  the  conftitution  as  to  produce 
fecondary  difeafes,  whilft  others  do.  I  have 
recorded  a  fpecimen  of  each,  and  think  it 
unneceflary  to  cite  more;  though  I  could 
bring  forward  a  confiderablfe  number.  The 
fecondary  fymptoms  in  the  firft  cafe  were 
very  obftinate,  and  thofe  furgcons,  who  are 
inclined  to  believe  all  thefe  difeafes  fyphi- 
litic,  may  probably  think  the  fymptoms  in 
this  inftance  were  fo.  To  me,  however,  it 
appears  that  the  moft  potent  mercurial 
courfe  was  inadequate  to  the  cure  of  the 
primary  fymptoms,  and  would  have  been  fo 
to  thofe  of  a  fecondary  nature,  while  the  latter 
were  readily  controulable  by  an   alterative 

■ 

courfe,  and  in  fome  inftances  got  well  (pon- 
taneoufly.  It  is  alfo  my  opinion,  that  their 
continuance  depended  much  upon  the  dis- 
ordered ftate  of  the  conftitution  produced  by 
former  irregularities  of  living,  by  the  kri- 
tation  of  difeafe,  and  the  debilitating  efFefts 
of  the  too  free  ufe  of  mercury  for  the  cure  of 
the  primary  fore.      I  could  produce  many 

K  3  inftanceg 


154  ^^  DISEASES 

inftanccs  in  which  the  fecondary  fymp- 
toms  were  more  (light  and  more  clearly 
pfeudo-fyphilitic,  than  in  the  one  which  has 
been  related.  The  prefent  cafe  I  brought 
forward,  becaufe  it  made  a  ftronger  impreC- 
fion  on  my  mind,  than  thofe  which  were 
lefs  vexatious,  and  becaufe  I  do  not  wifh  to 
rcprcfent  the  fubjeft  of  the  fecondary  difeaies 
in  pfeudo-fyphilis,  as  lefs  obftinate  and  feverc 
than  they  will  often  be  found  to  be. 

CASE  XX. 
On  Jlougbing  Sores. 

A  gentleman  about  thirty  years  of  age 
applied  to  me  on  account  of  a  floughing  fore 
about  the  fize  of  a  (hilling  on  the  dorfum 
penis.  I  defired  him  to  drefs  it  with  a 
watery  folution  of  opium,  covered  with  fjper- 
maceti  cerate  Ipread  on  linen,  and  to  furround 
the  penis  with  linen  kept  conftantly  wet  with 
water.  His  bowels  were  obftinately  coflivc, 
his  tongue  much  furred,  and  he  had  fo  much 
fever  and  head-ache,  that  the  ufe  of  mercury 
feemed  to  be  prohibited  by  the  difordered 
ftate  of  his  conftitution.    The  fore  fprcad  io 

a5 


RESJSMBUKO  SYVBltlfU  135 

asnearly  to  encircle  the  penis,  and  to  occupy 
its  whole  length.     Various  dreffings  were 
employed  until  the  furface  of  the  (ore  was 
no  longer  floi(ghy,  but  the  edges  ¥rare  thick* 
ened  and  very  fretful.    The&  ware  touched 
every  day  with  argent:  nitrat:  which  feemed 
to  counteradt  their  fretful  ftate ;  they  after- 
wards became  healthy,  and  the  fore  healed 
in  the  fpace  of  two  months  from  its  com^ 
mencement.     Before  thb  fore  healed,  fymp* 
toms  of  conftitutional  diforder  appeared*  The 
throat  became   fore,    but  did  not  ulcerate 
in  any  material   degree.      Spots  came  out 
on  the  (kin  and  bread.    He  had  afterwards 
a  rheumatic  affe^ion  of  the  knee  and  foot. 
All  thefe  fymptoms  dilappeared  fiicceffively 
without  the  ufe  of  mercury,  to  which  modi* 
cine  he  had  fo  flrong  an  averfion,  that  it 
would  have  been  difficult  to  perfuade  him  to 
take  it :  he  foon  recovered  from  the  tfhSt 
of  his  diforder,  and  felt  as  well  as  before 
he  had  contra£led  it.     The  medicines  which 
were  taken  in  this  cafe,  were  farfapariUa^  * 
nitric  acid,  bark,  and  aperients.    Seccmdary 
fymptoms  do  not  fucceed  to  evwy  floughing 
fore, and  thefe  fymptomsoccafionally  approach 

K  4  mor^ 


l$6  OK  DISEASES 

more  to  tibie  nature  of  fyphilis  than  in  the 
preceding  cafe;  yet  I  have  known  no  in- 
ftance  in  which,  either  from  the  irregularity 
of  the  progrefs  of  the  fymptoms,  and  their 
infufceptibility  of  cure  by  the  powerful 
aftion  of  mercmy,  they  could  not  be  dit- 
tinftly  recognifcd  as  pfeudo-fyphilitic. 

.  T  CASE  xxr. 

A  gentleman  had  a  floughing  fore,  which 
fpread  round  the  prepuce,  without  extend- 
ing backwards  to  the  integuments  covering 
the  body  of  the  penis,  yet  its  breadth  was 
fb  confiderable  as  to  involve  the  whole  of  the 
prepuce,  which  it  eventually  deftroyed.  The 
furgeon  who  firft  faw  the  patient  had  given 
him  mercury,  but,  doubting. the  propriety  of 
its  continuance,  I  was  confulted,  and  imme- 
diately oppofed  its  further  ufe.  Fumigations 
with  cinnabar  were  found  to  be  more  effi- 
cacious than  any  other  applications  which 
were  tried  to  this  fore;  thefe  quickly  arrefted 
the  floughing  procefs,  but  an  ulcerative 
one  continued  till  the  prepuce  was  eaten 
away.  After  two  months  from  the  com- 
mencement 


RESEMBUNO   SYPHILIS.  I37 

mencement  of  the  fore,  when  it  was  nearly 
healed,  the  confiif ution  of  the  patient  be* 
came  much  difturbed,  and  fecondary  fyrap 
tpms  appeared.  Thefe  were  fpots  and 
blotches  of  rather  a  livid  afpefi:,  the  latter 
of  which  in  many  parts  of  the  body  fpread 
out  into  extenfive  fores  which  had  a  Hough- 
ing appearance.  One  on  the  outfide  of  one 
foot  and  ancle  was  as  large  as  the  palm  of 
the  hand.  .The  original  fore  was  alfo  irritated 
by  the  difturbance  of  the  conftitution,  and 
began  to  ulcerate  again  very  rapidly,  info- 
much  that  the  glans  penis,  and  a  confiderable 
part  of  the  corpora  cavernofa,  were  de- 
ftroyed.  Neither  fiimigations  nor  any  other 
of  a  great  variety  of  applications  appeared  to 
retard  the  deftru6tive  progrefs  of  this  for^ 
and  mercury  was  employed.  The  patient 
was  ordered  to  rub  in  two  drachms  by  meafure 
of  mercurial  ointment  every  night  for  five 
weeks,  when  his  gums  became  tender  and 
fwollen,  and  his  conftitution  confiderably 
influenced  by  the  mercury,  yet  no  ma^rlal 
alteration  took  place  in  the  difeafe.  The  un- 
availing effedt  of  mercury  being  provied, 
the  patient  went  into  the  countiy,  where  all 

thefe 


thefc  complaints  gradually  difappeared.  Kis 
health,  however,  was  ftill  difordered,  and 
new  fymptoms  came  on.  His  nofc  became 
flightly  affefled,  and  he  had  pains  in  his 
l>ones.  He  now  removed  to  the  fea-fide^ 
and  after  continuing  there  fcH"  a  confiderable 
time,  he  wrote  to  me,  faying,  that  ulceration 
had  taken  place  in  his  nofe,  which  had  de- 
ftroyed  the  feptum  narium,  and  that  the  in^ 
teguments,  covering  a  kind  of  node  on  one 
fhin,  had  formed  into  a  foul  and  fi'etful  fore. 
I  now  recommended  an  alterative  mercurial 
courfe.  He  took  five  grains  crfpil:  hydrarg: 
at  night,  and  a  pint  of  the  decodt?  (aris& 
daily,  and  in  the  courfe  of  four  or  five 
weeks  he  was  apparently  well,  having  ao 
quired  health  and  ftrength  at  the  fame  time^ 
In  a  fecond  letter  he  expreffed  his  great  fur- 
prize  at  his  amendment,  and  wiflied  for  my 
further  direftions.  I  then  defired  he  would 
take  the  pil:  hydrarg:  every  fecond  night,  if 
the  ftate  of  the  biliary  feeretion  required  it ; 
but  M  that  was  not  the  cafe  he  took  no  more 
of  that  medicine,  and  has  fince  rcma^inc^ 
perfeftly  well, 

CASE 


CASE  xxn. 

A  gentleman  had  a  very  irritable  fore  on 
the  prepuce,  juft  behind  the  corona  glandis> 
which  was  covered  with  flough  5  this  having 
been  thrown  ofF  was  fucceeded  by  another 
flough,  and  the  fore  fpread  laterally  to  the 
right  and  left  ;  but  it  neither  extended  back<^ 
wards  fb  as  to  afFedt  the  Ikin  covering  the 
body  of  the  penis,  nor  forwards  fo  as  to 
touch  the  glans ;  neither  did  it  cat  deeply 
into  the  part  fo  as  to  affed  the  corpus  caver- 
nofum.  I  tried  various  dreflings,  but  none 
feemed  to  do  much  good.  I  touched  the 
Surface  of  the  fore  with  argentum  nitratum, 
but  that  did  harm.  I  therefore  was  obliged 
to  foothe  this  fore,  fince  I  could  not  correft  it% 
A  falve  made  of  fpermaceti  cerate,  with  as 
much  aq:  litharg:  acet:  and  tin6l:  opii  as  could 
be  incoi-porated  with  it,  feemed  to  anfwer 
beft ;  and  the  parts  were  kept  cool  by  en- 
veloping them  in  linen  moiftened  with  the 
deco6tion  of  poppies.  The  moft  perfeft 
quietude  was  enjoined,  and  the  part  laid  up- 
on a  pillow  with  the  extremity  rather  raifed 
above  a  horizontal  line.  I  had  given  the 
ptient  fpme  pilule  hydrargyri  in  the  firft  in- 

ftanc^ 


\ 


140  OH  DISEASES 

ftance,  but  his  conftitution  was  fo  deranged 
by  the  irritation  of  the  fore  that  it  would 
have  been  abfurd  to  perfevere  in  the  ufe  of 
mercury.  The  fore  continued  to  flough,  and 
to  extend  in  a  circular  dire£lion  nearly  all 
round  the  prepuce,  the  lower  part  of  which 
became  extremely  fwoln*  This  took  up 
nearly  two  months :  about  five  weeks  after 
the  commencement  of  the  difeafe,  a  fpot  ap- 
peared more  than  an  inch  from  the  corner  of 
the  mouth.  It  was  fbon  covered  over  with  a 
fcab,  which  rofe  far  above  the  furface.  It  had 
increafed  to  the  lize  of  a  fixpence,  when  I 
thought  right  to  drcfs  it,  that  I  might  diftin- 
gujfh  the  furface  of  the  fore.  I  found  that 
the  ulcer  was  very  deep,  but  I  could  not  fee 
the  furface  few  a  very  vifcid  difcharge,  which 
adhered  to  it  like  mucus.  Poultices  and  va* 
rious  dreffings  were  employed,  but  the  ap- 
pearance of  the  fore  was  unchanged,  and  it 
gradually  became  of  the  fize  of  a  fhilling. 
At  length  a  kind  of  fungus  fhot  from  that 
edge  of  tlie  fore  fartheft  from  the  mouth.  A 
fimilar  fpot  had  made  its  appearance  on  the 
car,  and  was  alfo  increafmg.  The  adlivity  in 
the  difeafe  of  the  prepuce  had  gradually  de- 
clined. 


RESEMBLING   SYPmLIS*  141 

clined,  ''and  I  begqin  again  to  try  fome  medi* 
eated  applications: — the  fore  feemed  much 
benefited  by  touching  it  daily  with  argentum 
nitratum;    but  when  this  was  omitted  th« 
floughy  appearance  of  the  fore  again  took 
place,  and  it  increafed  in  dimenfions.   It  was 
now  agreed  at  a  confultation  that  this  patient 
fhould  ufe  mercury,  and  he  rubbed  in  two 
drachms,    by  meafure,    every  night  for  fix 
weeks.     As  the  mercury  took  efFe£t  it  feemed 
to  operate  beneficially  oa  the  fpot  on  the  ear^ 
which  gradually  died  away ;  and  on  the  fore 
of  the  penis,  which  alfo  gradually  acquired  a 
healthy  appearance,    and  the  parts  became 
ibund,  except  at  one  part  where  the  prepuce 
was  not  quite  deftroyed,  and  which  flill  retained 
an  unhealthy  appearance.  The  mercury,  how- 
ever, did  not  affedt  the  fore  on  the  cheek ; 
the  fungus  which  I  mentioned  feemed  to  in- 
creafe,  and,  after  a  time,  flcin  formed  over  ifi 
fo  that  the  fore  healed  in  an  unhealthy  man- 
ner at  the  edge  fartheft  from  the  mouth. 
But  it  ftill  fpread  in  the  other  direftion  till  it 
reached  the  angle  of  the  mouth,  and  it  after- 
wards extended  itfelf  along  each  lip.     On  the 
upper  lip  it  had  fpread  to  the  extent  of  one 

6  third 


third  of  an  inch,  and  (till  retained  the  fam^ 
difeafed  appearance  which  chara6lerized  it  at 
the  beginning.  It  was  deep,  and  its  furface 
could  not  well  be  feen  on  Account  of  a  vifcid 
matter  which  adhered  to  it.  It  was  now 
agreed  in  confultation  to  leave  off  mercury, 
left  the  irritated  ftate  of  the  mouth  fhould 
increafe  the  deflrudtion  which  the  ulcer  was 
committing  on  the  lips.  The  fore  now  no 
longer  fpread  5  it  very  flowly  loft  its  difeafed 
ftate,  and  healed.  This  alfo  happened  in  the 
remaining  difeafed  part  of  the  forci  on  thc- 
prepuce, 

CASE  xxin. 

r 

0 

Of  Sores  which  become  indurated  in  their  Cir^ 

cumference. 

A  medical  man  CQutrafled  a  fore  on  the 
prepuce,  which,  while  it  was  healing,  becanic 
indurated  in  its  circumference,  and  when, 
healed,  it  became  foft  and  apparently  healthy 
in  the  middle.  The  patient  had  taken  and 
rubbed  in  mercury  from  the  commencement 
of  the  complaint;  in  fliort  he  treated  it 
ftriaiy  as  fyphilitic*     When  it  afTumed  the 

appear- 


tlESEMBLINa   SYPHILIS*  I4| 

appearance  and  chara^lcr  which  I  hav< 
defcribed^  h€  (hewed  it  to  me.  I  advi&d 
him  to  continue  the  mercury,  in  fuch  fmall 
quantity  as  not  to  afFe£l  his  health,  until  th^ 
induration  fubfided,  left  from  want  of  diis 
precaution  it  fhould  fret  into  a  lore.  Under 
this  plan  of  treatment,  however,  conftitu- 
tional  fymptoms  occurred*  The  throat 
became  ulcerated,  and  numerous  fmall  CpoU 
came  out  all  over  the  body«  His  health  was 
alio  much  difordered,  and  he  could  only  take 
fuch  fmall  quantities  of  mercury,  as  could 
have  no  influence  on  true  fyphilis.  He  took 
at  the  fame  time  the  deco6t :  farfae.  All  the 
fymptoms  gradually  difappeared,  and  he  got 
perfeftly  well  in  the  courfe  of  a  few  months; 

CASE  XXIV. 

A  gentleman  who  had  juft  left  London  on 
a  vifit  to  fome  friends  in  the  country,  per- 
ceived a  fore  on  the  prepuce,  which  he 
undertook  to  manage  for  himfelf.  He  drefled 
it  fimply,  and  took  from  ten  to  fifteen  grains 
of  the  pil :  h^^drarg :  daily.  After  a  month  he 
came  to  town  with  the  fore  much  enlarged, 
halving  difeafed  indurated  edges,  but  with  a 

9  healthy 


144  ON    DIStASES 

healtliy  furface.  As  his  mouth  was  affefted 
I  defired  him  to  continue  the  mercury  in  lefs 
quantity,  fo  as  not  matenally  to  difturb  his 
conftitution.  The  fore  healed  under  this 
treatment,  in  the  courfe  of  another  month, 
but  it  exhibited  the  appearances  which  cha- 
rafterize  thole  ulcers  of  which  I  am  now 
fpeaking.  It  was  foft  in  the  middle,  but  had 
a  circular  hard  rim,  of  the  extent  of  a  fhil- 
ling.  At  this  time  his  health  was  much 
difordered,  and  his  throat  ulcerated.  Deep 
and  foul  ulcers  alfo  took  place  in  his  cheeks 
pppofite  to  the  grinding  teeth,  and  ibmc  fores 
appeared  on  his  tongue.  His  gums  were 
fpongy,  and  loofened  from  his  teeth,  like 
thofe  of  a  perfon  having  fcurvy.  I  now 
recommended  him  entirely  to  difcontinue 
the  mercury,  and  to  take  the  nitric  acid, 
which  he  did,  in  the  dofe  of  from  60  to  go 
drops  daily.  Under  this  treatment,  both  the 
conftitutional  fymptoms,  and  the  remaining 
induration  of  the  primary  fore  got  well  in 
the  courfe  of  fix  weeks.  Nearly  a  year  after- 
wards, he  had  a  fevere  and  intractable  oph- 
thalmy,  attended  with  nervous  fymptoms, 
and  diforder  of  his  conftitution.     After  a 


RESEMBLIKO   SYHflLIS.  I45 

lime,  (pots  again  appeared  on  his  flcin,  and 
he  then  applied  again  to  me.  By  taking 
deco6^ion  of  farfaparilla  daily,  and  five 
grains  of  pih  hydrs^rg:  every  fecond  night, 
at  the  fame  time  paying  attention  to 
keeping  his  bowels  regular,  his  health  was 
rtftoi^ed,  and  ail  thefe  complaints  totsdly 
di&ppeared  in  about  five  weeks. 

