CASE II

Climate

London

Preceflion ot the feafons

three very cold and long winters, a vef

yarm beginning of the fpring, but two cold months from a north-eaft wind

•

Prefent temperature

cold tor thu feafon ,

Epidemics

in different parts of the town different difeales were

more frequent. In the part where the patient lived, violent fevers and difeafes with fyraptoms of irritation prevailed

Temperament

bilious ftrongly marked ; complexion brown ; ftrong blackilh hair ; judgment accurate; determination great ; habits fixed

Peculiarities

none

Mode of living

free but equal; dined at the fame hour, five; eat heartily; drank a bottle of port after dinner;

no fupper

ufed much exercife

•

Times and contingencies

aged thirty- five ; not married.

but does not abftain from w'omen

Occalional caufes

fat up with a friend who died of a violent lever a fortnight before the attack

CO

Pulfe.

Skin.

Heat

Therm

Heat feel of pat.

Heat

Touch.

Eyes.

Tongue.

Refpka-

tion.

Praecor-

dia.

Stomach.

Food.

Drink.

f

Inteftines

. Sleep.

Urine.

Occalional Remarks.

1 Medicines.

June.

4 p. ra.

27

w.

ifi

130

very dry and con- tradled, & of a dulky colour

105

very cold

cold ex¬ cept in the palms and mouth

unmean¬

ing

white mu cous co¬ vers it

very diffi¬ cult

tenfe'

naufea

he had lived as ufual be¬ fore the attack

regular

he was feized at three wif coldnefs, or rather a numb nefs growing into coldnefs

Tjhora oftava vefpiertina fumar -jipec. gr. vj. cum tart. emet.

1 S'"- j* R ''in. antim. tart. Jij. fumat gutt. XXX. cum hauft, fequent. fexta q. h. R aq. menth. fativ. g j fs. fp. cin- nam. gij. fach. pur. gfs. m-

I p. m.

28

Th.

Ill

104

contraft- ed, not fo dry, more of a dirty yellowifh colour.

102

very hot

hot, and in the palms of the hands burning

a ftupid flare

more

flimy

relieved

ftill tenfe

naufea gone off, no naufea

no folid food

only bar¬ ley-water

had two evacua¬ tions in the night

a little confufed

a white flaky fedi- ment

very great head-ach above the eyes, and externally at the back of his head

perftet in ufu medicam. au- Jgendo dofin vin. antim. tart, duabus guttis fingulis dofibus

moon

29

F.

2d

102

nearly the fame

103

the fame

not alter¬ ed

the fame

no appe¬ tite, but medicines and drink agree

as before

no evacu¬ ation

confufed and Ihort fleeps

one in the

niorring

clear.

Four

white

P.aky fedi- ment

head-ach continues, and he is a little delirious

repetan. hauft & vin. ant. tart.

R infuf. fen.'^j. fs. tinft. fen. giij. tart, folub. jj. ft. hauft. ftatim fumendus. Applicentur epifpaftica pone aur.

3 p. m.

r

S.

3d

106

fame

104

complain¬ ed much of the heat

npt fo burning

moifler

browner

frequent

the fame

no appe¬ tite with¬ out naufea

as before

was purg¬ ed twice^

lafled the night with great reft- eflhefs, ittle a,nd

quite tranfpa- rent, and ligher co- oured

head-ach fomewhat relieved, but confufion continues ; forty drops of the medicine made him fick ; the dofe was only thirty- eight

perftet in ufu medicamentorum hauft u laxante omiffo

July-

.8 p. m.

1

1 t

Sun.

5

1

dry and

contraft”

ed.

105

violent

burning

more con- fufed

«

\

more co-

vered with mucus, a little brownifti

the fame

not fo tenfe

as before

no evacu¬ ation

broken

deep

lad rather a better night

tranfpa- rent thro’ the whole day

head-ach but little in the morn¬ ing, but is now returned

perftet in ufu medic.

/

noon

1

I 2

M.

5

104

moif, anc not much contract¬ ed

lOI

not very great

0

milder

fomewhat more fen- fible.

Sill co¬ vered with a dry brownifti mucus

not very uneafy

not tenfe

the fame

Tuits, loiled larley, i^afe, po¬ tatoes

'mall

leer, bar- ey-water actu¬ ated

natural

evacu¬ ation this morninq-

0

t

very con¬ fufed the firft part of the night, flept af¬ terwards

tranfpa- rent and high co¬ loured, except the aft, in which a mucous cloud

head-ach not fo violent as in the evening; not altogether free from delirium •

1 1

perftet in ufu medic.

3 p. m.

3

Tu.

6

1 00

nearly the fame

103

fame

rather

more

pungent

again more con- fufed

the fame

no evacu¬ ation

fliort and reftlefs through¬ out the night

tranfpa- rent the whole pe¬ riod.

head-ach ftill, and confufion of ideas

perftet in ufu med. Sumat pulv. rh, gr. xx.

I p. m.

4

W.

7

loS

dry and contradlec

too

great

not very pungent

more con- fufed

dry, and browner fer

more dif¬ ficult

tenfe

\

as before

the fame

one eva¬ cuation this morn¬ ing

none till four, fince that time broken

quite tranfpa- rent and ligh co- oured

head-ach continues, and is at¬ tended with delirium, without any appearance of fulnefs of the velfels, or flufhing. He grew much worfe in the even¬ ing, was extremely reftlefs, became very delirious about twelve, but grew a little more compofed about four

nuch. applicetur epifpaft. hauft vefpert. adde fp. aether, vitriol, gj. vefp. extremitat. inferior, applicetur fotus ex aqua calida per horas ij.

3 P-

5

Tlu

8

I io

not quite fo con- trafled

104

not fo

confider-

able

the fame

not fo difficult

tenfion

lefs

as before

the fame

no evacu¬ ation

fliort and broken through the night

the fame

this night was not fo confufed as the preceding, but very un¬ eafy

perftet in ufu medicam. injici- atur enem. e decoft. pro enem. gxiv. eleft. ien. Jj. etol. lini

noon

•

6

F.

9

1 12

dry, and very much contracted

/

the pa¬ tient is not fen- fible

enough to judge

not fo lungent, except in lis palms

very much confufed and wan¬ dering

the fame

very diffi¬ cult

not very tenfe, but forae ten¬ fion of the^ abdomen

cannot

udge

the fame

K

the fame

two co¬ pious foe¬ tid ftools

hardly

any

the fame

paffed a very reftlefs and deli¬ rious night; the delirium is now confiderably abated as to raving, but he is confufed, and does not know well wKat is about him .

perftet in ufu medicam. onin.

2 p. m.

7

Sat.

10

108

not fo dry

103

\

the fame

ftill darker brown

not fo dif¬ ficult

the fame

no naufea

the fame

a little

wine

added

no evacu¬ ation

very much dift'urbed, and not more than lalf an lour at a time

nearly the I'ame

clyfter came away without fe¬ culent matter

the fame

\

^ p. m.

8

Sun.

12

118

very dry, and very much con- tradted

105

very deli¬ rious, and not able to explain

very pun¬ gent

unfteady

very dry, and fome¬ what

glazed on the fur- face

frequent

great fla¬ tulency in the inief- tines, and tumor of the abdo¬ men

does not

reje(fl;nou-

rilhment

the fame

milk and water for drink added to larley water

a copious and very foetid eva¬ cuation

lad a bet¬ ter night

in the morning a ittle

cloud, at laft quite tranfpa- rent

great reftleflfnefs and delirium, fo that he knows nobody

R aq. menth. fati. fs. caft.

ruflT. in p. trit. gr. x. tinft. opii gutt. viij. fach. alb. gj. fpirit. cinnam. gj. m. ft. hauft fextis horis fumendus. Repet. enem.

a p. m. I

9

M.

I 2

104

hitherto has been much Jbftrua- :d, but lowwith efs obit, fmall & weak

not very dry or contradled

102

very deli¬ rious

not pun¬ gent

a little ftupid

no fur, but a very glafly fur- face when dry

not much

diforder-

ed

continues the fame

the fame

the fame with a lit¬ tle more wine, a lint in 24 lours

the fame

none, but great de- iriura till five, flept or dofed a little af¬ terwards

a little cloudinefs

\

perftet in ufu medicamen.

2 p. m. I

10 1

T.

'3

108

moifter

too

the fame

very ftu¬ pid

the fame

flatulency more con- fiderable

the fame

the fame with beef tea

two co¬ pious foe¬ tid evacu¬ ations

dofed the

whole

night,

hardly

flept

the fame

perftet in ufu medicamen.

I p. m. I

[I

W.

4 ^

r

f

t

\

100

nd

nuch

offer,

ut

veak

noift

98 '

not ca¬ pable of explain¬ ing

not differ¬ ent from a man in health

the fame

tongue moift, but rather raw

eafy

ftill con- fiderable

the fame

one, but not till the morn¬ ing

flept two hours this morning

a confi- derable cloud, and the fluid moft water

the firfl: part of the night was pafled with extreme difficulty, and with hardly any expefla- tion of the patient’s living til the morning, from the extreme debility and delirium

perftet in ufu medicamen.

noon

2

Th. I

q

p

108 c

ut not

uite

egular

ry

96

the fame

feels bet¬ ter

i-

the fame

dry and glazed

the fame

one foon after the clyfter, copious, flatulent, and foetid

flept three hours without interrup¬ tion

a lateriti- ous fedi- ment in the urine

with great difficulty the at tendants can be reftrained froir giving him more wine

perftet in ufu medicamen.

1 ^

From this Time the Patient gradually recovered without any particular Crifis.

/

I

T R A N S A C T I O N S

O F A

SOCIETY

FOR THE

. ./ ,

IMPROVEME N-T

1 ' os

MEDICAL AND CHIRURGICAL

t

\ ,

KNOWLEDGE,

ILLUSTRATED WITH

«

COPPER-PLATES.

LONDON:

PRINTED FOR J. JOHNSON, N2 72, ST. PAUt’s CHURCH-YARD. 1793.

\

Jr\

$

\

- . ✓

V

r

.-v- • • -r -

A

CONTENTS.

I. ✓Reservations on the Small-Pox, and the V-/ Caufes of Fever. By G. Fordyce, m. d.

F. R. s. &c. - . - - I

.11. Obfervatlons on the Inflammation of the internal Coats of Veins. By J. Hunter, Efq. f.r.s. &e. i8

III. A Procefs for preparing pure emetic Tartar by

Re-cryftallization. By Mr. Jenner - 30

IV. An Account of the DifTedlion of a Man, that died of a Supprefiion of Urine, prodaced by a Col¬ lection of Hydatids between the Neck of the Blad¬ der and Rectum : vdth Obfervatlons on the Man¬ ner in -which Hydatids grow and multiply in -the human Body. By J. Hunter, m.d. f.r.s. &c. . 34.

V. Cafe of a Gentleman lahouring under the epi- ■

' demic .remittent Fever of Buflbrah'; drawn up by

.Himfelf " * ” . ” 53

VI. On the Want of a Pericardium in the human

Body. By M. Baillic, m.d. f.r.s. See. 91

VII. On introfufeeption. By J. Hunter, Efq.

F. R. s. &c. - ' - - 103

Vill. Of uncommon Appearances of Difeafe in Blood- ve'lTels. By M. Baillie, m.d. f.r.s. Szc. 119

IX. An Account of Mr. Hunter’s Method of per¬

forming the Operation for the Cure of the'popliteal Aneurifm. By E. Home^ Efq. f.r.s. &c.' ■ 13S

X. A Cafe of Paralyfis In the Mufcles of Deglu¬ tition, cured by an artificial Mode of conveying Food and Medicines into the Stomach. , By J.

' Hunter, Efq. f.r.s. Szc. ‘ - 182

XI. Of

/

CONTENTS.

Page

'XL Of a remarkable Deviation from the natural Stru6lure in the urinary Bladder and Organs of Generation of a Male. By M. Baillie , m. d.

F. R. S., &C. - - 189

XII. Cafe of Emphj'fema, not proceeding from local Injury. By the Same - . - ’202

Xill. Cafe of unufual Formation in a Part of the Brain. By 'Mr.. A: Carlifle ' - . 21^

XIV. Hiftory of a fatal Haemorrhage from a Lace¬ ration of the Fallopian Tube, in a Cafe of an

• , extra-uterine Fcetus. By J. Clarke, m. d. &c. 215

XV. Some Obfervations ^on the loofe Cartilages found in Joints, and mofl: commonly met with in

^ that of the Knee. By E. Flome, Efq, f.r.s. See, 229 XVL An Attempt to improve the Evidence of Medicine. By G. Fordyce, M. d. f.r.s. &c. 243

XVII. Obfervations, and Heads of Inquiry, on Canine Madnefs, By J. Hunter, m.d. f.r.s. &c. 294 XVIII. Some Obfervations on Ulcers. By E. Home*, Efq. f.r.s. . - _ - 330'

Blank Schemes for taking Cafes according to Dr, Fordyce^ 5 Plan^ fmilar to the two Sheets at p, 289, may be had at Mr, Johnson’^) St, Paul’s Church-^yard, Price 1 s.

: TRANS-

0

1^

5

TRANSACTIONS, &c.

l

I. Obfervations on the Small-Pox^ and the Caiifes of Fever. By George Fordyce, M. D. F. R. S. Senior Phyfcian to St. Fhomas" s Hofpitaly and Fellow of the Royal College of Phyficians in London. Read De¬ cember 5, 1783.

Nine years ago I inoculated a family confining of three young ladies, for the fmall-pox. It was my cuftom, at that time, to make three fmall punffcures in one arm. It happened in the eldeft, that the fuppuration in one of thefe, came much for¬ warder than in the other two : it was per¬ fect on the feventh day, and the fever took place. I expedted a great increafe.of the fe¬ ver, which was already confide rable, when the other two pundlures fhould perfedl their

* This paper was printed in the year 1778, but not publifhed,

B fuppu-

[ 2 0

fuppu ration, and was not a little alarmed for the fafety of my patient : but was greatly furprized to find, when the firfi; of thefe per- fedted its fuppuration on the beginning of the eighth day, that it produced no efFed: what¬ ever on the fever; neither did the fecond, which perfeded its fuppuration on the end of the eidith.

O

The reafon of making more than one punc¬ ture, was to cnfure the difcafe’s taking place, as it was fuppofed that a fecond inoculation could not be made with fafety, till it flaould be certainly known that the firfi; had not taken place, which is not till eight or ten days in many cafes, a time of dreadful an¬ xiety to parents. I conceived now that this opinion was erroneous, and accordingly made no more than one pundure after that time.

It was not till the year after, that a cafe happened, in which I was in any doubt of the taking of the firfi: pundure ; and that was in a young gentleman, in his feventh year. On the third day after the firfi: punc¬ ture, I made a fecond. They both came for¬ ward. The fever was produced by the fup- piiration of the firfi:, was very flight, and when the fecond fuppur^ited, was not at all

.9 increafed ;

I

[ 3 ]

increafed ; and there were not twenty puflules in all. . •

It happened in about a month afterwards, that I was employed to Inoculate a boy of four years. His parents fcnt him a little way into the country, fappofing he^would be fafer in a purer air. In viliting him, the day after the eruption had appeared, I found a child of the woman who kept the houfe playing with my patient. I afced the mother if he had had the fmall-pox ; was told No, but that he was preparing for inoculation, which was to be performed in two or three days.- It occurred to me, if the natural infecflion had taken place, that it might be prevented by immediate inoculation, as I had grounds to believe, that it was generally from twelve to fourteen days after receiving the infection, that the natural fmalhpox took place. It was impoffible to meet the other pracftitioner till the next day. I therefore perfuaded the mother to let me inoculate the child imme¬ diately ; flie infilling, however, that I Ihould not mention it ; which, as I conceived the life of the boy was at ftake, and there was no pecuniary conlideration, I confented to. Three days after, the child was inoculated a

B 2 fecoud

[ 4 ]

fecond time ; my punflure being fo flighty as

not to be perceived. It inflamed however ;

the fuppuration was perfected on the eighth

day, the fever took place, and the eruption

was beginning. The wound made afterwards,

fuppurated ; but no new fever arofe, and the

patient had about fifty puftules.

I have now fo often repeated this pradtice,

that I have no doubt, but that variolous mat- «

ter has loft all its power of producing fever, after the firft twenty-four hours, from the time it is carried into the blood vefiels. I wiflied, however, to try the effe(5l of inocu¬ lation upon a perfon who had gone through the difeafe, and accordingly inoculated myfelf on the back of the hand, by a flight punc¬ ture. It inflamed in the ufual way, and a puftule arofe ; fo that I was under fome ap- prehenfion of having the difeafe, efpeciaHy as I had already had two eruptive difeafes, which my phyficians believed at the time were the frnall-pox, infomuch, as after the; firft, no care was taken to avoid expofing me. to the infeftion. I fllould believe, that they w^re miftaken in the firft. On the fifth day, when die puftule had arifen to the fize of the head of a large pin,, it was hard,, and with¬ out

[ 5 .1

out any matter, and gradually went away without llippuration, I have inoculated rny- felf feveral times fince. Sometimes the fame i:ind of puftule has taken place, and fome- times there has been no inflammation at all.

Dr. Rutherford, my learned mafter, in his ledlures on the prad:ice of phyfic, to af- certain the time the natural infeftion of the fmall-pox is latent, before it produces the fever, mentioned the cafe of a party of fol- diers marching through a village where the difeafe was, that they were feized from twelve to fourteen days afterwards with the fever, and that this was the ufual time. I have feen many cafes fince^ which confirm this opinion, although it alfo happens, that the infedlion fometimes takes place fooner. I therefore thought, that, if inoculation ren¬ dered the fyflem callous, if I may fo fpeak, to variolous matter, inflead of there being any danger in inoculating a patient who had already caught the difeafe, as the infeftion was quicker in its adiion, the * inoculation had a great chance of preventing any mif- chief, by producing the inoculated inftead of the natural difeafe. And this explained a circumftance, which had before furprized

B 3 and

[ 6 ]

and aftcniilied me, viz. the fool-hardinefs of certain empyrics, who brought a perfon to be inoculated into the room of a patient, when the fmall-pox were at the height, as in many inftances he muft catch the na¬ tural fmall-pox at the fame time ; but the inoculation coming before the natural kind,

’ prevented the mifchief. It is neverthelefs a dangerous practice ; for, if the inoculation • fhould not take place, and the patient be infected, there is all the rilk of the natural fmall-pox.

Since the time of my forming thefe opi¬ nions, I have knowm many inftances which confirm them ; fo that I have no doubt in recommending it to any perfon, who may chance to have been expofed to the natural infedlicn, to be inoculated immediately.

To afeertain the caufe of the fmall-pox being more or lefs numerous, has been a matter much wi&ed for In the family I have already mentioned, the lady in whom one pundlure fuppurattd before the others, and alone operated in producing the difeafe, the fmall-pox were much more favourable than in the other two, where all the punc¬ tures fuppurated together. This led me to

refledl

[ 7 ]

rcfle(5l on the cafe of a girl ' of five years of age, whom I had inoculated about a month before. The mother of this child was ex¬ ceedingly anxious, would hold the child herfelf, and ftarted in fuch manner, that the two firfi: pundlure-s hardly drew blood, and I was induced to make three more ; five in all. This child had the difeafe very fe- verely, which I confidered at that time as accidental only, but now began to think, that the quantity of matter abforbed, and adling fo as firft to produce the fever, was the circumfiance which rendered the difeafe more or lefs favourable. I therefore refolved to try a very fmall puncture for the future, which has fucceeded fo well, that although I have inoculated a great number fince that time, I have not met vcith one cafe in the fmalleil degree unfavourable ; whereas, when I made a wound as I did at firft, and applied the matter on a pledget, the difeafe was often unfavourable, and the wound very trouble- fome, which made me change my method to making pundtures, of which I made three, rather deep ones, and ftili I met with many unfavourable cafes, fo as always to inoculate with terror. I apprehend then, that the

B 4 pnnei-

[ S ]

principal, if not the only confidcration in In¬ oculation, is the manner of making the punc¬ ture, which fliould be done as follows. Run a lancet into a puftule, either at the time of fuppuration, or before, fo as it be moiftened v/ith the matter ; let it dry 5 moiften it a fe- ' cond time ; let it dry ; view the point with a magnifier ; if it be covered to the very point, it is properly armed 3 if it be not, it muft be dipped in the matter again, until the point is covered compleatly ; juiT; before the pund:ure is to be made, dip the point in wa¬ ter for a fecond ; let it lie for a minute or two, till the matter be foftened again ; lay bare the arm, and about the infertion of the deltoid mufcle make a puncfture, penetrating the fcarf fkin, fo that it may be felt on raif- ing the point of the lancet : if no blood ap¬ pears, the better. Or if you have frefh mat¬ ter in a quill, dip the point of the lancet in it, fo that the point be perfedlly covered, and proceed to make the punfture as before. Or if you have dry matter in a quill, moiften it with a very fmall quantity of water, fo as to bring it to the confiftence of recent matter, and then proceed as before directed. It is not neceflary to apply any thing to the arm ;

after

/

[ 9 ]

after three days examine the arm ; if there be no rednefs, make another puncflure about an inch diftance : this, however, will very rarely be found neceffary.

Thus, I flatter myfelf, I have found what is mofl: elTential in inoculation. Prepa¬ ration, it is true, has been fuppofed to be of great ccnfequence : but I believe this opi¬ nion is only a taint of that fuperilition, which originated with medicine, from the firfl:' prac¬ titioners, in the lefs cultivated fliate of man¬ kind, being priefts and conjurers,, as well a phyficians ; and I am afraid we fhall never be

able to get clear of this taint, which is the

/

foundation of quackery. Preparation is a great inftrument of fuperilition. A man is prepared to die, by rubbing a little oil on his breaft ; turning a chair three times round, is an excellent preparation for playing at whifl ; fo eating foup for a month, renders the body perfedtly prepared for mercury. •

Taking the matter of preparation ferioufly, the propofition is, to put the body into a flate, in which matter of the fmall-pox fhall produce lefs fever, fewer puilules,' or fo that the puilules fhall have lefs effedl on the fyftem. Now unlefs this flate be known, how Ihall we know in \vhat manner it is to

5 be

[ lo ]

be produced ? Will any one fay, that he knows, on producing a perfon to him, who is to be afFedted with the fmall-pox, whether he will have them fivourably, or not ? Cer¬ tainly he cannot, on any pHnciple hitherto known, I have had opportunities frequently, in St. Thomas’s Flofpital, of feeing perfons ufing mercurial, antimonial, and other regi¬ mens, recommended as preparations, (eized with the fmall-pox, which were in no ways more favourable, than in thofe who were not ufing any of thefe remedies. The only thing that feems to have been of any advantage, is living for a little time on vegetable food ; and this is even doubtful. I have the greateft reafon to believe, that it is hot of the fmallefh confequence, whether the matter be of the mild or confluent kind. I never knew of an inftance of any other difeafe being communi¬ cated by inoculation of the fmall-pox.

There is therefore only one other circum- ftance, excepting the pundture, to be at¬ tended to; which is, that, of the children who have died in London of inoculation for many years, as far as I have been able to col- ledt, more than two thirds have been under nine months; and therefore I have confi-

dered

s

[ “ ]

dered it as improper to inoculate before teeth¬ ing. It happened to me, that a family came from America, whofe children had not had the fmall-pox. One of thefe was under nine months, and on the breaft. They applied to me. I refufed to inoculate this child, and advifed that it fliould be kept out of the way while the others v/ere inoculated; but rather than fubmit to this inconvenience, they ap¬ plied to another pradiitioner, who inoculated the whole, and this child died.

Since frefh variolous matter has no effeft on the fever in the fmall-pox, it follows, that that which is already in the blDod-veffels has alfo no further effedt, after the difeafe is per- fedly brought on ; and as other fevers are fo exadtly limilar to that of the fmall-pox, that it is impoflible to diftinguifli them till the eruption takes place, it is very probable, that other iiifeftions, as well as the variolous, only adt for a fliort time in producing the fe¬ ver, and that They alfo have no further ef- fedt. That this is the cafe, we have greater reafon to believe, from this obfervation, that patients who have caught infedlious fevers in St. Thomas’s, and other Hofpitals, and con¬ tinued there, have gone thmugh the difeafe

in

[ 12 ]

in a ward where the infeftion was ftrong, with as mild fymptoms, as where peculiar care has been taken to keep the air as pure as poffible. And in general many more people recover of fevers in our Hofpitals than in pri¬ vate families, with fimilar pradlice ; owing moft probably to the directions of the prac¬ titioners being more ftridtly attended to ; for fuch is the difpofition of mankind to quack¬ ery, that you can hardly ever prevent, even a fond mother, from trying experiments on her only fon, lying ill of a dangerous difeafe.

Moreover, if a crifis fhould take place in the middle of an infectious fever, it happens when the infeCtion is ftrongelt, and its effeCts therefore the moll powerful, if it aCts at all on the patient.

Again, thofe who have once gone through the fever, are lefs fubjeCt to the infeCtion, than thofe who have not had the difeafe. This has been long remarked in the plague. I have obfei ved it in our Hofpital, in which there are alrnoll always violent fevei's, and therefore infectious ones ; for all fevers, from whatever caufe they arife, I have obferved, generate infectious vapour, and commonly according to their violence. Another Itrong

inllance

[ 13 ]

inftance Is, that fome of the felons, who have brought infecftion into a court of juf^ tice, fo as to deftroy almoft half the court, have had no fever at the time. In the la ft cafe which happened at the Old Bailey, the felon was not at the time affedled with fever, or any other difeafe.

From all thefe circumftances we may con¬ clude, that during the courfe of a fever, which arofe from infedlion, the Infeftious matter has nothing to do with the fever, nei¬ ther increafing, nor dimlnifhing, nor any ways altering it; and that therefore it is not ne- ceflary to pay any attention to it in the cure of the difeafe.

It is worth while enquiring, how far other caufes of fever have effecft upon it, after it has once taken place. Expofure to cold or moifture, or to anxiety, are two other caufes

which I have known produce fever. I have

1

feen feveral cafes, in which thefe have un¬ doubtedly brought on the difeafe, which has arifen immediately on their application. Where the anxiety is gone off, the fever has neverthelefs continued ; and when the patient has been brought into a warm and dry air, the fever has continued, and gone through

its

[ H ]

its natural courfe ; fo that it is only necelTary, that thefe caufes of fever fliould be once ap¬ plied, fo as to make an impreffion. The dif- eafe being once produced, goes on of itfelf ; neverthelefs, both anxiety, and cold or moif- ture, have an effedt in keeping up fever* When intermittents cannot be cured in fenny countries, they give way eafily ,on the pa¬ tient’s coming into dry air; as I have ob- ferved in patients brought from Lincolnfliire to the Hofpital, who have been eafily cured, although ■ the fame remedies have been ufed before without fuccefs. And I have, in fe- veral inftances, feen continued fevers fpun out to four, five, fix weeks, in confequence of diftrefs of the mind.

Why violent fevers fhould have been called putrid ones, is very difficult to guefs, as fre¬ quently we find them pafs through their courfe without any fign of putrefadlion. There are no purple fpots or marbling, no loofenefs of the gums, no blacknefs of the. tongue, no hemorrhage, mo fetor in the ex¬ cretions except the fasces, no fetor in the breath, no frothinefs in the urine, in a great many of them when they are highly infec¬ tious ; fo that inteciious vapour is a matter

totally

[ 15 ]

totally different from the vapour which arifes from putrid fubftances, which, however, is alfo certainly a caufe of fever, and which has been fuppofed to adl by being introduced in¬ to the blood-veffels, and producing putrefac¬ tion of the fluids. Now it may be quef- tioned, whether putrid vapour does not alfo adl uno zBii, in the fame manner as the caufes we have already enumerated. That it does not adt by inducing putrefadlion of ,the fluids is rendered probable, in as much as this flats of them in a fever depends evidently on the depreflion of flrength, and may accordingly be forefeen. If at once the mufcular ftrength be greatly depreflbd ; if there be great fenfe of weight about the precordia, with fighing ; if there be great flupidity in the eye, and want of attention and general diflrefs of the mind ; we may expedt fym.ptoms of putre- iadlion to appear, whatever might be the caufe of the fever.

Moreover, thefe fymptoms of putrefadlion when they appear are always the confequence of the fever ; for it is feveral days after the fever takes place, before they make their appearance.

Again, I have known them go off entirely when a phlegmon has arifen, and the fever

flill

[ i6 ]

ftill continued. This happened In two cafes. In lefs than twelve hours, the pulfe be¬ came hard and ftrong, inftead of having that lanraor with which it beat before. And

o

fometimes in fevers arifing from putrid va¬ pour, no appearance of putrefadlion takes place, and the fluids do not become putrid more readily in thefe with the fame depref- fion of ftrength, than in others ; and the progrefs of the fever is feldom different in confequence of thefe fymptoms of putrefac¬ tion ; fo that I fufpedl that a fever brought on by putrid vapour. Is alfo independent of its caufe, and would go on, when once pro¬ duced, if there were no longer the leafl: par¬ ticle of putrid matter in the body.

Food of difficult digeftion, T have alfo known evidently produce a fever, and very often occafion relapfes of fevers. Thefe fe¬ vers go on when the prim^ viae have been cleared of alf offending matter, and therefore are independent of their caufe. All fevers, however, are much increafed by improper food, from whatever caufe they arife.

Upon the whole, therefore, it would ap¬ pear, that a fever produced from any of the known caufes goes on, notwithftanding the

caufe

[ "^7 ] •

caufe be totally removed ; and that the adtion of infedtious, and probably putrid vapours, in bringing on a fever, renders the body in¬ capable of being farther alfecfted by thefc va¬ pours, in fome cafes, for a fliort time only, and in others for the whole life-time, of the patient ^ and that therefore it feldom is of ufe, to employ any remedy to remove the caufe of the difeafe after the fever has actually taken place'.

f‘ I

>

II. Ob*

c

t ]

II. Obfervations on the Injlammatlon of the internal Coats of Veins, By John Hun¬ ter, Efq. F. R. S. Surgeon Extraordi¬ nary to His Majesty, and Surgeon-gene¬ ral to the Army, Read Feb. 6, 1784.

The following obfervations will fhew that the infide of veins, as well as of all other ca¬ vities, is a feat of inflammation and abfcefs. I have found in all violent inflammations of the cellular membrane, whether fpontane- ous or in confequence of accident, as in com¬ pound fradlures, or of furgical operation, as, in the removal of an extremity, that the coats of the larger veins, pafling through the inflamed part, become alfo confiderably in¬ flamed j and that their inner furfaces take on the adhefive, fuppurative, and ulcerative in¬ flammations : for in fuch inflammations I , have found in many places of the veins adhe- fion, in others matter, and in others ulcera- tion. Under fuch circumilances, the veins would have abfcelTes formed in them, if the ' matter did not find in many cafes an eafy

palTage

[ 19 3

paflage to the heart along with the circulat¬ ing blood, fo as to prevent the accumula¬ tion of the pus : but this ready paflage of the matter into the common circulation, does not always' happen. It is in fome cafes prevented by the adhefive inflammation tak¬ ing place in the vein between the place of fuppuration and the heart, fo that an abfcels is formed, as will be fvirther obferved.

Where the inflammation is mofl: violent, there we find the vein moft inflamed ; there alfo, after fuppuration, we find the purefl pus ; and as we trace the veffels from this part, eithe;* farther from or nearer to the heart, we find the pus more and more mixed with blood, and having more of the coagulated parts of the blood in it.

As th^fe appearances are only to be feea in dead bodies, they cannot be defcribed but from thence ; but it is fo common a cafe, that I have hardly, ever feen an inftance pf fuppuration in any part, furnifhed with large veins, where tfiefe appearances are not evi¬ dent after death. I have found them in the bodies of thofe who have died from ampu¬ tations, compQun4 fraftures, and mortifi¬ cations.

C z

Thefe

[ 20 ]

*

Thefe Circiimftances all confidered lead lis to account for a very frequent complaint, that is, an inflamed arm after bleeding ; a complaint Vvhich has by fome been imputed to the wounding of a tendon ; becaufe the tendon of the biceps mufcle lies under fpmc of thofe veins, in v/hich we often bleed> and when the complaint occurs, it is unjuftly fuppofed to arife from want of flcill in the operator ; by others it has been fuppofed to arife from the wounding of a nerve ; and again it has been kid to the charge of a bad conftitution.

But if we cbnfider more critically this confequence arifing from bleeding, we fhall ■find that it happens frequently after bleeding in veins where no tendon could poflibly be 'wounded, and alfo where no particular nerve ' could be in the way. It feems likewife to happen as frequently in conftitutions where there is no appearance of want of health, as in thofe difpofed- to difeafe. As a proof of this laft, upon bleeding in another vein in the fame perfon, perhaps with a view to aflift in the cure of the inflammation ari¬ fing from the firft bleeding, the wound has

healed very readily.

o'.

