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*J * 



'V '• ■■ 



i 

ir 



f 



. / 



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 
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- 

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 



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-