•  Thefe  circumftances  occurred  in  the 
{pring  of  the  year,  and  in  the  autumn  the 
pituitary  membrane  of  his  nofe  began  to 
ulcerate,  and  it  continued  to  do  fo  more  or 
Ids  daring  the  whole  winter,  and  even  fbme 
diicharge  c(mtinued  for  the  fpace  of  a  year. 
The  ulceration  deftroyed  a  great  part  of  the 
cartilaginous  part  of  the  feptum  narium, 
£>  that  the  alas  nafi  being  lefs  fupported  funk 
a  little,  and  made  the  termination  of  the 
bones  apparent  beneath  the  fkin.  The  de« 
l&nnity  was,  however,  too  trivial  to  attraft  the 
notice  of  an  indifferent  or  inattentive  fpe6bator. 
For  this  difeafe  thd  alterative  plan  of  treatment 
which  had  been  fo  fuccefsful  on  the  former  oc« 
caiidn  was  again  inftituted,  though  with  little 
advantage.  At  fii:^:,  when  the  patient's  appre* 
vol.  ir.  L  henfions 


hmfioM  Were  confiderable,  as  .the  iterative? 
cdjtirfe  of  merwry  failed  to  do  good,  thp' 
dpfe  wa$  incfieaied  qye»  fo  jse  to  aSk^,  the 
ipoutJ^,  but.tke  diieafe  wa3  (O  evidently  ag^ 
grtvated  by  it,  thftt  the  medicine  was  for  a 
tkn©  left  off  j«nd  with  manifeft  advantage.. 
Ipi  the:auti«an  Qf ;:(he  fucceeding  year  slapv 
difeafe  occurred,  A  large  deep  idcer  formed 
in  the  throat,  which  had  all  the  charadters 
qf  fyphilit^  Iti  however^ .  very  fiiddenly  ac* 
quired  if?  ]^g.Qfti^dinienfioHS^  being  abpuf: 
afi  ii}ch  in  lengt;h  .^d  hal£an  inch  in  l^readtb^ 
It  was.  fituateri  pbUqwly  bcitween  the  top^ 
of  the  tonfil  and  thp  front  of  the  velum  pa^ 
lati.  It  was  very  deep.  As  fe  littJi^fuccefe  had 
Jtttended  the  alterative  cotirfe  of  mercury  in 
the  ulcerative  difeafo  of  the  noije,  and  as  the 
progrefs  of  the  prefent  ulcer  -could  be  noted^ 
no  mercqry  was  epfiployed,  ^Xkd/m  about  a 
month  this  ijjcer  was  w^ll,  aijdrthe  patient  hat 
not  fince  had  any  relapfe  j  and,,frOm  the  length 
of  time  which  has  fince.  elapied,  it  is  highly 
probable  that  he  never  will  have  any. 

. .  .  ^ 

I  have  already  faid,.  that    fore$  which 
indurate  in  their  circumference  do  not  in 

2  every 


RJBSfiMBLIKO   SYPHILIS.  I47 

•▼cry  inftarice  produce  conftitutional  fymp- 
toms.  Apprized  t>f  their  nature  I  geaeraUy 
bixler  for  the  patients  that  dofe  of  i  qierctir}r» 
which  may  be  taken  without  affefliiig  the 
conftitution^  as  adifcutient  of  the  havdnefs, 
arid  I  have  known  nearly  fix  months  elapfe 
before  it  has  been  completely  .difperf^Tlds 
kind  of  partial  induration,  is  fo .'different 
bam  the  prc^refs  of :  true  fyphilis^  that<  I 
think  it  muft  be  readily  granted  not* kd  be  :of 
that  nature*  ^  It  muft  however  b&alib.'rck 
i^embered,  that  fores  whiph  indqrate  in  all 
parts  are  not  always  fyphilitic.  Afe  h  havje 
already  related  two  inftances  I  think '  it  un» 
neceilafy  tb' add  more.    .     * 


*-  » 


I .  i. 


-  Having  thus  endeavoured  to  reprefeitt  the 
conftitutional  elFefts  refulting  from  fores> 
which  differ  materially  in  their  chara^ecs 
And  progrefs  ft^om  fyphilitic  chancres^:  I 
^ifh  to  fubyoin  another  caie^:  though'  I  am 
doubtful  whether  the  difeafeoriginated  from 
lnfe6lion, '  or  was  the  produA  of  coni3ita« 
tional  difordc^n  I  think  it  4^iT08  to  h% 
jWorded  on  account  of  itf  duraticm.       ^ 


V 


L  2  In, 


14'  oir  mssAsts: 

>  la  the  year  1793,  a  gentlemsn  agel 
twenty-fi:c^  who  had  been  married  two  years^ 
had  a  .paralytic  affei^ion  of  the  whole  of 
the  left  fide^  ftom  which  be  gradually  but 
Bot  coihplately  recovered  m  about  nisie 
monthsy.  the  latter  of  which  he  fpenf  ia  thft 
country^  and  he  attributed  much  benefit  to 
the  country  »r.  Aix^ut  four  moptbs  from 
the  con^merioement  <>f  the  pasralyfis^  he  had 
an  indolent  enlargement  of  tbeteftb  as. big 
as. a.  large  fift,.  which  did  no£  iiibfule,  but  i» 
1796  fiippiirated,  broke,  and  very  AoMf 
got  \ft)l.  In  1797,  he  had  an  ulcerated 
fore  throat,,  for  which  he  went  through  m 
very  regular  and  fevere  courfe,  q6  mercury^ 
He  was  confined  from  July  to  November, 
and  the  mouth  was  m  a  greater  or  k&  degree 
afic^ted  during  the  greater  part  of  that,  timc^i. 
The  .throat  fbon  got  well.  The  year  j  798  ht 
fpenl  in  the  countiy,  and  regained  his  heakh 
and  flrength  in  a  very  confiderable.  decree. 
In  r8o2,  a  node  appeared  about  the  middk 
of  the  right  fhin».  which  was.  removed  by  9 
blifter  kept  open  fpr  Jfome  tinje.  H[e  ha4  at 
the  fame  time  a; pimple  on  thenofe  whicU 
formed  a  fcabby  ulcer^  but  (lowly  got  well 

.^    .  from 


lt£S£Mfil«IHO   0YPIULI8.  t4^ 

from  the  appUcati^a  6f  a  iblutlon  of  the 
liy^rarg:  xnuriat:  -He  had  fubfequently  feveraf 
cFjyipUons^  forming  icabs  upon  the  trunkof  the 
body  and  arms  whkhdid  hot  ulcerate^  and  got 
wfiU  withoiit  tnedijcincu  In  1804,  there  was 
H  duck^mvig  about  thi;  os  cakis  and  tendo 
nchiilis,  whkh  threatened  to  fuppurate.  In^ 
1805,  I  firft  iaw  the  patient;  his  tongue 
yifBS  furred^  the  fecretion  of  bile  irtegular, 
yv^h  a  great  ^degree  of  nervoujs  irritation; 
fit  was  alio  fubje£t  to  rheumatic  pains  which 
particularly  affected  his  knee.  I  rccom^ 
9iended  a  ftridl  attention  to  the  ftate  of 
the  bowels,  and  foothing  applications,  with 
prefTore  to  th«  h$el.  Under  this  treatment 
the  heel  gradually  got  well  and  the  fpots  dif"^ 
appeared.  Jn  th^  fpring  of  1 806  fome  nodes 
appeared  on  different  parts  of  the  Ikull, 
whoi  I  told  the  patient  to  profecute  the 
^Bffat  plan  of  treatment,  and  if  they  got 
fetter  to  ^ifrf^rd  them,  but  if  worfe,  to  let 
me  iibe  themr  In  the  autumn  of  this  year, 
he  cabled  i)pon  me  with  ths  nodes  on  his  head 
confiderably  augmented;  one  on  the  right 
fidt  of  the  forehead  was  as  big  as  a  large 
Wfdnut,  ^d  threatening  to  break,  and  two 

1-3  on 


on  the  left  parietal  bone/ but  of  l6h  (iz6^ 
had  broken  and  healed.  There  was  aliib  a 
xcvf  coniiderable  node  near  the  top  of  the 
left  tibia,  which  had  been  opened  by  cauftic, 
and  had  left  a  foul  ulcer.  I  then  recom- 
aiended  the  deco6^;  farfa?  with  a  compound 
calomel  pill, .  night  and  morning.  This 
plan  was  continued  from  Novefftb^  te  the 
end  of  May,  when  the  decoftion  was  lisft  off, 
though  the  pill  was  continued  in  a  finalter 
dofe  for  fomc  time  longer.  Under  this  cotiffe; 
which  never  produced  the  flighteft  mercurial 
efFeft  on  the  conftitution,  all  thefe  complaints 
got  well,  and  the  patient  became  healthy 
and  fat,  and,  as  he  fays,  better  than  he  has 
been  from  the  commencement  of  his  dif. 
orders  which  is  fourteen  years  ago. 

This  cafe  appears  to  me  to  be  very 
iimilar  to  that  related  at  page  87,  In 
neither  do  I  believe  that  the  fymptoms  were 
theefFefts  of  poifon  imbibed,  but  on  the  con^ 
trary,  of  a  difordered  ftate  of  health. 


\  i 


Whilft  I  was  attending  this  patient,  hk 
wife*s  throat   ulcerated  to  a   cdnfidertibic 

degree. 


degree.   Both  tonfils  were  tflo*ated,  and  the 
ulcer  continued  from  one  albng^^thc  edge  bf 
the  velum  palati  to  the  txtrttiilty  of  the 
uvula.     The  ulcers  were  hollowed,  covered 
by  vifcid  matter,  and  furrounded  by  inftam- 
tnation.     I  (hould  without  hefitation  have 
pronounced  thefe  fores  fyphilitic  had  they 
-fucceedcd  to  a  chancre.    Another  furgeon 
had  no  doubt  of  their  nature.     The  patient's 
bowels  were  difordcred,  and  Ihc  felt  generally 
unwell.     I  direfled  her  to  take  fome  decoc- 
tion  of  farfaparilla,  and  fmall  doies  of  rhu- 
barb, whilft  I  attentively  watched  the  pro- 
grels  of  the  ulcer.'    In  the  courfc  of  a  week 
it  was  fo  decidedly  amended,  that  1  had  iio 
doubt  of  its  not  being  fyphilitic.    Where  it 
ran  down  the  fide   of  the   uvula,    it  haid 
granulated,    and  was    in  a  great  meafure 
healed.    As  the  difcharges  from  the  bowels 
were  blackifh,    I   direfted    five  grains   of 
the  pilul:  hydrarg:  to  be  tdken  every  night 
for  a  fortnight,  which  gradually  fcorf efted 
ihe    biliary    feeretion,    and    in    that   time 
the    ttkers    were   fferfcftly    hcdlcd.      l^he 
patient  took  the  pills  every  fecbnd   night 
foP'  •  another   fortnight    when    the   bowels 

L  4  being 


tja  ON   DIBIASI* 

being  in  all  refpe^ts  rights  and  the  conftitir* 
tion  in  general  relieved  from  all  diforder^ 
they  were  diicontinued. 

About  fix  months  afterwards,  this  patient 
being  in  the  country,  thought  fhe  had  caught 
a  cold  in  her  head,  as  (he  had  frequent  occa- 
fion  to  blow  her  nofe,  and  as  fhe  fnufBed  in 
fpeaking ;  this  complaint  gradually  increafed, 
and  after  a  fortnight  had  elapfed,  fhe  perceived 
a  difficulty  of  deglutition,  which  alarmed 
her,  becaufe  it  reminded  her  of  her  former 
indifpofition.  She  was  at  this  time  alfo  very 
unwell,  and  felt  in  the  fame  manner  as  when 
her  throat  had  ulcerated.  Thefe  fymptoms 
gradually  increafmg,  after  another  fortnight 
fhe  came  to  town.  There  was  no  doubt 
but  in  this  fecond  attack  ulceration  had  taken 
place  in  the  upper  furface  of  the  velum  pa- 
lati,  for  the  ulcer  had  eaten  through  the  fbft 
pdate  at  a  fmall  diflance  from  the  termina- 
tion of  the  bone,  there  prefenting  a  circular 
aperture,  about  as  large  in  circumference  as^ 
a  pea.  This  complaint  was  made  perfectly 
well  in  three  weeks,  by  the  fame  treatment 
as  was  inflituted  in  the  former.     The  health 

m 


R£S£MBUNG   SYPJ^ILIS.  1 53 

in  general^  and  the  digeftive  organs  parti- 
cularly, were  difordercd  in  the  fecond  attack 
as  they  were  in  the  former  one,  and  botjiwere 
fet  right  by  the  meafures  that  were  purfued*. 

I  have  known  many  ulcerated  throats, 
which  could  not,  by  infpe6Uon,  be  dif- 
tinguiflied  from  fyphilitic  difeafes,  and  which 
were  even  fuppofed  to  be  fo  on  account 
of  the  difficulty  of  curing  them,  arife  from 
an  irritable  ftate  of  the  ftomach,  and  they 
have  readily'  got  well  by  the  treatment 
above  defcribed. 

The  foregomg  cafe  might  have  been  one 
of  this  defcription.  Might  it  not,  however, 
have  arifen  from  contagion,  and  have  been 
caught  from  her  hufband?  I  have  recoiled 
it  chiefly  on  this  account;  for  I  am  de- 
iirous  of  mentioning,  that  I  have  feen  feveral 
inftances  of  pfeudo-fyphilitic  difeafes  commui^ 
nicated  from  hufbands  to  wives,  where  there 
were  no  fores,  nor  apparently  any  morbid  dif- 
charges  from  the  genitals.  If  this  fuppofition 
be  true,  it  would  probably  Jbc  coniidered  as.  a 
very  curious  f^Gty  ^d  I.ipe^tion  it  to  excite 

.    »  general 


154  ^^  lAMMM 

general  obfcrvation,  by  which  alone  it  can 
be  confirmed  or  confiited.  I  fhall  briefly 
relate  another  cafe, .  fuggeftirig  the  fame 
opinion* 

A  gentleman  had  been  my  patient  on 
account  of  a  chancre,  for  which  he  regu- 
larly took  mercury  fo  as  (lightly  to  afFe£t 
his  mouth.  He  had  afterwards  an  ulcerated 
throat,  which  got  well  without  the  ufe  of 
any  medicine.  Shortly  afterwards  he  mar- 
ried a  very  healthy  woman,  who  in  about 
three  months  became  very  unwelU  and  had 
pfeudo-fyphilitic  difeafes,  for  which  a  mer- 
curial courfe  was  inftituted  without  benefit. 
As  I  ha^  attended  the  hufband,  I  was 
once  confulted  on  her  cafe.  She  had 
then  a  deep  and  foul  ulcer  between  the 
ala  nafi  and  upper  lip.  Her  difeafes  after- 
wards got  flowly  well  under  a  plan  of 
treatment  calculated  to  reftore  her  general 
health. 

■  I  am  aware  that  the  cafes  which  I  have 
Telated  by  no  meini  ttprefent  all  that  deferves 
to  be  difphyed,  in'  order  to  convey  to  the 

^2  reader 


RE8EMBL1KO  8TPSILI8.  f55 

reader  that  extenfivc  knowledge  of  the  fub* 
je6t  wluch  afurgeon  living  in  this  metropolis^ 
may  aiid  ought  to  poiTefs. 

".  ' 

For  example,  I  have  not  related  any  cafe 
to  Ihew  that  the  primary  fores,  in  many 
inftances,  arc  fubjeft  to  paroxyfms  of  dif- 
order ;  that  they  will  amend  and  feem  in- 
clined to  heal,  and  when,  from  their  appear- 
ance, the  greateft  hopes  are  entertained,  on 
a  fudden,  a  renovation  of  diforder  takes  place 
and  more  parts  become  difeafed  or  deftroyed. 
This  circumftance  happens  whether  mer- 
cury be  employed  or  not,  and  under  an 
equal  operation  of  mercury  on  the  patient's 
conftitution.  Alfo  in  fyphilitic  and  pfeudo- 
fyphilitic  afFeftions,  fometimes  difeafes  occur 
•which  are  the  effeft  of  derangement  of  the 
conftitution  at  large,  fuch  as  unhealthy  ab- 
ceffes  and  fores ;  and  whilft  mercury,  if  em- 
ployed, afts  beneficially  on  the  fymptoms  for 
which  it  was  adminiftered,  it  often  has  a 
prejudicial  efFe6l  on  thefe  acceffory  difeafes. 

I  have  now  lying  before  me  the  written  re- 
cords of  many  cafes  fimilar  to  the  foregoing, 

each 


J^6f  ON   018XAS^9  * 

each  of  which  exhibits,  ibme  interefting 
variety  obfenrable  in  thefe  difeafes.  I  forbear, 
however,  to  adduce  more  inftances,  from  a 
conviction  that  recorded  cafes  will  never 
make  a  forcible  impreffion  on  the  minds  of 
practitioners,  and' that  they  merely  fenre  to 
induce  attention  to  the  occurrences  which 
are  met  with  in  practice,  fo  as  to  lead  each 
perfon  by  obferving  circumftances  to  which 
he  had  perhaps  before  been  too  little  attentive 
to  acquire  pra£tical  information  and  knaw^' 
ledge  from  his  own  experience. 


>  J 


s 


HEiBRStMO   SYPHILIS.  1 57 


SECTION  V. 

On  the  treatment  of  Ffeudo-Sypbilitic  Difeafes. 

rpiiE  impropriety  of  pntting  patients  under 
^  a  iiill  mercurial  courfe,  fuch  as  is  nccel- 
fey  for  the  cure  of  fyphilis,  without  taking 
into  confideration  the  nature  of  the  pri-^ 
mary  fore,  or  watching,  even  for  a  (hort 
time,  the  progrefs  of  the  conftitutional  fymp- 
toms,  muft  I  think,  be  to  every  one  fuffi-^ 
tiently  evident.  If  the  conftitutional  lymp- 
toms  proceed  in  the  manner  detailed  in  the 
Second  feftion,  and  get  well  fpontaneoufly,  it 
would  be  abfurd  to  ufe  mercury ;  but  if  they 
areprogreflive,  and  threaten  to  deftroy  parts  of 
importance,  even  though  we  may  have  great 
reaibn  to  believe  that  they  are  not  truly  fy- 
philitic,  an  alterative  courfe  of  mercury,  with 
the  addition  of  decoftion  of  farfapaiilla,  feems 
to  be;  in  genefal,  the  moft  efficacious  means 
crf^cffefting  a  temporary  cure. 

>  la  the  ieeond  f«6tion,  I  ftated,  that  after 
hft^g  waited  till  I  was  aflfured  that  the  con* 

ftitutional 


158  ON   DISEASES      -i-.F 

ftitutional  fymptoms  were  not  truly  fyphi- 
litic,  and  confequcntly,  did  not  require  for 
their  cure  a  ftrong  mercurial  courfe,  I  ge- 
nerally gave  the  compound  calomel  pill  with 
a  view  to  ftiorten  the  duration  of  thofe  fymp- 
toms. This  pra£tice  has  been  faid  to  be 
ridiculous.  I  only  wifli  to  fhew  that  in 
general,  it  is  the  molt  fuccefsful  that  can  be 
purfued.  The  cafes  which  have  been  related 
atteft,  that  an  alterative  courfe  of  mercury 
will  cure  difeafes  which  a  potent  one  will 
aggravate  j  and  that  neither  eourle  can  be 
confidered  wily  as  producing  the  tempo- 
rary cffeft  of  curing  the  prefent  fymptoms 
without  eradicating  the  conftitutional  dileafe. 
In  proof  of  this  point,  I  could  adduce  the 
nioft  abundant  and  cleareft  evidence.  1 
take  the  liberty  to  mention,  that  feme  emi- 
nent furgepns  of  this  metropolis,  who  con- 
cur with  me  in  opinion  refpeiSing  the 
nature  of  thefe  diieafes,  are  aveifc  to  em- 
ploying mercury  for  their  cure  ^  and  as 
fuch  fentiments  and  practice  may  becpip? 
very  general  amongft  thofe  who  clearly 
percdve  that  the  moft  powerful  merciffial 
courfes  will  not  radically  cure  thefe  dileaies, 

and 


RESEMBLING  aVPHJUS.  I59 

and  that  they  will  get  well  without  that 
medicine,  I  feel  it  neceflary  to  difcufs  the 
fubjeft  a  little  more  at  large. 