If

I

[ 21 ]

%

I£ .we examine the proportion which th number of thofe inflamm.ations that hap¬ pen after bleeding, bear to thofe which arife from as flight a wound where no large vein has been injured, and even perhaps where the wound has not been rnade by fo clean a cutting inflrument, and the fame pains not taken to clofe it up, Vvc fliall find that thofe from wounded veins are much the mofl fre¬ quent ; and that fuch inflammations feldom or. ever happen under the laft mentioned cir- cumftances ; therefore, we mufl: look for fome other caufe to explain this effed: of bleeding.

The manner in which thofe fore arms

f ; > ■

come on, fhows* plainly that they arife from the wound not healing by the firfl: intention; for the external wound,' in moft cafes, firfl: fefters or inflames, then fuppurates and ulcer¬ ates, fo that the cavity of the vein becomes im¬ pervious. In fome this fuppu ration is only fu- perficial, the vein and parts below having unit¬ ed. In others thefkin lhall appear to be united, but not clofe to the vein, fo that a fmall ab- fcefs' fhall form between the Ikin and the vein ; it fbali burft and difcharge a thin wa- Uvy fluid, and no iurther miiciiief happen ;

C 3 but

■>

[ 22 ]

but when this imperfection of union is conti* hued on to the cavity of the vein, then the vein inflames both upwards and downwards, and that often for a confiderable way, and the furrounding parts join in the inflammation.

We find all thefe variations in different cafes ; for the difeafe fome times goes no fur* ther than an inflammation in the vein near to the orifice, which is often refolved ; at othct times the inflammation is carried further, but fuppuration is prevented by the adhefive in* fiammation taking place in the vein at this part, fo as to exclude the fuppurative inflam¬ mation, and the veins in fuch cafes may be plainly felt after the furrounding tumefadlion has fubfided, like hard cords. But this fa- lutary effedt is not always produced, and fup¬ puration in the vein is the confequence, but often fo confined, that only a fmall abfcefs forms in the cavity of the vein near to the orifice. The confinement of the matter in this part of the vein, arifes from adhefions in the vein a little above and below the orifice* But in many cafes the inflammation and fup¬ puration are not confined to this part from the adhefions not having taken place; for it frequently happens that an abfcefs is formed,

occupying

[ 23 ]

occupying a conliderable length of the vein both ways ; and we often have more than one abfcefs, nay at times there is a feries of them, and generally in the direction of the vein, between *the orifice and the heart ; but not always in this courfe, for we find them fometimes betv/een the wound and the ex¬ treme parts.

I have feen from a wound in the foot the vena faphaena inflamed ail up the leg and thigh, nearly as high as the groin ; and I have been obliged to open a firing of abfcefles almofl: through its whole courfe.

In cafes where I have had opportunities of infpedling veins after death, in which the in¬ flammation had been violent, upon examining the vein at fome diflance from this violence, I found the inflammation in the adhefive ftate: in fome places the fides of the vein were ad¬ hering, and in others the inner furface of the veins was furred over with coagulable lymph. Where different abfcefles had formed, I have always found that the fpaces of the vein between them had united by the adhefive in-, flammation, and it is this union which cir- cumfcribes the abfceffes.

C4 '

Upon

I

[ 24 ]

Upon examining the arm of a man who had died at St. George’s Hofpital, I found the veins, both below and above the orifice, in many places united by the adhefive inflam¬ mation. I alfo found in many parts of the veins, that fuppuration had begun as we find on an inflamed furface, but had not yet ar¬ rived at ulceration ; and in feveral other places ulceration had taken place, fo as to have de- ftroyed that furface next the fkin, and a cir- cumfcribed abfcefs was formed. The vein near to the axilla had taken on fuppuration, beyond which adhefions had not formed, and this had given a free pafTage for the matter intO'dhe circulation, of which mofl: probably the patient died.

In thofe cafes where larger abfceffes have come on than thofe formed Amply from the ulceration of the wound made by the lancet, I have always found that the vein was after¬ wards obliterated, having united and healed up as any other cavity does, fo that fuch pa¬ tients could never be bled in the fame vein again, which is a proof that the fides of the vein can unite by the adhefive inflammation.

Inflammation of a vein is a common effedt after bleeding horfes, which is ufually done

in

[ 25 ]

In the neck. The operator on this animal does not always take fufficient care to clofe up the external wound ; for although the method ufually employed would at firft fighf appear to be a good one, that is, by a pin paffed through the wound from fide to fide, as in the hare-lip, and over-tied by a thread or hair, yet, if not executed with fufficient attention, I fhould be inclined to believe that it is the very worft, as it very readily pro¬ motes inflammation in the cavity of the vein, either of the adhefive or fuppurative kind, according as the ligature does or does not communicate with the cavity.

In fome of thefe inflammations of horfes I have feen the jugular vein inflamed through its whole length, and all the fide of the head has been confiderably fwelled, and the, in¬ flammation carried along the vein quite into the cheft. In thefe cafes there is always an abfeefs formed at the w^ound, and often fe- veral along the vein, as in the human fub- jed: ; and whenever the complaint is carried fo far as this ftage, the cavity becomes united at thofe places by granulations, and the vein is ever after impervious. Many horfes die of this difeafe,but what is the particular circumllance

' which

[ 26 ]

which occafions their death, I have not been able to determine. It may either be that the inflammation extends itfelf to the heart, or that / the matter fecreted from the infide of the vein, paflTes along that tube in conflderable quantity to the heart, and mixes with the blood.

I am inclined to believe that the expofure of cavities of the larger veins in cafes of ac¬ cidents, and alfo of operations, is often the caufe of many of the very extend ve inflam¬ mations which fometimes attend thefe cafes, and indeed may be the reafon why inflamma¬ tions extend or fpread at all beyond the fphere of continued fympathy.

In all cafes where inflammation of veins runs high, or extends itfelf confiderably, it is to be expefted that the whole fyftem will be alFedled. For the mod; part the fame kind of affedtion takes place which arifes from other inflammations, with this exception, that where no adhefions of the fides of the Veins are formed, or where fuch adhefions are incomplete, pus paifing into the circula¬ tion may add to the general dilbrder, and even render it fatal.

In

[ 27 I

In all cafes of inflammation where adhe- iions take place, they arife from an extrava- fation of coagulable lymph ; but how fuch adhefions fliould take place on the internal furface of veins, appears at firfl: fight difficult to conceive, fince it is moft obvious, that the coagulable lymph thrown out by the exha- lants on the internal furface of the vein, mixing with the fame fluid circulating with the other parts of the bloocf, would be fwept away without producing any effeft. But fince fuch adhefions do in fad: happen, the coagu¬ lable lymph muft undergo fome change con- neded With the difpofition which produces its extravafation.

Although the operation which is the moft frequent caufe of this complaint is to ap¬ pearance trifling, yet as it is often of very ferious confequence, both to the life of the patient and the charader of the furgeon, it requires particular attention in the operator to prevent as much as poflible an evil of fuch magnitude. With this view he will be parti¬ cularly attentive to the mode of clofing the wound, and binding up the arm. This is to be' done by bringing the two fides of the w’ound together, that they may unite by the firft in-

4 tention.

[ ]

tentlon. To accompliih this, let the fur- geon, with the thumb of that hand which holds the arm, pufli the fldn towards the orifice, while he draws it on the other fide to the fame point with the comprefs ; thus the flvin will be thrown into folds at the wound over which he is immediately to ap¬ ply the comprefs. The comprefs fliould be broad, to keep the fkin better together ; and thick, to make the compreflion more certain. Another advantage arifing from this caution, is the prevention of the vein bleeding a fe- ,cond time. I have known an inflammation attack the orifice, which appeared to have arifen from the firft union having been broke through, and no fecond union formed; but ,this probably did not arife from the vein being opened a fecond time, but from the fides of the orifice not having been again brought together. I would recommend a comprefs of linen, or lint, in preference to flicking plafler ; for I imagine that the bloqd drying over the orifice is a kind of bond of union more natural and effedlual thair.any ^ other application : ' and this conclufion is drawn from pra(fl:ice ; for I have feen more fore arms in confequence of bleeding wheye

plaflers

\

[ 29 ]

plafters have been afterwards applied, than from any other; and in cafes of the compound fradture, when attempted 'to be cured as a iimple fradlure, if the wound will allow of being fcabbed over, I have feen it always do well ; whereas if it has been kept moift, or prevented from evaporating by plafters, or other applications, it has always fuppurated.

When inflammation takes' place beyond the orifice, fo as to alarm the furgeon, he ihould immediately make a comprefs upon the vein at the inflamed part, to make the two fides adhere together ; or if they do not adhere, yet Ample contadt will be fuflicient to prevent fuppuration in this part ; or if in¬ flammation has gone fo far as to make the furgeon fufpedl . that fuppuration has taken place, then the comprefs mufl: be put upon that part of the vein juft above the fuppura¬ tion. This I once pradlifed, arid, as I fup- pofed, with fuccefs.

HI. A

I

r 3<> j

III. A Procefs for preparing pure Emetic Tartar by Re-cryfallixation, By Mr. Jen- NER, Burgeon at Berkeley. In a letter to John Hunter, Efq. Read June 1784.

Sir,

I BELIEVE it is generally acknowledged, that no preparation of antimony obtains fo much in the modern practice of phyfic as emetic tartar; yet how greatly ought it to be lamented, that a procefs of fuch confequence to the health of mankind has hitherto been conduced upon an imperfect plan. In the ufe of this valuable medicine, the phylician’s warmeft hopes are too frequently allayed with fear : for, while fo many formulce for the com- pofition of emetic tartar are extant in difpen- fatories and chymical treatifes, the pradtiti- ' oner, wanting a fixt criterion of its quality, muft often- prefcribe with uncertainty, and generally be difappointed in his conclulions. Indeed the faculty are well aware that a tin¬ gle grain prepared by one chymid; may excite full vomiting, though the fame quantity pre-

[ 31 ]

pared by another may not even produce a ' naufea. Thefe confiderations, added to the great importance of the medicine itfelf, have induced me to attempt fome experiments, with a view of bringing it to the greateft de¬ gree of purity. The refult of thefe proved favourable to my wifhes; and without enter¬ ing into a tedious detail of them, I flatter my- felf that emetic tartar made according to the inclofed procefs, will bear the tefl: of a fcru- pulous examination. It will be found to be a pure neutral fait, compofed entirely of tar¬ tar and the reguline part of antimony, formed in cr}^fl:als beautifully white and tranfparent, and perfectly foluble either in water or wine. I am.

Sir,

Your mofi: obedient

and obliged fervant,

Berkeley^ fib. 5, 1 7 84.

Edward Je#jner.

[ 32 ]

Frocefs fir preparing pure 'Emetic Tartar by Re-c?y/iallization»

Take cream of tartar and glafs of anti¬ mony levigated, of each one pound. Mix them together, and pour upon them in a clean earthen veffel two gallons of boiling water. Stir the whole together a few mi¬ nutes, and the cream of tartar will be fully faturated. Let the faeces fubfide, filter the liquor, and boil it immediately in a well^jtin- ned vefihl, till the whole be nearly evaporated to drynefs. Pour as much boiling water on the emetic tartar, thus rudely formed, as will dilTolve it ; put it into an earthen velfel, and let it remain twenty-four hours. Emetic tartar will now be formed in cryftals adhering to the fides and bottom of the veffel, but not perfectly bright and free from impurities. Decant the liquor, and boil it till a pellicle appears on the furface. Set it by to cryftal- lize. Colled; thefe cryftals, and mixing them with thofe formed before, diffolve them in as much boiling water as is fufiicient for that purpofe. Filter the folution immediately 5 put it into clean glafs veffels, and let it re¬ main

V

[ 33 J

main twenty-four hours. The cryftals which appear now are in a perfeft ftate. Having waflied them with a little clean cold water> place them in the (hade on white fpongy pa¬ per to dry. To obtain the whole of the eme¬ tic tartar contained in -the remaining liquor^ the proceffes above mentioned muft be again and again repeated* . ' ,

[ 34 1

IV. An Account of the DiJJeBion of a Man,, that died of a SiippreJjiGn of Urine^ produced by a Collection of Hydatidsy between the Neck of the Bladder and Redfum ^ with Ob-- fervations on the Manner in which Hydatids grow and ?nultiply in the human Body, By John Hunter, M. D. F. R. S. and Rhyfcian to the Army, Read April 17,. 1787.

Th OMAS Bell, aged forty- fix years> a carpenter, and a ftout man, died fuddenly, March the 17th, 1786. The following par¬ ticulars were all that could be learned re- fpedling his difeafe previous to his death : that he had been complaining for four or five weeks of more or lefs pain and diffi- .culty in making water, which he himfelf fuppofed to proceed from gravel, but by thofe about him was fufpedled to arife from fome venereal complaint. In confequence of this fufpicion he was vifited by a furgeon, who. examined the penis y and found a natural phi^ rnojisy but no venereal complaint. When queftioned jefpedling his difficulty of making water, he faid, that he had been in much pain,

, ' but

* f

\

' t 35 ]

but was now ealier, and that fome urine had come away involuntarily. He was able to fit up in bed at this examination, but in an hour after, in attempting to turn himfelf, he ex- ' pired.

The body was examined thirty hours after death.

Head. — The brain was in all refpedls na¬ tural ; it was not firm, however, for fo fiiort a time after death. The water in the ven¬ tricles was in the ufual quantity. The blood in the veffels was fluid both in the head and other parts of the body.

Thorax. The vifcera were all found.

Abdomen. The belly was very tumid, which, on removing the common integu¬ ments, w;as found to proceed from the im- menfe fize of the bladder. It was diflended enormoully, and reached fully eight inches above the pubis ; its fundus was within* two inches of the arch of the colon. Upon let¬ ting out the water, which amounted to five or fix pints, it appeared that there was a large tumour between the neck of the bladder and the return, which completely filled the pelvis, and thruft the bladder forwards and upwards. On cutting into the tumour much water!

D 2 rulhed

t 36 1

rallied out, and along with it many hydatids

of various fizes ; the largeft was about an *•- *

inch and an half in diameter, and the fmalleft not larger than a pin’s head. The tumour was intirely filled with hydatids and the water that furrounded them, and both together they were more in quantity than a pint and an half* There were befides two or three fmaller tu- nioiirs near the neck of the bladder, alfo con¬ taining hydatids ; and there were two bodies, fiot larger than common beans, adhering to the bladder, containing a foft cheefe-like fiibitance.

Between the flomach and the fpleen, and over one end of the pancreas, there was a large tumour, to v^hich the three above parts adher¬ ed; the ftomach and pancreas flightly by cellu- ' lar membrane ; the fpleen more intimately, fo as to make a oaf t of the tumour : with the fpleen it was about ten inches in diameter. It was irregularly fhaped, and made up of feveral fmaller tumours. There was confi-r derable variety in the contents of thofe tu¬ mours ; in one there were hydatids of various fizes, like thofe mentioned above ; in another there was a fubflance like ifinglafs, a little foftened in water ; in a third there was clear

9 ^

water

Flatel, p.^j.

[ 37 ]

water in a confiderable quantity, with very minute particles, like fmall grains, adhering flightly to the fides ; and in a fourth there were hydatids, fome full, others burft, and with their coats compreffed together, and forming the ifinglafs-like fubftance. The tumours or - facs had all thick coats, endowed with a ftrong contractile power, that forcibly pro¬ truded their contents through any opening made into them. They had two coats ; an outer, which was flrongeft and thickeft, and an inner, which was tender, foft, and pulpy.

. As to the ftruClure of the hydatids, it was -the fame in large and fmall 3 a tranfparcnt bag, uniformly round and fmooth, filled with clear water. The bag appeared to confifi: of two coats, or layers 3 for on handling them, r the outer coat would get rumpled, and occa- fion a degree of opacity, but, by wiping the hydatid, it became again clear and tranfparent. They appeared to be completely fpherical, except that the. large ones were a little flat¬ tened by their own weight, when laid on a plate They adhered no where to the fides of the fac, nor to one another. When they were opened, their coats polTeffed a llrong

♦ Vid. Plate Ift. Figt i.

D 3

con-

[ 38 ]

coiitraftile force, fo as to roll themfelves up ill part. On examining a number of hyda¬ tids, fome of them appeared of an amber co¬ lour, and with thicker coats than the reft ; and when opened, their inner furface was found covered with fmall hydatids, which were not fo large as the heads of pins, and looked .like minute pearls or ftuds fet in the inner coat '

I Some .of the water containing the fmall grains mentioned above, was examined with a microfcope, and found to have floating in it numerous minute hydatids; of which the largeft were the little grains vifible to the na¬ ked eye, and t-o-o part of an inch in diameter ; the fmalleft were lefs than a red globule of blood ; and they were^ of all intermediate fizes. The coats of the largeft were a little .rough with numerous filaments, or w7//; and, on ufing a deeper magnifier, they had fome- what of a mulberry appearance •f*. - , When the young ones growing in the coats of the larger were examined with the micror fcope, they were found not to be fet in the coats, like pearls, but to be covered by a

' * Vid. Plate Ill. Fig. 2o t Vid. Plate H. Fig. 5.

< thin

f 39 1

thin tranfparent membrane, fo as to lie be¬ tween two layers. It is not improbable that the -fmall globules attach themfelves by the villi to the fide of the hydatid, and to each other, and thereby give the appearance of being covered by a thin membrane. How¬ ever that may be, the globules being found of various fizes floating in the liquor. Teems to prove that they are originally formed there, and not in the coats of the hydatid, upon which they are afterwards depofited. The jiumber of thofe that had young ones in them, W''as few in proportion to the others.

The * hydatids in their growth and decay appear to - pafs- through various ftages ; they are firfi; found floating in the fluid that fills the’ hydatid, and afterw’ards attached to its coats. The hydatid thus pregnant with young, if the exprefiion may be allowxd, ad¬ heres to the neighbouring parts, increafes in fize, and becomes itfelf a fac, containing nu¬ merous fmall hydatids. Thefe after a certain time decay, and the fleins or empty bags are fqueezed together into a fubftance like ifm- glafs. It is probable they ftiil undergo a fur¬ ther change; two fmall bodies, of the fize 4>f the common bean, of a cheefe-iike con-

D 4 fiftencc.

[ 40 1

fiftence, and covered with a ikin, were taken . notice of adhering to the bladder near its neck; it may be a queftion whether thofe were not the remains of hydatids ? but that muft be determined by future obfervations. It is to be obferved, that the young hydatids are found in two very different ftages ; in the one they are attached to the coats of an hy^ datid, that floats loofe in the parent bag or fact; in the other, extremely fmall globules adhere flightly to the inner furface of a bag or fac, which is firmly attached to the neighbouring parts, and covered with a ftrong outer coat. It is obvious that the progrefs of growth is very unequal in thofe two, and indeed invert¬ ed ; fordn the firft the young ones are as large as the heads of pins, while the parent bag is not larger than a walnut, and floats unattached ; but on the contrary, in the fecpnd there is a large fac with a flrong outer coat, and a more tender inner one, adhering ftrongly to the furrounding parts, while the young ones, that are very flightly attached to its fides, are not of a larger diameter than a part of an inch. Whether thofe are merely accidental differences in the growth, or depend upon

fome

[ 41 ]

fome more effentlal diftindlion, muft remain * to be determined by future obfervations.

The term hydatid is ufed in different fenfes ; thus the hydatids of xht p lac e7it a ^ of the ova-- ri'a, and of the kidneys, which may be con- fidered as morbid changes in the fubftances of thofe bodies, are totally different from the hydatids of the prefent cafe, which produce their like, and multiply in great abundance, without any further connediion with the hu¬ man body, except in fo far as it affords them a nidus. The obfervations I am going to make are confined intirely to this laft men¬ tioned kind. They have been found in va¬ rious parts of the human body ; they have been difeharged both by vomit and by flool they have been brought up from the lungs by cough 'f ; they have been voided by urine ; and they have been difeharged from tumours in different parts of the body J. Le Cat has taken notice of their inner coat being covered with fmall inarnillc^i an appearance produced by the young ones, and fuppofes them to be the glandular grains of the fpleen diflended

* Philofoph. Tranfaft. Vol. xxii. p. 1797*

+ Med, Tranfad. Vol, ii. p. 486. .

J Philofoph. Tranfaft. Vol. xxy, p. 2344.

with

/

[ 42 ]

-with lymph. They have alfo been confi- dered as difeafed lymphatics ; but it muft be obvious, that the young ones growing within the larger; at the farxfe time that thefe laft are floating in a liquid without connection with the lides ’of the fac, cannot proceed from any difeafe in- thd lymphatic fyftem, if by that he utiderfto6d^%e ^ablorbent veffeis. ''Tt is un- 'heceflary to aniiriadveft upon Le Cat’s opi- nion,"^as anatomy has^-iiot hitherto been able to' demonftrate the ‘exiftence of any glandular grains in the fpleen, which appears to be a congeries of blood- veffels. It may be a quef- 'tion, whether the hydatids are not of an ani¬ mal nature^ and poiTeffing a life peculiar to Themfelves ? We are not yet in poffeflion of • a fufficient number of faCls to afcertain this point ; but the difcoveries that have been made refpeCting the nature of hydatids in 'other animals, promife to throw fome light Upon the prefent fubjeCt,

" Tlienngenious naturalifl: Pallas, in his Mif- cellanea Zoologica has given an account of the obfervations made by others upon hyda¬ tids, and added difcoveries of his own. There .are only two before him, who knew the hy- * jEd. Hagac Comitum, 1766, p* 157,

datids

' [ 43 ]

datids in animals to be alive, and to pbffefs a peculiar ftrudure and power of motion. Thofe were Dr. Tyfon and Phil. Jac. Hartmannits, Pallas confiders Tyfon as the firft difcoverer, but feemingly v/ithout reafon, for Hartman - nus publifhed his account in the year 1685 ^ ; and Tyfon in 1691 ‘f*. Neither of them ap¬ pears to be acquainted with the other’s difco- very. Tyfon obferved the neck and niouth of the animal, and faw them in motion ; Hart¬ mann further faw the ‘whole body in motion by putting them in warm water.’ iTallas has examined them .very minutely, and gives theth the name of hydatigena, from finding th^ir heads of the fame ftrudlure as that oTthe fce^ nia. But in all that Pallas faw he never found any pregnant, fo that he was unacquainted •with the manner in which they multiply. Goetze, a German writer. Has given figures of the young ones adhering > to the parent bag ; and Mr. Hunter has preparations of that kind in his colledlion. The Abbe Fon¬ tana X obferved them in fbeep, feen the motion of the young'- ones adhering to the fides, and alfo with a microfcope

* Mifcell. Nat. Cur. dec. 2. An. ^to.

+ Phil. Tranf. for that year, ppufcoli Scelti, tom. 6,

5

.^xamine^

r 44 3

examined the heads of them, and found them refembling thofe of teenier. So far the ob- fervations of authors go with refpedl to the hydatids of animals ; in regard to the hy¬ datids of the human fpecies, Tyfon has re¬ marked that they are diiferent from the for¬ mer 5 that they are uniformly round, with¬ out any appearance of a neck or head ; but . he declines giving any opinion of their na¬ ture. Pallas ^ likewife mentions a kind of hydatids found in the human and other bo¬ dies, without any neck or mouth, but leaves their nature to be decided by future obfer- vations. He fays their coats are very elaftic, and when cut re trad: with fo much force as to roll themfelves up, turning the infide out.

' It is not altogether allowable to conclude, from the refemblance of the human hyda*- tids to thofe of quadrupeds, that the firft as well as the laft form a part of the animal kingdom; yet they agree in fo many cir- cumflances, that fuch a conclufion .appears very probable. In quadrupeds they have their feat generally in the abdomen^ and moft commonly in the liver or fpleen 5 the fame is true of the human hydatids. In the human

♦ P. 172.

they

-[ 45 ]

they multiply by the young growing on the ilifide of the hydatids ; and the fame has been obferved in quadrupeds. The analogy fails when we look for a mouth and neck in the human ; nor has any periftaltic, or undulat- Ine motion been obferved in their coats ; but

o

this laft appearance has not been looked for in a proper way, that is, by putting them in tepid water as foon as they come from the human body.

With regard to the time requifite for the growth and decay of the different facs con^ taiaing hydatids, it is difficult to form a con- jedure. Our patient was able to follow his trade as a carpenter till five weeks before he died ; it is probable therefore that in that time, or a little more, the fac between the neck of the bladder and redum had grown to that iize, which produced a fuppreflion of urine and deaih. The growth and decay of the hydatids ferve to explain the increafe and diminution, which have been obferved in tumours of the abdomen proceeding from this caufe, as in the cafe mentioned in the Medical Tranfadtions It will not be deemed out of place to mention fome par¬ ticulars of a diffedtion that have come to

my

^ Vol. II.

[ 46 ] •

iny knowledge, that in a great meafure ex¬ plain the appearances in , the cafe above al¬ luded to, and confirm the truth of the con- jedlurc fubjoined to it. '

A patient died in the Infirmary at Edin¬ burgh, with the fymptoms of the encyfted dropfy. His abdomen was fwelled with many irregular protuberances. On examin¬ ing the body, , there were found numerous encyfted tumours full of hydatids. They had their bafis in the liver, from which they proceeded not only downwards into the abdo¬ men, but upwards into the thorax, and mak¬ ing their way through the diaphragm, came in contacft with the lungs. Had the patient lived a little longer, it is not improbable that a communication between the bags contain¬ ing the hydatids and fome of the branches of the trachea arteria would have taken place, which muft have produced the fame fymp¬ toms as in the cafe abovementioned.

To return to the dififedlion. The hyda-* tids did not appear to have done any injury to the parts, except by mechanical preflure, for the vifcera were all uncommonly found. Of the numerous cafes of hydatids related by writers, it may be remarked tliat hardly any

of

(

[ 47 ]

of them proved fatal whenever they found an outlet. In the prefent cafe, the preffure vtpon the neck ’ of the bladder, and confe- quent fuppreffion of urine, are evidently the caufes of death. The manner of death from fuch a caufe is not unufual ; after a time, the pain produced by the diftention of the blad¬ der ceafes, there are no more efforts to make water, and yet the patient dies fuddenly. This fudden death has been 'imputed to a tranllation of the urine, as it has been 'ex- preffed, to the brain. If any idea is to be annexed to thefe expreffions, it mull be, that the urine is effufed either in the ventricles, or upon the furface of the brain ; but no ap¬ pearances of that kind were obfervable in the prefent cafe.

When the prefence of hydatids is fufpedled, it would appear to be of great confequence to procure them an outlet ; but it mull be obvious, that being generally feated in the abdomen, that bufinefs mull be left intirely to nature. Upon . the fuppofition that they belong to the animal kingdom, no internal medicine promifes to be of fo much ufe as mercury, which appears to have been given in one cafe wtih advantage But this is a

o

* Med. Tranf. Vol. II.

fubje(ffc

I

i 48 ] ,

fubje£t there is no entering upon without a greater number of fadls..

To this account I will fubtjoln a query re- fpeding the manner in which the hydatids came to be ^ lodged between the redlum and bladder. It has been obferved that they are moft commonly found in the liver and fplecn, and In. the prefent cafe their original feat would appear to have been in the laft of thefe vifcera ; may not, however, one of the facs or bags In the fpleen have burft, by which the contents would be fpread all over the ab¬ domen, and from their own gravity would naturally fall into the pelvis ; and may they not have adhered to the neighbouring parts, and fo multiplied there ?

I have been more particular In relating the circumftances of this cafe, becaufe fuch fel- dom occur even to^perfons in extenfive prac¬ tice ; in confequence of which it often hap- , pens in rare cafes, that the views and expe¬ riments fuggefted by one cafe, are of no avail, for want of another opportunity to verify them. It will therefore be underftood, that what is advanced refpedting their being en¬ dowed with a life of their own, and alfo

their

f 49 1

their mode of breeding or multiplying^ is given merely as probabilities, and as well deferving of further inveftigation, whenever opportunities may offer*

Charks-Sireet^

April 17, 1787.

-SUPPLEMENT.

In the year 1788, I had an opportunity of examining fome hydatids that \vere found in the abdomen of a fheep. Before I faw them the bowels had been taken out, and they were adhering to the fat about the kid- nies, and alfo to the liver, and to the fat near the urinary bladder, in confiderable number. They would appear to differ in fome effential particulars from the human hydatids, yet they refemble one another in fo many things, ^ that there is reafon to infer therefrom, that both belong to the animal kingdom.' It ap¬ peared to me, that a fhort account of them would form a proper fupplement to the cafe of human hydatids, read fome time ago to the fociety.

E

The

[ 50 ]

The hydatids in the fheep were exad;ly the fame with thofe defcribed by Tyfon They confift of a mouth, neck, and oblong fpherical body. The mouth had nothing of the cruci¬ form appearance, if I may be allowed the ex- preflion, that late writers have made the cha- radleriftic mark of tcenia, and which they fay is to be found in all hydatids. The mouth, ex¬ amined with fome care with the microfcope, appeared to be a fimple longitudinal aperture. The neck was compofed of rings, and there appeared very line circles furrounding the body. They varied in lize, from that of a chefnut to the dimenfions of a turkey’s egg. When put in W'arm water, though it muft have been 'twelve or fourteen hours after the iheep had been killed, they moved briikly, with a'kind of periftaltic motion all over the body. Each hydatid was lodged in a feparate fac, which was little more than fufficient to hold it, for the neck was refledfed upon the body. The fides of the fac were lubricated with a mucous fluid.

The human hydatids havT no neck or mouth, and they are in great numbers in the fame fac^ and of various lizes. In thefe par-

^ Phil. Tranf, 1692,

tlculacs:

(

[ 51 ]

ticulars they differ from thofe of flieep ; nor could 1 find any young ones attached to the infide of the hydatid, as in the human. In their mode of decay, however, they refembled each other completely. The fac became thicker and ftronger, and at the fame time diminifhed in fize, and compreffed the coat of the hydatid into a fubftance like ifinglafs. In the laft ftage this fubftance became like a mixture of chalk and water, and the fide of the lac hardened, and appeared in fome degree petrified ; for the hardnefs was more like that of a ftone, than of a bone.

I had, in the fummer of 1791, an oppor¬ tunity of examinnig the hydatids which are found in the brain of flieep, producing the difeafe called, in Ibme parts of the country, the JicLggers, The hydatid is lodged in the fubftance of the brain ; in one fheep dicre were two hydatids, one in each hemifphere of the brain ; they were of an irregular oval fhape ; they had no mouth ; their coats had the fame appearance as in the hydatids found in the abdomen ; and, when put in warm water, they had a ftrong periftaltic motion.

In fome there were clufters of young ones, adhering to their inner coats, Thefe were

E fome-

I

[ 52 ]

fcmewhat oval in their fliape, and adhered by one end ; but on detaching them carefully, and examining ‘them >with good magnifiers, I could never find the cruciform mouth de- fcribed by fome writers.

We may obferve, that the mouth -is not eflential to the hydatid in fheep,' which ren¬ ders it ftill more probable, if not altogether certain, that the human hydatid is an ani¬ mal

■* There being great reafon to believe that hydatids form a diftinft genus in the animal kingdom, and being fo elTentially different from the watery veficles which are found in the oua- Ttuniy kidney, and placenta y it might be proper, in order to avoid ambiguity and confufion, to diftinguifh them by a name peculiar to themfelves. Linnasus (a) calls the hydatid in Iheep Hydra Hydatula ; buf neither his generic charader, nor fpecific differences, which are chiefly taken from the mouth, apply to the animals in queflion, in fome of which there is no mouth. The Greek language, that inexhauftible fource of derivation, readily fuppiies us with a name. The word ‘y^pluy Hjdriay is very appoflte. If that be adopted, we fhall have Hjdria Hu^ tmnay Hjdria On)illay &c.

(a) Syflema Natunv, Vermes, Zoophyta, Hydra,

« „ ^ V.

\

C 53 3

V. Cafe of a Geiitleman labouring under the epidemic remittent Fever of Buforah^ in. the Tear 1780 ; drawn up by himfelf', with an Account of various Circimfances relat¬ ing to that Difeafe. Communicated by John Hunter, Efq. F. R. S. Read June 17, 1788.

INTRODUCTION.

The follov/ing cafe is that of a gentleman, not unacquainted with medical learning, tho' not of the profeffion. To this circumftance it is owing, that an explanation is neceffary of the fenfe annexed to the term plague^ which occurs frequently. Our author ufes it in a fomewhat vague fenfe, but probably fuch as is cuftomary at Buffo rah ; and calls by that name the remittent fever, which prevails every year, with various degrees of violence, in confequence of the annual overflowings of the Euphrates. But there is no refemblance be¬ tween the plague, properly fo called, and the remittent fever ; they differ in their fymp- toms, progrefs, and caufes, of which any one may eafily fatisfy himfelf, by confulting the excellent treatife lately publilhed by Dr.

E 3 Ruflell

[ 54- 1

Ruffbll on the Plague. There is further this remarkable difference between them, that they prevail in different feafons of the year. The warm weather of the month of May puts an end to the plague at Bufforah, and it is not to be feen in the fubfequent hot months ; whereas the remittent fever begins in the month of May, in which the Euphrates ufually overflows its banks in the neighbour¬ hood of Bufforah, and prevails chiefly in the warm months that follow. Our author fre¬ quently mentions the plague of 1773? flip- pofing the remittent fever, and that epedemic, to be the fame difeafe ; but that is not the cafe. It w^as the real plague which raged at Bufforah with fuch violence in 1773; and from au¬ thentic accounts of it in the poffeflion of Dr. Ruflel, it appears that it firft fhewed itfelf in February, increafed in March and April, be-; gan to diminilh early in May, and by the end of that month intirely ceafed.

It is impoffible to read the narrative of the fufferings of the patient, without wifliing that he had had the affiftance of medical people, who had been acquainted with the proper mode of adminiftering the bark in fuch fe¬ vers. The numerous remiflions he had, fur- niflied the beft opportunities of giving it ;

and

[ 55 ]

and as in the end he owed his life to it, fo there can be no doubt but a more early ufe of it, would have faved him from niuch fuf- fering and mifery.

Ever fince the great plague of i773> in which it is eftimatcd feven-eighths of the inhabitants peridied, Buflbrah has feldom efcaped, every third, or fourth year, a vifita- tion from fome malignant putrid difeafe. Whole families died, and remained unburied, until covered by the ruins of their houfes. Thoufands were interred in the ftreets, but fo near the furface, that I have feen the bones of the dead in many places appearing above ground. To complete the calamity, the in-^ habitants, in lefs than three years after this plague, fuftained a liege of thirteen months againft the Perfians, in which they expe«- , rienced every diftrefs that the fword, ficknefs and famine, can inflidt upon mankind.

The overflowing of the Euphrates, and its waters ftagnating on the defart, have always been accounted the leading primary caufes of epidemical difeafes at Buflbrah. The great floods, from the melting of the fnow on the mountains of Diarbekir, happened in the year

E 4 1780

[ 56 ]

1 7^0 early in the month of May, when the heats in Perfia and Arabia began to be excef- live. The defart, which reaches to the gates of BulTorah, is, for many miles, incrufted with a furface of fait, which, when mixed with the ftagnated waters and expofed to the fun, produces the moil noxious effluvia. So early as the 25 th of May, the town was fur- rounded with a fait marfh, the heated fteam ariiing from which was, at times,' almoft in¬ tolerable j but the canal that runs through a great part of the city being filled with the dead bodies of animals, and all kinds of pu^ trid matter, and at low tides all thefe fub- flances expofed to the fun, made the air in the town fcarcely fupportable ; and being to¬ tally deftitute of police, the ftreets were in many places covered with human ordure, the bodies of dead dogs and cats, which emitted ^ flench rnore difagreeable and putrid than any thing I ever experienced in my life.

From the accumulation of fo many caufes, it is not furprifing that epidemical diforders fhould have reigned at Buflbrah in the year 1780 j it is more wonderful that thefe difeafes are not both more frequent, and more fatal.

As to the degree of folar heat during the period of which 1 am about to fpeak, it far '

exceeded

• t - - - ‘

[ 57 1

exceeded what I conceived the human frame to be capable of bearing. The fenfatlon under this heat was totally different from what I had ever experienced ; it refembled the approach of a heated fubftance to the body. Accord¬ ing to Farenheit’s thermometer the quicks filver rofe in the fun to between 156 and 162 degrees. From the 30th of May I never faw it fo low as 156, but generally between 158 and 160. The glafs was fixed to a wall, covered at top, but expofed to the refledled rays of the fun. I am told, that after I left BulTorah it was feveral degrees higher.

In the cooleft part of the houfe, with the aid of every invention to decreafe the heat, the quickfilver rofe to 115 degrees; but after I came away I was informed that it rofe ftill higher, even at feven o’clock in the morning, the hour which we accounted the cooleft in the day. Much about this time two gentle¬ men, who had hitherto efcaped the infedtion, were taken ill, and fled from the fadtory; they reported that on the day on w^hich they left BuflTorah, the heat was fo intolerable that no one could expofe himfelf to it long enough to obferve the thermometer in the fun,

I have

[ 53 ]

I have heard from fome of the oldefl: in¬ habitants of Buflorah, that they never re¬ membered to have felt, or to have heard of fuch a degree of heat in any part of Arabia or Perfia. Before we were all taken ill, the natives of the country appeared more alarmed at the heat of the weather than* the Euro¬ peans ; nothing could induce them to expofe themfelves to the fun after ten o’clock.

From the loth of May the people of Buf¬ fo rah began to foretell that the feafon would be marked by a fevere and general ficknefs. This predidion was foon verified ; towards the end of the rnonth an intermitting bilious fever made its appearance in the town, which •in a« very few days fpread with fuch amazing rapidity, that upon a computation not a fourth part of the inhabitants were exempted from this calamhy.

About the latter end of May I was fenfiblp at times of extreme and unufual internal heat and glowings, with fenlations which I cannot defcribe, and once or twice I perceived an inclination to fhiver. I feldom made water piore than once in twenty-four hours, and then in fmall quantities, and of a very deep r colour*

/

[ 59 ]

colour. My appetite and every, other cir- cumftance continued as ufdal.

I left' Bufforah for Aleppo the 30th of May. On our arrival at Zebire, the heat was lb intenfe that even the Arabs funk un¬ der it. Moft of the gentlemen who had ac¬ companied me to this place' felt it in a ftill more fevere manner. I was quite overcome; I felt an unufual languor, weaknefs, alternate heat and cold, and many other fymptoms which indicated an approaching fever. I could not immediately be prevailed upon to relinquifh my journey ; and although upon refledlion I had not a ray of hope that I iliould be able to proceed, yet at that time a difap- polntment appeared to me equaiiy dreadful with certain death in the defart. At night eveiy fymptom increafed, the enfuing day all hopes of purfuing my journey vanilhed, and in the evening I was carried Back to Bufforah. In two days I got tolerably well, but pains in my back, loins, limbs, and great proftra-.

I

tion of ftrength ftill remained. About this time two gentlemen of the fadlory were feized with the fever, which now began tp rage with violence.

[ 6o J

5 til June. From this day I date the ac¬ tual commencement of my fever. About two o’clock after dinner I was fuddenly at¬ tacked with a violent glowing heat ' all over my body, uneafinefs, anxiety, and oppreffion, but in a very inconfiderable degree to what I afterwards experienced ; alfo a fwelling in my tongue, which had been coming on fome days, and is one of the firft fymptoms of the fever that prevailed. The fit continued about two hours ; a flight perfpiration fiicceeded, which removed the fever, but left a head-ach, thirftj and pains in my back and limbs. In the evening with afliftance I got upon- the ter¬ race, when the moon and ftars appeared of a bright yellow, and all obje(fl:s had that colour through the whole of my difeafe ; alfo the pain in making water and acrofs my loins became intolerable, like that felt in com¬ plaints of the ftone in the bladder. I took fome tartar emetic, which brought up a great deal of bile, and the next morning a purga¬ tive of Rochelle falts, manna, tamarinds, and annifeeds.

6th June, In the forenoon a fi*ee, copious perfpiration, and a perfedt intertniifion of the feyer i at night became very refilefs and un-

eafy.

[ 6i ]

eafy, could not fleep, which I partly imputed to a draught of ftrong muflard whey, with fome antlmonial wine, which inftead of caufing perfpiration, produced the oppofite effeft.

yth. By the advice of a phyfician I took fome weak decodlion of bark, i oz. to two pints boiled to one, in the quantity of three tea-cups full before dinner. At three in the afternoon I had another hot fit, but not very fevere. In the evening grew worfe, heat and thirfi; exceflive, drank muftard whey on going to bed, but had a very bad night; — no fieep, much oppreffed, fevere head-ach, and pain over my loins.

8th. I took a gentle purge of cream ^of tartar and manna, which operated and gave me fome eafe. Left off the bark, as it feemed to increafe the febrile fymptoms, and drank fage and apple tea, decodion of prunes, ta • marinds, &c. At ten o’clock in the fore¬ noon a very fevere hot fit ; heat intenfe, op- preilion in my ftomach and breaft almoft in-

fufferable. Mr. ; - furgeon of the Eagle

cruifer, gave me a mpfl; naufeous faline mix¬ ture, which vomited and purged me feverely. The quantity of bil^ which came olf my fto- . . I mach

i 62 ]

mach was incredible, yet I felt no relief, and

t

the agony of the hot fit continued till four o'clock in the afternoon, when it went off by a moft profufe perfpiration. During this fit my thirfl was conftant and intenfe. In the evening my fkin became dry, the thirfl returned, and I had a very bad, fleeplefs night.

I now began, to experience fome of the dreadful fymptoms which are I believe pecu¬ liar to fevers in Turkey and Arabia, a fenfa- tion of dread and horror totally 'unconnefted with the fear of death, for while the patient is moll affli(5led with this fymptom, it is for the moll part accompanied with a flrong de¬ fire to put an end to his exiflence. The agony from the heat of the body is beyond conception ; I have heard fome of my fellow- fufferers roar hideoully under the violence of the pain.

9th. I’ill noon tolerably well. About one o’clock the hot fit attacked me, and was full as fevere as yefterday; heat, and thirfl rather greater, and but little relief for more than an hour after the perfpiration com¬ menced. This attack left me very weak, much exhaufled with cold weakening fweats,

quick

[ 63 ]

quick unequal pulfe, fevere head-ach, con- fufion, anxiety, and inceffant third: ; a fleep- lefs night, ftartings, anxieties, and a conftant wiih to terminate my fuiFerings by death loth. Forenoon, pretty free from fever. Attacked at the fame hour as yefterday. The lit more violent, delirium. The agony of the heat -not to be expreffed ; the whole body as if on fire ; unremitting third:, profufe perfpi- ration, yet no relief till late in the evening ; no deep, a dreadful night, &c. Pulfe about 120, unequal and fluttering.

A mere relation of fafts can give but a faint idea of the wretched fituation to which the fadory was now reduced : by this time eleven twelfths of the inhabitants of Buflbrah were taken ill, numbers were daily dying, and the reports from Bagdad and Diarbekir of the increafing ravages of the plague, left the fur- vivors not a ray of hope that they could efcape from the calamity. On every countenance pain^ ficknefs and horror were ftrongly paint¬ ed 5 nor were we even left the comforts of fympathy, as every mind was too much eii- grofled with its own fufferings to think of adminiftering confolation to others. Four of us lay under the portico of one of the fquares

of

[ H ]

of the fadlory, calling out for water In a • phrenfy of thirft. We ufed to fnatch it from each other, and to fupplicate for a mouthful ^ with as much fervor as a dying criminal for an hour of further life.

About this period of the fever my eyes became very weak, and every objed: I faw was quite yellow. This effed was moft per¬ ceptible at night, in looking at the moon and ftars. In the evenings we were fome times carried in our cots upon the terrace of the fadory for air, but the wind was fo heated by the burning lands of the defart, that we felt it more intolerable than even the lower apartments. We all remarked that the She- maal, or northern winds, which blew with¬ out intermiffion at that time, greatly increafed our heat and third.

The daily very evident increafe of my fe¬ ver, and its eifeds upon others becoming every day more fatal and alarming, determined me, while any ftrength remained, to embrace the con ful’s offer of flying from the feat of infedion to Bufliire, in the Ranger cruifer.

I ith. After an exceeding bad night I was carried early in the morning on board the Ranger, and was not very ill untihabo.ut nine

o’clock.

f

[ 65 ■]

o'clock, when I felt the fever coming on, with new and more alarming fymptoms, vio¬ lent head-ach, giddinefs, dimneft of fight, approaching delirium, horror, and a mo ft painful oppreflion and burning heat in my- flomach.

In defpair, and to try to quench the un- fufferable heat in my Itomach and bowels, I took a pretty large dofe of nitre. The op- ' predion and pain increafed, in my confufion I took a paper of tartar emetic, which imme¬ diately began to operate. From that time, about ten o’clock, till half pad: two in the af¬ ternoon, I know but little of what paded.

I was almofl all that time either diftraded wdth pain, or in a fwoon ; and had it not ^ been for the extraordinary care and attention of the commander of the cruifer, who fup- ported me in his arms, and adminiftered fcch cordials as I, in the diort moments of recol- ledllon, could call for, I have not a doubt but I mud: have funk under this attack. He counted eight times that I fainted, and fome- times an interval of ten minutes before he ' could perceive any fymptoms of returning life.

I was chiefiy fupported by wine, hartdiorn, and fpirits of lavender. About three o’clock

F I had

I

[ 66 ]

I, had recovered my recolleftion : moft co¬ pious and continued fweats had carried ofF ^the violence of the fever, but fain tings and total privation of ftrength and fpirits remain¬ ed upon me till late in the evening, when I became to all appearance, for a fhort time, perfectly well. A little ftrength returned, every fymptom of fever vanifhed, and my feelings were almoft the fame as if in perfedt health. Some circumftances having pre¬ vented the Ranger’s carrying me to Bufoire, I was taken ailiore in the evening. When I was brought to the fadlory I had an appetite, and ate fome chicken broth for fupper. Mr. Rofs, who had hitherto efcaped the fever,

’ adminiftered a potion of laudanum, and, I believe, antimonial wine, on going to reft. I flept pretty well, and waked refrefhed in the morning. I, however, foon became ill; and at noon I had a fevere attack, which con¬ tinued three or four hours, and left me greatly weakened, niy llvin extremely dry, pulfe quick, fluttering, and irregular, beating from loo to 1 20, with an unquenchable thirft, which no liquids could allay. We had no acids of any kind, which we had great reafon to regret.

I did

[67] .

I did not know till late in the evening that Mr. Abraham, the vice-conful, who for fome days pafl had been ill of the fame fever, had determined to embark in the Eagle cruifer next morning for Bulhire, as the only chance of fav- ing his life ; and a converfation which I over¬ heard to this effed:, that as I was fo very ill, and no hopes of my recovery, it would be better to leave me behind to die at Bufforah, made me ftill more anxious to fly from the place, although I remember well I had not the mofl: diftant hope that I could live. I had fulfered much at the fadory, and in the peevifhnefs of illnefs I thought (perhaps. unjuflily) that my living or dying feemed to be a matter of too little confequence to thofe, whom in health I had treated with much kindnefs and affedion.

About ten o’clock, as I was lying in my cot, on a terrace adjoining to the flairs from whence the boat was to put off, I was feized with fuch a fluttering, palpitation, ftarting, difficulty of utterance from the fwelling of my tongue, that I lay in momentary expec¬ tation of breathing my laft. This w^as, how^- ever, probably the caufe of my hearing the preparations for the departure of the boat.

F 2 About

[ *68 ]

About midnight they were leaving the fliore.

I could not make myfelf heard, and I was too weak to get up without help. I made feveral efforts, and at laft overfet the cott I was lying upon, and brought myfelf to the floor, from whence I crawled on my hands

I

and knees to the fide of the river. Huma¬ nity pleaded for me, and I was taken into the boat in a fltuation of wretchednefs I never can forget. We were, after being feveral hours on the Euphrates, carried on board the Eagle, oppofite to Margil, a country houfe belonging to the fadlory, a few miles diftant from Bufforah.

1 2th. The day was uncommonly hot, and my fever came upon me about ten o’clock.

The heat was intenfe. Mr. - , a young

unexperienced Frenchman, gave me tama¬ rind water and cream of tartar, which had not a good effedl. I now difcerned the firfl: fymptoin of a cold fit, but it was flight, and of ihort duration. This day, however, I fupported the fever rather better than ufual, and in the evening had a fhort intermiffion, and flept a little during the night. The air on the river was this day cooler and more re- frefliing than on fliore.

1 3th.

[ 69 ]

13th. About eleven o’clock had a regular, cold flilvering fit, fucceeded by a very fevere hot fever, which continued till five in the evening, when I was fomewhat relieved by perfpiration. — This day the agony of the hot fit was inexpreffible, with great pain in my loins, and a conftant Inclination to make wa¬ ter, which came from me in drops like blood. ~I had a very bad fleeplefs night.

14th. By Mr. — — ’s advice, I took a dofe of tartar emetic, which not working, he gave me fome ipecacuanha. I brought up a great deal of bile, but the fever increafing, my fufferings under it were greatly increafed by the operation of the emetic, which worked powerfully both upwards and downwards. — This was a trying day indeed. I can give, no idea of what I fuffered, which mufl: have been intolerable, attended with intervals of delirium, and frequently fwooning. About five the fever began to abate a little, and at fix Mr. - gave me a fmall dofe of decoc¬

tion of bark, which feemed inftantly to caufe a return of the fever, heat, third:, anxiety and pain.

My fellow-fufferer, Mr. Abraham, was in violent agony this day ; he cried out repeat-

F 3 edly.

[ 70 ]

ediy, that a fire was confuming his bowels, and that he was in exquifite torture. The captain of the cruizer had been complaining ; he, -Mr. Abraham, and myfelf, lay in the fame cabin. About four o’clock in the after¬ noon, when my pain was exceffive, I crawl¬ ed from my cott, with an intention to drop myfelf from a port-hole which was under the captain’s bed, into the river. I had nearly acccmpliflied my purpofe, when the captain perceived me, and had me carried into my bed. I was not delirious ; and, in fpite of all my refolution, the agony I fuffered this day made me repeatedly fcream out. One of our feamen died fuddenly, and the blood, I was told, inftantly flowed from all parts of his body.

This evening we arrived at Bulhire. On our coming to an anchor, Mr. Abraham was immediately carried afhore ; but I was too ill to be moved, and accordingly followed in the morning with Captain Sheriff, after a very fevere fleeplefs night.

The heat was fo exceflive this dav, that even the natives we had on board funk under dt, and many of them were ftruck down with the fun. By noon nobody could keep the . ^ ' deck ;

[ 71 ]

deck ; and about this time tlie velTel run aground on the bar at the mouth of the Eu¬ phrates, but fortunately beat over, and got into the guiph. Tv/o more of our people died in the evenin^^ : and I fliould have men- tioned, that, in failing down the river, we faw them throwing many dead bodies from the veffels wliich were at anchor below Buf- ‘ forah, and many boats crouded with people from the Arabian Ihore, ‘palling over to Perfia.

The Perfians at firfl oppofed the landing of our lick, and threatened to burn the fhip ; but they were prevailed upon, by the com¬ pany’s agent at Bufliire, a moll worthy man, to permit us to come afliore.

15th. I was fo weak, that it was with difficulty they could carry me afhore in my cott ; my ftrength was quite gone, and I was helplefs as an infant. Some grapes, v/aterr- melon, and ice, had been got for Mr. Abra¬ ham : of the latter he had eat freely ; I was much prelTed to do the fame, but I was afraid of its increaling my pain, and could hardly be prevailed upon to tafte it ; I, however, fwallowed a little, but by this time my tongue gnd throat were fo fwelled, that I had dlffi-

F ' 4 culty

L 72 j

culty in getting any thing down. About ten o’clock I was attacked as ufual, but I was become fo weak, and the fever running even higher than ufual, that I appeared in the courfe of this day, more than once, to be in the agonies of death ; perfpiration gave no relief to the violent pain and oppreffion I la¬ boured under.

The fadlory at Bufhire Is a miferable, wretched, mud building, bearing mucli more refemblance to a liable than a human abode ; the few rooms, or rather cells, are infulFer- 'ably hot, even to thofe in health, and the reft of the building has no cover from the fun. In one of the bell of thefe recefles in the wall Mr. Abraham and I were placed, and on the fame bed, as there was not room for two ; our agonies were great, our cries dreadful. About feven o’clock in the even¬ ing I perceived my companion in the agonies of death. The company’s agent, Mr, Beau¬ mont, moft humanely afforded him every af- fiftance in his power ; and, when every other perfon was afraid to come near us, he him- felf attended, and adminiftered fuch cordials as he thought might give us relief. Mr. A- braham died in great pain ; and for fear of .

alarming

$

[ 73 ]

alarming the inhabitants, or rather command¬ ant or fheik of the town, Mr. Beaumont thought It nccellary to conceal his death. It w^as fome time before the dead body could be removed, v^hich had become very putrid, and covered with purple fpots. I have been fincc told, that Immediately after death great quan¬ tity of blood or bile flowed from him, as . black as ink, and fo highly ofFenfive, as to -be fmelt at fome diftance from the fadlory. Pafl: midnight we were both removed to the terrace, but, unfortunately for me, there was only one fpot where we could lie, and the fmell of the dead body was become intoler¬ able ; I was, however, by the humane aflifl;- ance of Mr. Beaumont, cleaned and put in¬ to another bed, who fat by me, and treated me with uncommon tendernefs. I recover¬ ed a little, but pafTed a dreadful night indeed. I fliuddered at the agony which I was to feel on the return of the fun, »and rnofl anxioufly wifhedfor death, as the only relief from pain, that I could expedt. I was unable at this time to move hand or foot, and at times could not fpeak. I told Mr. Beaumont- that I thought a gentle dofe of phyfic, if it could be got down, might alleviate the racking pain

in

[ 74 ]

in my breaft, ftomach, bowels, and loins ; he accordingly prepared fome falts, manna > and tamarinds, and gave it to me in the mornings

1 6th. At eleven o’clock the violence of the fever came on ; I grew delirious, fwoon- ed, and the fymptoms of approaching death, I was afterwards told, grew evident to thofc around me. My eyes were fixed, my tongue hung from my mouth, and my face grew quite black. I recovered from this fit about twelve o’clock, and felt excruciating pain, and a burning fufFocating heat. My ftomach and bov/els feemed all on fire, my lungs played with the utmoft difficulty, and I felt a pain and fenfation about my heart which I cannot dcfcribe. I was unable to move ; my fervant lifted rne ^ I fell into a fwoon for a few minutes,

' and, when I came to myfelf, a great quantity of black DUtrid bile flowed from me. Relief

X

'.was inftaiitaneous, and I flept or fwooned till .^bout five o’clock, when 1 found myfelf free from fever, and able to fpeak, my recollection clear, and my mind perfectly compofed, but my body fo weak that I had no power of mov¬ ing, except one of my hands. They gave me fome fuftenance ; I had a little fleep ; but

abQiU

[ 75 ]

about midnight I fell into a fituatlon, which I had all the reafon to think indicated the immediate approach of death. My tongue cleft to my mouth, my extremities were as cold as ice, and the coldnefs alfo appeared to extend up my thigh ; my arm was defliitute of pulfe, nor was the fmalleft pulfation of the heart perceptible ; I never had my recollec-^ tion clearer, or perhaps fo clear, in my life. My fervant was lying by my bedfide ; I was convulfed for fome minutes; and, on recover- ing, I got out the word Boy.— Fortunately for me he was not afleep, and heard me ; I then got out the word Wine ; on which he brought me a glafs of claret, which, with much difficulty, I got down ; I felt myfelf much revived ; I reflefted on my fituation ; and, although I had not the moft remote idea of furviving that night, I recolleded that I had fome fine powdered bark in my trunk, and it occurred to me, that if any thing could be done to preferve my life, it would be that medicine taken in red wine ; but my fpeech immediately failing me, I could not diredl the fervant to give it to me. Death feemed ap¬ proaching ; coldnefs had feized all my limbs ; my fight became <:onfufed, as I perceived

from

[ 76 ]

from looking at the liars, which danced be¬ fore me ; and the rattle or noife in my throat was very perceptible to the fervant, as he af¬ terwards told me. I fainted, and continued in a ftate of infenfibility, I believe, for about an hour. The loud lamentations of the fer¬ vant, bewailing his own misfortune in loling his mailer in a country fo remote from his own, feemed to recal me to life. I felt as if refreihed with a little lleep, and got out the words bark and wine ; it was inllantly brought, and the man gave me two large tea-fpoonfuls, in a large glafs of claret. The effedt was in- llantaneous, and operated like a charm ; the coldnefs left me, I could fpeak intelligibly, and could move my hands. I told the fer¬ vant to give me a tea fpoonful of the bark every hour, in a glafs of claret. By eight in the morning I had taken lix dofes, and more than half a bottle of claret. I was con- fiderably ftrengthened, and could converfe with Mr. Beaumont, who encouraged me to perfervere in the bark, and treated me with uncommon attention. I had been fadly ne- gledled at BulTorah, but this was amply made up to me by the humane and tender atten¬ tions of Mr. Beaumont, who was a great pre-

deftinarian.

f

I 77 ]

deftinarian, and who never fhunned danger when he felt it a duty to affift a fellow-crea- atiire. He waited upon me like a nurfe, con- foled me under pain and ficknefs, and, when my fever was at its greateft height, he has often held me in his arms, when I wanted to be removed, or my bed fhifted. About this time my legs and thighs became covered with blotches of a dulky brown hue, fome of tliem as broad ^s the palm of the hand, quite dry, and they itched intolerably. At the fame time feveral little boils broke out in different parts of my body, but there was only one, over my eye, which came to fuppuration ; the others, and the eruption on my legs and thighs, all diiappeared.

I continued the bark till twelve o’clock, and then left it off till four, w^hen I topk another dofe. The dreadful fever of the preceding days did not return on this, but I was ftiU extremely ill, had very great difficulty in fpeaking and breathing; a. fwelling alfo in my throat, parched tongue, and unquenchable thirfl. I had not the mofc diftant hope of living. I tried to take fome broth, but the fwelling in my throat prevented my fvvallowing. I paffed a very badmight, with dartings, anxiety, and great

pain

-[ 78 ]

pain over the kidnies, and what little deep I got feemed to make me' worfe 5 I was fatigued with it, and under the conftant dread of fuf- focation 5 towards morning my throat grew worfe, and my thirfl: was exceffive.

1 8th. Left olf the bark, uncertain what I ought to do — no fever, but the fame fymp- toms as the day before — drank a little chicken- broth, which was the only fuftenance I had taken for four days before; great oppreffion and heat in my ftomach and bowels. Mr. Beau¬ mont found out an Armenian, who profeffed phyfic. This man gave me a clyfter, which gave me 'great relief, and a water to drink, famous as a febrifuge among the Berdans ; I drank of it freely, and found much benefit from it. But the moft extraordinary of all the fymptoms I experienced was this, that the third day after the firfl: intermifiion of my fever, one of my teeth, and one of the nails of my hand, came out without the fmalleft pain, only a little fw^lling in the gum, and, on the nail falling off, fome matter flowed from the end of my finger ; I never had had the tooth-ach ; at this time the boil on my eye fuppu rated.

From

[ 79 ]

From the i8th of June to the 5th of J uly, being feventeen days, my fever did not re¬ turn. I recovered ftrength flowly, and could walk a little, fupported by two men. My food was chiefly chicken and veal broth, and about a glafs and a half of Madeira wine a ^day. Yet I had ftill many fymptoms of dif- eafe hanging about me — reftlefs fatiguing nights — great thirfh — bad tafte in my mouth, every thing I took feemed bitter and fait; pains in my back, fldes, and loins, and great difficulty in making water. In this tinie I' palfed much bile, naturally and by clyfter, and' I had a purgative from the Armenian, which weakened me' greatly.

The fprings lifted, as feamen exprefs it, the iff; of July, that is three days before the change. The opinion is univerfal in thofe countries, and alfo in India, particularly Bom¬ bay, where intermittents are prevalent, that the change and full of the moon has an efFecb upon all intermitting difeafes, of which after¬ wards I had many proofs in my own calc. To prevent a relap fe, I took forne decodioa of bark, but in too fmall quantities to anfwer tlic purpofe.

4th

4th July. My water, from being thick and muddy, became quite clear.

The 5th of July, after dinner, I was taken with a flight hot fit, which Continued about two hours, and then went off by copious per- fpiration ; the remaining part of the evening I Was intirely free from fever.

• 6th. I took decodtion of bark — no fever.

7th. At eleven o’clock a regular cold and hot I fit; the former continued three quarters of an hour, the latter two hours. Although much lefs fevere than my former fever, yet I fuffered a good deal from the hot fit. Left off the bark by the advice of the Armenian, who told me that it heated me, and made me worfe. — Much weakened by this day’s illnefs — nor did the perfpiration intirely free me from the fever.

8th: Had a clyfler thrown up, and early in the morning took a draught from the Ar¬ menian,' compofed of fine vinegar, fugar, and a country feed infafed overnight in wa¬ ter. — A flight hot fit, but of fhort conti¬ nuance.

pth. The draught of yeiferday repeated — at ten a regular cold and hot fit,' rather lefs violent than the laft.

6

I

loth.

loth. No fever — tolerably well.

1 1 th. Between eight and nine in the morn¬ ing a cold and hot fit, much more fevere than the laft — great heat/ thirft, and oppref- fion — much weakened. • I now perceived I had got a regular tertian, and determined on the bark, but was prevailed on by the Ar¬ menian not to life it, he promifing to cure me in a day or two. He gave me water-r melon, and his infufion of vinegar and feeds.

1 2th. No fever — find the water-melon to difagree greatly with my ftomach.

1 3th. Had not as yet indulged much hopei of a recovery. I felt ftill, even in thofe days previous to this laft relapfe, many alarming fymptoms of difeafe, which made me appre¬ hend I could not recover ; and this laft attack had again reduced me fo low, that it was evi¬ dent that, unlefs I could get i*emoved from thofe fcorching climates, a very fhort time would put an end to my life. Except in the humanity and goodnefs of Mr. Beaumont, I ' was without a fingle comfor-t or conveniency of life at Buihife. The heat of the \yeather feemed daily to increafe, and the houfe we were in hardly covered us from the diredt rays of the fan. My fervant was taken ill,

G and

[ ]

ftnd appeared to be dying : it was with the greateft pleafure, therefore, I received the accounts this day of the Eagle cruizer having arrived laft night from Bufforah, on her way to Bombay.

At half pall feven o’clock I had a very fe- vere fit — the hot fit was uncommonly violent, and continued about three hours. I was much reduced, and refolved, at all events, to take the bark in powder and in large dofes, and difmifs the Armenian. In this I, was confirmed by Mr. Puget, who informed me that the few furvivors at BulTorah owed their lives intirely to the bark, which had at laft been given in very large dofes.

14th. I took four dofes, or eight tea- fpoonfuls, of powdered bark. It purged me, and carried off a great quantity of black putrid bile. — This evening I was carried in my cott on board the Eagle ; refolved at all events, even if I had been certain of dying in the boat, to leave Bulhire, where I had hardly Ihelter from the fun, and where the heat was fo excellive> that Capt. Alderfon of the Eagle, and two paffengers, were taken ill from it laft night. I got on board very late,

. yet

/

[ 83 ]

yet found myfelf much refreflied from the fea air.

15th. .The fever did not return. — I con¬ tinued to take the bark as yefterday, and found myfelf furprifingly ftrengthened. I perfevered under this courfe till the 3d of Auguft, when the veffel arrived at Mufcat, and I was aftonifhingly recovered for the fhortnefs of the time.

From the 14th of July to the 3d of Au¬ guft I had taken feven ounces of bark ; and as the fever had returned upon me the laft day of the fprings at the preceding change of the moon, two days before this change I in- creafed my daily dofe, and continued in this manner till the 4th, when the fprings being over, and perceiving no fymptoms of fever remaining, I left off the bark intirely. I had generally taken fix tea-fpoonfuls every day.

From the 15 th of July till my arrival at Mufcat, a fea-port on the coaft of Arabia, my recovery was exceedingly rapid. I had a keen appetite, a pretty good digeftion, found refrefliing fleep, and my daily increafe of ftrength was very perceptible. My diet, till this time, had been generally chicken broth,

G 2 rice.

rice, and boiled fowl, light pudding, &c. On leaving off the bark I obferved no parti- ciilar regimen, only abftaining from faked and high- feafened meats, and confining myfelf to three or four glaffes of Madeira. I found that an infulion of prunes, with a fmall quan¬ tity of cream of tartar, was of much fervice to me during the courfe of the bark, as it kept me cool, and my body open. I was fenhbie, at times, during my recovery, of a flight but troublefomie pain under my fifth rib on the right fide, cfpecially when I lay on that fide ; but from feeling and preffing my hand over the region of the liver, and from other circumftances, I had no reafon to fufpe«£l that my liver was affedted ; and as it foon left me, the caufe was probably tri- flino' or accidental.

O

On my leaving Mufeat, a large hoil came upon the hip-bone, the fize of a fmall melon, extending fome way up the fide and down the thigh, with a hard bafis. After arriving at Bombay, wdiich we did in fourteen days, it broke, and in a few^ days healed - up. I fhall only add, that at Bombay I was detained fpur months, before I had an opportunity of preceeding to Europe. In that time T had 9 three

, C 85 ]

three returns of mj ague, but, on taking a few dofes of bark, it left me. Thofe attacks happened at the change of the moon. From Bombay to Europe I had three or four flight fits of the ague ; the worft on our making the coaft 'of South Guinea, at the fettlem.ent of Benguela, where we found the wretched remains of a Fortugueze garrifon, the fur- vivors of a fatal putrid fever, which, as they told us, raged in thofe parts for eighteen months before. The lafl; attack I had was the day we made the Rock of Lifbon, flnce which time I have had no returns of the ague, f although, when the wind continues long at eaft, I 'am fenfible of a tendency to that com¬ plaint.