»      ■ 

I  have  found  a  ,  compound  calomel  pill 
or  five  grains  of  the  pilul:  hydrarg:  taken 
every  fecond  night,  fufiicient  in  many  cafes 
to  heal  fores  more  rapidly  than  I  wiftied, 
while  in  others,  the  fame  pill  taken  every  night 
has  been  infufficient,  and  the  diieafe  has, 
been  controlled  and  cured  when  the  pill  was 
taken  night  arid  morning.  The  dofc  which 
has  beei|i  moil  fuccefsful,  has  been  one  that 
has  not  perceptibly  affeiSted  the  moutli^ 
nor  weakened  the  conftitution;  during  its 
ufe,  on  the  contrary,  patients  have  ac- 
quired mufcular  ftrength  and  increafe  of 
bulk. 

The  conftitutional  fymptoras  in  thefe 
cafes  frequently  occur  when  the  patient's 
health  is  much  difordered,  and  it  may  ht 
feared  that  any  courfe  of  mercury,  however 
trivial,  may  increafe  the  weaknefe  and  irri- 
tability of  the  conftitution.  However,  it  will 
be  founds  on  the  contrary,  that  an  alterative 

courfe 


1(6  cYy  diseases 

courfc  of  mercury,  by  controlling  the  difeafe, 
will  produce  a  diminution  of  irritability,  and 
increafe  the  ftrength  of  the  patient.  All  per- 
ibns  who  are  not  familiarly  acquainted  with 
the  faft  are  extremely  furprifed  at  the  won- 
derful acquifitioii  of  bodily  ftrength  and  vi- 
gour obtained  by  the  patient  during  the  ufe 
of  a  medicine  which  they  have  always  confi- 
dered  as  likely  to  debilitate.  The  difficulty 
is  to  afcertain  the  precife  dofe  that  ihall  cure 
the  local  difeafes,  without  apparently  pro- 
ducing any  mercurial  efFeft  on  the  conftr- 
tution  ill  general.  This  dofe  muft  neceflaiily 
be  various,  as  the  fufceptibility  of  being  a£led 
on  by  mercury  varies  greatly  in  different 
perfons.  < 

Refpefting  doubtful  cafes,  and  of  this  de- 
fcrlption  muft  many  be,  which  are  prefented 
to  the  notice  of  a  ftirgeon  who  has  had  no  op- 
portunity of  obferving  the  charafters  of  the 
primary  fore,  &c.  I  wiih  to  afk  the  follow- 
ing queftion.  If  a  difeafe  that  may  be  fuf- 
pefted  to  be  fyphilitic  gets  well,  when  the 
patient  takes  only  five  grains  of  the  pilul: 
hydrarg:  each  night,  (taking  alfo  the  dccoc- 

.  tion 


Resembling  syphilis.  i6i 

tion  of  farfapariUa  in  the  day)  without  the 
mercury  apparently  difturbing  his  conftitu- 
tion,  but,  on  the  contrary,  contributing  to  the 
increafe  of  his  ftrcngth,  ought  fuch  a  difcafe 
to  be  regarded  as  fyphiHtic,  and  requiring  a 
perfevering  courfe  of  mercury  for  its  cure? 
Were  I  to  anfwer  this  queftion  agreeably  to 
the  dictates  of  my  own  experience,  I  ihould 
reply  in  the  negative,  becaufe  I  have  feen 
many  fuch  inftances,  wherein  it  was  evident 
that  the  difeafe  was  of  the  kind  which  I  have 
termed  pfeudo-fyphilitic.  Within  thefe  few 
months  three  cafes  have  come  under  my 
obfervation,  in  which  the  throat  was  deeply 
and  very  badly  ulcerated,  and  the  general 
health  greatly  impaired ;  and  yet  ail  the  pa- 
tients got  well  in  about  a  month  by  fuch  a 
courfe  of  medicine  as  I  have  dcfcribed,  increas- 
ing in  health  as  the  local  difeafe  amended, 
and  without  any  mercurial  effe£t  on  their 
conftitution  being  manifeft. 


This  Is  a  point  of  pra6lical  condufl,  much 
deferving  of  confi deration,  and  requiring  to 
be  cftablifhed.  It  would  appear  wrong  to  ule 
more  force  for  cfFc6ling  a  purpofe  than  is 
requifite.    In  fyphilis  the  cure  of  the  difeafes 

VOL.  ir.  M  for  I 


.  l6z  ON  DISEASM 

for  which  mercury  is  adminiftered  is  a  proof 
of  the  fufficiency  of  the  mercurial  courfe. 
Syphilitic  fymptoms  will  not,  however,  as 
Jar  as  my  experience  enables  me  to  determine, 
give  way  to  fo  trivial  a  quantity  of  mercury^ 
Therefore  the  mode  of  cure  of  thefe  difeafes 
may  ferve  as  a  teft:  of  their  nature,  and  as 
a  guide  for  our  condu6l  on  a  recurrence  of 
fymptoms^  •  in  cafes  where  no  other  evidence 
can  be  obtained. 

Were  this  queftion  determined,  were  it 
decided,  that  truly  fyphilitic  fymptoms  would 
not  yield  to  an  alterative  courfe  of  mercury, 
which  produced  no  apparently  mercmial 
efFe6t  on  the  patient's  conftitution,  but 
under  which  it  acquired  a  natural  degree 
both  of  tranquillity  and  ftrcngth,  another 
enquiry  would  yet  remain.  Are  we  war- 
ranted in  continuing  ov  augmenting  the 
mercurial  courfe,  in  ordei*  to  prevent  a  re- 
turn of  the  fame  or  fimilar  fymptoms  ?  Were 
my  own  experience  to  direct  me  in  my  reply 
to  this  queftion  alfo,  I  fhould  again  anfwer 
in  the  negative ;  becaufe  I  have  frequently^ 
in  fiich  dubious  cafes>  put  patients  under  a 
full  mercurial  courfe,  in  order  to  prove,  tliat 

if 


RESEMBLING    SYPHILIS.  1 63 

any  relapfe  fhould  occur,  the  difeafe  could 
not  be  fyphilitic,  or  curable  by  fuch  a  courfe 
of  mercury.     The  cafes  to  which  I  allude 
were  thofe  of  officers  and  perfons  of  ftrong 
conftitutions,   in  which  it  feemed  necefTary 
to  eftablifh  this  fa£V,  with  a  view  to  the  fubfe- 
quent  treatment  of  any  fymptoms  that  might 
occur.    Yet  in  thefe  cafes  new  fymptoms  were 
manifefted.    I  have  alfo  been  frequently  con- 
fulted  with  refpedl  to  the  degree  to  which  a  mer- 
curial courfe  fhould  be  carried,  and  the  time  it 
fhould  be  continued,  that  had  been  inftituted  for 
thecureof  pfeudo-fyphilitic  fymptoms,  which 
had  been  miftaken  for  thofe  of  true  fyphilis ; 
and  I  have  recommended  thai  it  fliould  be  con* 
tinued  to  that  degree  and  for  that  duration, 
that  fhould  render  a  repetition  of  it  unnecef- 
fary,  by  proving  it  to  be  unavailing,  fhould  a 
recurrence  of  fymptoms  enfue.     Yet  in  thefe 
cafes  alfo,  either  the  fame  fymptoms  returned 
or  fimilar  difeafes  took  place,  and  in  mofl 
inflances    thefe    returning    fymptoms   have 
got  well  without  the  ufe  of  mercury.     The 
cafes  alio,  which  I  have  detailed,  Ihew  how 
unavailing  the  mofl  potent  couri'cs  of  mer- 
cury are,  in  efFedting  the  radical  cure  of  thefe 

M  2  difordcrs. 


1^  ON    DISEASES 

diforders.  It  fecms  therefore  better  to  defift 
from  the  ufe  of  medicine,  when  the  local  dif  ■ 
eafes  are  well;  and,  fliould  they  recur,  to  cure 
them  again  by  an  alterative  courfe  of  mer- 
cury, which  appears,  from  its  efFedts,  to  be  not 
only  innocent,  but  even  falutary.  In  fomc 
cafes  which  1  have  attended,  after  having  cured 
the  local  fymptoms  by  an  alterative  courfe  of 
mercury,  with  the  addition  of  the  deco£tion 
of  faifaparilla,  without  producing  the  flightefl 
apparent  mercurial  efte6t  on  the  patient's 
conftitution,  I  have  recommended  the  con- 
tinuance of  half  this  innocent  quantity  of 
mercury  for  a  confideiablc  time,  in  order  to 
prevent  a  relapfe,  and  in  many  inftances, 
this  plan  of  treatment  has  fecmed  to  fuc* 
ceedj  whim  in  others  it  has  failed. 

In  fome  cafes  of  pfeudo-fyphilis,  one  fet  of 
fymptoms  will  difappear  without  the  ufc  of 
mercury ,yet  new  fymptoms  occurring,  they  will 
be  progreflive  and  deftructive  fo  as  to  require 
mercury  for  their  cure.  The  reverfc  of  this 
alfo  happens;  one  fet  of  fymptoms  feemed  to. 
require,  and  to  have  been  cured  by  an  alterative 
courfe  of  mercury  ;  yet  others,  fubfequently 
arifing,  may  difappear  without  its  admi- 
niflration. 


RESEBIBLIKG  STPHltlS.  16$ 

niftration.  Even  an  innocent  and  alterative 
courfe  of  mercury  fhould  not,  in  my  opi- 
nion, be  haftily  reforted  to.  The  objeft 
which  we  are  to  keep  in  view,  throughout 
the  whole  treatment  of  the  difeafe,  is  to 
tranquillize  and  invigorate  the  conftitution, 
and  only  to  check  or  cure  deftru6live  or 
very  diftrefling  fymptoms  by  an  adequate 
quantity  of  mercury.  Though  an  altera- 
tive courfe  of  mercury  is  fo  generally  bene-* 
ficial,  yet  in  fbme  inftances  it  aggravates  thcfe 
difeafes.  There^  are  perfons  of  fo  peculiar  a 
conflitution,  that  the  fmalleftdofes  of  mercury 
cannot  be  given  without  producing  irritation^ 
and  difordcr.  Mercury  alfo  may  fail  to  be 
beneficial,  when  adminiftered  at  one  period  of 
thefe  difeafes,  and  yet  have  the  moft  de- 
iirable  effeft  at  another.  It  may  for  inftance 
fail  to  do  good  at  an  early  period  of  the  dif- 
eafe, when  it  is  in  a  ftate  of  confiderablc 
aftivity,  and  yet  may  counteract  and  fubdue 
it,  when  its  vigour  is  on  the  decline.  The 
cafes  furnifli  examples  of  thefe  fafts. 

Though  in  general  the  decoftion  of  farfa- 
parilla  appears  to  be  the  beft  medicine  that 
can  be  ^iven  in  addition  to  alterative  dofes 

M  3  of 


l66t  OK   Z>I9CA8£8 

of  mercury;  yet,  when  the  cbnftitutlon  of 
the  patient  is  weak,  it  is  ufeful  to  give  me- 
dicines of  a  tonic  and  cordial  kind*  This 
practice  is  peculiarly  proper,  when  it  re- 
quires a  more  powerful  operation  of  mer- 
cury than  I  have  in  general  defcribed,  to 
control  and  cure  urgent  fymptoms  *• 

Such  is  the  refult  of   the  obfervations  I 
have  made  on  the  treatment  of  thefe  moft 

*  It  may  be  thought  by  fome,  that  I  have  relied  too  much 
in  the  treatment  of  the  foregoing  difeafes,  upon  the  internal 
admin iftration  of  mercury,  and  have  not  fufficiently  tried 
jt8  effe^is  by  inundiion.  I  therefore  think  it  right  to  ex* 
plain,  that  it  feems  to  me  immaterial,  whether  a  mild  oxyd 
of  mercury,  fuch  as  fliould  be  contained  in  mercurial  oint- 
ment, and  quickfilver  pills,  is  abforbed  from  the  fkin  or  the 
alimentary  canal.  I  generally  find  that  as  much  of  the 
quickfilver  pill  can  be  taken  internally  as  is  neceffary  to 
produce  the  degree  of  mercurial  affeftion  of  the  fyftem, 
which  is  requifite  for  the  cure  of  pfeudo-fyphilitic  fymp- 
toms, without  in  the  leaft  difordering  the  funftlons  of  the 
digeftive  organs  j  but  on  the  contrary,  with  evident  benefit 
by  exciting  and  maintaining  the  natural  and  healthy  anions 
of  thofe  organs. 

It  is  right,  however,  to  add,  that  the  pilul:  hydrarg: 
which  I  have  always  employed,  has  been  procured  from 
the  Apothecaries'  Hall ;  and  that  when  it  has  been  ob« 
tained  from  other  places,  its  effedis  have  by  no  means 
correfponded  to  what  I  have  reprefented  of  them^  either 
in  this,  or  the  preceding  volume. 

vexa- 


llESElilBLING    SYPHILIS.  167 

vexatious  difeafes  ; — difeafes  which  muft,  I 
believe,  perplex  all  furgeons,  whatever  opi- 
nions they  may  entertain  refpefling  them, 
and  whatever  conduct  they  may  purliie  with 
a  view  to  their  cure.  They,  who  believfc 
them  all  to  be  fyphilitic,  and  regard  mer- 
cury as  the  only  remedy,  muft  be  perplexed 
by  difcerning  its  ineffic^cy.  They  who 
abftain  from  it  muft  be  perplexed  by  obferv- 
ing  the  pertinacious  nature  of  the  difeafe, 
and  the  frequent  recurrence  of  new  and  diA 
treffing  fymptoms.  They  who  fteer  a  middle 
courfe,  as  I  have  done,  will  not  avoid  diffi- 
culties. Without  any  particular  inveftiga- 
tion  of  the  nature  of  venereal  difeafes,  two 
dififerent  modes  of  treatment  feem  to  have 
been  adopted  by  the  profeflion.  One  party 
has  ufed  mercury  liberally  for  evident  reafons* 
It  fcemed  neceffary  for  the  cure  oF  fyphilis; 
and  it  has  been  fuccefsful  in  cafes  of  that 
difcafe.  Believing  all  venereal  difeafes  to  be 
of  that  nature,  and  further  incited  by  fre- 
quent recurrence  of  fymptoms,  one  party  of 
prdfefiional  men  has  ufed  mercury,  as  I 
believe,  in  a  moft  injurious  degree :  whilft 
others,  from  witneffing  the  beneficial  effefls 
of  an  alterative  courfe  of  mercury  in  pfeudo- 

M  4  fyphilitic 


ON    DISEASES 


fyphiliticdifeareSjhaveconfideied  fuch  acourie 
to  be  all  that  was  necelTary  in  every  inftancc. 

No  improvement  in  pra6lice  could  poffibly 
take  place,  whilft  former  opinions  prevailed  j 
whiUl  furgcons  regarded  every  conftitutiona! 
difeafe  that  had  the  appearance  of  fyphilis  to 
hp  really  of  that  nature,  and  treated  it  accord- 
'  ingly.  This  was  done,  whatever  might  have 
[  been  the  characters  and  progrefs  of  the  pri- 
mary fore  from  which  it  originated;  and  even 
when  it  was  preceded  by  no  fore,  it  wa$ 
confidered  as  an  inftance  of  fyphilis  long 
lurking  in  the  conftitution.  Even  Mr.  Hun- 
ter, who  fo  accurately  obferved  difeafes,  and 
fo  clearly  diftinguifhed,  that  there  were 
jnany  difeafes  refembhng  fyphilis  which  were 
not  of  that  nature,  muft  have  been  exceed- 
ingly perplexed  in  his  opinions  and  practice, 
^s  he  believed  chancres  might  be  modified 
\)y  the  difeafed  propenfities  of  the  conftitu- 
tion,  when  he  met  with  ulcers  in  the  throat, 
eruptions,  and  nodes  confequent  to  fuch 
chancres,  which,  not  even  his  accurate  ob- 
fervation  could,  I  will  venture  to  affirm,  in 
many  cafes  diftinguilh,  from  thofe  of  fyphilis, 
he  muft,  I  think,  have  deemed  it  right  to  treat 
them 


RESEMBLING    SYPHILIS.  169 

them  as  if  they  were  fyphiUtic.  The  cafes, 
to  which  I  now  allude^  are  recorded  in  the 
fecond  feftion. 


But  in  thefe  cafes,  the  fymptoms  will  recur 
in  general  after  the  feverelt  courle  of  mer- 
cury. That  he  met  with  fuch  cafes,  and 
was  perplexed  by  them,  may  be  inferred 
from  his  opinions,  he  having  accounted  for 
fuch  failures  by  faying,  that  mercury  will 
cure  the  difeafe,  when  in  an  aftive  ftate, 
but  will  not  cure  the  difpofition  to  difeafed 
actions,  which  certain  parts  may  have  af- 
fumed.  I  believe,  however,  it  will  be  found 
that  mercury  cures  both  the  aftions  and  dil^ 
pofitions  to  acl  in  true  fyphiiis,  and  that  the 
perplexing  cafes  were  of  a  different  nature  to 
that  difeafe.  How  far  the  difeafed  aftions 
incited  by  fyphiUtic  poifon  admit  of  confi- 
derable  modifications  from  peculiarity  of  con- 
ftitution  in  the  primary  fores  or  chancres, 
we  have,  I  believe,  yet  to  learn.  There  are, 
however,  good  reafons  for  fuppofing  that 
when  a  poifon  is  abforb.-d  without  hiducing 
a  fore,  and  when  that  fore  is  of  a  nature  very 
difcordant  to  thofe  of  fyphiiis,  that  the  con- 
ftitutional  fymptoms  will  be  found  equally  to 
differ 


170  OK  DISEASES 

differ  from  thofe  of  fyphilis  in  their  nacurc, 
and  require  a  different  mode  of  treatment. 