I flhall now give a brief 'account of the fate of my fellow-fufferers at* Bufforah. This unfortunate party conflfted of Capt. Sheriff, of the Eagle cruifer ; Mr. Brown, a Bengal merchant, carrying goods from India to Alep-

t

po ; Mr. Palmer, a gentleman returning with his fortune from Bengal to Europe ; Mr. Rob- fon, furgeon to the factory \ Mr. Abraham, the vice-conful ; Dr. Rofs, who had pradtifed many years at Conftantinople, fome time in Bengal, and' was then taking the opportunity * G j of

[ 86 }

cf accompanying me acrofs the defart ; Mr. Smith, a merchant from India; and an Italian Carmelite, the vicar of Bufforah, who came from Bombay. It is unneceffary to fay, that the feea dab is a common fymptom in the Turkiih fever, or, in other words, a ftrong defire of felf-deftrudiion. We had a fatal in- fiance of it in our party. Mr. Brown, the fecond day of his fever, being left alone, got to his piflols, and, throwing in four or five balls, difcharged it into his bread:, and was found dead a few minutes afterwards. I be¬ lieve every one of us at times would have done the fame, had we been poflbfled of the means of accomplifhing it. Mr. Robfon died the third day of his fever in great agonies, but perfectly fenfible ; his was a continued high fever, without any remiffion. Mr. Palmer died the fourth day under the fame fymptoms as the preceding. The Carmelite, the fecond morning after he was taken ill, had opened a vein in his arm, and bled to death, mofl probably intentionally. Captain Sheriff was feized with the fever on his return from Buf¬ forah to Bufhire. He died on the third day in a manner which is even painful to relate. He was a man of Angular ftrength of confti-

tution.

[ 87 i

tution, and fufFered unufual agonies before he died. His cries were heard all over the fac¬ tor)^ ; he foamed at the mouth, gnaflied his teeth, and tore his arms with his teeth. Thofe who heard him compared his cries to the bellowing of a mad bull. He was no fooner dead but his body was covered with purple fpots, and fo offenfive that the people could hardly carry it out to be buried. Mr. Sheriff's was what they call the worft kind of plague.

Mr. - whom I have mentioned,

was an uncommon charad:er. He was fhut up in a mud houfe at Bufforah during the great plague in 1773, which he efcaped. He had fortunately a large ftock of Bengal cotton goods with him, which he difpofed of to the inhabitants to wrap their dead in. They ufed to depofit the price in a bailee t, which by means of a long rope he let down, which was then hauled up, and lowered again with the cloth purchafed. He had an account of 70,000 winding-fheets which he fold during the calamity. This fad: was attefled by Mr. Abraham and the conful. He was a well in¬ formed fenfible man, and an excellent linguift. On his voyage to Bufforah he was feizedwith

G 4 a fpecies

[ §8 ]

a fpecies of infanity : he fufpected the captairi and fupercargo of his fhip to have confpired his death, and he fancied he overheard their

• f

deliberations on the fubjedl : he always flept ^vith piflols in his cott, and refufed all man¬ ner of communication with his confpirators, as he called them. He then imagined him- felf poffeffed of the fingular faculty of over¬ hearing, by the peculiar confcrudtion of his ears, the moft diftant w^hifper to his preju¬ dice. Although fuch an idea was abfurd, yet

he could argue upon it with a great deal of

*

ingenuity. In all other refpedts he was per- feftly reafonable, and converfed on every other fubjedl with much good fenfe and propriety. On the breaking out of this ficknefs at Buffo- rah he Ihut himfelf up in the upper room of an Armenian's houfe, and had no intercourfe whatever v/ith the other Europeans. It was riot known how he exifted ; he, however, efcaped the infedlion. Ele afterwards came , to England, where I have feen him, and he appeared' perfedlly well.

Dr. Rofs', whom I have mentioned, on the firft rumour of the plague put himfelf under a courfe of bark, which he continued taking ill large quantities while I remained at Buffo-

i ■ ■

rah.

' «

[-89 ]

rah. I have fince feen him in England, and he told me that when the illnefs began to abate, he was taken with an intermitting- fe- ver ; that he fled from BufTorah in an* open boat towards Bagdat, but was taken by a party of Arabs, who carried him upon the defart. He contrived to get away from them^ orolTed the defart to Aleppo, and afterwards got to England. , . ^

It was computed that 275,000 died in the town of Buiforah of the plague of 1773? and that 25,000 died in the town and neighbour¬ hood of this lait plague. We heard of its approach from Afia Minor ; it ravaged Diar^ bekir, antient Aflyria, and kept the courfe of the river Tygris to Bagdat, where many died. From thence it followed the courfe of the Euphrates to BuflTorah, and for about twenty miles lower. The oppofite, or Perfian fhore, although within a few miles, was exempted ; nor did it fpread more than a few miles inio the defart.

The firfl: fymptoms of this fever, or plague, are generally fwelling of the tongue, a violent head-ach, bleeding at the nofe, pains all over the body, a conllant inclination to make wa¬ ter, which comes in drops, and attended with

great

^ •

[ 90 1

great pain, and is as high-coloured as blood ; (if the urine, on ftanding, becomes purple, it is faid to be a certain fign of death) extreme heat, great apprehenfion, all objed:s appear¬ ing of a yellow colour, uncommon terror, and at the fame time a great defire for death ; there are alfo boils or eruptions on the Ikin, which moft commonly appear either jufi: be¬ fore the dif^afe proves fatal, or the patient be¬ gins to recover.

[ 9» ]

VI. On the Want of a Pericardium in the^ Human Body. By Matthew M.D. F.R.S. and Phyfcian to St. George's Hofpital. Read Dec. i6, 1788^

It is of importance to afcertain, any devia¬ tion from the ordinary ftrucflure of animals, becaufe it either affifts in explaining fomo circumftance in the animal oeconomy, or tends to give a more accurate view of nature. This, however, is not equally the cafe with every deviation ^ but it is of more confequence to afeertain it in proportion as it may be rare, as doubts may have arifen with regard to it, or as it may be more connedled with any great operation of an animal body. In which ever of thefe lights we confider the lingular phae-* nomenon of a want of pericardium, it is very, worthy of being noted.

This is one of the deviations -from the or¬ dinary ftrufture of an animal in which nature has been moll fparing; "very few anatomifts. have had an opportunity of obferving it, and the defeription which thofe few have given

4 has

[ 92 ]

lias been very imperfe6t The appearance alfo of an adhefion of the pericardium to the heart might be miftaken for a want of this 'membrane altogether ; and hence the bell: ’modern anatomifts have confidered this lufiis as never having taken place. Even Haller, who was by no means difpofed to be incre¬ dulous, has denied its exiftence. An opinion thus taking its origin from the authority of the moft eminent anatomifts, had at length fpread into a general belief that the want of a

pericardium

* I have met with the following inftances of a want of peri¬ cardium being obferved by different anatomifts.

** Difcipulum item in Romana Academia mortuum fecur faderat excellens Medicus Alex. Trajanus Petronius, a eivitatc Caftellana^ acris judicii vir) huic mifero juveni pericardium de craf, itaque fubinde in fyncopen incidebat, fubinde mortuo ftmilis confpiciebatur, quo genere morbi exan;matus eft,” — > Reald. Columb, Lib. xv. p. 265.

Cor pericardio plane denudatum quod & femel Columbo obfervatum. Dextra auricula circa venae arteriofae orificiuna aneuryfmatis modo ultra juglandis magnitudinem diftenta erat.”' Vid, Barthol. Centur. iv. Hiftor. 20. p. 266.

. Monf. Lhtre.a trouve dans une femme de 54 ans le coeur fans pericarde & enferme abfolument a nud dans la cavite de la poitrine. II etoit fee dur c^unc furface inegale, raboteufe, il :ivoit peu de graiffe & une graiffe peu onftueufe. On voit affez par ce qffil y avoit d’extraordinaire dans ce coeur a quoi doit fervir le pericarde, &c.” — Memoires de PAcademc Royale, .

P-37-

“ II

V

X.

[ 93 ]

pericardium had never occurred in the human body. It will appear, however, that this ge¬ neral opinion has been taken up too haftily, and that fuch a lufus does fometimes happen.

Upon opening into the cavity of the cheft in a m.an about forty years of age, in order to explain at ledlure the fituation of the thoracic vifcera, I was exceedingly furprized to fee the naked heart lying on the left fide of the cheft, and could fcarcely at firfl be-

“ II naquit a Grenoble un foetus monftrueux mort mais qui fa mere avoir fenti remiier peu de terns avant fa nailfance,’^ &c.

‘‘ Celui la (fcilicet le Foetus) portoit f®n coeur en dehors pendu a fon col comme une medaille de forte qu’il pouvoit aller & venir fur la poitrine. Ce cceur etoit d’une conformation naturelle fans pericarde, attache a fes gros vaiffeaux qui lui tenoient lieu de cordons & qui etoient a decouvert comme lui. M. de Vau- bonnais envoya cette relation a M. Parent bien atteftee par des medicins & des chirurgiens de Grenoble.’' — Id, p. 39.

“ Qu’il (fcilicet le Coeur) puiife etre fans pericarde jel’ai vu dans un chien fort vigoureux, mais je fuis ici un temoin recu- fable, mes amis f^avent pourtant qUe j’ay de la bonne fai par excez & que je fuis fincere dans le chofes mefme ou mon interet m’obligeroit de dilfimuler.”— Difcours iv. p. iii, 112. Paris 1685.

“ In fine, I have obferved in a new-born female infant the heart without a pericardium, and turned upfide down, fo that its bafis, with all its veflels, had fallen down as low as the navel, and its apex, ftill on the left fide, lay hid betwee^ji the tw'o lungs, ^ Philofoph. Tranfa<flions, An. 1740 — 1741. N®46j,

Ueve

[ 94 ]

Iieve wKat I faw, but the circumftances were too ftriking to keep me long in doubt. The heart was 9S bare and diftinft as it commonly appears in opening into the cavity of the peri¬ cardium, and eveiy collateral circumftance confirmed the fadl*

The mediaftinum confifled, as in common cafes, of two laminae of pleura ; but it was fomewhat changed in its direition, being in¬ clined to the right fide of the cheft, and ly¬ ing upon, the right of the heart. Both la¬ minae were connefted together through the extent of the mediaftinum by the common intervention of the cellular membrane, and croflTed over the vena cava fuperior about an inch above its entrance into the auricle. The heart lay loofe in the left cavity of the cheft, unconnefted in any way except by its veflTels ; was of a large fize, elongated in its fhape, and had its apex oppofite to the eighth rib. The right auricle was obvioully in view in the fame manner as when the pericardium has been opened, and the vena cava fuperior and inferior were clearly obferved entering into it. The appendage of the left auricle was as clearly in view ; and when the heart was inverted, fo as to have its apex turned

upwards.

[ 95 3

Upwards, the extent of its cavity was feen^ with the two pulmonary veins of the left fide entering behind the appendage. The right and left ventricles were diftind:, with the coro¬ nary vefiels running upon them ; and the aorta and pulmonary artery were feen clearly emerging from them.

The heart was involved in the refledion of the pleura belonging to the left fide of the cheft, which became its immediate covering, and, upon making the llightefl: incifion into the fubftance of the heart, its rnufcular ftruc- ture was laid bare, as in any common heart deprived of its pericardium. There was no connedion between the heart and the dia¬ phragm, but they were entirely feparate; and the diaphragm oppofite to the flattened part of the heart was covered only by a refledion of the pleura. It is well known, that, in ordinary cafes, a portion of the pericardium adheres firmly to the diaphragm, which forms a medium of connedion between it and the heart. In adhefions, too, of the pericardium to the heart, its attachment to the diaphragm is always the fame as in the ordinaiy healthy ftrudurc of thefe parts.

The

t

{ 96 ]

Th6 apex of the heart being lower dowii than ufual, there was a deficiency of the left lung correfporiding to this change of fitua-^ tion.

The phrenic nerv^ of the tight fide ran between the two lathing of the mediaflinum, near that edge of it which was applied to the right fide of the heart. The left phrenic fterve ran between the fame two laminas of the mediaflinum, almofl immediately under the flernum. This is a great deviation from its natural courfe, for it commonly paffes on the outfide of the pericardium, following the ob^ liquity of the left edge of the heart.

All thefe circumflances were feen upon limply removing the flernum with a fmall portion of the ribs, and therefore put the want of pericardium in this fubjedl beyond all doubt. '

In the adhefion of the pericardiurrl to the heart, the diredlion of the mediaflinum can¬ not be altered, the heart cannot be feen ly¬ ing loofely in the cavity of the chefl, uncon-^ nedted with the diaphragm, the appearance of its feveral cavities and veiTels cannot be diflindl, nor can any of the other circum-^ fiances take place which we have mentioned.

Did

[ 97 ]

_ ^

Did the afcertaining of this fingular lufus* naturae require any other evidence than the defcription which we have given, it would happen to be fupported by a very large tefti- mony, for it has been feen by many medical gentlemen in this metropolis, who are emi¬ nently {killed in anatomy, and by a great number of ftudents, who are veiy capable of judging.

In this lufus we may remark, that the mediaftinum paffed fomewhat to the right, fo that the heart was intirely in the left ca¬ vity of the' cheft. Upon a little refledlion we fliould fuppofe that this would happen. Had the mediaftinum been joined to the body of the heart, it would have been difturbed in its fundlion, from being confined by a tight cord to the fternum. To avoid this incon¬ venience, the mediaftinum was fituated a lit¬ tle more to the right, and the heart a little - more to the left, than common.

The right phrenic nerve pafled very natu¬ rally between the laminae of the mediaftinum, for this was nearly its ufual courfe j but that of the left phrenic nerve was necefiarily much changed. It could not pafs over the body of the heart, or of the lungs, which were each

H of

[ 98 ]

<bf them to be in conilant motion ; it had therefore to feek for fonie fixed channel, and the only one was in the mediaftinum. Ac¬ cordingly it was found, as defcribcd, between the two lamina? of the mediaftinum, almoft immediately behind the fternum.

It was natural to fuppofe, as there is a de- ' ficiency of the lungs in ordinary cafes, oppo- fite to the apex of the heart, that where the

apex of the heart was altered in its fituation,

^ •

there fliould be a change in the fituation of the deficiency in the lungs correfponding to it.

It may be a queftipn, how far the increafed bulk and elongated fhape of the heart, in this particular inftance, depended on a want of the pericardium ? It might be fuppofed that the heart, being free from its ufual reftraint, had grown beyond its common limit. This, I think, however, will appear, after a little re¬ flexion, not to have been the cafe. The heart, under the common circumllances, is originally inclofed in a pericardium which grows along with it, and the increafe of growth keeps 'pace in each. If, then, there fhould be at any tme a difpofition to form a large iheart, there is alfo formed a large pericardium to

contain

I

[ 99 ]

contain it ; or if the heart be fmall, there is proportionably a fmall pericardium. If it be ftill faid, that the pericardium tends to limit the growth of the heart, a queftion na¬ turally arifes, What checks the growth of the

/

pericardium? Is it a principle within itfelf? Why fliculd not the heart be poffelTed of the fame principle ? I confider, therefore, the increafed bulk and elongated fliape' of the heart, in this particular inflance, as an acci¬ dental circumftance, and by no means de¬ pending on a want of the pericardium.

From the want of a pericardium' in an. adult who had arrived at the middle period of life, it is reafonable to think that its ufe is not very effential. One ufe which has been attributed to the pericardium is, the fecretion of a liquor to lubricate the furface of the heart for its eafy motion. This fort of rea- foning would appear a priori to be ill founded. It is is impoffible to fee how a bag like the pericardium, or any other bag, fhould be pe¬ culiarly fitted for this purpofe. The furface of the heart itfelf, and of the lungs, might have had a power of fecretion ; and accord¬ ingly we find in this particular fubjecS a fluid fuppjied by them for lubricating the heart

H 2 without

I

r

t lOO ]

without a pericardium. This account of the ufe of the -pericardium was very unfatisfactory to the mind of Haller, and upon the grounds we have mentioned.

The more ftriking ufe of a pericardium is to keep the heart in a fteady fit nation, fo as to enable it to carry on its fundion uniformly. This one is more difpofed to confider as its ufe from its being a very ftrong membrane, capable of bearing a good deal of reiiftance ; and from its being firmly attached to the tendinous portion of the diaphragm, which preferves always nearly the fame fituation. If we refled, however, a little, we fhall perceive, that 'a heart without a pericardium is not really left loofe in the cavity of the cheft, but is confined in a great meafure by the parts being exadly adapted to each other, and completely filling up that cavity. The heart may in this manner be fufficiently confined to perform its fundion, although it cannot be fo fteadily maintained in the fame fituation, as when enclofed in its pericardium.

/ Such are the circumftances which prefent themfelves to the mind as matter of reafon- ina in the cafe before us ; but I was anxious to learn fomething of the hiftory of the per-

fon

[ loi 3

fon during life, becaufe it appeared not unlikely that it might throw light upon the fubjed:. My inquiries, however, have been without effedl. I cannot find that anjf particular obfervatioa had been made upon the pulfe by the phyficians who attended him. It is not fair to conclude from thence, that the adiion of the heart is exadly the fame whether it be inclofed or not in its pro¬ per membrane ; but it is furely enough to fhew that the adtion is not very much affed:- ed by the want of it. The different confi- derations which have been mentioned above, will ferve, I hope, in fome meafure to explain this effed:, and to point out how the circu-* lation may be carried on, even for a very long period, under thefe particular circumftances.

H 3 Expla-

I

1

[; 102 ]

I

Explanation of Plate II.

The fternum broken ofr at the joint be-

tween its firft and fecond bone.

\

B. .The mediaftirmm diredled a good deal towards the right fide of the cheft, and confifting evidently of two la¬ minae of pleura.

CC. The edges of the diaphragm, which, together with the lower end of the mediaftinum, v/as pulled upwards at the time the drawing was made, in , I order to give a more diftindt view of the left fide of the chefi:.

D. The heart fee n naked, as it appeared

upon fimply raifing the fternum. — The two ventricles, the right auricle, the aorta, the pulmonary artery, and the vena cava fuperior, are feen dif- tindtly.

E. The lung of the left fide collapfed.

F. The fpace between the heart and diaph¬

ragm, ftiewing that there was no con¬ nexion between them.

Gi A porti^on of the lung on the right fide feen collapfed. ^

VII. On

[ 103 J

VII. On Introsusception. By John Hunter, Efq. F. R. S. Surgeon Extra-- ordinary to, the Kmgy and Surgeon General to the Arfiiy^ Read Augujl i8, 1789.

Introsusception is a difeafe produced by the paffing of one portion of an inteiline into another, and it is commonly, I believe, from the upper paffing into the lower part.

If the mode of accounting for introfufcep- tion, which I am going to offer, .be juft, it will moft frequently happen in the way I have ftated, although there is no reafon why it may not take place in a contrary diredlion ; in which cafe, the chance of a cure will be in- creafed by the natural adlions of the intefti- nal canal tending to replace the inteftine ; and probably from this circumftance it may' oftener occur than commonly appears.

When the introfufception is downwards it may be called progreffive, and when it hap¬ pens upwards, retrograde. The manner in which it may take place is, by one portion of

H 4 ' a loofc

[ 104 1

a loofe inteftine being contra6led, and the part immediately belov/ relaxed and dilated ; un¬ der which circumftances it might very readily happen, by the contraded portion flipping a ' little way into that which is dilated, not from any aftion in either portion of inteftine, but from fome additional weight in the gut above. How far the periftaltic motion, by pufhing the contents on to the contracted parts, -may force that into the relaxed, I will not deter¬ mine, but fhould rather fuppofe that it would not.

By this mode of accounting for an acciden¬ tal introfufception, it may take place either upwards or downwards ; but if a continuance or an increafe of it arifes from the aCtion of the inteftine, it muft be when it is down¬ wards, as we actually find to be the cafe ; yet this does not explain thofe in which a con- fiderable portion of inteftine appears to have been carried into the gut below : to undei*-^ ftand thefe, we muft confider the different parts which form the introfufception. It is made up of three folds of inteftine ; the in¬ ner, which pafies down, and being reflected upwards, forms the fecond or inverted por¬ tion, which being reflected down again, makes

the

1

[ 105 ]

the third or containing part, that is the outer- moft, which is always in the natural pofition.

The outward fold is the only one which is a6live, the inverted portion being perfedlly paflive, and fqueezed down by the outer, which inverts more of itfelf, fo that the angle of invertion in this cafe is always at the angle of refle(5lion of the outer into the middle por¬ tion or inverted one, while the innermoft is drawn in. From this we can readily fee how an introfufception, once begun, may have any \ length of gut drawn in.

The external portion acting upon the other folds in the fame way as upon any extraneous matter, will, by its periftaltic motion, urge them further ; and, if any extraneous fub- flance is detained in the cavity of the inner portion, that part will become a fixed point for the outer or containing inteftine to >ad: upon. Thus it will be fqueezed on, till at laft the mefertery preventing more of the in¬ nermoft part from being drawn in, will adl as a kind of ftay, yet without intirely hindering the inverted outer fold from going ftill further.

For it being tie middle fold that is ad:ed up¬ on by the outer, and this adlion continuing after the inner portion becomes fixed, the gut

AS

[ io6 ]

is thrown into folds upon itfelf; fo that a foot in length of inteftine lliail form an introfuf- ceptlon of not more than three inches long.

The diffe rent appearances which I have de- feribed as taking place in an introfufeeption, are diftindtly feen in the annexed plate, in which the different folds of inteftine are expofed.

I have afferted that the outer portion of inteftine was alone adlive in augmenting the difeafe when once begun ^ but if the inner one was capable of equal ad:ion in its natural direction, the effed would be the fame, that of endeavouring to invert itfelf, 'as in a pro- lapfus ani ; the outer and inner portioits, by their adion, would tend to draw in more of the gut, while the intermediate part only would, by its adion, have a contrary ten¬ dency.

The adion of the abdominal mufcles can¬ not affifl: in either forming, or continuing this difeafe, as it muft comprefs equally both above and below, although it is capable of produc¬ ing the prolapfus ani.

In cafes where introfufeeption begins at the valve of the colon, and nverts that in- tefline, we find the ilium is not at all affeded ;

4 which

I

[ ]

i

M'hich proves that the mefentery, by ading as a ftay, prevents its inverfion.

f'rom the natiiral attachment of the me¬ fentery to the inteftines, one vv^ould, at the

firfc view of the fubjed:, conceive it impof-

0

fible for any one portion of gut to get far within another ; as the greater extent of me¬ fentery that is carried in along with it would render its further entrance more and more difficult, and we ihould expedt.this difficulty to be greater in the large inteflines than in the fmall, as being more clofely confined to their fituation ^ yet the largefi: introfufception of any known was in the colon, as related by Mr. Whately*.

t

The introfufception appeared to have be¬ gun at 'the infertion of thedlium into the co¬ lon, and to have carried in the caecum with ' its appendix* The ilium pafied on into the colon, till the whole of the afcending colon, the tranfverfe arch, and defcending colon, were carried into the figmoide flexure and redlum* The valve of the colon being the leading part, it at lafl; got as low as the anus ; and when the perfon went to flool he only ernptied the ilium, for one half of the large

* Vid. Philof. Tranf. Vol. Ixxvi. page 305.

inteflines

f

[ io8 ]•

%

inteftines being filled up by the other,, the ilium alone, which paffed through the center, difcharged its contents.

Since that time the following cafe has oc¬ curred, which is in many refpedls fimilar; the patient was attended by Dr. Afli, and the body infpedted after death by Mr. Home. A. B. aged nine months, a large healthy well-looking child, who, as far as appeared, had never been indifpofed from his birth, was feized with a ftrong fpafm, ftretching himfelf out fuddenly, without having had any fymp- toms of previous ailment. Either during the fpafm, or immediately after it, he paffed a very large loofe ftool, and after that difcharged, at intervals, fmall quantities of mucous flime, covered over with little fpecks of recent fluid blood. Dr. Afh vifited him four or five hours after this attack, and found him in all other refpeds perfectly well ; the child fucked hear¬ tily, but Dr. Afh, on obferving his pulfe to be lefs quick than is ufual in children fo young, his heat to be rather below the common flan- dard, and, added to thefe, the fmall mucous and bloody difcharges, ffifpedled that morti¬ fication had taken place in the bowels, with¬ out being able to guefs at the caufe, as the

child

I 109 ] •

child had laboured under no previous indif- pofitlon. In this uncertain fituation, various _ineans of relief were attempted by purgatives, ibmentations, the warm bath, and different kind of clyfters, but without any good effed:. On his firft examination of the abdomen he felt (or thought he felt) a deep-feated fullnefs or hardnefs under the left hypochondrium ; blifters were applied to the part, and every pof- fible means attempted, without obtaining any evacuation by ftool, or any other apparent re¬ lief s his ftrength gradually funk, and his pulfe became gradually weaker, although he con¬ tinued to take the bread: eagerly till within a few hours of his death, which happened juft fixty hours after the firft fpafmodic attack.

The following were the appearances found in the dead body. Upon opening the abdomen, the fmall inteflines confiderably diftended with fluid contents, occupied fo much of the ca¬ vity as to prevent any of the other vifcera from being feen; and the mefenteiy was fo much confined, that the convolutions of the fmall inteflines could not be readily followed. This confinement was found to arife from an, introfufception of the ilium and its mefentery, together with the caecum, and afcending co-

loa

[ no j

Ion into the defcending part of the figmoide flexure of the colon, the inefentery of the ili¬ um being drawn up fo obliquely acrofs the root of the mefentery, as to prevent the je¬ junum from having its ufual freedom of at¬ tachment.

The only part of the colon which could be

i

feen was the figmoide flexure, in which was diftinclly to be felt a hard fubflance, confift- ing of the ilium and inverted colon. Thefe parts being removed, for the purpofe of a more accurate infpeclion of them, the fig¬ moide flexure of the colon was laid open, and was difcovered to contain the caecum, and co- ‘ Ion in an inverted ftate. The internal fur- face of thefe, when, expofed, were found to have put on a dark red appearance, approach¬ ing to black ; the whole appearing like a folid fubflance, rounded at the end, hanging loofe into the defcending colon, and about four inches long. Upon dividing the inverted co¬ lon, the ilium and appendix casci were feen lying clofe to each other, and their two openings found on the rounded end of the inverted co¬ lon, leading direftly into the figmoide flexure; the portion of the ilium was a little twilled, but not in the leafl corrugated, it was rather

' flretched

/

[ III ]

ftretched, and much prefled agalnfl the ap¬ pendix casci and its own mefentery, by the furrounding colon, and a convolution of the appendix near the termination was fo much preffed againft the ilium as to make a mark upon it, and probably had compreffed its fides fo as to prevent any thing from paffing. The portion of ilium was about four inches long.

The inverted colon had drawn in the mefo- colon, and a portion of the omentum that was attached to the tranfverfe arch. The portion, of the colon near the valve, which formed the extremity of the inverted part, was much thickened in its fubftance by the eftedls of inflammation, being four or five times its na¬ tural thicknefs ; it was a ’srood deal corru- gated, or folded upon itfelf, the folds at this part feemed to adhere to one another, and form one mafs. The inflammation and thick¬ ening only extending two inches, the gut be¬ coming gradually thinner till it was of its na¬ tural thicknefs and appearance ; fo that what was only four inches in length of introfuf- ception, contained a confiderably greater length of inteftine.

The figmoide flexure, which was the con¬ taining inteftine, had the natural appearance,

but

[ II2 ]

9

but was dilated or relaxed, and the other con¬ tents of the abdomen were in a natural ftate, nor had the child any other apparent difeafe. A reprefentation of the parts is annexed.

From the account I have given of intro- fufception,' it does not fcem probable that it fhould be of the retrograde kind, unlefs from an inveriion of the periftaltic motion, which could only continue for a fhort time, and the natural motion being reftored, a cure would probably be performed.

This difeafe happens moft frequently in the firft fifteen years of life, not occurring fo commonly in older people, neither does it, I believe, ever take place in the colon itfelf, although we find that gut affecfted by it An introfufception can never be perfedlly known till after death ; but where there are violent affedtions of the bowels, attended with conftipation, we have reafon, .from the cafes

,v

* A prolapfus ani is, in fome refpeds, fimilar to an intro¬ fufception, and may poflibly begin in the fame way, but is con¬ tinued by the adion of the abdominal mufcles, never by the ac¬ tion of the gut itfelf. It differs from introfufception as not be¬ ing contained in a gut; for, inftead of having an inclofing gut inverting itfelf by its own adion, there is an inclofed gut pro¬ truded by the adion of the abdominal mufcles, and the paffing of the faeces through it, and the point of inverfion is at the extremity of tlie protrufion, and as it inverts it pulhes out of the body.

which

[ ”3 ].

which have been examined in the dead body, to fuppofe that this difeafe may be the caufe of them : there are, however, fo many other difeafes which produce the fame fymptoms, that nothing can be afcertained. But if an introfufception is fufpefted, it will be proper, in the mode of treatment^ to fuppofe it to be of the progreflive kind*

In the treatment of this difeafe various me¬ thods have been propofed ; bleeding, to lelTeri the inflammation that might be brought on, and quickfilver to remove the caufe, are the moft obvious, and the means that are ufually recommended*

Quickfilver would have little effedt either in one way or the other, if the introfufeep- tion was downward ; for it is to be fuppofed that it would eafily make its way through the innermoft contained gut, and, if it fliould be flopped in its paflage, it 'would, by increafing its fize, become a caufe (as before obferved) of ,afrifl:mg the difeafe. In cafes of the retro¬ grade kind, quickfilver, aflfifted by the peri- ftaltic motion, might be expeded to prefs the

r

introfufception back ; but even under fuch circumftances it might get between the con¬ taining and inverted gut into the angle of re-

I fledion.

[ “4 3

fle(5llon, and, by pufliing it further on^ In- creafe the difeafe it is intended to cure.

From the account I have given of the manner in which it is produced, I fhould propofe the following treatment in cafes of progreffive introfufception.

Every thing that can increafe the aftion of the inteftine downwards is to be particularly avoided, as tending to increafe the periftaltic motion of the outer containing gut,, and thus to continue the difeafe. Medicine can never come in contadl with the outer fold, and, hav-^ ing paffed the inner, can only aft on the outer below, therefore cannot immediately affeft that portion of the outer which contains the introfufeeption ; but we mufl: fuppofe that whatever affefts, or comes in contaft with the larger portion of the canal, fo as to throw it into aftion, will alfo affeft by fympathy any part that may efcape fuch application, t fhould therefore advife giving vomits, with a view to invert the periftaltic motion of the containing gut, which will have a tendency to bring the inteftines into their natural fit nation.

If this praftice fhould not fucceed, It might be proper to epnfider it as a retrograde

intro-

5

[ ”5 ]

introfufception, and, by adminiftering purges, endeavour to increafe the perijftaltic motion downwards.

t

SUPPLEMENT to the Paper upo?% Introsusception. By Mr. Home.

t

The following cafe of introfufception up¬ wards has been communicated to me by the late Mr. Smith, furgeon at Briftol ; in whofe colleftion of morbid preparations I favv the parts which had been removed from the dead body, and preferved in fpirits. That the in¬ trofufception was upwards, is fufhciently af- certained from the preparation, r

The particulars of the cafe, as far as they came to the knowledge of Mr. Smith, who examined the body after death, were as fol¬ low :

A cabin-boy belonging to one of the fliips lying in Briftol harbour, was corredted by his mafter for fome mifcondudt, at which the boy was very much exafperated, and, in the heat of his paflion, fwallowed fome arfenic, which had been laid in different parts of the

I 2 (hip

[ ii6 ]

ihip to poifon rats* He was attacked with vio¬ lent pain in the ilomach and inteftines, at¬ tended with exceflive vomiting, and expired be¬ fore any medical afiidance could be procured.

Upon infpedion of the body, the internal furface of the ftomach was found inflamed to a very great degree, the inflammation extending a confiderable way along the tradl of the fmall inteftines, and in the ilium there was dlfco- Vered an introfufception of above two inches long, formed by a portion of the lower part of the gut having been inverted, and puflied into that immediately above it.

On flitting up the inteftine, to examine the introfufception more accurately, a long round worm was found coiled round the projedling introfufcepted part, and is preferved in that fituation in the preparation.

The circurhftances under which the round worm vvas found, determines the kind of in¬ trofufception, lince I have obferved that Ipe- cies of worm more commonly in the upper portion of the fmall inteftines, in which fitua- tion having been difturbed by the efted:s of the aiienic, it had confequently moved, to get at a greater diftance from the poifon. It is likewdfe probable, from the coming on of I inflam-

* .

{ ”7 ]

inflammation, that vomiting, an immediate cifect of the poifon, by which the pefiftaltic motion was inverted, and the introfufeeption produced, had been followed by a contrary aftion, or difpofition to purging, by which the worm being hurried along till it came to the introfufeepted part, was there flopped, and, in the endeavour to extricate itfelf, had .twined round the projecting part, in which fituation it died. If the introfufeeption had been downwards, the worm could not have been in that fituation.

It is probable, that if the boy had outlived the immediate effedts of the arfenic, and the periflaltic motion had perfectly recovered it¬ felf, the introfufeeption would have been by that means' unfolded.

Expla

[ ii8 ]

Explanation of Plate III.

I

a. The ilium paffing into the introfufcep- tion.

The portion of the ilium included in the introfufception.

The termination of the ilium in the valve of the colon j from which a bougie paffes, into the inteftine.

d. The orifice of the appendix cxci with a briftle introduced into it.

• ‘e

e e. The courfe and termination of the ap¬ pendix casci.

f ff The inverted or contained portion of the colon, the inner furface of which has portions of coagulable lymph ad¬ hering to it, the confequence of pre¬ vious inflammation.

g g The containing colon laid open, to expofe the introfufception. Upon its external furface are the appendiculae epiploicae.

VIIL

[ ”9 ]

VI I L Of uncommon Appearances of Difeafe in Blood^vefels, By Matthew Bail lie, M.D. F.R.S. and Phyjician to St. George's HofpitaL Read Septe?nber 15, 17S9.

It is of confequence to remark fingular appearances of difeafe in the body, even if they fhould not obvioufly lead to any ufefui obfervations in practice ; becaufe they open a more extended view of the operations of the animal oeconomy, point out more clearly the . refources of nature, and render the invention of the mind more generally fitted to affift, when her efforts would otherwise be inef- fedlual. It is in this point of view that I think the following remarks upon fome un¬ common appearances of difeafe in blood-vef- fels, may not altogether be unworthy of no¬ tice. Two of the appearances which I fiiali defcribe are certainly very rare, and the other by no means common.

It is known to every perfon who is ac¬ quainted with the animal ceconomy and pa¬ thology, that the blood coagulates, under cer¬ tain circumftances, in the veffels of the living

■ s

body. One cafe in which it coagulates is,

I 4 when

[ 120 J

when a ligature has been made upon a veffcl, and the blood is prevented from flowing thro’ it at that part, as in the artery of an ampu^ tated limb. Another c^fe in which it coagu¬ lates is, when a veflel is dilated at any part into a fort of bag, fo that the blood there moves flowly, and as it were out of the courfe of the circulation. The coagulum begins to be formed at the greatefl: diftance from the current of blood ; or, in other words, clofe to the fides of the dilated bag at the greatefl dif¬ tance from the cylindrical cavity of the artery. It is very rare that a coagulum is formed in an aneuryfmal artery, until it is confiderably en¬ larged beyond its ordinary fize, and the blood is a good deal removed from its natural courfe of circulation. It is flill more rare that the coagulum fills up the whole cavity in which it is formed, fo as to prevent the circulation al¬ together through that part pf the veflel. Were this lafl; circumflance often to take place, it would frequently become the natural cure of aneuryfm, and fuperfede the very painful means pf a doubtful operation. It fometimes hap¬ pens, however, that nature deviates frpm the ordinary courfe of difeafed operation,* and forms a coagulum fo complete, as to fill up entirely the cavity in which it takes place,

without

C I2I 3

without there having been any previous ftop- page to the circulation by a veffel being ren¬ dered impervious, and where a veflel is not much enlarged beyond its ordinary fize. I had an opportunity of obferving this in the ca¬ rotid artery of a man, who was brought, about two winters ago, to Windmill-ftreet for dif- feftion. The whole of the arterial fyftem in this man had a tendency to aneuryfm, the na¬ tural ftru(5ture being in many places changed, and the diameter of the arteries being fome- what enlarged beyond their natural fize. There was, however, no part dilated into a bag or fack, containing a coagulum, except, as I ihall immediately explain, in the carotid arteries,

In the right carotid artery, juft before it divides into the external and internal caro¬ tids, I found an oval uniform fwelling, about an inch and an half in length, and the dia-* meter of the artery was fcarcely enlarged to more than twice its ordinary fize. The fwel¬ ling was firm, giving the fame refiftance to the feeling as a healthy abforbent gland, and, if it had been felt through a thin layer of mufcle, would certainly have been mif- taken for one of a large fize. I mention this pomparifon, to giye a piore diftind: idea of

' the

I

[ 122 ]

the tumor. When I cut through the coats of the artery, I found its cavity completely filled with a firm coagulum of blood, which had not the appearance of blood being re¬ cently coagulated after death, as in the be¬ ginning of the pulmonary artery, but had the appearance of an old aneuryfmal coagulum.

The coagulum adhered every where fp firmly to the in fide of the veffel, that, in fe- parating it, the inner coat was, in many places, peeled off along with the coagulum. In cutting into its fubftance, I found it con- fifting of diftindl layers, as in a commori aneuryfm. There was no part of it which had the appearance of being recently formed, and, therefore, there cannot be any doubt of its having exifled for a Confiderable time be¬ fore the man’s death. It is obvious then, that in this cafe a coagulum had been formed in the carotid artery, undergoing the fame procefs as in aneuryfm, and that the ten¬ dency to aneuryfm had remedied itfelf. The whole cavity being filled up with the coagu¬ lum, there was no circulation whatever at this part ; hence the caufe of further dilata¬ tion was removed, and there was no danger of the rupture of the veflel, which is the principal daiieer in this difeafe.

A fev/

r 123 j

A few cafes only have been related by au¬ thors of aneuryfms being cured without any chirurgical operation, and even fome of thefe have been fufpedted not to be authentic* Two cafes have occurred lately to Mr. Ford, furgeon, defcribed by him in the London Medical Journal, about which there can be no doubt. Mr. Home has offered a very in¬ genious explanation of fuch cafes, founded on obfervations made by Mr. Hunter on the ftate of arteries in mortification, viz. that it is pro^ bable the blood coagulates in the artery above the feat of the aneuryfmal bag, fo as to ren-r der it there impervieus. This explanation, although it accounts fufficiently for the cafe to which it immediately refers, yet is not ap¬ plicable to all cafes where aneuryfrns under¬ go a natural cure. In the one which I have related there was no coagulum of blood forrn- ed except in the dilated part of the artery, no Heps whatever towards mortification had taken place, fo that the natural cure depended entirely on the coagulum fbrmed where the artery was enlarged. The blood here had coagulated much more readily than in pro¬ portion to the dilatation of the artery, fo that the whole cavity was filled up before it had

enlarged

[ 124 3

enlarged to any confiderable fize. Wherever there is a difpohtion in the blood to coagulate greater than in proportion to the enlargement of the artery, the coagulum will at length fill up the whole cavity of the dilated part, and produce a natural cure of aneuryfm* This ftate of the blood, or rather of the co- agulable lymph, may arife from fome con¬ nexion or fympathy it may have with the difeafed ftruXure of the artery, but it is per¬ haps impoflible to determine this with cer¬ tainty.

We may remark, that in the left carotid artery of the fame perfon, exaXly before its divilion into the external and internal carotids^ a dilatation and coagulum were formed s but the dilatation had more the fhape of a com¬ mon aneuryfmal fack, and the coagulum did not entirely fill up the cavity of the veffel. There was only, however, a fmall canal for the current of blood, and I am inclined to think that the whole cavity would very foon have been filled up, fo that on this fide alfo there would have been a natural cure for the aneuryfm. — From the litiiation of the two carotid arteries I fhall juft beg leave to ob- ferve, that it is not improbable a perfon might

live

[ 125 ]

live without circulation through' a part of the main trunks of both carotid arteries, fo' that if it fhould become abfolutely neceffary in

T ^

any chirurgical operation, they might be taken up by ligature. Mr. Hunter, in his Ledtures upon Aneuryfm, has mentioned nearly the fame opinion

OJ' the Obliteration Vessels.

a ■*

It is well known, that under certain cir- cumftances both arteries and veins become changed in their ftrudture, lofing their cavi¬ ties, and degenerating into a fort of fpungy ligamentous fubftance. This happens when it is no longer necelTary that the blood fhould

* This opinion is in fonie m^afnre confirmed by an experi- ment made by Valfalva, where he tied up both carotid arteries of a dog, which lived for two and twenty days afterwards, and might have continued to live, but that he was killed for the pur- pofes of difle^lion. In two othe/ experipients of the fame fort the dog lived a much ftiorter timej in one inftance three days, and in another fix,— Vid. Valfalv. Opera, Cura Morgagni, Epift, xiiU p, 507.

It would require a great many, experiments to afeertain the common event of fuch an operation; but from what has been faid it appears very obvious that it is capable of fucceeding, and it could never be propofed by any perfon of common un- derftanding, except as the oal/ means left pf faring a patient’* life*

circur

circulate in them, as in certain changes in the circulation of an animal at a particular period of life. When a child is born, it is neceffary that the whole blood of the body fhould be carried through the lungs, in order to undergo a change which is intimately con- nedted with life, and that there fliould be no

f

other communication between the blood cir¬ culating in the "pulmonary artery and in the aorta, than through the lungs and the left fide of the heart. Hence the dudus arterio- fus gradually contrads itfelf after the birth of the child, till at length it becomes a fort of ligamentous fubftance without any cavity. The time which is occupied by this procefs is not long, although it varies in different perfons, and in fome few inftances the yelTel has been found in the adult date not entirely obliterated. In proportion as the dudus ar- teriofus contrads itfelf, the two branches of the pulmonaiy artery become enlarged, till at length they are able to convey to the lungs the whole of the blood, which is thrown out

* Although I have mentioned here, and in othef parts of this paper, that blood-veffels degenerate into a fort of ligamentous fubftance, the expreflion is not perfedlly accurate. When theif cavities are obliterated, they refemble a good deal ligament, but they ftill retain many properties of ftrufture which belonged originally to them, efpecially their dafticity.

[ 127 1

>

by the right ventricle of the heart, and in this way the full circulation through the lungs is completed. In the fame manner the umbilical arteries and vein degenerate into . a ligamentous fubftance when all com^ munication between the child and placenta has ceafed, and when the blood is to be thrown in different channels for the growth of the child. It fometimes happens, how¬ ever, (although I believe it to be extremely rare) that there is a procefs of obliteration without any of thefe circumftances, depend¬ ing upon fome difpofition in the velTels, which we cannot explain. — Some years ago a woman was brought to Windmill-ftreet for dilfedlion, in whorn the vena cava inferior was found ta be changed into a ligamentous fubftance, from the entrance of the emulgent veins even to the right auricle of the heart. The cavity here was fo entirely obliterated, as not only to prevent all circulation of blood through this part of the vein, but even in a great meafure to prevent the admiflion of air by in¬ flation. It was in an attempt by Dr. Hunter to inflate the vein from the lower extremity which made this peculiarity be difeovered. The blood being prevented from pafling thro* the vena cava inferior, flowed into the lum^- • : bar

'bar veins, enlarging them gradually as that vein became contradted, till at length they were of a fufficient fize to receive the whole blood which returns by the vena cava. From the communication between the lumbar veins and the vena azygos, the blood paffed into this vein, and was conveyed to the heart. It happened in this particular inftance that there was an additional vena azygos, upon the left fide of the fpine, fo that the blood was con¬ veyed more readily to the heart than if there had been one vena azygos, as in ordinary cafes. The enlarged veins were in fome places thrown into varices, as mull naturally take place under the circumllances we have men¬ tioned. What time was confumed in the obliteration of the vena cava inferior, it is impoffible to fay ; but, if we confider the proCefs as analogous to the obliteration of the dudlus arteriofus, and the umbilical arteries and vein, it could not be long; we ought not, however, to reft a very ftrong opinion upon this analogy^,

t We ought not to reft any ftrong opinion upon this analogy, becaufe it is cafy to fee a reafon why the obliteration of the cavity in the ductus arteriofus and umbilical arteries fhould be a Ihort procefs ; but there is not the fame reafon for its being a (hort procefs in the obliteration of the vena cava inferior, which we have juft deferibed.

This

[ 129 ]

This cafe fhews, that, on fome occafions, a procefs of obliteration takes place in the blood veffels, independent of the natural cir- cumftances formerly explained. It fhews alfo the very great refources of nature, that it can bear the function of the largeft vein in the body to be fufpended without endanger¬ ing the life of the animal ; for it cannot be doubted that the obliteration we have men- ' tioned had no fhare in producing the woman's death. The blood ft ill circulated in the com¬ mon quantity to and ft'om the heart, but at one place it took a circuitous road inftead of a direct one. I think the natural refources of the body in this particular to be fo great, that I fhould not hefitate to believe, if the aorta was to be obliterated in any part of its paf- fage between the origins of the fuperior me- fenteric and inferior mefenteric arteries, that the circulation could be carried on by the communicating branches of thefe two veffels, together with the fmaller aids of the anafto- mofes in the lumbar arteries.

It is reafonable to think, that v/here an ob¬ literation takes place in any artery or vein, there are pretty large collateral veffels ; where there are none, or very few collateral branches, the difticuky of the blood’s being

K ^ impelled

[ 1 30 ]

impelled into other channels, would probably prevent the obliteration from taking place. In the natural obliterations we find; that there are always in the neighbourhood vcfTels of confiderable fize. Thus near the ductus ar— teriofus are the two large branches of the .pulmonary artery; near the umbilical arteries are the large and numerous branches of the internal iliacs ; and near the umbilical vein are the large branches of the vena portarum. In the fame manner, in difeafed obliteration of veflels, the collateral branches mmft be fuf- ficicntly large to carry off the current of blood -f*.

* Morgagni mentions an inftance of the fame fort of oblite¬ ration in veins, and confiders it as extremely lingular.

“ Iliaca igitur vena dextra aequo erat latior, at finiftra ejuf- que rami tenues adeo & pallentes ut rem nunquam antea a me vifara miratus cav^ imum truncum aperuerim. Quo fafto vel magis miratus fum. Nam pro Iliacae ejus venae oftio lineam in- veni ipfius coalitum indicantem, qua in linea duo aut tria parva erant ofcula cum iliaca vena communicantia, Quam cum fecun- dum longitudinem incidiffem & printer filamenta polypofa queii- dam fibrarum quafi fafciculum introrfum exftantem confpexiffem, mox facile animadvert! venae parietes ab uno latere inter fe coa- Juilfe, licque eum fafciculum mentiri cujus fpecies manu utraque parietes diftrahendo, neque enim perdilTi cilis erat fejunftio, pror- fus evanefeebat.” — Vid. Epill. 56. Artie. 10.

f I have had an opportunity alfo of feeing another inftance of obliteration in veins, very fimilar to what I have deferibed, at the Lyceum Medicum Londinenfe.

0

4

In

[ I3I ]

In writing upon this fubjed:, it may be worth while to mention, that I once found a ftricdure in the femoral artery of an adult fub- jecfl, juft under the origin of the arteria cru- ralis profunda. There was a contraftion of the artery fo complete, that at one part the fides were nearly in contaft, but, as far as I could judge, without any difeafed alteration of ftruc- ture. This took place where confiderable branches are given off, by which the blood could be readily conveyed to the femoral ar¬ tery, beyond the place of contraffion. What could be the caufe of this contracftion it is not eafy to imagine ; it certainly did not arife from any mechanical conftriftion, and there¬ fore would feem to depend upon fome adlion in the coats of the vefiel itfelf.

Let us fuppofe that an aneuryfrn had been previoufly formed in the femoral or popli¬ teal artery of this particular limb, what would have been the confequence? Would this con- traflion of the artery near the groin prove a natural cure of the aneuryfrn ? There is cer¬ tainly a great analogy between this natural pjro- cefs of contradtion in the artery, and the ope¬ ration for the aneuryfrn as lately performed by Mr. Hunter. This, in the operation for the popliteal aneuryfrn, confifts in fimply making

K 2 an

[ 132 ]

an incifion upon the femoral artery before It paffes through the tendon of the triceps muf- cle, and taking it up there by a ligature, which promifes to be a great improvement in the art of furgery. There is this difference, how¬ ever, between them, that when a ligature is made upon an artery, the blood is prevented all at once from paffing through it, and it takes a very confiderable time before the col¬ lateral branches enlarge, fo as to convey the blood in any quantity to the principal artery :

- befides, the ligature is made fo near the aneu- ryfm, that the enlarged collateral branches communicate principally with others arifing ‘ beyond it. In the cafe we have mentioned, the contradtion of the artery was probably a gradual procefs, the collateral branches en¬ larging in proportion as the contradlion en- creafed, fo that the fame quantity of blood was always circulating in the limb. But flill the Impetus of the blood rnuft have been greatly diminifhed by paffmg through a num¬ ber of meandring channels, inftead of one ftraight canal ; fo that if the progrefs of an aneuryfm could not be flopped by it, it would at leaft advance very flowly ; and if an aneu¬ ryfm had been formed near the feat of the con-

traftion.

I

[ 133 J

f

traction, it mufl: have been as efFefliually cured by it as by an operation*.

Of the Ossification of Vessels.

There is no difeafed change of ftrudlure more common in the body, than partial offifi- cations of the arterial fyftem at an advanced period of life. The time of life at which this procefs begins, and its progrefs, vary very much in different perfons. There is alfo con- fiderable difference in the fort of change. In fome there is a converfion of the coats of an artery into a fubftance, refembling very much the common bony matter % in others there is a converfion of them into an earthy matter, little blended with the animal gluten. This fort of change is fo common, that when a perfon dies about the age of fixty years, it is more frequently found to have taken place

* There is an inftance of this fort of contraflion in arteries mentioned by Morgagni.

“ .Sed illud peculiare quod fi eandem faciem (fell, interiorem aortas) infpiceres, tuniccE latus arteriae finiftrum & pofteriorem partem facientes ad angulum inter fe jungi, non curvae inflac linear videbantur.’" — Vid. Lib. v. Epift. 65. Artie. 5.

K3

in

[ 134 ]

in a greater or lefs degree, than that the arterial fyftem poffeffes its original healthy ftrudlure. The venal fyftem, on the contrary, is fo rarely liable to this fort of change, that it may be faid to be a difeafe in it almoft en¬ tirely unknown. There is one inftance, how¬ ever, in the colledion of Windmill-ftreet, where a confiderable oflification was formed in the coats of the vena cava inferior, near its bifurcation , into the two iliacs'^*. Why there fhould be this difference in the coats of arteries and veins, is not eafy to explain. There feems to be no reafon for it a priori. It might, perhaps, be faid, that it depends on the vafa vaforum being more numerous on the coats of arteries than of veins, but it cer- tainly does not depend upon this circum- fiance. The vafa vaforum are more nume¬ rous on the coats of arteries in younger than in older people, yet in the former oflification fcarcely ever takes place. — Belides, it is ob¬ vious, that a peculiar effed rnufl depend on a peculiar adion, and not finiply upon the

* This oflification was found in the fame vein whicli had the extraordinary obliteration we have defcribed in the former part of this paper. . ,

number

C 135 ]

number of veffels I do not, therefore, pretend to explain why offification fhould be fo commoman occurrence in the coats of ar- teries,'and fo rare in thofe of veins, but I know it to be a very rare occurrence in the latter, and for this reafon I thought if wor¬ thy of mentioning, as Angular matter of

fadt in the hiftory of difeafed appearances ‘f*-

*

0

* Bony matter, whether depofited in the coats of arteries of veins, can only be formed by the vafa vafonim fecreting bony matter in the fame manner as it is fecreted in the growth of bones generally. >

+ When offification takes place in the valvulae tricufpides, or mitrales, it perhaps may be confidered as an offifica^on belong¬ ing to the venal fyftem, but even this is very rare. .

PLATE

I

A. The right carotid artery, with its en-

♦ *'•

largement, of the fame fize exadlly as found in the body, the fize being taken by accurate meafurement. The tumour is laid open longitudinally, to fhew that it is entirely filled with coagulable lymph. i

B. The left carotid artery — d reprefenting

' ' the quantity of coagulable lymph in

it, E reprefenting the proportion of cavity for carrying on the circula¬ tion.

/ ^

!

/

PLATE

♦ ^

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ttk:

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. » V! /

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i

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I

1

[ 137 ]

I

PLATE V . . ,

s.

F. I G. I.

AA. Spme.

BB. Aorta, with the iliac branches.

C. The vena cava inferior, with a white ofTified part, more fully ihewn in Fig. 2.

' D. The obliterated portion of the vein.

E. Left emulgent vein enlarged.

F: The vena azygos confiderably enlarged be*

; yond its ufual fize. • ■

G. An uncommon 'vena azygos of the left fide, very much enlarged and tortuous.

^ H. Veins of communication between the left iliac vein and left vena azygos. — They are enlarged and tortuous. ► .

II. The two kidneys dried and fhrunk. > ,

f

F I G. II.

AA. A portion of vena cava inferior.

B. Reprefents the fize, fhape and irregularity of the oflified part,

\

( '

r-

N.^'B. Both of thofe drawings were taken from a ^ dried preparation long after it was made.

IX. An

/

[ ^38 ]

IX. An Account of Mr. HuNTER'i* Method of performing the 0 per at mi for the Cure of the Popliteal Aneurifm. By Everard Home, Efq-, F.R.S. AJJiJlant-Surgeon to St. George's Hofpital.

The popliteal aneuryfm being a difeafe which frequently occurs, and generally proves fatal, unlefs fome means are taken to prevent

it ; we carfnot be furprized that it has at-

\

tradled the attention, and called forth the exertions of the ableft furgeons in this coun¬ try to difcover fome method of cure.

Experience' has fhown that all the modes hitherto pradlifed are exceedingly precarious, being rarely attended with fuccefs, and the death' of the patient being, commonly a con- fequence of a failure of the operation ; a cir- cumftance which has led fome furgeons of great eminence to prefer the amputation of the limb in all fuch cafes.

Mr. Hunter, who has repeatedly performed the operation for the aneuryfm, finding that it in general fails, and having likewife ob- ferved that the removal of a limb fo high up,

from

C 139 ]

from a perfon in health, feldom fucceeds In preferving life, (and when it does, leaves the patient difabled,) was excited to confider this difeafe with more than ordinary attention. The refult has been a mode of practice that appears to poffefs many advantages over thofe hitherto recommended, and to be an* improve¬ ment in the practical part of furgery ; at leaft it is from this idea being ftrongly impreffed - on my mind that I am induced to commu¬ nicate it to this Society, as Mr. Hunter is too much engaged to permit his taking that talk upon himfelf.

An aneuryfm is a preternatural dilatation of a portion of an artery, and in general it is a very fmall part of the arterial coats which is thus afFedled. The dilatation is commonly on one fide only, and, when once begun, gra¬ dually enlarges, from the force of the heart propelling the blood againft the dilated part. Thus in time a fac is formed, which being in fome meafure out of the direcfl courfe of the circulation, the blood, where it is at the greateft diftance from the channel of the ar¬ tery, coagulates, and forms layers, or ftrata, upon the iniide of this fac. As the enlarge¬ ment of the fac depends intirely on the force

with

[ 140 ]

with which the blood is adled on by the heart, it does not, as at firft, continue to fwell out at right angles from the fide of the artery, but is increafed in a diagonal line be¬ tween that and the courfe of the artery itfelf, from the force of the blood being applied in that dirediion ; fo that the fac is protruded along the outfide of the artery, and, by its preflhre upon it, obliterates, in many in- ftances, the lower orifice, which communi¬ cates with the artery, and produces a total ftagnation of the blood in the fac.

If the coats of an artery are examined in the commencement of this difeafe, the firfl: appearance is a lofs of the natural luftre and tranfparency of its internal membrane ; that becoming opaque, afterwards thicker, acqui¬ ring a leather-like appearance ; and when the fac becomes larger, the coats retain no longer a refemblance to thofe of an artery, but have more 'that of a membranous bag, communi¬ cating laterally with the artery by a rounded orifice, (of different fizes,) the margin of which refembles the internal membrane of an artery, in a thickened flate ; but beyond that, gradually degenerates into a membranous fub- ftance.

The

[ HI ]

The popliteal aneuryfm, which we are at prefent to confider, is the difeafe above men¬ tioned, affeding the trunk of the popliteal artery, which funs down between the two ham-ftrings of the thigh. From the fitua- tion of the tumor, on whatever fide of the artery the dilatation is produced, it will be diftindly felt in the hollow between the ham- ftrings, and will be readily afcertained by a pulfation to be felt in every part of the tu¬ mor ; it feems to be one of the moft frequent fituations of aneuryfm ; and though it may be difficult to afcertain whether it occurs fo com¬ monly^ as in the aorta itfelf, it is certainly found oftener in this artery, than in any other branch which the aorta fends off. This cir- cumftance, as far as I know, has not hitherto been accounted for, and what is rather cu¬ rious, in many recent inftances of this difeafe, the patients have been coachmen and pofti- lions The popliteal aneuryfm has been in

general

* Morgagni and his friends found aneiiryfms of the aorta more frequently in guides, poft-boys, and other perfons who fit almoft continually on horfeback, which is attributed to the con* culTion and agitation. — Vide Letter xvii. Art. i8.

♦

When we confider the popliteal artery as affeded by the different pofitions of the leg and tiugh, and the obftrudion which

the

[ - 142 ]

general fuppofed to arife from a v/eaknefs In the coats of the artery, independent of the prefence of difeafe f if this were true, we might reafonably conclude, that, except in the part preternaturally dilated, the veffel re¬ mained in a found ftate, which would natu¬ rally fugged; the mode of pracftice generally recommended, viz. opening the fac, tying

the circulation mull inevitably meet with in that artery, when the limb is bent, we fee a probable reafon why it Ihouid be more liable to difeafe than any of the other ramifications of the aorta ; efpecially when it is found that aneuryfms in the aorta itfelf are moft frequent at the curve of that artery.

If this obfervation is allowed to have any weight, the reafon will be_evident why the difeafe Ihouid occur more frequently in coachmen and poftilions ; for their knees being almoft confiantly in a bent ftate, from the necelfary exertions of their bodies in their difterent occupations, and from the violent motion of their horfes and carriages, the circulation muft often be confi- derably increafed ; while the branches immediately below the popliteal artery will be in feme meafure obftruded by the aflion of the gaftrochnemii and folsei mufcles, in fteddying the body in the ftirrup, or againft the foot-board of the cahiage, '

- The unfavourable circumftances refpeding the popliteal artery, do not in common life feem of themfelves capable of producing difeafe, but when increafed to a great degree, as in the occupa¬ tions of coachmen .and poftilionS : They, at the fame time, from want of fufiicientexercife, have their legs weaker and lefs healthy than the reft of the body ; and the cafes to be mentioned appear ftill further to prove, that thefe circumftances may produce fuch a ftate of the artery at this part, as to difpofe to the formation of aneuryfm.

r

[ H3 ] ■

Up the artery above and below it, leaving the bag to fuppurate, and afterwards heal up like any common fore.

Mr. Hunter finding an alteration of ftruc- ture in the coats of the artery previous to its dilatation, and that the artery immediately above the fac feldom unites when tied up in the operation for the aneuryfm, fo that as foon as the ligature comes away, the fecon- dary bleeding deftroys the patient, was led to conclude, that a previous difeafe took place in the coats of the artery, in confequence of which it admitted of dilatation capable of producing aneuryfm. But not fatisfied with the experiments on frogs, given by Haller in fupport of the opinion that weaknefs alone was fufficient to produce the dilatation, he refolved to try the refult in a quadruped, which, from the veflels being very fimilar in their ftrufture to thofe of the human fubjedt, would be more likely to afcertain the truth or fallacy of Haller’s opinion. That the ex¬ periment might have as much as poflible the chances mofl: likely to produce aneuryfm, the carotid artery, as being near the heart, was feledled for that purpole.

Mr.

1

[ 144 ]

Mr. Hunter having laid bare the carotid artery-of a dog, for above' an inch in lengthy having removed its external coat, and after- wards diffe(fled oif the other coats, layer after layer, till what remained was fo thin that the blood was plainly to be feen through it, left the do Of to himfelf. .

o

In about three weeks the dog was killecf, and' the parts examined, when it appeared that the two fides of the wound having clofed upon the artery, the whole of -the furround¬ ing parts were confolidated, forming a llrong -bond of union, and the artery itfelf was nei¬ ther increafed nor diminifhed in fize.

This experiment appeared very conclufive, as the coats of the artery were v/eakened to a much greater degree, without dilatation, than can ever happen from accident in the -living body, independent of morbid affedlion : but it was objected, on the other hand, that the parts having been left to themfelves, im¬ mediately clbfed upon the weakened portion of the artery', and, being cemented together by the coagulated blood, eifedfually fecured

it againft any dilatation. To try the force of

/

this objedion, I made the following experi¬ ment.

I laid

[ H5 1 '

I laid bare the femoral artery of a dog, about two inches below Pouoart’s ligament, for about an inch in length, and differed off the coats, till the hemorrhage from the vafa vaforum was confiderable, and the circulating blood was ' dift-inflly feen through the internal membrane of the artery. The hemorrhage foon flop¬ ped by expofure, the furface was wiped dxy> and afterwards covered with a doffil of lint, to prevent the fldes of the wound from unit¬ ing. The dog continued very well, 'and the wound healed up from the bottom ; after fix weeks the dog was killed, and the artery was injedted, that it might be . examined with greater accuracy. It was not perceptibly en¬ larged or diminifhed, and its coats at this part had recovered their natural thicknefs and appearance.

The refults of thefe experiments confirmed Mr. Hunter in his opinion, that the artery, in cafes of aneurifm, is in a difeafed flate ; and led him to believe, that the difeafe often extends along the artery for fome way from the fac ; and that the caufe of failure in the common operation, arifes from tying a difeafed artery, which is incapable of union, dn the

L - time

[ 146 ]

time neceffary for the feparating of the liga¬ ture.

The femoral and popliteal arteries are por- ^ tions of the fame trunk, prefenting them- felves on different fides of the thigh, and arc readily come at in either fituation ; but where the artery is pafling from the one fide to the other, it is more buried in the furrounding parts, and cannot be expofed without foinc difficulty.

In performing the operation for the pop¬ liteal aneurifm, efpecially when the tumor is large, the ligature is commonly applied on the artery at that part where it emerges from the mufcles. This mode of performing the operation will be found inadequate, if the dif- "eafe of the artery extends above the fac ; for if the artery fhoiild afterwards give way, there will not be a fufficient length of veffel re¬ maining, to allow of its being again fecured in the ham. To follow the artery up through the infertion of the triceps mufcle, to get at a portion of it where it is found, becomes a very dilagreeable part of the operation ; and, to make an incifion upon the fore-part of the thigh, to get at and fccure the femoral ar¬ tery.

6

[ H7 ]

tcry, would be breaking new ground ; a thing to be avoided, if poffible, in all operations.

Mr. Hunter, from having made thefe ob- fervations, was led to propofe, that in this operation the artery fliould be taken up in the anterior part of the thigh, at fome dif- tance from the difeafed part, fo as to diminifh the riik of hsemorrhag-e, and admit of the ar- tery being more readily fecured, fhould any fuch accident happen. The force of the cir-r culation being thus taken taken oft from the aneurifmal fac, the progrefs of the difeafe would be fcopped; and he thought it pro¬ bable, that if the parts were left to them- felves, the fac, with its contents, might be abforbed, and the whole of the tumour re¬ moved ; which would render any opening in¬ to the fac unneceflary.

Upon this principle, Mr. Hunter perform¬ ed the operation at St. .George’s Hofpital.

The patient was a coachman,, forty-five years of age ; he was admitted into the hofpi¬ tal in December 1785, with a popliteal aneu- rifm, which he had fir ft perceived three years previous to his admiffion, and had obferved it gradually to increafe during the whole of that period. It was fo large as to diftend the

L 2 two

[ 148 ]

two ham-ftrings laterally, and make a very confiderable riling between them ; the pulfa- tion was very diftindl, and to be felt on every fide of the tumor. The leg and foot of that fide were fo fwelled as to be much thicker than the other, and were of a mottled brown colour ; the fwelling was not of the cedema- tous kind, but felt firm and brawny, pro¬ bably from the extravafation of coagulable lymph ; the leg retained its natural fhape, excepting that it was larger. Previous to performing the operation, a tournequet was applied upon the upper part of the thigh, but not tightened, that the parts might be left as much in their natural fituation as poflible.