Having  been  inftrufted  by  Mr,  Hunter  to 
believe,  that  there  were  difeafes  refembling 
the  venereal  difeafe,  which  were  different  in 
their  origin  and  progrefs,  having  perceived 
nothing  to  contradift,  but  on  the  contrary, 
every  thing   to  confirm  that  propofition,  I 
have  in  this  publication,  avowed  my  opinion 
of  their  exiftence  to  a  far  greater  extent  than 
Mn  Hunter  fuppofed.     Knowing  how  much 
opinions  influence  our  judgment  and  con- 
duct refpefting  fa£bs  which  come  under  our 
obfervation,  I  have  even  wifhed  that  thefe  opi- 
nions, if  they  be  correft,  might  become  general 
and  confirmed.  Being  confcious  that  they  have 
not  been  haftily  adopted ;  and  that  in  furvey- 
ing  the  fa6ls  upon  which  they  are  founded,  I 
have  endeavoured  to  keep  my  mind  as  unpreju- 
diced as  poflible,  I  fliould  tliink  myfelf  guilty 
of  a  culpable  timidity,  were  I  not  to  avow  them. 
If  the  opinions  be  corre6l,  it  muft  indeed  be 
acknowledged,  that  cafes  of  true  fyphilis  arc 
much  lefs  frequent  now  than  formerly,  and 
for  this  I    have  endeavoured    to   affign    a 
jx^(on  in  the  fecond  fe6lioh.    Well  aware 

how 


RESEMBLING    SYPHILIS.  I7I 

how  liable  an  individual  is  to  err,  in  form- 
ing general  conclufions  from  his  own  limited 
experience,  and  confcious  that  the  opinions 
which  I  entertained  refpefling  thefe  difeafes 
were  different  from  thofe  of  a  great  number 
of  eminent  furgeons,    I   at   firft  publifhed 
my  obfervations  on  the  fubjetl  in  portions ; 
and  the  fame  apprehenfion  as  to  the  pof^ 
fibility  of  error  has  now  induced  mc  to  re- 
publifh  them  in  a  lefs  methodical  manner 
than  I  could  have  wifhed.     I  thought  this 
mode  would  fhew  better  the  rife  and  progrefs 
of  thofe  opinions  which  I  cannot  but  enter- 
tain ;  inafmuch,  as  they  appear  legitimately 
to  be  deduced  from  fa6ls.     Had  I  publifhed 
all  I  knew  and   thought,  relative   to  thefe 
fubje6ls  under  another   title,    had  I  called 
the  book  additional  obfervations  on  venereal 
difeafes,    or  on    progreflive  arid    remittent 
fyphilis,  it  might  have  been  better  received, 
becaufe  it  might  have  been  more  accordant 
to  the  notions  of  others.     Yet  in  whatever 
way  I  might  have  reprefented  the  fubjeft  the 
the  difference  would  only  have  been  in  the 
manner  of  difplaying  it ;  there  would  have 
been  none  in  the  matter  Jo  which  it  related,  as 
that  confifls  of  aftual  occurrences  in  practice. 


(    t7»    ) 


On  Difeafes  of  the  Urethra ;  particularly  of 
that  part,  which  is  furrounded  by  the  proflate 
Gland. 


"I7VERY  furgeon  will,  I  believe,  acknow- 
ledge that  an  obfcurity  hangs  over  the 
fiibjeft  of  ftriftures  of  the  urethra,  which  pre- 
vents us  from  perceiving  the  caufe  of  many 
circumftances,  which  occur  in  daily  praflicc. 
Contradtions  of  this  canal  are  fometimes  rea* 
dily  enlarged  to  their  natural  diameter  by  the 
introduftion  of  common  bougies,  and  the  cure 
thus  effefted  is  permanent.     In  other  cafes 
it  is  difficult  to  procure  even  a  temporary 
enlargement  of  the  contrafted  part ;  and  the 
.  ftriflure  returns,  when  the  means  by  which  it 
was  relieved  are  difcontinued.     This  variety 
r  in  the  event  of  different  cafes  may,  in  fomc 
[  inftances,  depend  on  the  kind  and  duration  of 
the  diieafe  in  the  ftriftures  themfelves ;  yet, 
in  many  others,  I  am  convinced  that  it  i& 
owing  to  other  circumftances,  which  it  is  my 
4  defign 


blSBASES  OF  THB  URSTHRA^  &C.  f  73 

dcfign  to  confider  in  the  prefent  paper.  Be- 
fore my  obfervation  had  been  direfted  to 
thcfc  circumftances,  I  was  much  puzzled  to 
account  for  the  difcordance  in  the  refult  of 
cafes  apparently  fimilar.  I  was  equally 
unable  to  underftand  fome  occurrences,  like  ' 
thofe  which  arc  reprefented  in  tlje  follow- 
ing  cafe. 

CASE  L 

A  getitleman,  whofe  life  was  made  un* 
comfortable  by  a  very  frequent  and  very 
urgent  propenfity  to  void  his  urine,  applied 
to  me  for  advice.  Two  ftriftures  were  dis- 
covered in  the  further  part  of  the  urethra, 
which  did  not  oppofe  the  paflage  of  a  bougie 
as  large  as  a  goofe-quill.  Some  difficulty  was 
experienced  when  the  bougie  entered  that  • 
part  of  the  urethra,  which  paffes  through  the 
proftate  gland  5  and  the  patient  complained  of 
pain,  which  was  confiderably  incrcafed  at  the 
orifice  of  the  bladder.  The  inftrument,  how- 
ever, entered  the  bladder,  though  with  diffi- 
culty ;  and  it  feemed  to  be  grafpod  by  the 
iphin£ter.  The  proftate  was  enlarged  to  twice 
its  natural  fize ;  which  circumftance  feemed 

to 


174  ^^  DISEASES 

to  me,  to  explain  the  caufc  of  the  flight  im- 
pediment which  occurred  to  the  pafTage  of 
the  inftniment  through  it.   The  urethra  was 
unufually  long  in  this  patient ;  and  though 
bougies  had  been  frequently  introduced,  I 
fufpeft  that  they  had  never  been  pafled  into 
the  bladder.  The  patient  was  of  this  opinion, 
from  the  peculiar  fenfations  which  he  expe- 
rienced, and  which  he  had  never  felt  before. 
He  called  upon  me  four  days  afterwards,  (aid 
that  he  was  much  relieved,  and  requefted  to 
have  the  operation  repeated.  The  fame  bougie 
which  had  been  ufed  before  now  paffed  with 
much  greater  facility.     The  patient  ftill  felt 
peculiar  fenfations,  though  much  diminiftied 
in  degree,  as  the  inftrunient  went  through  the 
proftate.     It  entered  the  bladder  without  dif- 
ficulty, and  without  appearing  to  be  grafped. 
I  now  introduced  a  larger  bougie,  which  went 
through  the  ftriftures  with  lefs  difficulty  than 
the  fmaller  one  had  done  on  its  firft  intro- 
dudtion.    This  produced  the  fame  uncafy  fen- 
fation  on  entering  the  proftate  -,  it   was    re- 
tarded for  a  moment  at  the  orifice  of  the 
bladder,  and  was  (lightly  grafped  at  its  en- 
trance.   All  the  fymptoms  were  ftill  more  re- 

2  licved 


OF  THE  URETHRA^   &C.  IJg 

lieved  by  this  fecond  introdu6lion.  The  fame 
operation  was  repeated  a  few  times  ;  at  fu'ft 
every  fourth  day,  and  afterwards  once  a  week, 
till  a  bougie  of  the  largefl:  fize  could  be  paffed 
without  occafioning  any  uneafmefs.  The  pa- 
tient, during  the  latter  part  of  the  time,  did 
not  require  to  void  his  urine  more  frequently 
than  is  common.  He  was  relieved  from  a 
great  trouble  ;  and  though  many  years  have 
elapfed,  he  has  not  experienced  fimiiar  in- 
convenience. 

Such  cafes  as  the  preceding  induced  me  to 
fufpeft  that  a  ftri6lure  might  exift  in  the  ori- 
fice of  the  bladder.  The  following  cafe  gave 
me  new,  and,  as  I  think,  juft  ideas  relative  to 
this  fubje6l.  Whether  the  opinions  be  cor- 
reft  or  not,  the  cafes,  it  muft  be  admitted, 
deferve  attention. 

CASE  II. 

A  gentleman,  more  than  leventy  years  of 
9ge,  had  experienced  for  about  fix  years  a 
difficulty  in  voiding  his  urine,  which  gradu- 
ally increafcd,  till  the  ftream  became  very  linall. 
This  was  attended  with  a  frequciic  propcn- 

firy 


Ij6  ON   DrSZASES 

fity  to  difcharge  the  urine,  which  diftura 
him  every  fecond  or  third  hour  during  the 


light.     At  laft 


took 


complete  retention  ' 
place  when  he  was  in  the  country ;  and  a 
furgeon  attempted  to  introduce  a  fmall  ca- 
theter, which  however  was  prevented,  by  a 
ftridture,  from  paffing  farther  than  fix  inches. 
The  patient  immediately  came  to  London, 
when  I  direi5ted  him  to  take  fome  caftor  oil, 
and  to  bathe  the  perinieum  and  adjacent  parts 
frequently  with  warm  water.  After  fome  time 
the  urine  flowed  again,  and  he  was  relieved 
from  the  prefent  urgent  fymptoms.  In  two 
days  I  examined  the  urethra,  and  found  a  ftric- 
ture  at  fix  inches,  through  which  I  could  not 
pafsevena  very  fmall  bougie.  I  touched  this 
with  the  argentum  nitratum  ;  but  the  appli- 
cation did  not  produce  any  alteration  in  the 
circumftances  of  the  difeafe.  On  the  third 
day  the  bougie  pafied  on  to  a  ftnflure,  at  (even 
inches,  which  was  alfo  touched  with  cauftic  ; 
and  the  fame  treatment  was  repeated  wdth 
another  ftrifture,  at  the  diftance  of  half  an 
inch  from  this.  The  bougie  now  pafled 
through  all  the  ftriftures,  and  entered  the 
proftate,  when  I  was  obliged  to  witlidraw  h 
imme- 
\ 


OF  THB  URXTHRA,  &C.  IJf 

immediately,  from  a  fudden  attack  of  pain 
and  faintnefs.  No  enlargement  of  the  proftate 
was  difcovered  by  an  examinatioa  per  anum ; 
nor  was  it  tender  when  compreflfcd.     I  told 
tiie  patient  that  I  confidercd  it  yery  defirable 
to  introduce  a  tubular  inftrument  into  the 
bladder,  but  that  the  minutenefs  of  the  ftream 
ci  urine  rendered  it  doubtful  whether  this 
could  be  accomplifhed.     I  requefl-ed  him  to 
call  in  another   furgeon,    that  the  attempt 
might  be  made  by  us  conjointly.     A  flexible 
vamifhed  catheter,  containing  a  ftrong  wire, 
was  readily  paffed  into  the  proftate,  but  could 
not  be  made  to  enter  the  bladder.    The  at- 
tempt was  not  long  perfevered  in,  from  an  ap- 
prehenfion  of  doing  injuiy,  if  the  inftrument 
were  not  guided  in  the  right  track.  No  blood 
flowed  upon  withdrawing  the  catheter.     A 
{light  retention  of  urine  followed  this  at- 
tempt ;  but,  after  a  few  days,  the  patient  was 
in  the  fame  ftate  as  before.  On  examining  the 
urethra  four  days  afterwards,  I  found  that  the 
iinalleft  bougie  would  not  pafs  farther  than 
fix  inches  ;  io  that  the  contraftion  of  the  firft 
llrifture  had  been  re -excited  by  the  irritation 
occafionyl  by  our  late  attempt.   As  the  appli- 
cation of  the  argentum  nitratum  had  fb  fud^ 
TOL.  II.  N  dcnly 


denly  and  completely  relieved  this  fl:ri£liire  in 
the  firft  inftanee,  I  now  repeated  this  appli- 
cation, although  I  knew  that  the  ftridture  was 
-merdy  fpafmodic.  In  the  courfe  of  a  few 
days  a  fmall  bougie  was  introduced  into  the 
.proftate,  and  afterwards  a  larger  one.  .  I  now 
wilhcd^to  afcertain  whether  I  could  pafs  the 
bougk  into  the  bladder,  or  learn,  by  means  of 
(that;  iriffrument,  the  caufe  of  the  obftruftion. 
As  the  patient  found  that  he  could  void  his 
urine  mbft  eafily  when  lying  on  the  left  fide, 
,itfeemed  probable  that  the  orifice  of  the  urc^ 
ithra  might  be  found  in  that  direftion,  I 
therefore  .deprcffed  the  point  of  the  inftni- 
ment,  andlcarried  the  other  extremity  towards 
the  right  groin,  when  moft  unexpedledly  it 
.went  forwards  into  the  bladder.  When  the 
bougie  was  withdrawn,  a  confiderable  quan- 
tity of  clotted  blood  and  mucus,  with  fome 
matter,  oozed  out  of  the  urethra;  and  the  pap 
tient  afterwards  voided  in  a  large  ftream  about 
eight  ounces  of  turbid  and  foetid  u«ine  mixed 
.with  mucus  ;  afier  which  he  felt  as  if  his 
bladder  were  completely  emptied.  From  this 
time  he  had  no  occafion  to  void  his  urine 
more  frequently  than  is  natural,  and  he  ex- 
pelled it  in  as  large  a  ftream,  and  with  as 

much 


OP  THE  UR£THRA^   &C«  I/9 

much  facility,  as  he  had  ever  dohe  at  any 
period  of  his  life.     The  bougie  was  for  fomc 
time  introduced  every  third  day,  and  after- 
wards once  a  week.    It  paffed  eafily  not  only 
through  the  urethra,  but  into  the  bladder^ 
when  guided  in  the  direftion  which  has  been 
mentioned*  At  firft  the  point  was  foikd  with 
blood  and  matter,  but  afterwards  the^  ap-* 
pearances  were  no  longer  obfervable,.  whidx 
led  me  to  conclude  that  the  circumference  of 
the  ulcerated  orifice  of  the  bladder  had  com- 
pletely  healed.     Two  years  afterwards  thii 
gentleman  experienced  a  recurrence  of  his 
former  complaints ;  a  fmall  bougie  only  could 
now  be  introduced   into    the  bladder.     A 
larger  bougie  was  paffed  through  the  ure- 
thra on  the  next  attempt;    but  was  not 
carried  forwards  into  the  bladder,  from  an 
apprehenfion  of  irritating  the  proftate.  After 
a  few  days  the  larger  bougie  was  introduced 
into  the  bladder,  and  met  with  a  little  refift- 
ancc  at  its  orifice.     From  this  time  it  paffed 
with  the  fame  facility  as  when  I  difcontinued 
my  former  attendance,  and  the  patient  found 
himielf  equally  well.     Two  years  have  now 
clapfed,  without  any  neceffity  for  repeating 

thefe  operations. 

N  2         .  la 


lib  ON   DISSASZ8 

In  this  cafe  a  difeafe  took  place  in  the 
proftate  gland,  without  producing  any  gvi- 
dfent  enlargement  gr  tendernefs  of  its  fbb- 
ftance,  though  it  had  proceeded  to  aftate  of 
ulceration.  The  difeafe  fecms  to  have  opc^ 
rated  on  the  continuous  parts  in  two  direct 
tioris }  backwards  upon  the  bladder,  rendering 
that  organ  irritably  ;  and  forwaixis  upon  thi 
urethra,  caufing  ftriftures,  which  were  in 
ibme  degree  organic,  though  chiefly  of  a*  fpaf- 
modic  Mature.  It  muft  be  allowed,  however, 
that  the  obftrudbion^of  the  aperture  into  the 
blidder  by  the  difcharges  from  the  ulcerated 
furface  contributed  in  a  great  degree  to  main- 
tain  the  irritability  of  the  organ,  by  impeding 
the  difcharge  of  the  urine.  This  difeafe  was 
alfo  of  a  nature  that  admitted  of  relief,  and 
the  paflage  of  a  bougie  feemed  to  efFeft  its 
cure.  It  had,  however,  a  tendency  to  recur, 
and  the  ufe  of  the  bougie  leflened  the  irri- 
tability of  the  part,  and  arretted  the  progrefe 
of  the  difeafe. 

Thfe  circumftances  of  this  cafe  do  not 
indeed  unfold  the  caufe  and  precife  nature 
of  the  diforder,  which,  however,  will  in  my 
opinion  be  elucicjated  by  thofe  which  follow. 

They 


OF  rUBf  URETHKA^  &C.  184 

They  induced  mc  to  fuppofe  that  thofe  in- 
ftances,  which  I  had  formerly  met  with, 
and  which  appeared  fo  unintelligible,  were 
of  a  iimilar  nature ;  and  they  made  me  par^ 
ticularly  attentive  to  the  ftate  of  the  uredira, 
where  it  paffcs  through  the  proftate  glands 
as  I  faw  the  pojQibility  of  this  canal  being 
difeafed,  without  the  proftate  being  mate* 
rially  implicated  in  the  diforder^  The  folt 
lowing  cafe  occurred  ibon  afterwards. 

CASE  m. 

A  gentleman,  between  fifty  and  fixty  years 
erf  age,  had  for  twenty  years  been  fubje6t 
to  occafional  fits  of  dyfury.  I  was  defired 
to  fee  him  in  one  of  thefe,  which  had  been 
very  fevere  and  long  continued.  He  was 
obliged  to  void  the  urine  at  leaft  every  hour. 
The  calls  were  fudden  and  urgent,  and  the 
pain,  continued  for  a  confiderable  time  after 
the  urine  had  been  difcharged.  He  had  fome 
^er^  which  fuch  irritation  would  naturally 
produce.  A  moderate-fized  bougie  ftopp^ 
at  two  ftriftures,  but  pafTed  through  them 
without  much  di65.culty :  when  it  entered  the 
proftate,  the  patient  complained  of  burning 

N  3  pain 


OK  DISEAS19 


pain ;  of  a  ftrong  irritation  to  make  water ; 
and  grew  fo  faint  that  I  had  merely  timc^ 
by  a  gentle  preffure,  to  afcertain  that  the 
bougie  would  pafs  into  the  bladder :  when 
I  withdrew  it,  the  point  was  covered  with 
blood.  The  patient  was  directed  to  bathe  the 
perinaeum  with  warm  water  frequently,  if  the 
dyfury  was  urgent.  He  was  much  relieved 
by  the  introdu6lion  of  the  bougie,  and  did 
not  want  afterwards  to  void  his  urine  oftener 
than  every  fecond  or  third  hour.  The  calls 
were  lefs  urgent,  and  the  fubfequent  uneafi- 
nefs  lefs  in  feverity  and  duration.  After  two 
days,  a  bougie  of  the  fame  fize  was  intro- 
duced to  the  extent  of  eight  inches,  and  with- 
drawn J  no  blood  adhered  to  its  furface.  A 
fmaller  bougie,  much  curved,  was  now  pafled 
into  the  bladder ;  the  patient  complained  of 
the  fame  uneafy  fenfation  as  before,  when  it 
entered  the  proftate  ;  but  he  did  not  grow 
faint.  The  point  was  bloody  for  three  quar- 
ters of  an  inch,  but  lefs  fo  than  on  its  firft 
introduftion.  More  relief  was  experienced 
this  time.  The  urine  was  now  voided  only 
every  fourth  hour.  Two  days  afterwards 
the  bougie  was  again  introduced  into  the 

bladder 


OF  THE  URETHRA,   &C.  I^} 

bladder,  confiderably  curved,  and  with  the, 
point  carried  along  the  upper  furface  of  the 
urethra,  where  it  paffes  through  the  proftate 
gland.  The  point  was  foiled  with  a  yellowifh, 
fluid,  flightly  tinged  with  blood.  As  the 
patient  was  getting  much  better,  the  ope- 
ration was  not  repeated  till  after  four  days, 
and  then  after  the  interval  of  a  week  -,  at. 
which  time  the  blood  and  the  yellow  fluid 
had  entirely  difappeared.  The  urine  was 
not  voided  more  frequently  than  natural,^ 
nor  was  its  expulfion  attended  or  fucceeded 
by  any  painful  fenfation.  The  flridtures 
in  this  cafe  felt  firm,  and  not  eafily  dila- 
table :  I  thought  it  neceflary  to  relieve  them, 
left  they  fhould  contribute  to  re-induce  the 
irritation  in  the  proftate;  but  the  patient 
felt  himfelf  fo  well,  that  he  was  averfe 
to  any  thing,  which  might  renew  his  former 
fufFerings,  and  he  has  had  no  fymptoms  of 
dyfuiy  fince  that  period.  The  proftate  in 
this  patient  was  not  enlarged  nor  tender. 
Conclafions  fimilar  to  thofe,  which  were 
deduced  from  the  former  cafe,  may  be  more 
fairly  drawn  from  this ;  viz.  that  a  difeafe 
may  occur  in  the  membrane  of  the  urethra 

N  4  where 


184  OK  disease;^ 

where  it  paflcs  through  the  proftate,  and 
that  it  may  render  the  bladder  irritable,  and 
produce  ftriftures  in  the  urethra ;  for  in  this 
cafe  there  was  no  mechanical  obftrudtion  to 
the  expulfion  of  the  urine  to  produce  irrita* 
tion  in  the  bladder.  It  alfo  appears,  that  the 
difeafe  admitted  of  relief  by  the  introduftion 
of  a  bougie. 