The operation was begun by making an incifion on the anterior and inner part of the thigh, rather below its middle, which in- ciljion was continued obliquely acrofs the in¬ ner edge of the fartorius mufcle, and made ‘ large, to give room for the better performing of whatever might be thought neceflary in the courfe of the operation. The fafcia which covers the artery was then laid bare about three inches in length, after which the artery itfelf was plainly felt. A flight incifion, about an inch long, was then made through this fafcia, 4 aloi^

I

[ 149 3

along the fide of the velTel, and the fafcia diired:ed oif ; by this means the artery was expofed. Having difengaged the artery from its lateral conned; ions by the knife, and* from the other adhering parts by the help of a thin fpatula, a double ligature was paffed be¬ hind- it, by means of an eyed probe. The doubling of the ligature brought through by the probe, was cut fo as to form two fepa- rate ligatures. The artery was now tied by both thefe ligatures, but fo llightly, as only to comprefs the fides together. A fimilar ap¬ plication of ligature was made a little lower. The reafon for having four ligatures, was to comprefs fuch a length of artery as might make up for the want of tightnefs, it being wifhed to avoid great preflure on the veflel at any one part. The ends of the ligatures were carried direcdly out at the wound, the fides of which were now brought together, and fup- ported by flicking plaifler and a linen roller, that they might unite by the firfl intention.

The limb was found, feme hours after the operation, not only 'to retain its natural heat, but even to be warmer than the other leg. The fecond day after the operation, the brawny firmnefs of the leg was confiderably diminifh-

L 3 ed,

C 150 ]

ed, it was become foft, loofe, and a good deal fmaller, and the aneurifmal tumor had loft more than one third of its fize.

Nothing could fhew more plainly the aeftion of the abforbents, than the change the leg had undergone in fo fhort a time ; the dimi¬ nution of the tumor probably arifing from the fluid blood which it contained having paffed into collateral branches, or into the tibial artery.

The fourth day, on the removal of the dreffings, the edges of the wound were found united through its whole length, excepting where prevented by the ligatures ; there .was neither pain nor tumifadlion in the part ; but the anuerifmal tumour was the fame as on the fecond day.

On the ninth day after the operation, there was a confiderable difeharge of blood from the part where the ligatures paffed out ; a tournequet was therefore applied on the artery above, which flopped the- J)leeding ; and, although the tournequet was taken off a few hours after, no blood fol¬ lowed. The head of a roller was then placed upon the wound,, in the direction of the ar¬ tery, and over that the tournequet, which

was

[ I5X-]

was not, however, tightened more than was thought fufficient to take off the impetus of the blood in that portion of the artery.

On the tenth day appearances were much the fame, only that between the comprefs and the knee there appeared a little fullnefs, like beginning inflammation. On the eleventh day this was gone off, and on the fifteenth fome of the ligatures came away, followed by a fmall difeharge of matter, the tumor in the ham being leflened. On the feventeenth day the parts furrounding the aneurifmal tumor were more reduced, and pliable, fo that it was diflindlly to be felt.

About the latter end of January, 1786, fix weeks after the operation, the patient went out of the hofpital, the tumor at that time being fomewhat leflened, and rather firmer to the feel. He was ordered to come to the hofpital once every week, and, in the mean time, to make fome degree of preflhre, by application of a comprefs and bandage, with a view to excite the abforbents to adion, which , in moft cafes has a good efFed:.

About the middle of February the tumor had decreafed, and was become ftill firmer. March the 8 th, the wound, which had cica-

h 4 trized,

[ 152 ] ,

trized, broke out again, and the patient was taken into the hofpital. About the 8th of April, fome of the remaining thread of the ligature came away, and an inflammation ap¬ peared upon the upper part of the thigh. In the middle of May, a fmall abfcefs broke at fome diftance from the old cicatrix, at which opening fome matter was difcharged, but no pieces of ligature wxre obferved. Se¬ veral fmall threads were, at diflerent times, difcharged from the old fore, and the fwell- ing fubfided ; but the thigh foon fwelled again to a greater lize than before, attended with confiderable pain. In the beginning of July, a piece of ligature, about one inch in length, came away, after which the fwelling went off intirely, and he left the hofpital the 8th of July, at which time there reniiained no ap¬ pearance of tumor in the ham, he being in every refpeft well.

After leaving the hofpital, the man returned

to his ufual occupation of driving a hackney-

0

coach ; and being, from the nature of his em¬ ployment, much expofed to cold, in March 1787 he was feized with a fever of the re¬ mittent kind, which carried him off. He had not made any complaint of the limb on

which

[ 153 ]

which the operation had been performed, from the time of his leaving the hofpital.

He died on the ift of April, 1787, fifteen months after the operation ; and leave was procured, with fome trouble and confiderable expence, to examine the limb, feven days af¬ ter death, at which, time it was intirely freC' from putrefadlion.

The cicatrix on the anterior part of the thigh was fcarcely difcernible, but the parts under it felt hard. The ham had no appear-- ance of tumor, and was to the eye exadlly like that of the other limb ; there was, however, a folid tumor perceptible to the touch, filling up the hollow between the two angles of the thigh-bone. .

The femoral artery and vein were taken out above the giving off the branch called profunda, and a little b^low the divifion into the arterise tibiales and interoffea. The ar¬ teries and veins that were pervious being in¬ jected, the whole was carefully diffeCted. .

The femoral artery was impervious from its giving off the arteria profunda as low as the part included in the ligature, and at that part there was an ofiification for about an inch and an half along the courfe of the artery,

of

r 154 ]

of an oval form, the rim of wliich was folld, becoming thinner towards the center, and not bony, but ligamentous. Below this part, the femoral artery was pervious down to the sneurifmal fac, and contained blood, but did not communicate with the fac itfelf, having become impervious juft at the entrance.

What remained of the aneurifmal fac was foniewhat latger than an hen's egg, but more oblortg, and a little flattened, extending along the artery below for fome way ; the blood preffing with greater force in that direeftion, and diftending that part fo, as in fome meafure, to give the appearance of a fepa- rate bag. The fac was perfectly circum- ftribed, not having the fmalleft remains of the lower orifice into the popliteal artery ; w^hether this arofe from the artery being preflfed upon by the inferior portion of the fac, as appears to be the cafe in common, or was in confequence of the fac contradling after the operation, I will not pretend to de¬ termine ; but it contained a folid coagulum of blood, which adhered to its internal fur- face. A feeftion made of this coagulum, ap¬ peared to be compofed of concentric lamellae,, uniform in colour and confiftence.

The

[ I5S ]

The popliteal artery, a little way below the aneurifmal fac, was joined by a fmall branch, very much contraifted, which muft ...have arifen either from the profunda, or the trunk of the femoral artery. About two inches below the fac, the popliteal gave off, or divided into the tibiales. '

The profunda was of the ufual fize, but a rood deal offified, for fome length after leav- ing the femoral artery ; the two tibials, where they go oiF from the popliteal, were in the fame ftate.

The trunk of the femoral vein, where it paffed along the fide of the tumor, muft have been obliterated ; for at this part it appeared to fend off three equal- fi zed branches, paffing over different parts of the aneurifmal fac : thefe muft have been dilated branches, none of them having the courfe which the trunk of the vein (hould have purfued.

Thefe appearances throw fome light upon the changes which took place in the limb after the operation. The ligature upon the femoral artery impeded the paffage pf the blood into the fac fo much, as to allow its contents to coagulate, and render the opening into it from the artery impervious. By this

a ftop

[ 15^ ]

a- flop was only put to the increafe of the tu¬ mor, its reduction to the tize met with in the dead body, mu ft have been the effedt of ah- forption.

The conclufion-to be drawn from the above account, appears a very important one, viz. that fimply taking off the force of the circu¬ lation from the aneurifmal artery, is fufficient to efFecft a cure of the difeafe, or at leaft to put a ftop to its progrefs, and leave the parts in a fituation from which the adlions of the animal ceconomy are capable of reftoring them to a natural ftate.

In confirmation of the cure of aneurifm depending on taking off the force of the cir¬ culation, I fhall mention a cafe of aneurifm that recovered without an operation, and in which the mode of recovery depended upon the fame principle.

The aneurifm was in the femoral artery, and the fwelling appeared upon the anterior part of the thigh, a little above the middle, extending upwards nearly to Poupart’s liga¬ ment ; an attempt was made, by compreffing the artery above the tumor, by means of an

W . « • •

inftrument fomewhat refembling a fteel trufs, to give the blood in the fac a chance of co¬ agulating,

[ ^57 ]

agulating, and by that means to put a flop to the progrefs of the difeafe. But, from the pain which it occafioned/ every attempt to make a permanent compreffion on the artery proved ineffeduah The tumor increafed to a very conflderable fize, a great degree of in- , flammation and fwelling took place in the fac and common integuinents, and mortification appeared to be coming on the Ikin. While in this ftate, no pulfation could be felt in the tumor, or the artery immediately above it ; fo that the fteps preceding mortification had taken place which put a flop to the dila- . tation of the fac, and all its confequences. From the time the pulfation in the fac fcopped,

' the inflammation and fwelling fubfided, al¬ though very flowly ; and as the tumor di- miniflied it became firm and folid, and the patient got perfectly well.

It appears from thefe cafes, that furgeons have laid too much ftrefs upon the fuppofed neceflity of large collateral branches, to in-

On examining the bodies of thole who die. in confequcnce of mortifications, the artery leading to the mortified part is completely Hopped up with a firm coaguium for feveral inches ' in length ; this muft precede the mortification, and feems in¬ tended to prevent haemorrhage.

From Mr, Hunter s LeFlures.

fure

fare the fuccefs of this operation ; an opinion 'which mail: have arifen from anatomical know- leclge, rather than obfcrvations' made from pradlice.

The fecond time Mr. Hunter performed this operation, was upon. a trooper about forty years of age.

A tournequet having been loofely applied upon the thigh, the operation was begun by a longitudinal incifion through the integuments, and the artery and vein were expofed, as in the former cafe, but not taken up with a num¬ ber of ligatures, for nothing appeared to have been gained by filch praftice, and the bad ef- fedls of it were obvious in the progrefs of the cure ; they were included in one ftrong liga¬ ture, fufficiently tight to prevent the pulfa- tion in the fac, without injuring the coats of the veffels. The ends of the ligature were brought out at the wound, which was in this cafe dreffed from the bottom. The advan¬ tages propofed by this treatment were, to be able to fee the progrefs of the cure, and to come readily at the artery, if any unfa¬ vourable circumftance occurred ; fince the abfeeffes in the former cafe were fufpeded to have arifen fcom the mode of healing.

After

[ 159 ]

After the operation, the fuperficial veins of the leg became exceedingly turgid and nume¬ rous, and the limb, although warm, became rather lefs fo than the other, particularly the foot.

The next day the leg was fwelled, and the heat 12° lower than the other; the fecond day it exceeded the other 5° ; and on the fourth day the two limbs were equally warm ; tlie patient was free from fever.

^ On the fourteenth day the ligature came away, and the tournequet was loofely applied, as a precaution againft bleeding ; the farto- jius mufcle was a good deal enlarged, and co¬ vered the paffage down to the artery, fo as to prevent the matter from having a free djf- charge^ a good deal being confined behind it, and with difficulty fqueezed out at each dreffing.

On the nineteenth day there was an hae¬ morrhage from behind the mufcle, the fwell- ing of which rendered it nearly as difficult to come at the veflel, as if the parts had healed by the firft intention ; the bleeding was flopped by applying prefiiire, after having lofl about ten or twelve ounces.

On

r i6o ]

On the twentieth there was a flight bleed¬ ing, which was readily flopped : yet five hours afterw'ards the femoral artery gave way, and he loft about one pound of blood before the tournequet was applied. The artery was laid bare, and tied a little higher up, the patient being very v/eak and low ; in this ftate he continued till the twenty-third day without bleeding, when it bled again from a fmall veffel. On the twenty-fixth a confiderable haemorrhage having taken place, he became faint, then delirious, had vomiting with hic¬ cough, and died the fame day.

Upon examining the limb, finufes were difcovered both upwards and downards, in the direction of the artery and fartorius mufcle, befides fmaller ones in different diredlions.-

In this cafe, the bad confequences and death of the patient, do not appear to have arifen from the operation, but were intirely the re- ' fult of the mode of treatment afterwards, as

t

v/ill appear from the following cafes.

The third patient-operated upon by Mr. Hunter was a poftillion, thirty-five years old. Compreflion upon the femoral artery was at¬ tempted, but the pain v/as fo great that it could not be continued.

In

[ i6r J

In performing the operation only one liga¬ ture was ufed, and the parts healed by the • firft intention.

On the feven th day after the operation, the firft dreffings were removed, and a good deal of matter came out by the fide of the liga¬ ture. On the fourteenth the ligature came, away, and in four weeks the wound healed.

The fac in the ham, from being chafed previous to the operation, burft at this itime, but healed up like any other fore, and at the- end of three months he was perfectly re¬ covered.

Mr. Hunter s fourth patient was a coach¬ man, thirty-fix years old.

The tumor in the ham was not very large, and fituated lower down than ufual, the whole leg being fwelled, and the veins turgid. The pain he complained of was exceedingly vio» lent, but being in a very bad ftate of health, an operation was not thought advifeable, and gentle prefliire on the tumor was attempted ; but, from the pain it occafioned, the opera¬ tion was had recourfe to, as the only chance of faving his life, although, from the irritable ftate in which he then was, even that feemed a forlorn hope.

M la

[ 'i62 ]

In performing the operation, the vein was not included in the ligature, but in other rc- fpefts it was fimllar to the former.

Immediately after the operation the limb was benumbed, and continued fo for fome time, which was Angular, as the nerve had not been included. It became, on the fame day, four or five degrees hotter than the other leg, and continued fo for the firft fourteen days, when the temperature became the fame as that of the other limb.

The fixth day the firft dreflings were re¬ moved, and the ikin was united every where except at the paffage of the ligature. It re¬ mained in this ftate till the twenty-firft, when the cicatrix inflamed and ulcerated, with a floughy appearance, and hardnefs up the thigh.

' On the twenty-ninth day the ligature came away ; the fore now put on a better appear¬ ance, fuppuration took place where the hard¬ nefs had been in the courfe of the artery, and the parts became fofter, the difeharge gra¬ dually diminiflied, and in the feventh week the wound was healed.

But it did not continue fo ; for in three days an inflammation took place, and an ab-

fceft

[ i63 ]

fcefs formed, and burft at the cicatrix, which alfo healed up.

About the end of the tenth week he^was attacked with a very fevere remitting fever, which lafted fourteen days, and left him much reduced ; but in the fourteenth week he was fo far recovered, as to leave the hofpital and go into the country, for the recovery of his health.

The fifth patient upon whom Mr. Hunter performed this operation was Jofeph Cafwell, aged forty-two, a man not accuflomed to horfe exercife, or any mode of life which could in the lead; aflifl: in producing the dif- cafe. The aneurifm was in the ham of the left legi

In performing the operation, the artery alone was included in a fiirong fingle ligature, and the wound was healed by the firfi: in-, tention, leaving a pafTage for the ligature. The local inflammation was extremely fmall, and confequently attended with little lympa^ the tic fever. The ligature came away the eleventh day, and in five weeks he went into the country, able to walk with a ftick, the Wound perfectly healed.

M 2

In

[ 16^4 ]

In this cafe the heat of the two legs was caerfully examined twice a day, from the fecond to the ninth after the operation, and the limb operated upon was uniformly colder than the other.

He came to town fix months after the ope¬ ration, and faid that the left leg was fully as ftrong as the right, but, when expofed to cold, he was more fenfible of its effedls up¬ on that leg. About two months after the operation he had a violent pain in the upper part of the left foot, limilar to what is felt when a nerve is preffed ; this lafted for about fix weeks, and afterwards went entirely off. As no nerve was included in the ligature, this affedfion probably arofe from the nerve in its paffage through the confolidated parts being deprived of its natural freedom. There was a fmall tumor, the remains of the aneurifmal fac, very diftindlly to be felt in the ham, but \vithout pulfation, and to the feel perfectly folid.

The following cafe was operated upon by Mr. Lynn, furgeon of the Weftminfter Hof- pital, in the fanie manner as abovementioned ; and the account of the operation is given in his own words.

Samuel

[ J

Samuel Smart, an hackney coachman, twenty-five years of age, had a popliteal aneurifm, for which I performed the opera¬ tion in the following manner. I made an in- cifion down to the femoral artery, a little* be¬ low the middle of the thigh, and having fe- parated the artery from the contiguous parts, I paflhd under it, by means of an eyed probe, a broad ligature, which was tied fo as to cut off all communication with the tumor, and the lips of the wound were brought together, and retained by flicking plaifier, and the patient put to bed ; this leg was rather colder than the other, and ordered to be fomented. The next day he was free from pain, and the limb was warmer than the other.

On the fourth the dreflings were removed, and the parts were found united, except at the ligature.

“ On the thirteenth the ligature came away, and in the courfe of the month the whole was healed, and the patient foon af¬ terwards perfed:ly recovered.

Wm. Lynn.’*

«

This operation of Mr. Hunter’s having fucceeded in the firft inftance, furgeons of

M 3 different

[ i66 ]

diiferent hofpitals were led to adopt it, but with fome variation, according to their own judgment> and the circumftances of the rc- ipediive cafes. Thefe I did not introduce in the order in which they took place ; for not being performed exactly in the fame manner, they would have interrupted the regular feries of thofe cafes above related. But I fhall now give them either in the words of the furgeons who performed the operations, or as corredlly as I can from having myfelf been an eye- v/itnefs ; and although they were not attended ’with fuccefs, that circumftance will not be found to affedl the propriety of the mode of performing this operation which has been re¬ commended above.

' In a cafe of aneiirifm of the femoral artery, the (Operation was performed by Mr. Birch, furgeon to St. Thomas’s Hofpital, who relates the hiftory as follows :

John Lewis, a negro, aged forty- three, received a blow on the anterior part of the right thigh j about a month after he perceived a fmall tumor, which gradually increafed, and his own expreffion was, that he could feel it thump, thump.

As

[ 167 ] -

As the tumor enlarged, he came to Lon¬ don for advice, applied at St. Thomas’s Hof- pital, on Thurfday, the 26th of Odlober, and was direftly admitted. On examination I found a large tumor, extending within two inches of Poupart’s ligature upwards, and oc¬ cupying two-thirds of the thigh ; a pulfation could be felt, and there was no doubt of the difeafe being an aneurifm of the femoral artery.

I directed feven ounces of blood to be taken from the arm, and an opiate to be given at night ; the patient refted well, and the next day a confultation was held, in which it was propofed to perform an operation, and endea¬ vour to pafs a ligature round the femoral ar- tery, giving the patient the chance of -nouriih- ing the limb by the arteria profunda, and other anaftomifing veffels.

On Friday, the 3d of November, it was determined to perform the operation ; Mr. Cline undertook to comprefs the artery as it paffes through Poupart’s ligament, which he eafily efJe(5ted with a hard comprefs, in the flaape of a T, with a broad bafis.

It was agreed, previous to the operation, that an iilcifion ihould be carried in a femi- •lunar form round the upper part of the aneu-

M 4 rifmal

[ i68 3

riimal fac, in order to make room fof the lon¬ gitudinal incifion neceffary to dilTedl: down to the artery ; this was accordingly done, and the integuments raifed, fo as to make room to feel for the pulfation of the artery ; fome portion of cellular membrane and lymphatic glands were neceffarily differed and removed : v/ith my fingers I then feparated the mufcular fibres, and tore away the conned:ing parts till the artery could be plainly felt in pulfation ; it was then neceflfary to divide a part of the fafeia covering the artery, which was done by carrying the back of the knife on Mr. Cline’s nail, while his finger prefled upon the naked artery; after which the finger and thumb could furround and comprefs the veffel ; an eye probe, armed with a ftrong flat ligature, was then puflied through the cellular mem¬ brane, and carried under the artery. This being effedled, we had fuch command of the veflcl as to be able to ftrip it down, and pais another ligature fomewhat lower. This lafl: ligature was then tied, the firfl: being left loofe, to fecure us againft accident.

The threads being feparated and fccured, the wound was lightly dreflfed, the tumor left in its natural fituation, and the patient put to

bed.

[ 1^9 ]

bed, with the lofs of only four or five ounces of blood during the operation. No pulfation could be perceived in the tumor after the liga¬ ture was tied.

On Saturday, November the 4th, he had flept well, was eafy, and there was fufficient warmth in the extremity to affure me of fome circulation. On the 5th the difcharge from the wounded lymphatics was fo abundant, as to make it neceffary to remove the fuperficial dreflangs ; the tumor was rather fofter to the touch, and the fkin about the apex of it be¬ gan to fhrivel. . .

The difcharge of lymph continued till the 9th, and then the wound began to digeft, affording, however, a very fmall quantity of pus. The tumor grew thinner at one point, and feemed as if difpofed to ulcerate the in- ' teguments. This day I paffed a bleeding li¬ gature round the leg, jufi; below the knee, and the veins tumified fufliciently to have bled 'freely if they had been pundlured. loth. He was feverifii in the evening, iith. He had flools from fome laxatives ' I had diredled, and was better.

12th. The tumor was very thin at one part, and a fluftuation evidently to be felt.

The -

. .[ 17° I

The limb was warm and moveable, but the patient was feveriih, and delirious at night ; a decoftion of bark, with a fedative bolus, v/as diredled for him, but he would not take them.

13th. The wound looked florid, and af¬ forded good pus, the patient was feverifli and delirious, the tumor was threatening to burft. This day he took his medicines.

'14th. He became fenfible, but was lan¬ guid and hot ; the tumor burfl:, and difeharg- ed ferum and grumous blood ; he fainted ; the dreflings were not difturbed; he flept compofedly ; fainted again about fix o’clock in the evening, and expired. I faw him at feven, when the limb was ftill warm ; I re¬ moved the dreffings, and found a fmall ftream of freih arterial blood which had ifliied from the wound.

It appears probable that if the patient had applied for relief before the tumor was fo much enlarged, the operation might have fucceeded, as we Ihould then have been able to have tied the found artery fo much lower down.

J. Birch,

The

[ J7I 1

The body was examined the morning after the patient’s death by Mr. Cline.

The integuments on the middle of the tu¬ mor were mortified. The blood contained in the tumor was very putrid, and the greater part of it fluid, it appearing to have been dif-

I

folved by putrefiid:ion.

Water inje<5led by the external iliac artery, efcaped freely from the wound at the ligature where the artery was open, and appeared to have ulcerated at that part.

In laying open the artery from the ligature to the 'heart, its internal furface appeared of a bright red. This appearance leflened at the curvature of the aorta, yet it was very evident in its femilunar valvesl

The arteria profunda, which pafled off from the femoral artery rather lefs than half an inch above the ligature, was alfo inflamed within. There were near two inches of the femoral artery between the ligature and the aneuryfmal fac, the internal furface of w^hich

t

was of the ufual white colour ; from this a membranous-like fubfliance could be peeled off that feemed to refemble coagulable lymph.

The opening where the artery pafled out of the aneuryfmal fac was near three inches

'*V

below

[ 172 J

below the part where it entered. In opening this part of the artery from the fac to the ham it appeared quite found, and of its na¬ tural colour. H. Cline.

4

This mode of operating was adopted by Mr. Pott in a cafe of popliteal aneuryfm in St. Bartholomew’s Hofpital; which opera¬ tion having been the object of medical atten¬ tion for fome time, I fhall give a brief ac¬ count of it, as I was prefen t at the time it was performed.

Mr. Pott began the operation by making an incifion, about five inches in length, upon the pofterior part of the thigh, through the common integuments, a little higher than the tumor, and in the diredlior. of the thigh, between the two ham-fl:rings ; he then dif- fedled down to the veflels at the upper end of the incifion, which being there deep feat- ed, proved both tedious and difficult* Ha¬ ving come to the veflels, a double ligature was paffed, and the two portions tied iepa- rately, at nearly half an inch diftance. The depth of the incifion made it difficult for any but the operator, and thofe immediately af- fifling him, to fee what was included in the

ligature.

(

[ 173 ]

ligature, and at the time the popliteal artery was fuppofed to be fecured by it. The wound was dreffed up in the common way.

The fecond day after the operation, a pul- fation was felt in the tumor, which afterwards enlarged fo much that Mr. Pott amputated the limb.

It is faid, that the aneuryfm appeared, upon an examination of the limb, to have been In an anaftomifing branch, not in the trunk of the artery.

The following remarks upon this operation will te{id in fome meafure to illuftrate the method recommended and pradtifed by Mr. Hunter.

The mode of taking up the artery in the ham muft be always unfavourable to the fu¬ ture fuccefs of the operation, .if either the artery itfelf fhould be difeafed, or if the tu¬ mor, by being fo contiguous to the violence done in the operation, fhould be affedled by the confequent inflammation ; which feems to have been the cafe in Mr. Pott’s operation, as I underfland two abfeeffes were formed clofe to the fades of the fac.

Had the aneuryfm been fituated in an anaf¬ tomifing branch of the popliteal artery, given

■ 4 off

[ 1/4 ]

off below the ligature, there fhould have been no pulfation afterv^ards in the tumor j and were it in a branch going off above the liga¬ ture, the pulfation in the tumor fhould have continued immediately after the operation, and fhould have been increafed by it; neither of which effefts appear really to have taken place, which throws a doubt upon the litua- tion of the aneuryfm, if the popliteal artery was rendered impervious by the compreffion of the ligature.

Mr. Cline, Surgeon to St. Thomas’s Hof- pital, performed the operation for the popli¬ teal aneuryfm in the following manner, at which I was ;,rcfent; and although not ex- aftly as recommended by Mr. Hunter, it was very nearly fo. The particulars of the cafe I have not received from Mr. Cline, but have taken them from my own obferva- tion, and the information of gentlemen who attended the patient, and were prefent at the examination after death.

The patient was a failor, who came into St. Thomas’s Hofpital to undergo the opera¬ tion for the popliteal aneuryfm.

Mr, Cline made a longitudinal incihon on the anterior part of the thigh, and having

[ 175 ]

I

laid bare the artery, pafled, by means of a tin inftrument, a double tape, about one inch broad, behind the artery, the two pieces of tape lying one over the other ; the piece of tin which conducted the tape was cut off, and a cork, nearly an inch long, was laid upon the artery, and confined 'to its fituation by means of the upper tape, producing in this way a fufficient prefTure upon the veflel included between the ligature and cork to flop the circulation, and confequently the pulfation in the tumor in the ham ; the other portion of tape was left loofe. The inten¬ tion of fecuring the artery in this way, was to comprefs the fides of the veiTel together, and produce an union without ulceration.

The patient went on very well, and the ninth day the tapes were removed, and every thing feemed to be going on very favourably, when the patient was attacked by a fever, (which was fuppofed to be caught from ano¬ ther patient in the fame v/ard) of which he died.

Upon examining the (late of the limb after death, it was found that ulceration had taken place through the whole extent of the artery included in the tape ; and finufes v/ere formed

. I both

\

[ 176 ]

both upwards and downwards, in the courfe of the thigh, to fome diftance.

I cannot conclude this paper without ob- ferving, that it is feldom in giving an account of a new operation, we are able to colled: materials fufficient to render it fo fatisfadory as the prefent, having in our poffeffion not only the fuccefsful and unfuccefsful cafes, but alfo an account of the appearances after death, under both circumftances, fo that the

caufes of failure are rendered evident in thofe

, ^ '

, inftances in which it did not fucceed, and the means that are likely to infure future fuccefs are clearly pointed out.

The operation is in itfelf Ample ; It re¬ quires but a fhort time in the performance, and produces little, if any, affedion of the conftitution ; but its advantages are more clearly feen by con trailing it with the com¬ mon mode of operating for the popliteal an- curyfm. This is by expofing the fac in the ham through its whole extent, laying it open, fcooping out the blood, fearching for the two orifices leading into it, and taking up the ar¬ tery with a ligature both above and below the fac. When this operation is over, there re¬ mains a large deep-feated fore, compofed of

parts

i 177' 3

parts not perfectly In a natural llate, and In a moft difadvantageous fituatlon ; which fore is to fuppurate, granulate, and heal ; a pro- cefs that Is not foon performed, and which muft leave a ftiff knee for fome time after¬ wards. Yet this is confidering the operation in the moft favourable view, fince there is always a rilk, from the artery being dif- eafed fo clofe to the fac, of the patient- dying from a fecondary bleeding ; and when that does not happen, there Is Hill fome danger of not being able to fupport the conftitution during the healing of a large fore, under circumftances fo very unfavourable.

It is in comparifon with this operation, the only one before in ufe, that the prefent improvement is to be confidered, and it is in this view that I have thought it deferving the attention of the Society.

I cannot clofe this account without infert- ing the following cafe, in addition to thole already ftated, in favour of this operation.' I have received it juft time enough to give it a place, as the paper was in the prefs before it came to hand, and feel myfelf obliged to Mr. Earle for his readinefs in communi¬ cating it.

Hano^

[- 178 ]

I

Hattover-Square^ March lO, 1792.

Sir,

At your requeft I fend you fome account of the following cafe, and am

Your moft obedient Servant,

James Earle,

John Smith, about fifty years of age, was received into St. Bartholomew's Hofpital on account of a fever. After having been un¬ der the care of the phyfician fome time, he complained of a fwelling and pain in his left leg, for which I was defired to vifit him. He faid, about fix months before, he had fallen from a fcaffold ; that his leg was caught between the rounds of a ladder, which broke his fall ; that he felt immediately pain in the upper part of his leg ; foon after it began to fwell, and had gradually increafed to its pre- fent fize. On examination there appeared a large hard fwelling under the heads of the gaftrocnemii mufcles, reaching up to the bend of the leg. A pulfation was plainly to be felt in it, and there was no doubt of its being an aneuryfm. It was now increafmg very fall in fize ; the tumor, by its prelTure, - .► caufed

2

[ m ‘ ]

caufed exquifite • pain,* all. .the lower part ot the leg was loaded with; oedematous fwelling, and it became abfolutely necelTary to performt fome operation to prevent a mortification ta- .king place^

Having noticed with much fatisfaftion the fuccefs which attended Mr. Hunter’s method of tying the artery in the thigh, in a iimilar . cafe, I decided in favour of that operation ; but as, in the prefent inftance, the artery ap¬ peared to be in its natural and perfed; ftate in the ham, and in its whole courfe, till it reach-' ed the dilatation below the knee, I preferred taking it up in that part, rather than to tie it in the middle of the thigh, under the far- torius mufcle^ though it lies there more fu- perficial, and more eafily to be got at ^ be- caufe I thought the chance of the circulation being carried on was equal, if not greater, and if it fhould fail, and fymptoms fhould •occur to create a fufpicion of an impending mortification, there might be an opportunity of removing the limb above the ligature, which would be impracticable if the artery was tied in the middle of the thigh.

Jan. 28, 1792. The patient being laid on jbis face, and the tourniquet loofely applied,

N 2 I made

[ iSo ] .

1 made an inclfion about five inches long, in the direftion of the artery, within thofe ten¬ dons which compofe the inner ham-ftring.

I then gradually feparated the cellular fub- ftance ; in doing this the nerve was expofed, which ran in its ufual courfe, external to the aftery, and rnuch more fuperficial. In find¬ ing the artery, fome difficulty occurred on account of the tumefaction of all the parts* affeCled by their vicinity to the aneuryfm, and from the imperceptibility of pulfation in the artery till it was aClually laid bare : how¬ ever, having difeovered it in its ufual fitua- tion near the bone, and in its natural undi¬ lated ftate, I pafled a ligature round it, about two inches above the tumor. I now again examined, and being convinced that the ar¬ tery was included alone in the ligature, I gradually made it tight, till I felt a pulfation above it, and none below, when I defifled, concluding that any preflure beyond this de¬ gree would be ufelefs and dangerous,

I will juft obferve here, that I found the common aneuiyfmal needle with a handle very inconvenient, and would recommend in , this cafe, where the artery lies fo deep, a

9 blunt

[ iSi ]

blunt femicircular needle, with the eye about half an inch from the end, without any handle.

The wound was clofed in the ufual man¬ ner, and the edges brought together by fu¬ tures. On the following day the man was free from pain, the tumor much lefs tenfe or hard, and the whole leg greatly unloaded. — No perceptible alteration in the heat of the limb could be remarked ; — when the current of blood was obflrudled in the fuperficial veins by prellure, on its tremoval they immediately again became turgid ; and in Ihort every ap¬ pearance indicated a continuance of perfect circulation.

On the 15th day fucceeding the operation the ligature came away, the limb was foft and unloaded, and the incifion nearly healed j at the diftance of fix weeks there remains a fmall tumor, with fome perceptible fludua- tion. The patient cannot perfedlly extend his leg, but is able to walk with the alTifi:- ance of crutches.

X. A

■[ ifSa l]

■ / , 'i ^ :r

* \

X.. A Cafe of Paralyfs of the Mtfcks of De^

.glutition\ cured, by ian artificial Mode of con-^.