I  have  lately  met  with  another  caife  in  a 
younger  man,  who  is  between  twenty  and 
thirty  years  of  age,  and  who  was  afilifled 
with  fimilar  fits  of  dyfury,  the  £aufe  of  which 
could  not  be  afcertained,  I  pafTed  a  bougie 
for  him  a  few  times,  but  found  no  ftrifhire  in 
the  urethra.  The  fame  painful  feniarions 
were  produced  in  the  proftate,  as  in  the  pre- 
ceding cafes.  The  bougie  did  not  appear  at 
the  time  to  relieve  the  dyfury ;  but  the  com- 
plaint gradually  ceafed,  and  the  patient  left 
town.  He  has  been  much  better  fince  this 
time,  and  attributes  hi$  relief  to  the  paffage 
of  the  bougie. 


CASE 


OF  THE  URETAkA)  &C*  iSj 

CASE  rv. 

A  gentleman,  about  fixty  years  of  age,  twrf 
affefted  with  dyfury,  which  incfeafed  witfi 
violence,  though  various  means  were  emM 
ployed  during  two  years  for  his  reltefi  Hd 
voided  his  urine  every  fecond  h6ur,  or  oftener; 
with  great  pain  and  fcvere  irritation;  M^hich 
continXied  for  fome  time  after  its  expulflon. 
He  had  fuch  a  fenfation  of  heat  and  uneafi-^^ 
nefs  in  the  perinaeum,  that  he  could  not  beaf 
to  bring  his  thighs  together;  atid  he  was 
obliged  to  ufe  a  cufhion,'  with  a  vacahcy  iri 
the  middle,  when  he  fat  down.  He  could 
not  ride  in-  a  carriage,  or  even  walk  otit,  al- 
though his  general  health  was  good.  A 
moderate  fized  bougie  halted  a  little  at  tw6 
ftrictures,  and  when  it  arrived  at  the  proftate 
produced  a  violent  burning  fenfation,  a  vehei 
ment  propcpfity  to  void  the  urine,  and  extrenrt 
pain  at  about  two  inches  from  the  orifice  of 
the  urethra ;  which  part  was  alwafys  particu-* 
krly  painful  during  the  tittie  of  voiding  th^ 
urine,  and  after  its  expulfion.  On  withdi'aw- 
ing  the  bougie,  which  had  entered  the  bladder, 
|ls  point  was  found  to  bb  covered  with  bldbd. 

Th« 


Xt6  ON  DISEASES,      . 

The  proftate  being  examined,  felt  rather 
broader  than  ufual,  but  was  not  tender.  The 
patient  was  relieved  by  the  introduftion  of  the 
bougie,  which  was  repeated  on  the  third  day : 
it  went  more  freely  through  the  ftrifhires, 
an^  the  fenfations,  caufed  by  its  paflage 
through  the  proftate,  were  diminiflied.  The 
point  of  the  bougie  was  bloody.  I  afcertained 
that  the  blood  came  from  that  part  of  the 
urethra  which  is  fituated  in  the  proftate,  by 
introducing  a  large  bougie  to  the  diftance  of 
eight  inches,  and  then  withdrawing  it :  the 
point  was  not  in  the  leaft  foiled  with  blood. 
The  fecond  introduftion  of  the  bougie,  pro- 
duced confiderable  relief.  The  urine  was  re- 
tained longer,  the  uneafy  fenfation  in  the  pe- 
rinssum  was  diminiflied,  and  the  patient  could 
walk  or  fit  down  more  comfortably.  The 
bougie  was  ufed  every  third  or  fourth  day  for 
three  weeks;  and  then  once  a  week  for  a 
month  longer,  its  fize  being  gradually  in- 
creafed.  The  appearance  of  blood  on  the 
point  gradually  ceafed  :  it  was  afterwards 
foiled  with  a  purulent  and  then  with  a  mu- 
cous fluid,  which  appearances  alfo  gradu- 
ally ceafed.  ^    The  water  was  now  voided 

only 


OF  THE  URETHRA,   &C.  187 

only  at  inten-als  of  four  hours,  the  fubfe- 
quent  pain  being  either  trivial  or  entirely 
wanting ;  the  uneafinefs  in  the  perinjeum  was 
fo  inconllderable,  that  the  patient  could  walk 
for  feveralhourSj  and  fit  down  without  pain. 
The  feminal  difcharges  had  been  attended 
witli  extreme  pain,  fo  great  as  almoft  to  pro- 
duce fainting,  before  the  ftate  of  the  proftate 
had  been  relieved :  they  afterwards  took  place 
without  any  unufual  fenfation. 

Thefe  cafes  fhew  that  the  uretlira  may  be- 
come irritable  and  difeafed,  where  it  pafles 
througli  the  proftate  gland,  without  any  ma- 
terial diforder  of  the  contiguous  parts.  They 
induced  me  to  pay  particular  attention  to  the 
ftate  of  that  part  of  the  urethra  ;  which  at- 
tention will,  in  my  opinion,  be  found  of  great 
confequence  in  directing  our  treatment  of 
thefe  diforders.  As  it  would  render  this  pa- 
per extremely  voluminous  to  detail  the  par- 
ticular cafes  which  I  have  met  with,  1  {hall 
merely  relate  the  obfcrvations  which  I  have 
made,  and  the  inferences  which  I  have  drawn 
from  them ;  that  the  profelfion  in  general  may 
inveftigate  the  fubjeft,  and  determine  how  far 
thefe  obfcrvations  and  opinions  are  correct. 
Firft 


J 


iSS  ON   DISEASES 

Firft,  then,  it  has  appeared  to  me  that  a. 
ftate  of  inilammatioa  and  irritation  may  take 
place  in  the  remote  part  of  the  urethra  to  a 
j^xater  or  lefs  jextent.  It  may  produce  in  thie 
proflate  that  peculiar  feiU&bility  of  tlie  part 
which  I  have  defcribed  >  and  in  the  peiina^um 
it  may  caufe  contra6Vion^  of  different  parts  of 
the  canaL  Either  of  thefe  affections  mtay  be 
more  permanent  than  thq  other^  even  wh^re 
each  part  has  been  equally  affed^  in  the  be- 
ginning. This  ftate  of  inflammation  and  irri- 
tation is  frequently  produced  by  gonorrhoea^ 
though  it  may  occur  from  other  caufts.  If, 
a  bougie  be  introduced  injudiciouilyi  when 
this  diforder  firft  occurs  in  a  gonorrhcsa^ 
numerous  fpafmodic  ftiiftures*  are  met  with^ 
the  patient  becomes  alarmed  by  the  difficulty 
of  pafling  the  inftiument,  and  by  the  name 
of  ftrifturesy  and  confults  a  more  experienced 
furgeon,  who  direfts  local  warm  bathing,  and 
the  application  of  leeches  to  the  peiin»um, 

^  I  have  ufed  the  term  fpaCnodic  ftriftures  in  the  in-^ 
^ifcri'minate  manner  in  which  it  is  generally  employed^ 
Aoirgh  I  am  aware  that  it  is  obj^AionaWe :  a  ftrithire 
from-  fpafm  is  not  a  ftriAmre  y  and  a  (lrit3;urc  may  b« 
yrriuble  at  fpaimodical,  or  othcrwife. 


OF  t^t  flRrWHAA,   &C.    -  ^89 

The  difoixier  is  cured ;  the  patient  expeSte  that 
ftriftures  remain ;  a  fulKfiz'ed  bougie  h  intro* 
diKred  to  latiaffy  him,  wjiidk  pafles  without  the 
leaft  difficulty.  1  am  imable  to  determine 
whetlicr  in  fuch  cafes  the  urfethra  is  ^Hefted 
in  the  firft  inftance  in  that  part  which  piaffes 
through  l3ie -proftate,  ^s !  never  made  any  ex- 
amination under  thefc  circumftances,  thotiigK 
I  think  it  very  probable  that  it  is  fo.  '  Wheft 
'a  gleet  becomes  unufually  protracted,  it  h 
fitquently  owing  to  the«eflfe6t9  of'this  difoi^ 
der  in  the  remote  part  of  the  urethria,  mairt* 
taining  a  degree  of  irritation  in  the  front. 
ILJtider  thefe  circumftances,  it  is  allowable  tb 
introduce  a  bougie,  when  ftriftures  wiH  fre- 
quently be  found  in  the  perinseum ;  and-  in 
many  cafes,  tlie  patients  whom  I  have  attended 
have  experienced  thofe  fenfations,  which  arc 
charafteriftic  of  tendemefs  in  the  memlM'an^ 
of  the  urethra,  where  it  paffes  tlirough  the 
proftate.  If,  therefore,  we  look  to  the  otigin 
of  thole  cafes,  which  we  are  called  upon  to 
attend  in  their  advanced  ftagesy  we  might  ej^ 
^6t  to  find  the  difbrder  of  the  urethra  various 
with  refpeft  to  the  land  and  extent  of  the 
^dtfeafe.    That  it  will  be  foutul  fo  in  pra^ice 

g  I  do 


tSfl  .     *        DK   DISEASES 

I  do  not  hefitate  to  affirm,  from  the  obrerva- 

tions  which  I  have  aheady  made  relative  to 

r  :this  fubje^.     In  fome  cafes,  ftridlures  in  that 

L  J)art  of  the  canal,  which  is  fubjeft  to  fuch  con- 

L  jtraflions,  will  be  the  fcle  difeafe.     In  others, 

I  ^an  uneafmefs,  and  fuch  fenfations  as  I  have 

[  ^efcribed,  will  be  complained  of  as  the  bougie 

[  |)afres  through  the  laft  inch  of  the  urethra, 

t  iwhich  is  contained  in  the  proftate  gland.     In 

jfome  cafes  alfo,  the  ftri6lures  will  be  the  lefs 

f  Jegree  of  the  difeafe,  and  the  irritation  in  the 

.proftate  the  greater ;  and  in  fome  cafes  it  will 

be  found  that  nothing  is  difcoverab!6  which 

'  ,<:an  fairly  be  denominated  a  ftridure,  and  yet 

I  ^e  tendernefs  which  I  have  defcribed  exifts 

Lin  a  moil  painful  degree. 


I:     A  ftudent  of  the  hofpital  who  had  a  flight 
ligleet,  but  of  long  continuance,  having  alio 
l^^me  pain  and  irritation  after  voiding  his 
l^ine,  though  without  any  frequent  defire 
,  ito  void  it,  palled  a  bougie,  which  arrived  at 
-the  proftatic  part  of  the  urethra  without  im- 
pediment, or  caufmg  him  to  feel  any  parti- 
cular uneafmefs ;    but  when  it    glided    on 
■through  the  proftate,  it  occafioned,  he  faid, 
3  a  burn- 


OF  THE  URETHRA)  &C#  ipi 

-  a  burning  pain  and  irritation,  fo  peculiar,  as 
not  to  admit  of  defciiption,  and  fo  fevere, 
that  he  could  not  have  believed  it,  but  on  the 
evidence  of  his  own .  fenfes .: 

• 

My  obfervations  have  alfo  led  me  to  believe, 
that  the  inflammation  of  the  teftis,  which  is 
fo  frequent  an  attendant  on  gonorrhoea,  is 
excited  by  inflammation,  of  this  part  of  the 
urethra,  and  not  by  a  fympathy  between  that 
gland  and  the  urethra  in  general. 

In  deducing  thefe  difeafes  from  the  inflam- 
mation which  gonorrhoea  excites,  I  mean 
only  to  trace  them  from  a  very  common 
origin.  The  fame  diforders  frequently  take 
place  without  having  been  pi^ceded  by  that 
complaint.  An  attention  to  the  circum- 
ftances,  which  have  been  mentioned,  feems 
to  me  to  explain  the  contradiftory  events 
which  happen,  when  a  fimilar  plan  of  treat- 
ment is  purfued  for  the  cure  of  difeafes  of 
the  urethra.  When  ftriftures  are  the  fole 
difeafe,  they  are  often  readily,  and  gene- 
rally permanently,  cured.  When  an  irri- 
tation, fuch  as  I  have  defcribed,  exiflis  in  the 

proftate. 


f^l  OK  M8IASBS 

proftatCj  it  is  difficult  to  enlarge  the  con- 
tracted portions  of  the  canal ;  and,  when  that 
is  acomplilbed,  theAri6tures  recur,  as  a  cauic 
of  irritation  to  theurcthra  ftill  continues.  In 
Ibme  cafes,  the  enlaigement  of  the  ftrifhires 
.£uls  to  mitigate  the  dyfury,  and  in  others  it 
is  augmented  by  the  meafures  which  have 
been  employed  to  cure  the  ftriftures,  when 
the  ftate  of  irritation  at  the  neck  of  the  blad- 
der has  been  unadverted  to.     Many  patients 
have  applied  to  me  under  thefe  circumftances, 
after  having  been  under  the  care  of  other  fur- 
geons.     They  have  ftated,  diat  (inaU  bougies 
only  could  be  paffed  in  the  firft  inftance,  and 
that  though  the  largeft  could  now  be  intro- 
duced, the  complaint  was  no  better;  nay,  fome 
have  thought  thcmftlves  materially  worfe.   A 
bougie  has  paffed  in  thefe  cafes  eight  inches, 
without  meeting  any  confiderable  obftruction, 
or  exciting  much  fenfation ;  but,  after  this 
point,  it  caufed  a  moft  acute  and  burning  pain, 
with  vehement  defire  to  make  water.     Some 
have   enquired   if  I   was  withdrawing  the 
bougie,  whilft  it  was  flowly  proceeding,  and 
fome  have  complained  of  great  pain  in  the 
front  of  the  uretha.     Similar  cafes  liave  oc- 
curred 


OF  THE  URETHRA,  &C.  1 93 

curred  in  my  own  praftice.  I  have  relieved 
ftriftures,  without  materially  benefitting  my 
patients ;  of  latexyears,  I  may  venture  to  fay, 
without  making  them  worfe  j  becaufe  I  have 
been  cautious  not  to  hurt  the  canal,  where  it 
paffes  through  the  proftate. 

Some  cafes  of  diforders  of  the  urinary 
organs  arc  made  worfe  by  the  attempt  to  cure 
ftri6hires :  and  I  think  I  deliver  an  important 
admonition,  to  the  younger  part  of  the  pro- 
feffion,  when  I  caution  them  to  beware,  in 
their  attempts  to  cure  ftriftures,  that  they  do 
not  irritate  nor  injure  the  laft  inch  of  that 
canal,  where  there  are  no  ftri6lures,  but  in 
which  coiifiderable  diforder  may  neverthelcfs 
cxift. 

In  fome  cafes  of  difeafed  urethra,  which  I 
have  not  unfrequently  met  with,  ftriftures  are 
found,  through  which  a  fmall  bougie  pafles 
with  difficulty ;  and  it  produces  thofe  fenfa- 
tions,  in  paffing  through  the  proftate,  which 
I  have  defcribcd,  as  peculiar  to  that  part  of 
the  canal  when  in  a  difeafed  ftate.  The 
patient,  however,  experiences  relief  from  the 

TOL.  II.  Q  intro- 


<94  ^^   DISEASES 

introduction  of  the  bougie  -,  and  if  it  be  paflcd 
again  on  the  third  day,  it  will  meet  with  no 
obftru6lion  from  the  ftriftures,  and  cauie  lefs 
uneafmefs  in  pafling  through  the  proftate.  I 
have  then  taken  a  bougie  of  a  larger  fize, 
fuch  as  it  would  have  been  impoffible  to  in- 
troduce in  the  firft  inftance,  and  this  has 
paffed  through  the  ftridhires  to  the  diftance  of 
eight  inches  -,  but  I  have  forborne  to  carry  it 
any  farther,  left  I  fhould  irritate  the  urethra 
near  the  neck  of  the  bladder.  It  appears 
therefore  to  me,  that  you  may  relieve  or  ag- 
gravate ftriftures  in  fuch  cafes  in  proportion 
as  you  diminifli  or  augment  the  morbid  fen|Si- 
bility  of  the  remote  part  of  the  urethra ;  and  « 
an  attention  to  the  ftate  of  this  part  is  on 
this  account  of  the  greateft  importance. 

Having  thu^adverted  to  the  probable  origin 
of  the  difeafe,  which  I  am  endeavouring  to 
defcribe,  and  its  connexion  with  ftriftures,  I 
proceed  to  obferve,  that  fuch  a  ftate  of  mor- 
bid fenfibility  in  that  portion  of  the  urethra, 
which  paffes  through  the  proftate,  may  per- 
haps exift  as  a  fymptom  of  an  irritable  blad- 
der. If  the  lining  of  the  bladder  be  in- 
flamed 


OF  THE  URETHRA,  &C.  1 95 

flamed  and  irritable,  it  is  probable  that  the 
diforder  will  extend  into  the  urethra  for 
fome  fmall  diftance.  In  the  fourth  cafe,  I 
believe  that  the  difeafe  in  queftion  was  com- 
plicated with  an  irritable  ftate  of  the  bladder; 
but  whether  it  was  to  be  confidered  as  an 
adjunft  circumftance,  or  in  the  relation  of 
caufe  or  efFeft,  cannot  be  determined.  The 
irritability  of  the  bladder  was  diminifhed,  but 
not  cured,  by  the  treatment  which  leffened 
this  difeafe.  In  one  gentleman,  who  appa- 
rently died  of  an  irritable  bladder,  and  who 
complained  of  the  fenfations,  which  I  have 
defcribed,  in  an  acute  degree,  on  the  bougie 
paffing  through  the  proftate,  the  difeafed 
parts  were  examined,  but  very  trivial  morbid 
appearances  were  difcovered.  The  lining  of 
the  bladder  was  not  perfeftly  natural,  and 
was  inflamed  ;  yet  the  difeafed  appearances 
were  not  ftriking;  and  in  the  urethra  the 
deviation  from  the  healthy  ftrufture  was  ftill 
lefs  obfervable. 

It  is  not  improbable,  however,  that  fuch 
a  morbid  fenfibility  of  the  proftatic  urethra 
may  arife  from  an  irritable  bladder.   Pei-haps, 

o  2  alfo^ 


196  ON   DISfiASl^l 

alfo,  it  may  occafionally  arife  from  the  irrita- 
tion of  the  laft  ftrifture.  Many  patients  with 
ftriftures,  who  complained  much  of  the  fen- 
fations  at  the  neck  of  the  bladder,  at  the 
commencement  of  the  treatment  of  their 
complaint,  have  aflerted,  that  they  felt  no 
unufual  fenfations  when  the  bougie  pafTed 
through  the  proftate,  after  the  ftriftures  had 
been  cured.  Yet,  though  I  would  admit  that 
a  tendernefs  of  the  canal  of  the  urethra  in 
the  proftate  may  fometimes  arife  from  its 
proximity  and  continuity  with  the  lining  of 
the  bladder,  or  with  the  laft  ftrifturc,  I  think 
it  more  frequently  exifts  as  an  original  and 
independent  difeafe.  It  has  been  fhewn, 
that  it  may  render  the  bladder  irritable,  and 
excite  contra6lions  in  the  urethra.  Some 
cafes  have  been  adduced,  which  fhew  that 
this  ftate  may  exift,  and  yet  the  bladder  may 
not  be  conftantly  irritable,  but  that  it  may  be 
affe6led  by  fits.  I  have  alfo  met  with  a  cafe 
where  this  fcnfibility  exifted  in  an  extreme 
degree,  and  yet  it  feemed  to  have  very  little 
influence  on  the  bladder.  I  have  likcwifc 
known  this  irritable  ftate  of  the  urethra  com- 
plicated with  enlargement  of  the  proftate.  ^ 

I  pro* 


OF  THE  URETHRA,   &C.  197 

V 

i  proceed,  in  the  next  place,  to  relate  what 
I  have  obferved  refpefting  the  treatment  of 
the  difeafe,   which!  have  been  defcribing. 
The  three  firft  cafes  (hew,  in  a  ftriking  man- 
ner, the  advantage  derived  from  the  intro*- 
duftion  of  bougies  j   and  I  have  fecn  many 
limilar  ones,  though  I  fcarcely  think  fo  de- 
monftrative  of  the  utility  of  this  mode  of 
treatment.     I  know  fome  patients  with  oc- 
cafional  attacks  of  dysury,  and  who  have 
this  tendcrnefs  of  the  remote  part  of  the  ure- 
thra, in  whom  the  paflhge  of  a  bougie,  toge- 
ther with  warm  bathing  of  the  perinaeum  and 
adjacent  parts,  very  fpeedily  relieves  a  difeafe, 
which  had  proved  very  tedious  and  diftreffing, 
before  thefe  meafures   were  adopted.     If  a 
bougie  be  introduced,  for  the  firft  time,  in  a 
cafe  of  this  defcription,  fevere  pain  is  felt,  and 
faintnefs  is  occaiioncd :  if  this  operation  be 
repeated  three  days  afterwards,  the  pain  pep 
haps  is  much  lefs  fevere,  and  it  may  dimi- 
nifli  at  each  fijcceeding  introduftion  of  the 
inftrument.     Should  this  be  found  to  be  the 
cafe,  furely  nothing  need  be  farther  faid  in 
commendation  of  this  mode  of  treatment. 
The  morbid   fenfibility  of  parts  is   dimi- 

o  3  nifhed 


198  ON  Z)I8EASI(8 

nifhed  by  it.  This  happened  in  the  three 
firft  cafes  in  a  remarkable  degree,  and  I  have 
known  it  take  place  in  many  others.  Nor  is 
there  any  thing  in  this  event  that  (hould 
excite  furprife :  every  furgeon  is  familiar  with 
the  fame  circumftance,  with  relation  to  ftric- 
tures  in  the  urethra.  The  firft  introduftions 
of  a  bougie  are  very  painful ;  the  fubfequent 
ones  become  to  be  even  difregarded*  Still, 
however,  I  think  it  may  be  ufeful  to  dwell  a 
little  on  this  fubjeft,  and  to  confider  the  pro- 
bable caufes  of  thefe  efFefts,  as  it  may  tend  to 
■eftablilh  rales  for  our  conduft  in  praftice.  It 
appears  to  me,  that  we  diminifh  the  morbid  as 
well  as  the  natural  fenfibility  of  parts  by  doing 
them  a  degree  of  violence,  fhort  of  that  which 
produces  a  kind  of  re- action  in  them,  by  which 
their  fenfibility  is  heightened.  This  is,  in- 
deed, the  confideration  which  guides  my 
praftice  in  thefe  and  in  many  other  cafes. 
If,  even  in  ftriflures  of  the  urethra,  the  fen- 
fibility of  the  canal  becomes  increafed  by  the 
introduftion  of  bougies,  or,  in  other  words, 
if  inflammation  is  excited,  furely  it  is  wrong 
to  profecute  fuch  meafures  at  this  junfture. 
If  the  morbid  fenfibility  be  diminifticd,  wc 

may 


OF  THE  URETHRA^   &C.  tp^ 

may  ufe  more  freedom  in  the  profecution  of 
our  meafurcs.  In  pafling  the  bougie,  in  the 
cafes  now  under  confideration,  it  ought  at 
firft,  I  think,  to  be  fo  fmall  as  not  at  all  to 
diftend  the  irritable  urethra.  I  have  always 
curved  it  confiderably,  and  kept  the  point  in 
contaft  with  the  upper  furface  of  the  urethra, 
as  it  pafTes  through  the  gland.  I  recom- 
mend warm  bathing  to  the  perinaeum,  with 
a  view  to  obviate  or  diminiili  irritation.  If 
I  find,  on  the  fecond  introduftion  of  the 
bougie,  the  fcnfibility  of  the  parts  diminifhed, 
it  induces  me  afterwards  to  proceed  more 
freely ;  but  at  all  times  with  a  caution  excited 
and  regulated  by  the  confideration  which  I 
have  mentioned.  Now,  though  fuch  con- 
du£l  has  been  fuccefsful  in  many  inftances, 
i  am  concerned  to  ftate^  that  it  has  failed  in 
fbme  others ;  and,  when  I  clearly  afcertain 
that  I  am  not  likely  to  fucceed,  I  ceafe  to 
make  farther  attempts  by  the  introdu6tion  of 
bougies,  and  purfue  only  general  methods, 
fuch  as  warm  bathing,  bleeding  by  leeches, 
&c.  When  there  are  ftri6lures,  which  it  is 
right  to  enlarge,  and  when  the  irritation  of 
the  proilatic  part  of  the  urethra  is  not  relieved 

04  by 


200  ON   D18£A8£8 

by  the  meafures  which  have  been  fuggefted,  I 
pafs  the  bougie  through  the  laft  ftrifturey 
without  carrying  it  on,  fo  as  to  uTitate  the 
tender  part  of  the  urethra,  which  lies  behind 
it.  A  knowledge  of  the  nature  of  difeafes 
cannot  but  be  defirable,  even  though  it  does 
not  enable  us  to  cure  them  all.  If  ftriftures 
arc  removed,  and  dy fury  remains,  I  believe  it 
is  common  to  confider  it  as  arifmg  from  an 
irritable  bladder :  now,  though  this  may  be 
generally  true,  there  are  many  exceptions.  I 
do  not  find  that  attention  is  paid  to  that  de- 
fcription  of  cafes,  which  makes  the  fubjcft  of 
the  prefent  paper :  I  was  unacquainted  with 
them  till  I  met  with  the  cafes  which  I  firft 
mentiuned  :  the  knowledge  which  I  have  thus 
obtained,  has  enabled  me  to  afford  relief  in 
many  cafes,  and  has  prevented  me  from  error 
in  others. 


OF  THE  URETHRA,   &C.  dOI 


SECTION  n. 

On  the  conjiitutional  Origin  and  treatment  of 

Difeafes  of  the  Urethra. 

TjAviNG  in  the  preceding  fe6lion,  pointed 
^^  out  one  caufe  which  renders  ftri6lurcs 
and  other  difeafes  of  the  urethra  difficult  of 
cure,  in  this,  I  (hall  advert  to  another;  I 
mean  a  ftate  of  irrijability  and  diforder  of  that 
canal,  produced  or  maintained  by  conftitu- 
tional  caufes,  ,To  explain  my  ideas  on  this 
fubjeft,  I  wifh,  in  the  firft  place  to  excite 
the  attention  of  the  profeffion  to  the  confti- 
tutional  origin  of  diforders  of  the  urinary 
organs.  That  they  arc  very  liable  to  be  dif- 
ordered  by  the  ftate  of  the  health  in  general, 
is  very  .  apparent,  Indigeftibn  becomes  a 
caufe  of  foul  and  unhealthy  urine,  in  confe- 
quence  of  much  unaffimilated  matter  being 
conveyed  into  the  blood  with  the  chyle. 
Nervous  irritation  affedls  the  kidney  and  im- 
pairs its  funflions,  fo  that  whilft  under  its 
influence,  fcarcely  any  thing  but  water  is  fe- 
parated  by  that  organ  from  the  blood.  The 
nervous  irritation  at  the  fame  time  operates 

on 


a02  CK   Z>I&£AS£G 


on  the  bladder,  and  creates  a  frequent  and 
fometimes  urgent  defire  to  void  this  unfti- 
mulating  urine.  Many  perfons  during  the 
day,  or  until  they  have  dined,  are  greatly  in- 
commoded by  this  circumftance;  whilft  on 
the  contrary,  after  dinner,  nervous  irritation 
ceafmg,  and  the  urine  becoming  in  confe- 
quence  loaded  with  falts  and  animal  matter, 
the  bladder  will  retain  the  acrid  mine,  even 
in  a  large  quantity,  for  a  great  number  of 
hours. 

In  other  cafes,  nei'vous  irritation  takes 
place,  and  limpid  urine  is  frequently  voided 
after  dinner  -,  which  I  merely  mention,  be* 
caufe  it  may  tend  to  throw  light  on  the  caufc 
and  nature  of  the  nervous  irritation*.  If  the 
kidneys  and  bladder  can  thus  be  operated 
upon  by  nervous  irritation,  it  is  i-eafonable 
to  fuppofe,  that  the  urethra  will  participate 

*  The  qualities  of  the  urine  are  fometimes  the  only 
circumftances  by  which  we  can  difcover  that  there  is  ge- 
neral irritation  of  the  nervous  fyflem  ;  they  alfo  denote 
hnperfeft  digeftion ;  they  may  further  indicate  the  ftate 
pf  the  blood ;  and  for  all  thefe  reafons  they  deferye  par- 
ticular attention  and  inveftigation. 

in 


OF  THB  URETHRA^   &C«  itOJ 

in  the  afFe£l:on;  and  I  am  convinced  by 
numerous  obfervations,  that  many  difeafes  of 
the  urethra,  in  both  fexes,  originate  from  a 
continuance  of  this  kind  of  conftitutional  dy^- 
fury.  The  cafes  of  fuch  difeafes  occurring  in 
females  who  have  paffed  the  middle  period  of 
life,  will  probably  be  confidered  as  affording 
the  moft  unequivocal  proofs  of  the  correftnefs 
of  thefe  opinions.  Under  fuch  circum^ftances, 
I  have  known  in  different  inflances,  flric- 
tures  in  the  urethra,  induration  and  tender- 
nefs  of  the  whole  tube,  and  even  ulceration 
of  its  orifice  to  enfue.  Though  I  have  feen 
relief  obtained  in  cafes  of  this  defcription 
by  bougies  and  local  remedies,  yet  I  believe 
the  treatment  of  fuch  difeafes  ought  to  be 
conftitutional,  and  that  fuch  treatment  will 
fucceed  in  curing  the  di&afe  without  local 
remedies*  I  know  one  inftance  in  which  the 
dyfury  had  been  very  fevere,  and  two  con- 
fiderable  flriftures  had  formed  in  the  urethra  j 
there  was  alfb  a  thickening  accompanied 
with  whitcnefs  and  hardnefs  of  the  mem- 
brane of  the  vagina,  caufing  a  contraftion  in 
the  orifice  of  that  canal ;  yet  all  dyfury  ceafed^ 
and  no  inconvenience  was  experienced  upon 

I  the 


i 


2C4  ON   DISEASES 


the  patient's  acquiring  better  health  ;  which 
change  was  efFefted  partly  by  medicine,  and 
partly  by  removal  into  the  country.  Wo- 
men will  fufFer  a  great  deal  from  thefe  dis- 
orders before  they  reveal  their  diftrefs  5  and 
when  from  the  urgency  of  the  iymptoms, 
and  the  belief  that  they  have  a  ftone  in  the 
bladder,  they  are  willing  to  fubmit  to  exami-  ^ 
nation,  'the  diforder  may  be  fpeedily  and 
completely  relieved  and  cured  by  means 
which  have  the  efFeft  of  tranquillizing  ner- 
vous irritation.  It  may  be  ufefiil  to  relate  a 
cafe  in  proof  of  this  affertion. 

CASE  V. 

A  lady,  between  thirty  and  forty  years  of 
age,  who  had  long  fufFered  very  confiderably 
from  dyfury,  agreed  to  permit  an  examina- 
tion to  be  made  of  the  nature  of  a  difeafe, 
which,  from  the  fevcrity  of  its  efFefts,  fhe 
could  but  believe  to  be  of  a  very  ferious  and 
alarming  nature. 

On  enquiiy,  I  found,  that  though  (he 
voided  her  urine  frequently,  and  with  great 

pain 


OF  THE  URETHRA,   &C.  20 J 

pain,  yet  it  flowed  freely,  and  that  fhe  did 
not  fufFer  that  extreme  and  continued  pain 
afterwards,  which  is  generally  the  confe- 
quence  of  the  ftone. 

» 

I  found  alfo,  by  enquiry,  that  her  bowels 
were  not  in  a  proper  ftate,  and  her  tongue 
was  much  furr'd.     Suppofmg  that  a  ftate  oi 
nervous  irrita^on  might  be  caufed  or  aggra- 
vated by  diforder  of  the  digeflive  organs,  I 
objefted  to  making  any  examination  of  the 
ftate  of  the  urethra,  &c.  till  the  funftions 
of  thofe  organs  were  put  right  by  medicine, 
becaufe  I  was  aware  that  nothing  but  a  con- 
viction of  the  indifpenfable  necellity  of  exa- 
mination would  have  induced  her  to  fub- 
mit  to  it.     In  a  very  fliort  time,  the  ftate  of 
the  primae  viae  being  correfted,    and   her 
health  in  general  amended,  all  dyfury  com- 
pletely ceafed. 

Dyfury  of  this  defcription  is  liable  to  oc- 
cur in  paroxyfms,  I  have  known  it  alternate 
with  diforders  of  the  bowels,  and  with  rheu- 
matic afFeftion,  which  I  think,  fliews  that 
there  is  a  common  conftitutional  origin,  pro- 

II  ducing 


<0^  ON  DI8SASSS 

ducing  fuch  various  complaints ;  and  I  repeat, 
that  I  have  known  fuch  dyfury  lead  to 
actual  difeafe  of  the .  afFefted  organs.  It  is 
very  common  for  men,  who  have  been  mar- 
ried many  years,  and  who  perhaps  never  had 
gonorrhoea,  (or  if  they  had  in  their  youth,  it 
is  probable  that  it  had  left  no  diforder  in  the 
canal  of  the  urethra,)  to  gradually  acquire,  as 
they  advance  in  life,  difeafes  of  the  urinary 
organs.  Surely,  then,  the  origin  of  fuch 
difeafes  muft  be  regarded  as  fpontaneous, 
and  likely  to  be  induced  and  maintained  by 
whatever  occafions  irritation  in  the  afFefted 
organs. 

There  is,  however,  no  period  of  life  exempt 
from  this  kind  of  dyfury.  Children  are  fre- 
quently much  affefted  by  it,  and  at  that  age 
when  the  bodily  powers  are  generally  in  the 
greateft  vigour,  if  they  become  difordered, 
dyfury  occurs  in  common  with  other  difeafes. 
I  have  mentioned  in  the  firft  part  of  thefe 
obfervations,  in  fpeaking  of  the.  conftitutional 
origin  of  local  difeafes,  that  I  have  known 
dyfury  of  this  defcription. 

Ifub- 


OP  THl  ViWLETnVLAi  &<%  iof 

I  fubjoin  another  ftriking  cafe  of  conffiU 
tutioiid  dyfuiy,  occurring  in  a  child* 


CASE  VL 

A  child^  about  two  years  of  age,  becanw 
affe6led  with  dyfury,  for  the  relief  of  which, 
various  means  were  tried  without  benefit: 
on  the  contrary,  the  fymptoms  increafed, 
and  ftrikingly  refembled  thofe  occafioncd  by 
9  ftone  in  the  bladder.  The  calls  to  void  the 
iirine  were  frequent  and  urgent,  and  the 
pain  afterwards  very  fevere.  There  was  an, 
elongation  and  flrifture  of  the  orifice  of  the 
prepuce,  which  induced  a  furgeon  who  at- 
tended the  child,  to  divide  that  part,  as  h^ 
thought  it  might  contribute  to  the  difficulty 
experienced  in  expelling  the  urine.  Under 
thefe  circumftances,  the  child  was  examined 
by  a  furgeon  of  great  profeffional  eminence^ 
who  had  no  doubt  that  the  fymptoms  were 
caufed  by  a  ftone,  which  he  thought  he  felt ; 
yet  recommended  that  no  operation  fhould 
be  attempted  till  it  had  increafed  in  fize* 
The  child  continued  to  fuffer  in  the  fame 
manner  for  two  years,  when  I  was  defired  to 

examine 


to8  ON   DISEASElT 

I 

examine  him.  I  could  not,  however,  difcover 
any  ftone,  and  upon  enquiry,  I  found  that 
the  child  complained  of  confiderable  paii^s 
in  his  loins,  and  that  his  digeilive  organs 
were  greatly  difordered  in  the  manner  that  I 
have  defcribed  in  the  firft  volume  of  thefe 
obfervatioHS.  Unirritating  and  undebili- 
tating  dofes  of  the  pilul:  hydrarg:  were  given 
every  fecond  night,  and  ftrifl  attention  was 
paid  to  keep  the  bowels  clear,  without  in- 
ducing what  is  ordinarily  called  purging. 
The  efFeft  of  this  treatment  was  furprifing, 
all  the  fymptoms  were  immediately  relieved, 
and  they  completely  ceafed  in  a  month,  at 
which  time  the  funftions  and  fecretions  of 
the  digeftive  organs  appeared  to  be  fo  cor- 
reftly  healthy,  that  all  medicine  was  difcon- 
tinued.  After  fome  months,  a  flight  relapfe 
of  dyfury  took  place,  which  immediately 
ceafed,  upon  refuming  for  a  ftiort  time  the 
feme  plan  of  treatment ;  and  the  boy  has 
fince  remained  perfectly  well,  though  feveral 
years  have  elapfed. 