■ 'v eying Food and Medicines into the 'Stomachs

r) By John Hunter^ • Efq. F. R. S. Sur-^.

— geon Extraordinary to the King y and Surgeon

General toAhe.Armf^ Read. September 21,

1790* '' ? ,

. V . • -1 i \ ■

*

Diseases which are not mortal in them- lelves, may )ofteri, from their fecondary ef- fedts, become the caufe of death ; but if thefe fecondary effedls are removed, the difeafe fre¬ quently adnlits' of a cure, or even Ceafes of itfelf. 'Thus difeafes, when they attack the vital ^organs, may, from the nature of the parts alone,-' prove fatal; and this will be -fooner or later, according to the particular funftions of the parts difeafed. ; v

Obftrudlions to breathing, to. .the paiT- ing of the urine, to the adi.of "fwallowing, or the difcharge of the faeces, will all terminate in death, if continued for a certain length of time, whatever be the nature of the difeafe.

Difficulty in fwallowing, the fubjedt of the prefen t paper, may arife from a variety of caufes, - . ' lince

[ ^83 ]

fince an obftrudllon in any part of the canal leading from the mouth to the ftomach, will produce that complaint.

The fwallowihg our food is a complicated operation, and includes two different adlions ; the firft of thefe conveys it into the oefopha- gus ; the fecond carries it along that canal in¬ to the ffomach ; and the parts which per¬ form thefe two aftions are in themfelves dif- tin&. ; fo that one may be obftrudled, or dif- eafed, while the other remains perfectly found.

The firft aflion^s often impeded, or wholly prevented by inflammation, but this is felflom of long continuance,* and the cure is probably promoted by the patient’s being obliged to abftain from food. It is alfo impeded by fwel- lings in the neighbouring glands, but this will commonly be in a lefs degree ^ and where 'it threatens fuffocation, or a total prevention of deglutition, the patient can often be re¬ lieved by an operation. '

The fecond adlion is fomfetimes obftrucfted by ulcers in the oefophagus, which have a cancerous appearance ; fom^times ftridluresin that canal, which are of a permanent nature ; alfo fpafmodic contractions, which are com-

N 4 monly

[• i84- ]

monly confounded with ftridtures, but may, I believe, be readily diftinguifhed both frorn ftridlures and ulcerations,

Ulcers and Hridures, from being perma¬ nent difeafes, in the end deflroy the patient j but fpafmodic contradlipns admit of being cured. I have known a cafe of this kind get well in a fortnight from the ufe of electricity, which had not been at all relieved by mer¬ cury, although the mouth was affeCled by it

for a month.

‘ • ... < «

There is another caufe of difficulty in fwaU lowing, which is the reverfe of contraction, viz. paralyfis ; whether the rnufcular coats of the cefophagus are ever affeCted by it, I can¬ not determine ; but the mufcles of the pha¬ rynx have- become paralytic, and the patient has died of hunger.

As this difeafe is only rendered dangerous from the want of a fubilitute for deglutition, jt becomes our duty to adopt fome artificial mode of conveying fopd into the fiomach, by which the patient may be kept alive while the difeafe continues, and fuch medicines may¬ be adminiftered as are thought conducive to the cure.

A fuc-

V

[ i85 ]

A fuccefsful inftance of this pradtice i» given in the following cafe of well marked paralyfis in the mufcles of the pharynx!; the relation of which is given by the patient.

John S - 1, about fifty years of age, be¬

came hypochondriac, and attacked by what arc called nervous diforders, in confequence of anxiety of mind, brought on by various dif- trefles. In the beginning of his complaints, he felt fomething crack within his head, and from that period his fenfations became very acute, his pailions, fympathies, and averfion^, exceedingly ftrong. , .

December 28, 1786, while under the ia- . fluence of an uncommon degree of hypochonf* drlafis, about one o’clock in the morning, he brought up a glutinous fubftance from his ftomach, like the white of an egg, which feemed to relieve him, but did not remove an averfioa which he had taken to his relations, his children, and even to life itfelf, of which he was tired.

JJe afterwards continued affedled with low

I

fpirits and pains in the head, became reftlcfs, and turned his mind to religious fubjedts ; as thefe affedlions either increafed or diminifhed, Jie had frequent and fevere fits of crying.

About

[ i§6 i

About the 2lfl: of Pebroary; 1790; he had a' violent cold in hi^' head,' with a cortfidefable running from %e nofe ; and on the 7th of March;-' between one and two in the morn- fng, '*^^oke with a 'fenfe of choakin'g, and ftlt^foOn after a numbhefs in the whole of his 'fide, together with a paralyfis of the iriufcle'S' of deglutitibh; ' which deprived him cif theipower of ^ '

' ' By the 'advice of ^^ phyliciati hc' was cupped, bliftered round the thtbaf / and eleblrified j he ^fcus/‘in 'the 'meah-^nWb, -fuppbrted by nouriih- ing clyfters. March the 9th, finding no be- nefit^from’ this plan, he waited upon Mr. Huhtet, /Vith a letter from Mr. Gumming, 'Watchmaket, accompanied'^ by Mr. Duncan thefiirgeon^ ' ;

'Mr. Hunter confideriiig-the fupport of the ^tient; and fome mode of adminiftering me¬ dicine; to be the firfl: objeft, propofed that a hollow ‘flexible tube fhould be pafled down into the flomach, through which he ’ might receive nourifhment and medicines; and men¬ tioned his having an inflrument of that kind, riiade of.fpiral wire, covered with gut for the purpofe'ofihjedling liquids into the ftomachs of animals, which might be applied to the - prefent

[ iS7 ]

prefent cafe ; but that Mr. Gumming was better able- to aflift them in getting a tube that would anfwer that purpofe. He alfo re^- commended, when’, the .tube was rnadcy to inject jellies, eggs beat aip* with a' lit tie water, fugar, .^nd milk, .or wine,' ’ by way ’of food, and that the : medicines might be - mixed with] it. . ‘

In Icompliance with .thefe direft ions -they ■ contrived a tube, anddnjedted intp'-the ftomach fome of the abovementioUedifubftances twice a day ; three, drams of valerian we-pe^tn^xedwitli this food, increanng. the dofe^'to^fe dram'S,. Laudanum was given in the dofe^offefty d4*6ps, by clyfter, and afterwards thirty^ drops by^ the mouth 3 but both dofes affedled-the head, with¬ out procuring reft. The valerian-was continued till the 26 th 'of* March, at which time hfc^'liad taken four 'ouhdes, ' and had evidently ireco- vered a degree of fenfation irt his throat. Mr. Hunter wag again confulted, '''and’ ordered twb fcruples of -flour of rhuflard, and one dram, of tinBure of valerian, twice a day ; under this treatment the’ power of fwallowing gradually returned, and on the 29th the ufe of the tube was no longer neceifary. The natural fenfa¬ tion of the throat and right arm had not re¬ turned in the month of April,

The

[ i88 ]

The inftt'ument made ufe of was a frefh cel-fkin, of rather a fmall fize, drawn over a probang, and tied up at the end where it covered the fpongc, and tied again clofe to the fponge where it is faftened to the whale¬ bone, and a fmall longitudinal flit was made into it juft above this upper ligature. To the other end of the eel-fkin was fixed a blad¬ der and wooden pipe, limilar to what is ufed in giving a clyfter, only the pipe large enough to let the end of the probang pafs into the bladder without filling up the pafTage. The probang, thus covered, was introduced into the ftomach, and the food and medicines were put into , the bladder, and fqueezed down through the eel-fkin.

The inftrument did not produce irritation in the fauces or cefophagus \ in fuch cafes, the parts lofing their natural fenfibility, allow greater liberties to be taken with them. An eel-fkin feems vei*y well adapted for this pur- pofe, being fmooth,* pliable, and readily pafTed into the ftomach ; but as cafes of tins kind may occur where eels cannot be procured, a portion of the gut of any fmall animal, as a cat or lamb, will make a vefy good fubftitute.

XL

[ 189 ]

XI. Of a remarkable Deviation from the na--

tural StruBure in the urinary Bladder and

Organs of Generation of a Male. By

Matthew Baillie, M. D. F. R. S.

and Phyfcian to St. George's HofpitaL

Read January 1 8 , 1790.

♦

The fubjeft of the prefent paper does not feem to throw any confiderable light either on the phyfiology or pathology of the hu¬ man body, yet it is not altogether unimpor¬ tant. It exhibits a view of a lingular va¬ riety in a very efiential part of the ftruc- ture of the human body, has been rarely ob- ferved, and, I believe, has not as yet been fully defcribed

The perfon in whom this variety was found was a man of about forty years of age, of a lliort ftature, of a robuft habit, and of a very dilTolute life. Having occafionally got a good deal of money, by exhibiting himfelf to pub¬ lic curiofity, and having acquired habits of idlenefs, he very readily fell into drunkennefs.

There is a Hiort hiftory of a fimilar monftrofity, by James Mowat, furgeon at Langholm, in which many particulars hav« been omitted, Vid. Edinb. EJajs, Vol. Ill, article 14.

the

[ 190 ]

the moft prevailing vice among the lower clafs of people. He was at length very rarely fo- ber, and in one of his fits of inebriety he 'died. Through the. kind offices of one of my medical friends, he was brought to Wind¬ mill- ft reet ’ for examination .

>

Description. External View.

In the external view of the abdomen was feen, immediately above where the fymphyfis pubis is commonly placed, a vafcular pulpy mafs, about two inches in tranfverfe diame¬ ter, and an inch and an half from its upper to its lower edge This mafs was feated in a deep bed, fcooped out, as it were, from the lower part of the Ikin and mufcles of the ab¬ domen. When this mafs was examined a little more particularly, it feemed to refemble fomewhat the pofterior furface of the tongue, but without any follicular appearance. In three places it projected into tubercles of no very confiderable lize, and upon two of thefe

the ureters opened. At the upper edge of

.<

This pulpy mafs was covered with a thick layer of vifcid

*

mucus in the living body, in order to defend it from the ftimu- lu« of the falts contained in the urinc^

this

[ I9I- J

this mafs. the fkln^was in one part finer than is natural, and a little puckered. This was all the appearance of na^el in this fubjedl, for there was* none in the ufual place. ,, At the lower edge of this mafs, and about. the middle of that edge, were fituated two diftindt rounded orifit^s, which were found to be the openings of the vafa deferentia and veficulas feminales. Between thefe two orifices, and a little above their level, was a confiderable canal, large enough to admit a goofe quill, and leading to the fubftance of the proftate gland.

' About half an inch under the vafcular mafs I have deferibed, the penis was feen, of the common fize v/ith refpeft to tranfverfe dia^ meter, and about a little more than an inch in length. The whole of the upper furface of the penis was fomewhat hollowed, and had a finer Ikin than the common covering of that part. Near its extremity, the canal correfponding to the urethra opened by a pretty large oval orifice. The gkns was of the common texture, but fomewhat different in its fhape, being hollowed upon the upper furface. It was covered by a thicker cuticle than ufual, from its being bare and .expofed to fridlion. Under the glands there was a

loofe

\

i

\ t

[ 192 3

loofe projedion of ikin, correfponding to the preptice. It was conneded to the glans by a chord like the fraenum, but was neither fuffi- ciently pliable- nor large to cover the glans, as in ordinary cafes.

There were two confidcrable oblong fwel- lings at the groin, covered with hair. , Upon the infide the fwelHngs were formed of fat, and had paffing through them the fpermatic chords. They terminated below in a fort of corrugated tuberculated ikin, forming the ferotum. The cellular membrane on the in- fide pf it, inftead of being fpungy as ufual, was of a very firm compact texture. By this membranous texture the tefticles adhered very firmly to the infide of the ikin of the fero¬ tum, and the ferotum was divided into two lateral cavities, by a ilronger feptum than I ever recolledt to have fecn.

Internal View.

Upon the infide, correfponding to the fitu- atlon of the vafcular fpungy mafs, there was a fort of projedtion, not unlike the pofterior outer view of the urinary bladder. It con- filled of an arrangement of mufcular fibres,

fimilar

t 193 ]

fimilar to thofe in the bladder, but fomewhat ftronger, and had opening through it the two ureters. Thefe ureters were of a larger than the ordinary fize, atid had probably been en¬ larged artificially.

This perfon had a cuftom of thrufting a knitting-needle 'up each ureter when he ex¬ hibited himfelf to gratify curiofity, which might, perhaps, encreafe a little the fize- of the ureters near their external openings.

Above this appearance of bladder, there was a confiderable fpace between the muf- culi re(5li abdominis occupied by tendon and the peritonaeum. In^the middle of this fpace palTed the umbilical vein, degenerated into a forf of ligament, fo as to reach' the upper edge of what correfponded to the blad¬ der, where it was loft behind the integu¬ ments. The umbilical' arteries climbed up each fide of what correfponded to the blad¬ der, and loft themfelves behind the integu¬ ments at the fame place with the vein. This place correfponded to the fine puckered fkin above the vafcular mafs mentioned in the ex¬ ternal defeription. . *

Upon each fide of the fubftance corre- fponding to the bladder, the redti mufcles

O paffed.

[ 194 ]

paffed, to terminate in the offa' pubis, at nearly four inches diftance from each other.

Between the fubftance correfponding to the bladder and the redum, were fituated the proftate gland, the veficulee feminales, and the extremities of the vafa deferentia.

The proftate gland was fcarcely one half of its ufual fize, and had an opening ex ter- • nally under the mufcular mafs by a large ca¬ nal, as formerly mentioned. The veficulge feminales were fcarcely more than a third of the ordinary fize; the extremities of the vafa deferentia were enlarged as in the natural ftrudure, and opened by two rounded orifices externally under the vafcular mafs.

The redum was, in its appearance, per- fedly natural, nor was there any reafon to exped it fliould be otherv/ife.

. The penis arofe by two crura from the af- cending rami of the ofla ifchii, being nearly of the ufual fize.

The crura afcerided for 'more than two Inches before they united, and between them was fituated the corpus, fpongiofum urethra?.

In that body was a canal, correfponding to the urethra, having the fame j vafcular lining, and the openings of lacunae. This canal

com-

[ *95 ]

•* i

communicated with a cbniiderable cavity, fituated at the bulb of the urethra, and hav¬ ing the fame lining of membrane with the urethra itfelf. In this cavity could only be feen the orifices of the lacunae, and pofteri- orily it terminated in a cul de fac.

The ere(flores penis and mufcles corre- fponding to the acceleratores urinae, had very nearly the natural appearance, but the tranf- verfi perin^i were feven or eight times larger than ufual. The mufcles about the anus were exacftly natural.

The tefticles were of the common fize^ but the tunica vaginalis was almoft obliter¬ ated on each fide, probably from inflamma¬ tion. Their texture was perfedWy natural; 'they were fuppliedin the common way with blood- veffels, and the vafa deferentia and epi- dydimis feemed of the ordinary flrufture^ The vafa deferentia and a portion of the epi- dydimis were injected with qilickfilver, to fhew that the canals were pervious. On- each fide the cremaflier mufcle was ftronger than I almoft recoiled: to have feen it in any body* There was alfo a hernia upon the right fide, in which a portion of the. omentum w'as

O 2

In

[ 196 ]

In the anterior part of the pelvis, where the fymphyfis pubis is ufually fituated, there was a deficiency of bone for nearly four inches. This was filled up by a broad ligamentous membrane, becoming a fupport to the vif- cera of the abdomen, and keeping fome of the parts which I have mentioned in a fixed fituation. The two acetabula were alfo re¬ moved at fcmewhat a greater diftance from r each other than in an ordinary male pelvis.

In every other part of the body of this per- fon, the ftrudture was perfedtly natural.

Such are the particulars of this very un¬ common monftrofity, and they afford very little room for refledUon.

It appears clearly, from the account wa have given, that this perfon was in every re- fpedl a male, and had no mixture whatever of the other fex. The tefticles and vafa defe- rentia were natural, fo that the fecretion of the femen could take place as in ordinary cafes.

This ftate of the tefticles was probably ac- companie'd by the venereal appetite as in or¬ dinary men, but ftill he may have been faid to have been impotent.

The

[ »97 ]

The vafa deferentia terminated by two ori¬ fices at the lower part of the abdomen, and there was no canal by which the femen could be ejected with force fufficient for impreg¬ nation.

The proftate gland too and veficulas femi- nales were in this perfon of a very diminutive fize, fo that their fundlion, whatever it may be as fubfervient to impregnation, was pro¬ bably imperfed:.

The openings of the vala deferentia did not bear the fame relative fituation to the pe¬ nis as in the ordinary ftrudure j yet I have no doubt that titulating the glans, fo as to produce eredion, promoted the fecretion of the femen as in common men. We are led to this opinion from confidering the general ftrudure of his organs, and it is in fome mea- jfure confirmed by the imperfed knowledge we have of his life. There was a woman who lived with him as his wife or miftrefs, and, from his very impudent behaviour in the . company of women, he would appear to have been fufficiently falacious.

The want of a bladder in this perfon fiiews Amply, that it is not a part effentially necef- fary to the body, but is only a refervoir to

O 3 , contain

I

[ 198 ]

.contain a certain quantity of urine, for the greater convenience of the animal. This might be readily inferred a priori from rea- foning, without a lingle inftance of it having occurred ; but it is certainly known from the claffes of animals in whom no bladder is na¬ turally found.

The deficiency of the pelvis at the antCr rior part, and the difcance between the two acetabula being a little greater than ufual, had feme effed: upon his manner of walking. His ftep was lefs firm, the lateral motion of his body greater, and his progrefs confequently flov/er, than in common men f.

* Since this paper W3.s written, I have met with a njonftrofity cf the fame- kind, in a young man about twenty, who is a na¬ tive of Cologne. . In the external appearance of the abdomen there is no difference between this cafe and that which I have deferibed, except that in the former the vafcular pulpy mafs was more protuberant than in the latter, and the opening of the ure¬ ters more dependent. The conjeflure which I have formed about the venereal appetite is confirmed by what I have learned from this perfon. His penis is often ereded at the view of fe¬ males, but, from the ftrudure of the parts, he is incapable of producing impregnation. — A defeription of the external appear¬ ance of the parts in this perfon has, I underfland, been given by profeffor Bonn of Amfterdam,

/

V.

/

PLATE

m

I

[ 199 ]

y '

\

L A ^VI.

A. Pulpy vaFcuIar mafs. "

’The ‘appearance of a cicatrix in the I ^ . 'ikin, ''as a fubftitute for .the navel. C. The penis, with an orifice feen upon V, ' its upper furface; and- under it a rrr, thick fold of Ikin, ‘as a fubftitute ' for the prepuce. ■ ■ : ! - / 's p, D.. The fcrotumr; with hairs upon it.^

: O 1

- , i- - i .

' 1 r I

- y ^

j K / \

■^v

.1

.. * * ’

• ■ < it.

/ (0:i.

" {

* *■) j t'

-f 1

r r

I

• e \

i. 1 « .

X -

* A

■ \ r ^ \ rv , ^ -j .

— * • * •m/ J ^ i ‘ -

O4 PLATE

[ 200 ]

L A T E VII.

F I G. I.

' I

• 4

A A, Portions of the mufculi re6li abdo¬ minis, feparated at a confiderable . diftance from each other.

B. * The umbilical vein feen over two

briftles, Ihrunk into a folid mafs.

C. The poflerior view^ of what corre- * fponded to the bladder, with the

two ureters feen entering into it. The ureters contain bougies.

D. A fmall imperfed proftate gland.

E E. Very fmall imperfect veficulae femi- nales.

F F. The vafa deferentia.

G. The reftum, with its internal vafcu- lar membrane feen.

H H. The origins of the corpora cavernola penis feparated at a great diftancc from each other.

t

FIG.

I

f

4m

;V<.»vij.»/,;.»'

■'. *i

:.}>t^}

:?>\v ■-■ ■• .--:5/.‘.^;:v-i?-ijs'5^

•** *'~* ' ^

4\'-V!.tf}

:a^.'

V'*-

^ . . t^e\.

sfi**«'

V ■- V ' -" -

■: ■ ; :• i

Mat

ii*

.sw41

s*

:9Sfe«^

y

[ 201' ]

F I G. IL

*

Two Lcvugies In the external open¬ ings of the two ureters upon the pulpy mafs.

Two briftles in the openings of the . veficulse feminales, and a bougie in an opening , which led to the proftate gland.

V /

XII,

[ 202 ]

XII. A'Cajh (^Emphys^ema,' 7tot proceed- ing from local Injury, By Matthew Baillie^ M.D. 'F.R.S. Bhyjician to St. George's Hofpital^ Read yuly 19, 1791.

I HAD lately an opportunity of obferving gi very uncommon appearance of difeafe in the living body, as well as of examining its ex¬ tent after death.

Margaret Buck, aged about ten years, was admitted nearly three months ago a patient Into St. George’s Hofpital, with anafarca and afcites. Two days before her death I was defired by the apothecary of the hofpital to fee her, as Dr. Ford, the phyfician, who had for fome time attended her, could not come on that day to the hofpital. When I faw her lying in bed, her appearance differed in nothing from that of a perfon highly anafar-' cous, nor fliould I have at all fufpedled that there was any peculiarity in her complaint. Upon attempting to feel her pulfe, however, I was furprized by the crackling of air under my fingers, and the fkin was confiderably 9 elevated.

[ 203 ]

,elevated, fo that the pulfe by that means was indiftiinftly felt. I then preffed upon the ikin of the back, breaft, beHy, &c. and there was the fame crackling of air. Air was alfo felt in the cellular membrane of the infide of the ‘thighs. There was at the fame time a confiderable quantity of water accumulated in the cellular membrane of the legs and face, as , could be readily diftinguiflied by the doughy feeling upon preffure. The girl her- felf lay in a fort of ftupid ftate, expreffing, however, a fenfe of confiderable pain, and having a good deal of difficulty in breathing.

After having examined the patient I fent for Mr. Walker, one of the furgeons of the hpfpital, who was at that time in the houfe, that he might have an opportunity of feeing ,this very curious appearance of difeafe, and defired that fmall openings might be made through the ikin for emptying the air. The patient died on the next day, and I took an .early opportunity of examining the full ex¬ tent of the difeafe by diffedlion.

Air was found diffufed through the oellular membrane of the trunk, arms, thighs, &c. as formerly related. Upon making an opening

into

[ 204 ]

into the cavity of the abdomen, the ftomach was found diftended, alinofl as far as it could ftretch, with air, and the whole inteftinal ca¬ nal was moderately filled v/Ith it. The air too had penetrated into fome parts of the cellular membrane of the ftomach and inteflines. The laminss of the peritonaeum, compofing the mefentery, were feparated at fome dif- tance from each other by the air which oc¬ cupied its cellular membrane, and the friiall vefibls running upon the ftomach and intef- tines were univerfally filled with it. There was about a gallon of water in the cavity of the abdomen.

Upon opening into the cavity of the chert, a great quantity of air was found in the cel¬ lular membrane between the pleura and the pericardium, but none could be difcovered in the cellular membrane connedling together the air cells of the lungs. A confiderable quantity of water v/as found in the cavity of the pericardium, and about two pints in the left fide of the thorax.

What Is remarkable in this cafe is, the colledion of air without any external inju¬ ry in the cellular membrane of any part of

the

[ 20,5 ]

the body. Emphyfema generally fpread over the body has been obferved to take place in two ways ; the one way is, by air efcaping into the cellular membrane of the body, in confequence of the lungs being wounded by a broken rib ; the other way is, when air is generated by a putrefadlive procefs, as occa- fionally happens in mortifications. Neither of thefe could have been the caufe of em¬ phyfema in the cafe which I have related.

I ft. It did not arife from any accident, as that of a broken rib wounding the lungs. We are perfedlly clear upon this point from the following circumftances, viz. when in¬ quiry was made, the patient could recoiled; no injury nor violence whatever having been lately done to her cheft, and upon examina¬ tion after death the ribs were all found to be entire.

I

2d. The emphyfema did not arife from putrefadtion . There was no fign of putridity whatever in the patient before death, and upon preffing out the air in our examination after death from different parts, there was no fetid fmell to be perceived, even in the fmalleft degree.

4

There

' [ 2o6 ;i

There are two ways in which emphyfeiiia,^ not arihng from external injury, particularly when preceded by anafarca, may be fuppofed to be produced ; the one is, that the watery fluids, poured into the cells of the cellular membrane, may undergo fome chymical change, by which ^lir is feparated from them; the other is, that the fmall blood-vefiels diflributed on the cells of the cellular mem¬ brane, may have fome power, under parti¬ cular circumftances, of fecreting air, which is afterwards accumulated in thefe cells* Which of the two was the caufe in the prefen t in- flance I will not politively determine, altho’ I am inclined to think it was the latter* In cafes, however, of emphyfema, generally 2ivit fing without external injury, I fliould not hefitate to believe, that the moft frequent caufe is, the fecretion of air by the fmall blood-weflel-s diflributed upon the cells of thd cellular membrane.

That the blood- veflels have this power, there ,can be no doubt. Complete bags are found in fome animals, containing air, being part of their natural flrudture, as for inftance- in many fiflies. The air could, under fuch circumflances, be feparated only by the fmall

veflels

[ 207 ]

veflels diftributed on the bags themfelves.. Complete bags, containing air, are fometirnes found attached to the mefentery of pigs, where it could not enter ab externo. It is very probable alfo, that in cafes of tympa¬ nites the air is fecreted by the Ifnall veflels opening upon the villi of the internal mem¬ brane of the inteflines, and thrown into their ‘ cavity*.

There is no difiiculty in our conceiving the poflibility of this adtion of the blood-veffels taking place ; it is juft as eafy to conceive air fecreted from the blood by the action of the velTels, as the fecretion of the bile, milk, or any other fecreted fluid How far the air found in the fmall blood-veflels of the fto- mach and inteftines in a dead animal is to be confidered as a decided proof of this opinion, I will not abfolutely determine ; but moft commonly where I have found air in the in-

* Mr. Hunter has,_taken notice, in his Efiay upon Digeftion,

of a power in blood- veflels to ft Crete air ; and he has illuflrated

it by fonie of the examples here given, as well as by others.

*

f What is the peculiar procefs of air being feparated from the blood in the blocd-vellels, I cannot pretend to fay; but wc arc equally unacquainted with the peculiar procefs which takes place in the feparation of any other fluid from it, *

teftlnal

[ 2o8 ]

teftinal canal, I have alfo found it in its fmall blood- veflels. The time taken up* by this procefs in the prefen t cafe was fhort ^ the emphyfema had not been obferved by the phyfician, who had feen the girl two or three days before that on which I was defired to vifit her ^ and Mr. Dampier, the apothecary, told me, that fhe had fwielled fuddenly about a day before I faw her.

Cafes of emphyfema arifing -»without ex¬ ternal injury or putrefaction, are extremely rare. In looking over a number of books, containing accounts of cafes and ’diffeCtions,

I have found only one example at all analo¬ gous to the cafe which I have related. It is defcribed in a collection of medical cafes U publhlied by Dr. Sickel, 1744 In the cafe to which I allude, emphyfema is faid to have fpread fuddenly over the body of a wo¬ man, aged above forty, without any external injury whatever, and on the next day to have left her in good health.

The account which the doCtor has given of the caufe of this complaint is, that, a lit¬ tle before its appearance, the , woman .had . eaten fome muftard-feed and eruca along .

* Vid, Sicelii Decad. quartam, p, 487.

with

I

. $

' [ 209 J

with a fail fa Q-e, which had expanded and fet in motion the air contained in the blood, and other humours, in confequence of w^hich it was carried into the cellular membrane pro-, ducing emphyfema. '

I have found fince writing this paper, that Monf Littre has mentioned, that where there is emphyfema from a wound in the lungs, the air taken in by refpiration may be forced into fmall blood- veffels, and carried over the whole body in the general circulation, fo as to affift in producing univerfal emphyfema. The expreliions are as follows in the account given of his opinion L’air etranger tou- jours pouffe peut comme il a efle dit, en-. trer dans les vcines & dans les routes de ** circulation, & par confequent fe repandre ‘‘ par toute Thabitude du corps'^.’' In this opinion I believe Monf. Littre to be miftak^ cn ; and the air let loofe by the v/ound in the lungs, is fufficient to account for the product tion of general emphyfema, without the aid of any other caufe v/hatever. W e fuppofe the air to be generated in the blood-veffels themfelves, and to be thrown out in the fprni pf a fecreted fluid Into the pellular membrari?^

‘ ^ Memoir. Apad. Sciences, 171^. ,

P I Hay'S

I have found too, that Dr. Huxham, in a .letter which he has publifhed in the Medical Obfervations, has mentioned as a conjedture the formation of elaftic air in the blood- veflels; but he has confidered it as a putrefadlive pro- cefs, and connedted only with putrid difeafes. His words are, and it is not improbable, that elaftic air may be generated even in the arterial and venal fyftem, and be produdlive of terrible fymptoms, vaft oppreffion, an- xiety, palpitation, intermitting pulfe, de- liquium, &c. which are too often obferved tovyards the end of putrid fevers We confider, however, the air depofited in the cellular membrane, in the cafe we have related, as having no connedlion with a pu- trefadlive procefs, but as being formed from the blood itfelf, by fome peculiar arrange¬ ment of its parts, and condudled into the cells of the cellular membrane by very fmall veffels. The opinion, therefore, brought for¬ ward in the prefent paper, is widely different from all of thefe 3 we believe it to be new, and we have been chiefly led to it by what

* See Medical Obfervations, Vol. Ill, p. 33. where a cafe is jclated by Dr. Huxham of emphyfema having arifen during the courfe of a putrid fever and fore throat.

Mr.

r

[ 2II ' ]

Mr. Hunter has faid about the formation of air in his Eflay upon Digeftion.

Whether the air contained in the cellular membrane and the inteftinal canal of the girl, whofe cafe I have related, was the fame, I cannot poffibly determine, becaufe I did not, at the time of examining the body, think of colledling the air; it is probable, however, that the procefs of forming air was exadlly the fame over the whole body, and therefore that the air itfelf, or the refult of that procefs, ^ was the fame like wife, I have twice exa¬ mined the air which is accumulated in the inteftinal canal. It was not inflammable, but, on the contrary, extinguifhed flame ; when made to pafs through lime-water, it rendered it turbid, and chalk was depofited. The air is, therefore, either entirely of that fort called fixed air, or at leaft that air is in fome very fenfible proportion I am not, however, fo much accuftomed to chymical experiments, as to be fatisfied with rny own examination of any fubftance whatever in that way.

* Dr. Pearfon has informed me, that he has examined fQme air from the inteftinal canal very lately, and that it confifted of iixed and phlogifticated air, the firft in a fmall, and the laft in 9 much larger proportion,

p 2 XIII. J

/

[ 212 3

XIII. A Cafe of unufual Formation in a Part of the Brain. By Mr. A. Carlisle; communicated by Dr. Bail lie. Read OB. 25, 1791.

MarY' Harvey, a woman apparently near tvveaty years of age, was admitted into the Weftminfter Hofpital on the 2d of July, 1791, with an ulcer alfedting the tarfal bones of the foot, and her general health being much impaired, die was advifed to have the -foot removed. The operation was performed by Mr. Lynn, on the loth of July, but a confiderable degree of fever fupervening, to¬ gether with great irritation, the died about eight days afterwards. In the courfe of exa¬ mining her body, which was done in prefence of Mr. Morel, one of the furgeons to the hof¬ pital, we proceeded to inquire into the ftate of the brain; and, upon removing the dura mater from the fuperior part of the cerebrum, a very uncommon appearance prefented itfelf. The falceform procefs was entirely wanting ; the lower edge of the triangular cavity, form¬ ing the fuperior longitudinal iinus, proje(2:ed ; but there was no portion of the dura mater

■whatever

f 213 ]

whatever appended to it, and this defeft pre¬ vailed equally from the crifta galli, backwards to the tentorium. A depreffion was evident along the middle of the fuperior^part of the cerebrum, about half an inch deep, which correfponded to the lower edge of the fupe- rior longitudinal linus ; but this v/as limply a depreffion, for there was no feparation of the cerebrum, as is ufual, into two hemi- fpheres, it being completely formed of one fubftance. Although much care was taken in the diffiedlion, and a very ffiarp knife ufed, yet not the fmalleft , portion of pia mater could be traced in the fituation of the natural cleft ; a tranfverfe fedtion was then made through the cerebrum, keeping above the level of the corpus callofum, but ftill no veftiges of membrane, or of cineritious fub- fiance, or of previous inflammation or adhe- fion, were to be found; fo that it fliewed every appearance of this being the original formation. The union of what ought to have been the hemifpheres, extended down to the corpus callofum, which was difficult to be diftinguiffied from the common medullary fubftance of the brain. Every other part of this organ was in a perfectly natural ftate,

P 3 excepting

[ 214 ]

excepting that the opening in the tentorium, through which the cerebrum joins to the cerebellum, appeared larger than is common. The woman, previous to the operation, had her intelleSual powers as perfedl as people ufually have ; and fhe was not obferved to complain of any particular affection in her head. I mention thofe circumflances, to fhew how little we know of the phyfiology of the body, as conned:ed neceflarily with its ftrudture ; for had the prefent appearance been difcovered in diffecting the body of a man, who had been fubjefl: during his life-r. time to any diforder which had been fuppofed to depend on the brain, it is more than pro¬ bable that it would have been affigned as the caufe of the malady. Such cafes, however, as the above may teach us, that although the formation of an organ in the animal body fhould be conliderably varied from the cufto- mary plan of nature, yet the perfedl and ufual fundlion of fuch a part may be carried on fo well by this fubftituted modification, that we can hardly call it an imperfedtion.