If,  then,  irritation  of  the  urinary  organs, 
even  to  a  degree  produdlive  of  local  difeafcs 

in 


OF   THE  URBTHRAy  &ۥ  209 

in  them  may  occur  from  conftitutional  caufes, 
and  more  apparently  from  a  diforder  of  the 
digeftive  organs,  I  need  not  then  urge  the 
propriety  of  our  endeavouring  to  keep  the 
latter  organs,  as  nearly  as  poflible,  in  a  ftate  of 
health,  whilft  we  are  endeavouring  to  relieve 
the  difeafes  of  the  former  by  local  meafures. 
Of  the  beneficial  efFefts  of  fuch  conduft,  I 
could  relate  many  inftances,  but  it  does  not 
feem  rieceflary  to  detail  cafes  in  proof  of  fo 
felf-evident  a  propofition,  I  have  explained 
in  the  firft  volume,  my  ideas  of  the  mode  by 
which  relieving  diforders  of  the  digeftive  or- 
gans, relieves  and  cures  local  difeafes  ;  and  ia 
local  difeafes  of  the  pelvic  vifcera  another  rea- 
fon  may  be  fuggefted  for  the  benefit  which  is 
obtained.  It  has  been  obferved,  that  in  difor- 
ders of  the  digeftive  organs,  the  lower  part  of 
the  inteftinal  canal  is  frequently  moft  afFc6led, 
Irritation  in  the  reftum  muft  afFeft  the  plexus 
of  nerves,  from  which  not  only  that  inteftine, 
but  the  pelvic  vifcera  in  common  derive  their 
energies ;  and  thus  it  may  lea4  to  a  fimilar 
participation  of  difeafe. 


VOJL.  II, 


3IO  OK   DISEASES 


SECTION  m. 
Onfonie  EffeSis  ofDtfeafes  of  the  Urethra, 

T  SHALL  take  the  prefent  opportunity  of  ex- 
^  citing  the  attention  of  the  profeflion  to 
fome  efFe6ls  of  diforders  of  the  urethra,  which 
have  not  hitherto  received  in  my  opinion  a 
fufEcient  fhare  of  attention.  If  a  violent 
affeftion  of  this  canal  can  produce  a  corref- 
ponding  degree  of  inflammation  of  the  teftis, 
as  it  frequently  does  in  gonoiTboea,  it  may 
reafonably  be  expefted,  that  a  lefs  degree  of 
diforder  in  the  urethra  may  produce  a  milder 
irritation  of  the  tcftis,  which  may  terminate 
in  a  flow  difeafe  of  that  gland.  Indeed  it  has 
appeared  to  me  that  there  are  two  circum- 
ftances  caufing  irritation  and  confequent  dif- 
eafe of  the  teftis:  one  is,  diforder  of  the 
urethra ;  and  the  other,  that  derangement  of 
the  conftitution  at  large,  which  I  have  de- 
fcribed  in  the  firft  part  of  thefe  obfen-ations. 
I  need  not  point  out  how  inefficacious  any 
local  treatment  of  an  irritated  or  difeafcd 
gland  muft  be,  whilft  we  leave  the  caufes 

which 


OF   THB   URETHRA,   &C#  211 

which  produced  it  ftill  to  operate  in  full 
force  for  its  continuance.  I  proceed  to  re- 
fate  a  few  cafes,  in  which  irritation  origi- 
nating in  the  urethra  firft  caufed,  and  fub- 
fequently  maintained,  difeafe  of  the  teftis, 

'  CASE. 

A  gentleman  who  had  been  confined  with 
a  chronic  difeafe  of  the  left  teftis,  which  had 
proved  very  fefraftory  and  irreducible  by 
various  means  employed  for  its  cure,  applied 
to  me  when  the  gland  was  four  times  its  na- 
tural fize,  and  very  hard.  I  recommended 
the  application  of  three  or  four  leeches  once 
a  week,  a  bread  and  water  poultice  at  night, 
and  aq:  ammon:  acetat:  during  the  day. 

This  treatment  was  purfued  for  fix  weeks 
with  very  little  benefit.  I  then  changed  the 
poultice  to  one  made  of  linfeed,  over  which 
mercurial  ointment  was  fpread.  The  oint- 
ment was  alfo  rubbed  upon  the  fcrotum  in  the 
morning,  and  a  foft  rag  applied  over  it.  The 
patient  likewife  took  a  compound  calomel 
pill  every  night, 

p  2  This 


II A  OK   OI8EASSS 

This  treatment  was  a^fo  perfevered  in  for 
about  fix  weeks,  but  with  no  manifeft  advan- 
tage. I  then  put  two.  fetons  *  through  the 
fcrotum,  and  continued  the  poultice  at  night 
and  a  dreffing  of  fpermaceti  cerate  during 
the  day.  Under  this  treatment  the  teftia 
diminifhed  very  confiderably  in  fize,  but  at 
the  end  of  two  months,  the  fetons  had  gra- 
dually come  out,  in  confequence  of  the  ul- 
ceration which  they  occafioned.  Shortly 
afterwards,  the  teftis  became  painful^  and 
it  enlarged  to  its  former  dimenfions,  fo  that 
no  advantage  was  obtained  from  all  thefe 
endeavours  to  reduce  the  difeafe.  I  had  fre- 
quently enquired  of  this  patient  refpcfting 
the  ftate  of  his  urethra,  and  been  as  often  told 
that  he  was  not  confcious  of  any  diforder 
exifting  in  that  canal.  Now,  however,  on 
repeating  my  enquiries,  he  faid,  that  he  had 

*  Setons  may  be  conveniently  made  and  worn  in  the 
fcrotum.  I  firft  employed  them  in  conformity  to  thofe 
general  principles  which  regulate  our  conduft  in  the 
treatment  of  local  difeafes ;  and  I  hare  known  feyend  in« 
ftances  pf  difeafed  teftis,  which  redded  various  local 
modes  of  cure,  and  even  confiderable  courfes  of  mercurj 
yield,  and  get  well  when  fetons  were  employed. 

5t  remarked 


OF  THfi  URETHRA,   &ۥ  21^ 

remarked  the  ftream  of  urine  to  be  fmall, 
and  that  the  calls  to  void  it  were  more  ur- 
gent than  formerly.  On  pafling  a  bougie,  I 
found  two  ftriftures  confidcrably  contrafted 
and  a  tender  (late  of  the  urethra  where 
it  paffes  through  the  proftate.  Thefe  dif- 
eafes  being  relieved,  all  irritation  in  the  tefHs 
ceafed,  and  the  enlargement  rapidly  fubfided ; 
fo  that  in  two  months  it  was  fcarcely  larger 
than  the  other,  and  all  difeafe  had  ceafed. 
This  happened  without  any  other  local  ap- 
plication than  a  poultice  at  night,  and  fup- 
port  by  a  bandage.  Even  the  poultice  at 
night  was  foon  difcontinued.  This  patient 
has  had  no  return  of  difeafe  of  the  teftis,  and 
many  years  have  elapfed  fince  the  occurrences 
which  I  have  been  relating. 

The  following  cafe  was  drawn  up  by  a 
medical  man,  of  confiderable  information  and 
talents,  who  was  himfelf  the  fubjeft  of  it, 
and  who  was  convinced  with  refpeft  to  his 
own  cafe,  of  the  truth  of  thofe  opinions 
which  I  am  now  offering  to  the  public. 


p  3  CASE 


214  ON   DISEASES  « 


CASE, 

•,  aetat.  thirty,  about  four 


years  fince  had  an  uneafy  fenfation  in  both 
tefticles,  which,  however,  occurred  fo  feldom, 
and  was  fo  trifling,  that  he  paid  little  atten- 
tion to  it;  about  a  twelvemonth  after,  he 
found  the  left  teflicle  harder  than  natural, 
but  not  enlarged ;  for  fome  time  previous  to 
this,  he  had  been  obliged  to  void  his  urine 
very  early  in  the  morning  from  great  irri- 
tation to  do  fo ;  but  nc*  too  frequently  du- 
ring the  day ;  and  occafionally  had  a  tight- 
nefs  and  fenfe  of  conftri6lion  in  the  peri- 
naeum,  with  frequent  aching  pain  in   the 
glans   pe]5iis.     The  tefticle  remained  in  the 
above-mentioned  ftate  (without  pain  or  in- 
creafe)  till  March  1806,    when  he  received  a 
blow  from  an  accident   on  horfeback;   no 
violent  pain  was  immediately  felt,  nor  did 
any  apparent  alteration  take  place  till  about 
a  fortnight   after,    when  he  perceived    the 
tefticle  larger  and  much  harder  than  it  had 
hitherto  been ;  and  it  gradually  though  flowly 
increafed  till  the  end  of  Auguft,  when  he 
faw  Mr.  i^bcrnethy.     The  teftis  was  at  this 
time  of  twice  its  natural  fize,  hard  and  pain- 
full 


OF   THE   UR£THRA,  &C.  ^15 

ful  to  the  touch.  Leeches  were  applied  once 
a  week,  and  the  tefticle  was  kept  fufpended, 
and  wrapped  during  the  day  in  a  cloth  dip- 
ped in  tinft:  opii:  and  water,  and  an  evapo- 
rating poultice  was  applied  at  night.  By  this 
treatment  it  gradually  became  lefs,  but  the 
hardnefs  ftill  continued.  He  faw  Mr.  A. 
again  in  September,  and  was  then  defired  to 
rub  camphorated  mercurial  ointment  upon 
the  tefticle,  and  cover  it  with  a  foap  plafter. 
The  tefticle  ftill  kept  decreafmg,  but  re- 
mained equally  indurated  till  the  twentieth 
of  November,  when  it  fwelled  with  confi-- 
dcrable  pain  and  irritation,  and  began  to 
adhere  to  the  fcrotum  *.  He  again  faw  Mr. 
Abernethy,  who  introduced  a  fmall  bougie, 
and  found,  a  ftrifture  about  fix  inches  from 
the  orifice  of  the  urethra,  and  a  fecond  the 
eighth  of  an  inch  from  the  fomier,  The 
bougie  paflTed  without  much  pain  or  diffi- 
culty through  the  ftriftures,  till  it  came  to 
the  proftate  when  much  pain  and  fenfation 

*  The  teftis  was  now  about  three  times  its  natural  fize, 
and  at  the  upper  part  of  the  epidydimis,  the  fcrotum  had 
adhered  to  the  fubjacent  part,  and  was  fo  inflamed  as  to 
indicate  the  probability  of  the  formation  of  an  abfcefe. 

p  4  of 


dfS  OK  DISEASED  ' 

of  heat,  irritation,  and  a  ftrong  inclination  to 
make  water  were  felt ;  the  bougie,  however, 
paffed  into  the  bladder,  and  was  clofely  held  by 
the  fphinfter,  Theperinaeum  was  then  ordered 
to  be  bathed  night  and  morning  with  warm 
water,  and  a  bread  and  water  poultice  to  be 
applied  to  the  tefticle,  which  were  done,  and 
at  the  end  of  the  week,  the  pain  and  irritation 
in  the  tefticle  were  greatly  relieved  j  the  fame 
bougie  was  then  paffed,  but  vnih  greater  eafe, 
and  the  painful  fcnfations  which  had  before 
been  felt  on  its  entering  the  proftateweremuch 
diminiQied.  The  warm  bathing  and  poultices 
were  continued,and  the  fame  bougie  pafled  at 
the  end  of  the  following  week  with  ftill 
greater  eafe  and  {lighter  fenfations.  At  the 
end  of  the  third  week  the  ftridtures  were 
touched  with  kali  pur:  which  produced  little 
irritation ;  and  on  the  week  following  a  much 
larger  bougie  paffed  with  eafe;  the  warm 
bathing  and  poultices  being  continued  in  the 
interval.  During  the  three  following  weeks 
the  large  bougie  paffed  with  great  eafe ;  no 
irritation  was  felt  after  it,  and  the  fenfations, 
whilft  it  was  going  through  the  proftate,  were 
flighter  each  fucceffive  time. 

The 


OF  TRX  URETHRA,  &C»  ftl/ 

The  tcfticle  at  the  end  of  this  time,  (fcven 
weeks)  was  reduced  to  its  natural  fize,  and 
was  become  nearly  undiftinguifhablc  from 
one  that  had  never  been  diieafed. 

Shortly  after  the  firft  introduftion  of  the 
bougie,  all  the  fhooting  pains  and  occafional 
uneafmefs  of  the  teftis  ceafed,  and  it  fo  ra- 
pidly and  regularly  declined  as  the  ftate  of  the 
urethra  amended,  as  to  leave  no  doubt  but 
that  the  amendment  of  the  teftis  is  to  be  af- 
cribed  to  the  relief  of  diforder  in  the  urinary 
canal. 

CASE. 

A  gentleman  between  twenty  and  thirty 
years  of  age,  confulted  me  on  account  of  an 
hydrocele,  from  which  I  difcharged  about 
fix  ounces  of  fluid.  The  tefticle  did  not  ap* 
pear  enlarged,  but  both  it  and  the  bag  of  the 
tunica  vaginalis  feemed  very  tender  to  the 
touch.  I  recommended  that  the  parts  fliould 
be  fupported,  and  that  Goulard's  wafh, 
Ihould  be  applied.  In  about  fix  months  the 
the  tunica  vaginalis  was  mOre  diftended  than 
at  firft,  and  as  the  part  was  troublefome  from 

ics 


2l8  OK   DISEASES 

its  fize  and  fenfations,  it  was  again  punc- 
tured ;  and  the  fame  circumftances  were 
noted  upon  the  evacuation  of  the  water. 
The  hydrocele  again  coUefted,  and  when  it 
was  full,  which  happened  in  about  fix 
months^  the  patient  was  defirous  of  having 
the  tunica  vaginalis  injefted,  in  order  that  he 
might  be  made  radically  well.  As  there  was 
nothing  prohibitory  except  the  tendemefs, 
I  confcnted  to  his  defire ;  but  when  the  fluid 
w?is  difcharged  this  time,  he  complained  of 
greater  pain  tlian  formerly,  and  could  fcarcely 
bear  me  to  touch  the  tefticle,  which  made  me 
diflike  to  perform  the  operation,  and  it  wa? 
therefore  poftponed  till  the  next  time  that  the 
hydrocele  fhould  become  full.  I  thought  it 
right,  however,  to  direft  the  application  of 
leeches,  once  a  week,  and  of  linen  kept  damp 
with  Goulard's  wafh*.  Under  this  treatment 

the 

*  I  have  known  many  cafes  of  hydrocele,  the  confequence 
of  irritation  and  inflammation,  cured  by  evaporating  wafhes: 
and  it  would  be  right  to  diftinguifli  the  kind  of  hydro- 
cele, upon  which  fuch  treatment  may  be  expefted  to  have 
beneficial  efFeft.  Without  fuch  difcrimination,  a  furgeon, 
feeing  a  hydrocele  cured  by  thefe  meansj  would  profecute 

6  tl^e 


OF  THE  URETHRA,   &Ct  21^ 

the  hydrocele  filled  very  flowly.  After  four 
months  had  elapfed,  the  patient  confulted 
me  relative  tp  fores  which  frequently  broke 
out  upon  the  prepuce ;  fome  of  which  were 
very  tardy  in  healing.  He  alfo  was  fubjeft 
to  a  confiderable  colle6tion  of  that  fubftance 
which  is  fecreted  to  moiften  and  lubricate  the 
prepuce.  I  told  him  that  thefe  fymptoras  were 
the  efFe£ls  of  irritation  of  the  prepuce,  and 
was  led  to  enquire  more  particularly  into  the 
ftate  of  the  urethra  than  I  had  done  before, 
becaufe  I  thought  both  the  diforder  of  the  teftis 
and  the  prepuce  might  originate  in  the  fame 
caufe,  that  is,  difeafc  in  the  urethra.  On 
examining  that  canal  with  a  bougie,  I  found 
flri6lures,  and  a  tender  ftate  of  it  where  it 
paffes  through  the  proftate.  By  local  wami 
bathing,  and  the  occafional  and  gentle  ufe  of 
bougies,  the  morbid  lenfibility  of  the  canal 


the  fame  meafures  in  an  indolent,  and,  as  I  may  call  it, 
dropfical  hydrocele;  or  finding  the  means  fail  in  many  cafes 
from  their  indifcriminate  ufe,  he  may  be  induced  to 
confider  the  treatment  upon  the  whole  as  inefEcacidus  j 
and  thus  negled  it  in  cafes,  in  which  it  is  likely  to  be 
beneficial. 


was 


tao  OK  DISEASES 

was  diminiflied.  The  ftridures  were  touched 
with  kali  purum,  and  in  conclufion,  I  could 
pafs  a  large-fized  bougie  without  occafioning 
any  particular  uneafmefs  in  one  part  more 
than  in  another. 

The  efFeft  of  this  treatment  was,  that  the 
remaining  fluid  of  the  hydrocele  was  foon 
difperfed,  and  the  teflis  was  no  longer  irri- 
table or  painful  when  comprefled,  to  that 
even  the  fufpenfory  bandage  was  laid  alide,hor 
has  any  inconvenience  been  experienced  (ince 
that  time,  which  is  more  than  four  years  ago. 

The  fores  alfo  on  the  prepuce  healed,  and 
that  part  was  much  lefs  irritable,  but  it  ftill 
remains  fo  in  fome  degree ;  indeed,  fores  have 
been  fince  contradled  from  fexual  intercourfe, 
which  circuraftance  may  perhaps  have  con- 
tributed to  prolong  the  diforders  of  that 
part.  I  alfo  fufpedl  that  the  urethra  may  again 
have  become  in  fome  degree  irritable. 

In  the  foregoing  cafe,  it  is  faid,  that  the 
habitual  occurrence  of  fores  on  the  prepuce, 

led 


OF  TH£  URETHRA^  &C»  321 

kd  me  to  fufpe6l  diforders  of  the  urethra  ; 
and  this  is  an  efFeft  of  fuch  diforders,  which 
I  think  has  been  but  little  adverted  to,  and 
which  is  neverthelefs  deferving  of  particular 
attention.  That  diforders  of  the  urethra 
do,  in  many  cafes,  caufe  temporary  or  con- 
tinual irritation  in  the  external  parts  which 
are  continued  from  its  orifices,  I  fhall  prove 
by  the  recital  of  a  few  cafes. 

CASE. 

A  gentleman  between  forty  and  fifty  years 
of  age,  had  for  fifteen  years  been  fubjeft  to 
fores  about  the  prepuce  and  glans,  fo  as  to 
oblige  him  to  pay  conftant  attention  to  pre- 
vent and  control  them.  He  had  confulted 
many  eminent  furgeons,  who  recommended 
various  wafhes  and  modes  of  treatment.  A 
new  application  had  generally  the  effeft  of 
healing  the  fores,  but  when  perfifted  in  for 
fome  time,  gradually  loft  its  efieft.  When 
the  patient  confulted  me,  the  whole  of  the 
(kin  covering  the  glans,  and  lining  the  pre-r 
puce,  was  thickened  and  white,  and  the  pre- 
puce was  fo  tliickened,  that  though  it  was 
naturally  large  and  loofe,  it  was  difficult  to 

unfold 


M2  ON  DISEASES 

unfold  it.  There  were  numerous  fores  of 
an  oblong  form  in  the  tranfverfe  diredlion, 
appearing  like  chops,  covered  by  adhering 
pus.  I  told  the  patient  that  it  was  ncceffary 
to  enquire  whether  there  were  any  caufe 
,  maintaining  this  irritable  ftate  of  the  pre- 
puce, and  mentioned  that  I  had  obferved  it 
very  frequently  to  depend  upon  ftriftures  of 
the  urethra. 

The  patient  had  no  fufpicion  that  he 
had  fuch  diforder,  for  he  voided  his  urine 
readily,  and  not  much  more  frequently  than 
is  common.  Upon  examining  with  a  bougie, 
however,  feveral  much  contrafled  and  very 
firm  ftriftures  were  difcovered;  and  thefc 
being  relieved,  the  fores  on  the  prepuce 
healed  without  any  further  attention,  than 
what  cleanlinefs  required.  The  forelkin  be- 
came foft  and  pliant,  as  did  alfo  the  fkin 
which  lined  it,  and  is  extended  over  the 
glans.  This  cafe  occurred  many  years  ago ; 
and  as  I  have  not  feen  the  patient  fince,  I 
conclude  that  the  relief  which  he  thus  ob- 
tained was  permanent. 


To 


/ 

% 


OF  THB  URETHRA^  &Ct  aij 

To  fhew  that  ftrifhires  may  cxift  in  the 
urethra,  and  may  perhaps  prove  the  caufc  of 
more  vexatious  diforders,  though  the  original 
exciting  caufe  efcapes  obfervation,  I  may 
mention  an  inftance  which  occurred  to  a 
medical  man« 

CASE. 

This  gentleman  had  been  fubjeft  to  fores 
which  frequently  broke  out  on  the  prepuce 
without  any  evident  caufe.  There  was  not, 
however,  any  ftriking  evidence  of  general 
irritation  in  that  part,  as  in  the  former  in- 
ftance. Sometimes  the  fores  which  occurred, 
put  on  the  appearance  of  chancres ;  and  in 
confequencc  of  the  advice  of  his  friends,  he 
underwent  a  falivation.  The  fores  for  which 
the  mercury  was  employed-,  healed  imder  the 
ufe  of  that  medicine,  but  broke  out  upon  its 
difcontinuance.  He  then  confulted  me,  and 
upon  my  mentioning  my  fuipicions  of  ftric- 
tures  exifting  in  the  urethra,  he  fmiled  at  the 
opinion,  and  faid  that  it  might  be  given  to 
patients  in  general,  but  not  to  thofe  of  the 
medical  profeffion.  I  told  him  that  nothing 
would  convince  me  that  I  was  in  error,  but 

his 


y 


a24  O^  DI8BA8Si 

his  permitting  me  to  examine  by  means  of  a 
bougie.  Two  confiderable  ftridtures  were 
found,  and  thefe  being  relieved,  the  fores 
healed  under  fimple  dreflings.  The  gentle^ 
man,  however,  did  not  refide  in  London, 
and  I  know  not  the  further  hiftory  of  ,thc 
cafe,  which  I  mention  merely  for  the  pur- 
pofes  that  have  been  ftated  in  the  beginning, 

I  have  alfo  feen  a  very  troublefome  phy- 
mofis,  in  which  the  prepuce  could  not  be 
retrafted  without  great  difficulty  and  pain, 
depending  upon  the  fame  caufe,  in  a  cafe  in 
which  the  patient  had  been  long  accuftomed 
to  the  daily  ufe  of  bougies  *;  but  after  the 

ftrifhires 

*  As  ftri£lures  of  the  urethra  depend  on  a  dilbrdered 
ftate  of  parts  of  the  canal,  fo  when  the  introdudlion  of 
fimple  bougies  fails  to  cure  them,  the  too  frequent  ufe  of 
thofe  inftruments  fometimes  keeps  up  and  aggravates  an 
irritation,  which  might  other  wife,  perhaps,  fubfide.  This 
is  a  fubjeft  foreign  to  my  prefent  purpofe ;  but  I  mention 
it,  to  introduce  the  following  cafe,  which  deferves  pub« 
lication. 

A  gentleman  more  than  fifty  years  of  age,  had  for  more 
than  twenty  years  been  in  the  habit  of  introducing  bou« 
gies  for  himfelf,  which  he  generally  kept  in  for  an  hour 
daily.  . 

At 


or  THE  nuaTHILA}  &C.  335 

'ftriflurcs  had  been  touched  with  kali^  and  | 

the  conftant  ufe  of  bougies  defifted  from,  the  I 

phymofis  relaxed,  and  the  prepuce  could  be 

At  length  his  urethra  became  fo  irritable,  that  he  could  ■ 

fcarcelyvoid  his  urine,which  he  was  frequently  called  upon  I 

to  attempt.     AppTehetiGve  of  cauftic  bougies  being  em-  I 

ployed,  he  confulted  me,  and  I  found  I  could  introduce  I 

a  fmalt  bougie  without  much  difficulty  ;  it  halted  at  fe- 
▼eral  llri^tures,  but  with  very  gentle  prelTure  it  paiTed 
ihtough  tliem.  I  recommended  him  to  bathe  the  peri- 
nxum  and  contiguous  parts  with  warm  water,  by  meant 
of  a  fponge,  night  and  morning,  and  told  htm,  I  wilhed 
to  introduce  the  bougie  again  after  three  days  had  clapfed. 
He  was  extremely  apprehenfive  that  the  paflage  would 
completely  clofe  during  the  interval,  and  Itrongly  remon- 
ftrated  agalnft  fuch  inefhcient  practice.  On  the  third 
(lay  he  acknowledged  that  he  palTed  his  urine  more  freely, 
and  the  bougie  which  I  had  Rrll  introduced  went  through 
the  urethra  without  impediment.  I  took  one  of  a  little 
larger  fize,  and  patTed  it  with  the  fame  fort  of  reliflance 
which  the  firft  had  met  with.  The  warm  bathing  wac 
continued,  and  by  purfuing  thefe  meafures  for  three 
week),  I  pafTed  a  bougie  one-third  larger  than  he  had 
been  able  at  the  bell  of  times  to  do  for  many  year*. 

The  patient  now  voided  his  urine  in  a  large  ftream* 

and  not  more  frequently  than  is  common  ■,  in  Ihort  he  felt 

himfelf  perfeilly  well.     Since  that  time,  no  bougie  has 

been  introduced,  except  once,  annually  by  myfelf,  that  he 

L       might  be  affured  that  the  llri^turet  had  in   no  degree  -J 

B       contrafled.  I 

I  VOL.  II.  Q^  retrafted  I 


\ 


iiS  OK  DISEA9£# 

rctraftcd    vdthout    the   leaft  difficulty  cr 
uneaiinefs* 

Thefe  cafes  arc  related  to  (hew,  that 
irritation  and  diieaies-may  be  induced,  in 
ji^rts^  which  have  a  fympathetic  conne6tion 
with  the  urethra,  even  where  the  ori^nal 
.affe£lion  may  have  been  top  trivial  to  aUra£t 
attention.  It  appears  to  me  to  be  of  die 
utmoft  importance  to  inveftigate,  as  fer  a» 
poflible,  the  caufes  of  di(eafes ;  for  hbW  can 
we  expedl  to  cure  the  effefl:,  while  the  pro- 
ducing cau&  continues  to  pperate  ?  The 
Secondary  diieafe  may  alfo  become  even  of  an 
eftablilhed  or  malignant  nature,  if  there  be 
difeafed  propenfities  in  the  conftitution  or 
afFefted  part, 

% 

Difeafes  in  the  canal  of  the  urethra  may 
not  only  caufe  fuch  effefls  as  I  have  reprc- 
fented,  by  producing  a  ftate  of  irritation 
on  the  continued  furface  of  the  glans  and 
prepuce,  but  they  may  alfo  caufc  fores  con- 
trafted  from  fexual  intercourfe  to  be  very 
irritable,  peculiar,  and  flow  in  getting  well. 
I  have  feen  many  fuch  inftances,  but  none  in 

9  which 


OP  TItE  URETHRA)   &d*  ftlJP 

which  the  faft  was  ;nore  ftrikingly  apparent 
than  in  the  following  cafe. 

.    CASt.        ,  .      . 

A  gentleman^,  who  had  juft  armed  in  thil 
country,  had  coiancftion  witha  female, 
which  was  followed  by  genetal'  irritation  of 
the  ppepuce^iand  fur&ce  ^f  %  the  glanSi 
portly  afterwapdi.  fvc  fores  fbrmpd,  three 
of  whicli  became  'of  ooniiderable  iiie«  I  jde4 
iired  Him  to  wafhfthe  pirts  three  times  a  day 
with  the  poppy-foinentation^^  and  to.  encircle 
liie  penis  by  linen  kept  damp  j^ith  it,  in  ocder 
to  lefTen  the  heat/of  the  paiX«  He  at  the  iame 
time  took  five  grdins  of  the  quickfilver  pill 
night  and  morning.' 

#  ■  -  • 

After  fome  days,  he  could  no  longer  r^ 
tradt  th6  prepuce,  {o  that  he  was  obliged  to 
cleanfe  the  part  by  means  of  a  fyringe.  After 
a  little  time,  a  weak  folution  of  zincum 
vitriolatum  was  tried,  but  the  pain  it  occa* 
fion^  was  too  fevcre  to  permit  its  continu- 
ance. It  was  therefore  left  off,  but  after 
four  days  tried  a  fecond  time,  when  the  pain 
which  it  occafioned  was  v^ry  tolerable,  and 

0^2  as 


■ 


SS8  ON   DISEASES 

as  it  diminiflicd  daily,  it  allowed  us  to  il^ 
creafe  the  ftrength  of  the  wafh. 

After  a  few  days  he  was  able  to  retraft  thff 
fore-flcin,  when  the  fmallcr  fores  were  healed 
and  the  principal  ones  had  granulated,  fo 
that  a  fungus  bulged  forth  above  their  fur- 
&ce ;  they  appeared  of  a  t*awny  colour,  and 
their  edges  were  flightly  thickened.  I  flightly 
touched  thefe  fores  every  third  day  with  ar- 
gentum  nitratum,  which  appeared  to  do  them 
much  good.  The  vitriolic  wafh  was  coiv 
tinued.  In  about  five  weeks  from  the  com- 
mencement of  the  diforder,  the  patient  wai 
quite  well.  The  mercury  had  occafionally  af- 
fcilcd  the  bowels,  which  obliged  the  patient 
frequently  to  omit  his  pill  in  the  morning. 
It  never  afFcfted  the  gutns,  nor  did  I  orge  the 
continuance  of  it,  after  his  fores  were  healed^ 
becaufe  I  did  not  believe  them  to  be  fy- 
phiHtic. 

About  three  weeks  afterwards,  being  iff 
company  with  fome  diffolute  females,  he 
had  his  paflions  much  excited,  and  one  cf 
them  forcibly  comprefled  the  penis  with  her 
hand. 


land.  The  irritable  ftate  of  the  forefldn 
again  took  place,  ^d  a  great  number  of 
fores  broke  out,  particiilarly  behind  the 
glans,  which  appeared  like  chops,  being  long 
and  not  wide,  and  the  matter,  which  jthey 
^charged,  adhered  to  the  fur  face. 

After  a  few  days  he  could  not  retraft  the 
prepuce,  fo  that  I  caQ  givjc  ao  diftin£l  account 
QjE  th^fe  nunierous  fores.  It  appeared  thajt 
they  were  very  fretful,  for  the  external  Ikin 
became  inflamed  oppofite  to  them  i  and  they 
gave  much  pain  when  prelTure  was  piade  oi> 
the  inflamed  paft. 

Th^e  external  inflammation  and  tenderaefs 
pn  prefTure  changed  their  (ituatioji,  ftiewing, 
that  a  fore  which  was  rtiofl:  fretful  at  one 
lime,  became  lefs  fo  a]t  ^other^ 

The  fores  were,  however,  fo  painful  as  to 
prevent  the  patient  from  fleeping ;  and  as 
no  amendment  of  the  complaint  took  place 
in  three  weeks,  though  various  local  mea- 
fures  were  employed  during  that  period,  the 
patient  wiihed  to  ufe  mercury,  and  I  acr 

%  3  ^uiefpe  * 


«jO  ON   DISEASES 

quicfced  in  his  defire.     As  this  medicine  for-t 
merly  afFeftcd  the  bowels,  I  defired  him  to 
rub  in  two  drachms  by  meafure  every  night, 
which  was  done  for  one  week,  without  any 
amendment  in  the  fores,  or  indeed  any  per- 
ceptible   efFeft   on  the  conftitution.      The 
patient  now  complained  of  a  pain  in   the 
perinaeum,  when  he  voided  his  urine  j  and  I 
direfled  him  to  bathe  that  and  the  conti-» 
guous  parts  for  feven  or  eight  minutes,  with 
comfortably  warm  water  by  means  of  a  large 
fponge,  three  times  a  day.      This  produced 
a  moft  evident  diminution  in  the  irritability 
of  the  fores,  and  convinced  me  that  there  was 
a  ftriflure ;    I  therefore  introduced  a  bou- 
gie,  and  found  two  ftriftures,  the  front  one 
of  which  was  fo  tigKt  and  tough,  as  to  admit 
but  a  fmall  bougie  to  pafs  through  it,  which 
it  grafped  and  indented.    The  warm  bathing 
was  continued.     I  touched  the  ftri6lure  with 
kali,    as    Mr.  Whately    has    recommended. 
From  the  time  that  the  ftriclure  became  an 
an  obje6l  of  attention,  the  fores  had  fo  ra- 
pidly amended,  that  in  a  fpw  days  the  patient 
was  enabled  to  retraft  the  prepuce ;  when  it 
was  foynd,  that  though  the  fores  had  been 

numerous 


OF   THE   URETHRA,   &C.  23I 

numerous  and  extenfive,  they  had  becii 
merely  fuperficial,  and  had  not  deftroyed  any 
part.  From  the  time  that  I  firft  paffed  the 
bougie  and  afcertained  a  ftrifture,  the  mer- 
cury was  difcontinucd,  neverthelefs  the  fores 
heakd  fo  rapidly,  that  in  ten  days  they  were 
perfeftly  well, 

.After  the  fenfibility  of  the  ftriflure  had 
been  heightened  by  the  touch  of  the  kali,  the 
patient  complained  of  acute  pain  in  the  fores 
when  he  made  water;  and  once,  when  I 
touched  fome  of  the  fores  with  argentum 
nitratum,  he  complained  of  equally  fharp 
pain  in  the  perinaeum, 

I  lately  attended  a  married  man,  who  had 
been  for  many  years  tormented  by  occafional 
fores  forming  about  the  prepuce,  which  were 
fo  irritable,  as  to  be  prohibitory  of  fexual  m^ 
tercourfe.  In  the  laft  attack  they  were  con- 
fidered  by  feveral  furgcons  as  fyphilitic,  but 
as  they  had  not  the  charafters  of  that  difeafe, 
I  diffuaded  the  patient  from  the  ufe  of  mer- 
cury otherwife  than  as  an  alterative.  This 
patient  upon  taking  food  had  the  pain  and 

inflanw 


V3«  OK    DISEASES 

inflammation  of  his  fores  fo  aggravated,  that 
he  was  obliged  to  rife  from  table,  and  bathe 
the  affected  parts  with  warm  water.  Thcfc 
fores  immediately  loft  tlicir  irritability,  and 
even  rapidly  got  well,  upon  a  llrictarc  in 
the  urethra  being  relieved  by  local  warm 
bathing  and  the  ufc  of  bougies, 

I  have  ftiU  further  to  obferve,  with  rc- 
fpefl  to  the  occafional  confequences  of  diiV 
cafes  of  the  urethra,  that  many  difeafcs  of 
the  glands  in  the  groin  originate  from  them. 
I  fhall  not,  however,  detail  any  cafes  in  evi- 
dence of  tliis  fa<St.  It  will  be  fufficient  to 
fay,  that  I  have  feen  ftveral  cafes  of  enlarged 
inguinal  glands  difperfed  by  relieving  dif- 
orders  in  the  urethra;  and  I  have  feen  in- 
ftances  of  foul  and  irritable  fores,  lofing  their 
difeafed  chara6ters,  and  healing  from  the 
fame  caufe.  The  latter  event  is  not,  indeed^ 
likely  to  be  a  frequent  pccurrence. 

In  a  gonorrhoea,  the  glands  in  the  groin 
are  commonly  irritated,  and  fometimcs 
Slightly  fwolleui  the  fwelling  rarely  increafcs 
and  fuppurates,  except  in  cafes  where  thcr? 

ii 


Is  i  frdiifpofition  to  difeafc  in  thofc  glands. 
If  then,  irritation  in  the  urethra,  occurring 
from  gonorrhoea,  idxi  thus  afFcft  the  inguinal 
glands,  it  flfiay  be  rationally  inferred,   that 
Other  caufes  oif  irritation  of  the  urethra  may 
produce  (iiflilar  confequences.      No6lumal 
emiffions  are  alfo  commonly  the  efFeft  of 
morbid  irritability  or  difeafe  of  the  urethra } 
ftnd  it  feenis  therefore  irrational  to  attempt 
to  cure  thciri  by  tonic  medicines  or  fedatives, 
ivithout  adverting  to  the  ftate  of  the  urethra. 
Indeed  in  many  of  the  perfons  who  are  fub- 
jeft  to  thefe  difeharges,  the  morbid  fenfibility 
of  the  urethra  is  connefted  with  a  difordered 
condition  of  the  digeftive  organs ;  which  is 
of  itfelf  a  fufficient  caufe  of  great  weaknefs 
and  hypocondriac  feelings.     After  thus  ad-- 
verting  to  fuch  caufes,  we  cannot  wonder  at 
the  terrors  felt  and  defcribed  in  cafes  of  tabes 
dorfalis^     That  difeafes  of  the  urethra  may 
cxift  without  producing  the  confequent  diiC- 
cafcs  which  I  have  been  defcribing  is  very 
manifeft  >  that  fuch  difeafes  may  arife,  inde- 
pendently of  the  caufes  to  which  I  have  at- 
tributed them,   is  alfo  evident.     My  objeft 
therefore  is  merely  to  announce,  that  I  have 

veiy 


jk j4  ON  DISEASES,   &C« 

very  frequently  obferved  the  difeafes,  which 
make  the  fubjedt  of  this  fe6tion,  to  ariie  from 
.a  difordered  ftate  of  the  urethra,  leaving  it  to 
the  experience  of  the  public  to  determine, 
how  far  fuch  cafes  may  be  regarded  as  fre- 
quent occurrences  in  general  pra£tice. 


■>       ■■     M 


Printers-^Ueet,  I«ondun. 


r.T-