XIV. Hi^ory

[ 215 ] I

XIV. Hijlory of a fatal Hamorrhage from a Laceration of the Fallopian Fiibe^ in a Cafe of an Extra-uterine Foetus, By John Clark’E, M. D. Phyftcian to the General Lymg-in Hofpital in Store-freety and to the Afylum for Female Orphans, Read OB, 25, 1791.

►

To Dr. B A I L L I E.

Dear Sir,

t

I WILL trouble you to communicate to the Society the following very remarkable hiftory of a cafe, which, in fome refpedls, is different from any, which it has occurred to me to meet with in the books that I have read.

It is accompanied with a drawing of the parts : and, as a farther demonftration of the fadts, I will beg you to fliew to the Society the preparation of ' the parts from which the drawing has been made, which both exhibits the ftrudlure ariling from impregnation, and alfo the lacerated furface, and the coagula at the extremities of the veffels.

I am.

Dear Sir,

Yours, &c.

John Clarke.

P 4 HIS.

[ 2i6 j

HISTORY.

The fubjecfl of the following cafe was a

tnafried woman, about thirty years of age.

Previoully to the attack of the complaint

which dejftroyed her, fhe had been occaiion-

ally fubjedt to fome bilious complaints : in all > •

other refpedts flae had enjoyed a tolerably good Hate of health, and had borne one child. About two months before fhe died, fhe per¬ ceived a return (as fire thought) cf what fhe called her bilious complaints, on account of which fhe took, of her owm accord, fome medicines, which fire had been accufLomed to employ upon fimilar occafions ; and fhe paid fo little attention to an obftrudlion of the men- ftruous difcharge for one period, as never to ha'/e mentioned it to her hufband, nor to her apothecary, until a few days before her death.

On the 1 2th of May, 1791, lire went into a warm bath, with a view to relieve her bi¬ lious complaints, and on Friday, the 13th of the fame month, in the morning, without 'any previous exertion, fhe was fuddenly feized with a violent pain in the lov/er part of her

belly.

C ^17 ]

belly, on account of which fhe lay down upon a fofa in the room, where (he fell into a faint¬ ing fit, from which, after a few minutes, fhs recovered*

At this time fhe fent for her apothecary, a very fenfible and intelligent man, v/ho, as fhe ftill complained of great pain, took away about eight ounces of blood, fuppofing that there might be inflammation in fome part of the cavity of the abdomen, and directed her to take fome laxative medicines, in order to evacuate the inteftines, which were attended with the defired.effed:. The: pain, however, ftill remaining, he exhibited an opiate to pro¬ cure relief, which it did in fome degree, tho’ 1^0 1 entirely. . : '

Ke kept the bowels open, and palliated the pain by 'anodynes taken internally, thrown up the redtum by’ clyfter, and applied externally by fomentation, which formed the plan of. treatment, and was purfued uniformly through the Vv^hole courfe of the difeafe. — Neverthe- lefs the pain was not removed by thefe means, but returned with great violence by paroxyfms, both in the belly and near the loins, and was generally accompanied with vomiting, , yawn¬ ing, and fainting. The pulfe during all this^

time

[ 2l8 ]

time was not frequent, and the tongue was of its natural colour.

By the frequency of thefe attacks her ilrength was very much reduced ; neverthe- lefs, oii Monday (May i6th) llie thought herfelf rather better in the courfe of the day; but towards the evening her pain returned with aggravated violence, and fhe became extremely faint and low.

At this time I was defired to fee her. I found her extremities in a cold fweat : — there was no pulfe at the wrift ; fhe was ex¬ ceedingly reftlefs, and almoft incapable of Ipeaking (though fhe had within a quarter of an hour been very fenfible) ; flie became in a few minutes more and more refllefs^ more and more faint, and expired.

After her death we were defirous of afeer- taining by difleftion, if it were poflible, the caufe of this uncommon difeafe, which proved fo fuddenly fatal ; and having obtained leave from her relations, we examined the body on the following day.

Upon dividing the integuments over the cavity of the abdomen, we were ftruck with the gufhing of blood in large quantity, which, when collected, amounted to nearly a , gallon.

[ 219 ]

gallon. It was partly fluid, and partly coa¬ gulated. When we had cleared away the blood, the vifcera prefented themfelves not only free from any appearance of inflamma¬ tion, but even more pale than they are com¬ monly found.

We now fought for the fource of the he¬ morrhage in the fituation of all the large velTels near the liver, fpleen, mefentery, Szc. but in vain. Upon taking hold of the uterus, it felt more pulpy than it commonly does, and was enlarged rather beyond its natural lize in an unimpregnated ftate. Pafling the hand into the cavity of the pelvis, in the pofterior chamber, to wit, between the broad ligaments and the rectum, I perceived ftill remaining there a quantity of coagulated blood. This I removed, and, after having carefully examined all the furfaces, difcovered a lacerated appear¬ ance, furrounded with maflcs of coagulated blood, in what at that time feemed to be the right ovarium. I therefore cautioufly removed the uterus with its appendages, and referved them for farther and more accurate invefliga- tion than could at that' time be afforded.

When the blood was removed from the part (which in the confuflon occafioned by

coagula

- [ 220 [

cOiigula appeared to be the right ovarium) a

laceration was found to be in the Fallopian

tube, about an inch and an half in length,

each extremity of wdiich was about an equal

diftance from the rcfpecftive termination of

the tube in the fimbriae and in the uterus.

*

The diftention of the tube at this part was nearly of the fize of a large walnut, form¬ ing a kind of pouch. More of the coagu¬ lated blood being removed from the lacerated part, the fliaggy velTels of the chorion im¬ mediately appeared, interfperfed with fmall coagula, and lying in contaft with the inter¬ nal furface of the pouch formed by the Fal¬ lopian tube : thefe being feparated, and the chorion divided> the amnios ihewed itfelf, containing a foetus perfeffly formed, of about fix or feven weeks growth. The Fallopian tube was pervious, both leading from the’ fimbriated extremity to the pouch con¬ taining the ovum, and from the pouch to the infide of the uterus, fo as to be capable of containing a briftle. The dianieter, or calibre of the tube between the fimbriae and the pouch, was rather larger’ than it is ufually found in the impregnated ftate. The right ovarium was the next objedl of examination,^

in

[ 221 ]

in which a large corpus luteum was found, occupying nearly half of the fubflance of the ovarium.

Laft of all the uterus was examined. This vlfcus (as I have already remarked) had a pulpy feel, and was larger than it is com¬ monly found in an unimpregnated ftate. Up¬ on cutting it open, two things worthy of tice appeared. Fir ft, the whole of the cer¬ vix was filled with that gelatinous matter which is not found except in the ftate of preg¬ nancy. Secondly, the whole of the body and fundus of the uterus was occupied by the membrana decidua, into the cavity of which the briftles inferted into the two Fallopian tubes penetrated.

Such were the appearances in this fingular cafe ; to which I beg the liberty of fubjoin- ing a few obfervations.

So many cafes of extra-uterine geftatlon have been recorded by various authors, that they ceafe to be matter of furprife. They have clearly proved the feat of impregnation to be in the ovarium, and have marked the progrefs or route of the ovum towards the uterus, 'its final deftination. They have alfp eftablilhed thefe points ; that the uterus has

HQ

>

t 222 ]

no exclufive power of forming or nourifhing a foetus ; that, in fad, it does not poflefs the former property at all, and the latter only in common with other parts ; but that it is only better calculated for this fundion by its be¬ ing entirely appropriated to it, and by having an external opening for the expulfion of the foetus.

One thing particularly deferving of notfce in the prefent cafe, is the formation of the membrana decidua in the uterus before the ovarian ovum ^ had reached it.

For the knowledge of this fad, which is eminently confirmed by the prefent cafe, we are indebted to the acute obfervation of Dr, William Hunter, who, in regard to the ana-- tomical invefdgation of the gravid uterus and its contents, flands high above all compa- rifon.

The uterus then with its appendages, the ovarium and the Fallopian tube, refembles a piece of mechanifm, each of whofe parts has

* By ovarian ovum, I mean the ovum as it comes from the ^ ovarium, or at leaft as it exifls in the Fallopian tube, conhft^ ing of two membranes, the chorion and the amnios, which con* tains the liquor amnii and the embryo, but without the decidua, which membrane is formed by the uterus.

offices

[ 223 ]

offices peculiar to Itfelf, though conducing to the fame general end.

Thus the ovarium, after impregnation, forms the foetus, which, with its membranes, is tranfmitted through the Fallopian tube, whofe particular funftion it is to catch the ovum as it comes from the ovarium, and carry it down into the cavity of the uterus. The office of the uterus is to form the de¬ cidua for the reception of the ovum, to fe- Crete the mucus in the cervix, to nouriffi the foetus during its abode there, and afterwards to expel it ; fo that each part has its own particular duty, feparate and diftindl from that of all the reft. But as each organ, the* individually defigned for certain purpofes, makes a portion of the whole fyftem for ge¬ neration, fo it feems that the fcimulus, or impreffion for aeftion, is communicated to the whole at once, confequently to every part of that whole. From the application of this flimulus, or impreffion for adtion, the ute- rus, as foon as impregnation has taken place, .begins to form the decidua, in order to pre¬ pare for the reception of the foetus. Even if the ovarian ovum ffiould not enter the ' uterus, the organ ftill performs its office,

having

Z

[ 224 ]

t

having already received the flimulus for that piarpofe, in confent with the whole, and in¬ dependently of the fortuitous delay of the ovarian ovum, either in the ovarium itfelf, the cavity of the abdomen, or the Fallopian tube. Another circumftance worthy of re¬ mark in this cafe is, the ficknefs which the patient had attributed to an habitual bilious complaint. There appears to be little reafoii for doubt, that this was occalioned by the ftate of pregnancy; and it feems to prove., that the ficknefs in pregnancy depends upon the general procefs going on, and not on the affedtion of any particular part ; at any rate, it has no connedlion with the refidence of the foetus in the uterus.

But the moft remarkable thing in this cafe, is the laceration of the Fallopian tube, and the fatal haemorrhage thereby occafionc-d, cfpecially when we confider that the patient could not have been in a pregnant ftate more than feven weeks. It is difficult to account for the rupture of the tube, which feems to have happened fpontaneoufly, at a time when the was not only making no extraordinary cx* ertions of body, but none at all, and one could

’ . hardly

V,

[ 225 ]

hardly have believed, a priori, that haemor¬ rhage to fuch an extent could have arifen from the Fallopian tube, even though en¬ larged in its capacity, as happened in this* cafe, from the growth of the ovum in it. It is plain, from a view of the pouch contain¬ ing the ovarian ovum, that the velfels are more numerous than in the natural ftate of a Fallopian tube ; yet ftill it feems very furprif- ing when we confider that the enlarged part did not exceed the fize of a walnut, fo much blood could have been poured out from fo fmall a part.

The firft fenfation of pain complained of by the patient, may be probably referred to the rupture of the Fallopian tube. As both the pain and the fainting occurred by parox- yfms, it is likely that the lofs of blood was reftrained in the intervals by the coagulation of a part of it at the extremities of the vef- fels, and that when the pain was aggravated, it w'as o wins' to an increafe of the laceration, from which more blood being poured out, the patient again fainted.

In hasmorrhages, which take place from parts expofed to the air, perhaps the mere expofure may have fome effedt, by ftirnulat-

ing

[ 226 ]

ing the extremities of the veffels, to produce contractions of them, and fo may reftrain the lofs of blood } but in deep-feated parts, where the temperature is favourable to the relaxa¬ tion of the veffels, the natural means of re- ftraining haemorrhage may be exerted with more difficulty, and therefore a larger quan¬ tity of blood will be loft than could be fup- pofed poffible from fo fmall veffels. But this I offer entirely as a conjedture. .

Upon the whole, the fymptoms which ac¬ companied this difeafe were fuch as could not have led any one to form a conjedhire refpedl- ing the nature of it : and even if it had been known, we could only have deplored the in- fufficiency of our art to remedy a fituation fo uncommon and fo fatal.

V

Expla-

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Flate.

8, p.2Z'J.

[. 227 ]

9

%

Explanation of the Plates*

PLATE VIII.

A view of the Fallopian tube, with the laceration in it. — The chorion and amnios are feen, the latter containing the foetus. — The dark fpots furrounding the chorion reprefent the coagula of blood formed at the extremi¬ ties of the uterine veffels. The briftles are - inferted in the two extremities of the Fallo¬ pian t^be. The upper leads to the uterus ; the lower to the fimbrise.

PLATE IX.

A front View of the Cavity of the Uterus,

A. The mucus in the cervix of the uterus,

formed in confequence of pregnancy, which IS with difficulty expreffed in an engraving.

B. The decidua, extending over the whole

cavity of the body and fundus of the uterus.

C. A fide view of the rupture of the Fal¬

lopian tube, and the foetus feen fuf- pended in the amnios.

0.2

PLATE

i

[ 2a8 ]

PLATE X.

u4 back View of the Uterus.

A. The ovarium cut open, fliewing the cor¬

pus luteum. -

B. A fide view- of the laceration in the Fal¬

lopian tube, with the foetus obfcurely feen fufpended in the amnios.

C. A part of the cavity of the Fallopian

tube feen through a cut made in its fide, with a briftle palling through it.

XV.

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PlatelO.p.zzS.

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[ 229 ']

XV. Some Ohfervations on the loofe Cartilages found in fointSy and mofl coni7nonly 7net with in that of the Knee, By Everard Home, Ef, F, R. S, and Afifiant Sur^ geoji to St, George's HofpitaL

. Such detached and moveable, cartilages as are the fubjec^t of the following obfervations, are not peculiar to the joint of the knee, they occafionally occur in other joints of the body ; but as they are moft frequently met with in the knee, and it is in that joint they produce fymptoms which render them the objedl of a chirurgical operation, I fliall con- fider them more particularly when lituated in that cavity.

Thefe fubftances, in their ftrudlure, are analogous to bone, but in their external ap¬ pearance bear a greater refemblance to carti¬ lage ; they are not, however, always exactly of the fame ftrudlure, being in fome inftances fofter than in others. Their external furface is fmooth and polilhed, which, being lubri¬ cated by the fynovia, allows them to be moved readily from one part of the joint to another, feldom remaining Iqng at reft, while the limb

0^3

IS

[ 23° 1

is in motion 5 when they happen to be in fuch lituations as to be preffed upon with force by the different parts of the joint, they occafion confiderable pain, and materially in¬ terfere with its neceffary motions.

The circumftance of their being loofe, and having no remains of a vifible attachment, made it difficult to form conjedlures refpedt- ing their formation; and I believe that no fatisfadlory account of their origin had been given, till Mr. Hunter’s obfervations threw light upon the fubjedt. The circumftances wffiich led him to the inveftigation of this fubjedt, appear at firft fight fo foreign to the purpofe, that they require fome explanation.

In the courfe of his experiments and ob¬ fervations, inflituted with a view to eftablifh a living principle in the blood, Mr. Hunter was naturally induced to attend to the phe¬ nomena which took place when that fluid was extravafated, whether in confequence of accidental violence, or other circumflances. The firft change which took place he found to be coagulation ; and the coagulum thus formed, if in contadt with living parts, did not produce an irritation fimilar to extraneous matter, nor was it abforbed and

taken

[ 231 ]

taken back Into the conftitutlon, but, in many inftances, preferved its living principle, and became vafcular, receiving branches from the neighbouring blood-veffels for its fup- port ; it afterwards underwent changes, ren¬ dering it fimilar to the parts to which it was attached, and which fupplied it with nou- rilhment.

In attending to cafes of this kind, he found that where a coagulum adhered to a fur- face, which varied its pofition, adapting it to the motions of fome other part ; the attach¬ ment was neceffarily diminiflied by the fric¬ tion, rendering it in fome inftances pendu¬ lous, and in others breaking it off entirely* To illuftrate this by an example, I ftiall men¬ tion an inftance which occurred in the exa¬ mination of a dead body. The cavity of the abdomen was opened, to examine the ftate of its contents, and there appeared lying up¬ on the peritoneum a fmall portion of red blood, recently coagulated ; this, upon examination, was found connedled to the furface upon which it had been depofited, by an attachment half an inch long, and this neck had been formed before the coagulum had loft its red colour.

0^4 This

[ 232 ]

This fteeped in water, fo as to become white, appeared like a pendulous tumor.

- From this cafe it became eafy to explain the mode in, which thofe pendulous bodies are formed, that fometimes occur attached to the infide of circumfcribed cavities, and the prin¬ ciple being eftabliflhed, it became equally eafy for Mr. Flunter to apply it under other cir- cumftan'ces, fince it is evident from a known law in the animal oeconomy, that extravafated blood, when rendered an organized part of the body, can alfume the nature of the parts into which it is effufed, and confequently the fame coagulurn which ' in the abdomen formed a foft tumor, when fituated on a bone, or in the neighbourhood of bone, forms more com¬ monly a hard one. The cartilages found in the knee joint, therefore, appeared to him to originate from a depofit of coagulated blood upon the end of one of the bones, which had acquired the nature of cartilage, and had af¬ terwards been feparated. This opinion was further confirmed by the examination of joints which had been violently ftrained, or other- ways injured, where the patients had died at different periods after the accident. In fome of thefc there were fmall projecting parts,

pra^ter-

C 233 • ]

pra'ternaturally formed, as hard as cartilage, and fo fitiiated as to be readily knocked off by any fudden or violent motion of the joint.

This opinion Mr. Hunter has mentioned for many years in his ledtures, and his argu¬ ments in favour of it are fo confonant to the general laws by which the operations of an. animal machine are regulated, as fcarcely to require further evidence : but the following cafe exhibits fo many fadls in confirmation of this theory, that it appears to me to afford a full explanation of the procefs abovemen- tioned, and completely to eftablifh the opi¬ nion.

' A man, fixty-cight years of age, was brought into St. George’s Hofpital, on the 20th of March, lyqij with a fimple fradture of the right thigh-bone. The fradlure was iituated about three inches below the great trochanter ; it was treated in the ufual man¬ ner, but no bony union had taken place in the beginning of June, about eleven weeks after the accident, the portions of bone at that time being readily moved ’ on each other. There being nothing in the man’s general health to account for this backward- nefs in the parts to unite, he was delired to

explain

[ 234 ]

explain whatever circumftance he was ac¬ quainted with refpedting himfelf, likely to throw any light upon it. This enquiry led the patient to mention, that his right os hu¬ meri had been broken three years and nine months before, but that the bones had con¬ tinued difunited, and admitted of motion more freely at that time, than immediately after the accident.

Reft having proved inefFe<ftual in producing union in the thigh, and it being evident, from the circumftance of the arm, that there was a natural backwardnefs in the conftitution to form bony union, he was directed to walk upon crutches, and to prefs as much upon the broken thigh as the ftate of the parts would admit, without confiderable pain, with a view to roufe the parts to aftion, forcing them by a fpecies of neceffity to ftrengthen the limb. In the courfe of a fortnight there was an evident firmnefs in the bone, and in lefs than two months the patient could walk with the affiftance of a ftick. As there was fome thing uncommon in the cafe, he was al¬ lowed to remain in the hofpital to acquire ftrength ; in this convalefeent ftate he was

feized

[ 235 3

feized with a complaint in his bowels, which was very violent, and carried him off.

After death the thigh-bone was found firmly repaired by bony union, but the bone of the arm, an account of which is more immedi¬ ately to the prefent fubjed, admitted of mo¬ tion in every diredlion at the fradlured part.

The arm was carefully diffedled, to examine the ftate of the fradlured parts, between which there was no callus, but a large bag filled with a glary fluid, refembling fynovia. The inter¬ nal furface of this bag was fmooth, like a capfular ligament, and its attachment to the . bones was of the fame kind : it adhered firmly to the furrounding parts, which were thick¬ ened and confolidated, rendering it very ftrong. The two ends of the bone were adapted to each other, all the irregularities having been abforbed, and their furfaces were of confider- able extent, from the fradture being oblique ; the upper one was (lightly concave, or rather had tw^o depreflions, with a middle ridge; the lower one was fmaller and rounded, and was adapted to both concavities, which re¬ ceived it in the different motions of the parts.

The furfaces of the bones fitted for motion were not completely covered with cartilage,

but

/

[• 236 ]

but ftudded over with it, and the bone was expo fed in the interftices ; a number of pro- jedling parts, covered with cartilage, grew out from the furfaces, fome exceedingly fmall, others large. From the edges of the bones and the capfular ligaments, thefe excrefcences were larger, extremely irregular in their fhape, broader in their attachments, fofter in their texture, and ferrated upon the external edge.

Thirty or forty fmall fubftances, fimilar to thefe .above mentioned, were found loofe in the cavity, varying in fize from that of millet- feed to that of a barley-corn, of a roundilh form, and fmooth on the furface ; the largeft of them were more flattened, and ferrated. Their hardnefs varied confiderably, fome of them being as foft as cartilage, others fo folid as not to be pierced by a needle. Thofe bo^ dies rnuft have been originally attached, and broken off by the friftion of the parts on one another.

The praeternatural cavity which I have de- fcribed, was in its nature and ufe fimilar to the naturally formed joints of the body ; thefe excrefcences and loofe bodies were its princi¬ pal peculiarities, the formation of which ap¬ pears to have been the refult of the violence

co.mmitted

I

[ 237 ]

committed on the parts previoufly to the for¬ mation of the joint, and may be explained in the following manner.

When the bone was broken, the ruptured veflels poured out their contents into the in¬ terfaces of the lacerated parts, for the pur- pofe of uniting them again ; this, however, not taking place, it was neceffary to accom¬ modate the parts to their difunited ftate, to this end the blood, which had now become ufelefs, was in part abforbed, and the new joint formed. The remains of the coagulated blood, which had not given the ftimulus for its own abforption, underwent changes in its nature, affimilating it as much as poffible to that of the furfaces to which it was attached, in fome parts its texture refembling ligament, in others being more allied to cartilage, or bone.

When we compare thefe fubftances with the loofe cartilages found in the knee-joint, which are alfo produced in confequence of accidental violence, and fimilar in their ap¬ pearance, we are naturally led to conclude that the latter originate from extravafations of blood, altered in its nature by the parts in which it is depolited, fimilar to thofe in the

artificial

[ ]-

artificial joint above defcribed. In both cafes they are evidently new formed fubftances, and the readieft mode by which we can account for their producftion, is to refer them thus to the blood, from which fluid every part of the body was originally formed.

Thefe loofe cartilages, as’ they have been commonly called, although they may occur in any joint of the body, are found moft fre¬ quently in the knee ; and in this joint, from the pain and inconveniences they produce, have become the objedt of an operation in furgery.

One or more of them may be formed in the fame joint, I have known one inftance in which there were three ; they are commonly > about the lize of a horfe-bean, often much fmaller, and fometimes confiderably larger; when very large, they do not give fo much trouble to the patient as the fmaller kind. A foldier in the 56th regiment has one nearly as big as the patella, which occafions little uneafinefs, being too large to infinuate itfelf into the moving parts of the joint.

In this difeafe, the removal of the loofe bodies is the only mode of relief ; and it is fortunate for thofe who are afflidted with it,

4

that

[ 239 ]

that the knee-joint is the moll favourable in the body for fuch an operation ; for the ca¬ vity extends a confiderable way beyond the moving parts of the joint, and is continued into parts, which, when divided, will m.orc readily unite than the common capfular liga¬ ments, and be lefs liable to communicate the inflammation that comes upon the wound to the general cavity.

As thefe loofe bodies cannot always be found, no time can be fixed for the operation ; but the patient, who will foon become fami¬ liar with his own complaint, mull arreft them when in a favourable lituation, and retain them there till the furgeon can be fent for.

Before the operation, the limb Ihould be extended upon a table in an horizontal poli- tion, and fecured by means of affiftants ; the loofe cartilages are to be pulhed into the upper part of the joint above the patella, and then to one fide, the inner fide is to be preferred, as in that lituation only the vallus internus mufcle will be divided in the opera¬ tion. Should there be feveral of thefe bodies, they mull be all fecured, or the operation fhould be pollponed till fome more favourable opportunity, fince the leaving of one will fub- 4 jedl

[ 240 ]

/

^ /

jedl the patient to the repetition of an opera¬ tion, not only painful, but attended with fome degree of danger.

The loofe bodies are to be fecured in the fituation abovemen tioned by an affiftant, a tafk not eafily performed while they are cut upon, from their being lubricated by the fy- novia ; and if allowed to efcape into the ge¬ neral cavity, they may not readily, if at all be brou.^ht back into the fame fituation.

The operation confifts in making an in- cifion upon the loofe cartilage,' which it will be bell to do in the diredion of the thigh, as the wound will more readily be healed by tliQ firft intention. If the Ikin is drawn to one fide, previoufly to making the incifion, the wound through the parts underneath will not correfpond with that made in the Ikin, which circumftance will favour their union. The incifion upon the cartilage mufi: be made with caution, as it will with difficultv be re- tained in its fituation if much force is applied. The affiftant is to endeavour to pufli the loofe body through the opening, which muft be made fufficiently large for that purpofe ; but as this cannot always be done, the broad end of an eyed probe may be palled under it, fu

as

[ hi ]

as to lift it out, or a lliarp- pointed inftrument may be ftuck into it, which will fix it to its fituation, and bring it more within the ma¬ nagement of the furgeon.

The cartilages being all extracfled, the cut edges of the wound are to be brought to¬ gether, and, by means of a comprefs of lint, not only prefiTed clofe to one another, but alfo to the parts underneath, in which fituation they are to be retained by flicking plaifter, and the uniting bandage.

As union by the firft intention is of the utmoft confequence after this operation, to prevent an inflammation upon the joint, the patient fhould remain in bed with the leg ex¬ tended, till the wound is perfedlly united, or at leall all chance of inflammation at an end. •

PLATE

r

[ 242 ]

P I. A T E XI.

A Reprejentation of the artificial Joint,

a. The head of the os humeri. h. The fradured extremity of the upper por¬ tion of the bone.

c, The lower portion of the bone.

d, d. The newly formed capfular ligament fur¬

rounding the cavity of the joint.

e, e. The furfaces of the fradlured ends of the

bone, adapted to each other for the pur- , pofe of motion j the upper furface having two' concavities, withl a middle ridge; the lower one being rounded and convex, in fome meafure fitted to move in either of the cavities. Both thefe furfaces are partially covered with a fubftance fimilar to cartilage, in the interflices of which the bone is expofed.

From the furface of the bones arife a number of fmall hard projedting parts, very narrow at their bafe. From the inner furface of the capfular liga¬ ment there are excrefcences of a fofter nature, very large, ferrated on their external edge, and attached by narrow necks. Many of thefe fubftances, both of the hard and foft kind, were found loofe in the cavity, their attachments being broken by the mo¬ tions of the joint.

XVI.

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[ 243 J

XVL An Attempt to improve the Evidence of Medicine. By George Fordyce, M.D. F. R. S. Fellow of the Royal College of Phy-- fciansy and Reader on the Pra^ice of Phyfc in London.

The evidence on which medical know¬ ledge is founded has hitherto been princi¬ pally deductions from the praCtice of medical practitioners, made by themfelves, and com¬ municated to the public. The cafes them¬ felves from which thefe deductions were made have feldom been publiflied ; and when they have, they have principally been of ex¬ traordinary difeafes ; and thefe have commonly been Rated, with a view to fome particular point, in fuch a manner that they cannot be brought as evidence fufBciently accurate to be depended upon.

The following fcheme is intended to make the evidence in cafes more compleat, by dif- feCting them, placing the progrefs of each particular fymptom by itfelf, and fliewing its connection with, and the relation it bears to, the other fymptoms of the difeafe.

R 2

If

t 244 ] • ,

If a perfedl fcheme of this kind was formed, and if a cafe was taken corredtly according to it, it is clear that fuch a cafe would bring into view the whole of its evidence ; and that a compleat colledion of fuch cafes would form ' X. perfedl body of medicine as far as it is hnown. The refult would be, that we ' fliould get rid of that variety of opinion which pervades the whole of the fcience ; and our opinions would be grounded on the folid foun¬ dation of obfervation, and not float, as driven by the mere caprice of practitioners.

A fecond effeCt a perfeCt fcheme of this kind would produce, is putting the evidence which is brought in any cafe in a true point •of view ; and fhowing what is ftill wanting to make it conclufive. .

In this country it is the ufage frequently to employ practitioners who are confidered as of lefs note at the beginning of a complaint ; and afterwards, if he thould not be thought capable of conducting, or df he fliould not cure the difeafe, another is fent for, as fup- pofed of greater fkill. I do not mean to ar¬ gue the propriety of this ufage 5 but as it exifts, it often happens that this fecond prac¬ titioner can obtain very little authentic evi¬ dence

I

V

[ 245 ] ■ ”

dence of what went before in the difeafe, by which he can judge of it. It is meant as another advantage of this fcheme to point out to thefe praftitioners the things they ought to take notice of: and if they fill up the columns of this fcheme at the time, good evidence will always be^ready both to them- felves, and to any other pradtitioner, of what has gone before in the difeafe.

The things to be confidered in a difeafe are divided in this fcheme into thofe which, happen before, or at the time' when^ the difeafe takes place ; and the things ^v/hich happen in the progrefs of the difeafe.

The things which happen before and at the time of the attack are placed in horizon¬ tal columns ; and under thefe the things which happen during the progrefs, in per¬ pendicular columns.

The things which have happened before and at the time of the attack are not after¬ wards changed ; reciting them once therefore is fufficient.

Thofe things which happen after the at¬ tack are conftantly changing ; all thefe are to be enumerated in the order they arife, and therefore mufi; often be repeated. Thefe

R 3 points

[ 246 ]

points are attained by placing them in this order, as is evident from infpedioii of the fcheme.

The firft of the horizontal columns is the climate in which the patient lives at the time of the difeafe. In which we are to remark,

I ft. T he part of the globe where it lies.

The evidence of fcience ought to be per¬ manent ; but towns and kingdoms are fluc¬ tuating, therefore the longitude of a place fl^ould be taken from fome part of the earth which is remarkable, and is likely to con¬ tinue. The latitude is not liable to any error from any fludluation that can happen for many ages.

zdly, The expofure to the fun.

^dly. The winds which ufually prevail ^ and the ftate of the atmofphere they pro- duce.

4thly, The fituation for height compared with the adjacent country, and above the level of the fea.

5thly, The nature of the foil in regard to Its moifture and drynefs-; and the fituation with regard to rivers, lakes, or marfhes.

6thly, The qualities of the waters ufed by ' the inhabitants, and the quantity they are

fupplied

[ 247 J

fupplied with ; as that will often point out the means by which the parts of the food not ufed, as well as all other putrefcent fub- ftances, are carried off.

ythly, The temperature of the atmofphere. 8thly, Any particular effluvia, or other mat¬ ter contained in the atmofphere in confequence of the largenefs of a- town, mode of living of the inhabitants, rnineral effluvia, &c. qthly. The ftru(5ture of the houfcs.

I othly. The modes of living of the inha¬ bitants, by which is meant the ufual manners and cuftoms of the inhabitants as to food, drinks, lleeping, drefs, exercife, and employ¬ ment of time, which often gives light into the nature of difeafes in every part of the community.

As an example I have endeavoured to de- fcribe the clim.ate of London.

London, latitude 51° 31' north, longitude 5' 37^^ weft from Greenwich, 5° 16' 23'^ eaft of the opening into the Mediterranean from the ocean. The town is large for an Eu¬ ropean towm, being in a body about five miles in length, and three in breadth,- befides a •number of rows of houfes lining each fide of the roads going out from it. A mile is 1691,

R 4 6485

i

I

[ 248 . ]

648 5 lengths of a pendulum fwinglng feconds. The greatefl: part of the town is lituated on. the north fide of a river called the Thames. The ground on which this part Hands is an hill, which rifes with a quick afcent from the bank of the river, and then gradually, although unequally, to the north weft, which is the rnoft elevated part.' The river on the fouth fide is confined by an artificial bank, the ground on that fide being flat ; but the water does not ftagnate in the ditches, being kept in motion by the tides. On this fide Hands a confiderable part ‘of the town called Southwark, in a body near a mile both ways : above this there is at prefen t chly a fmali line pf the tov/n on the fouth fide of the river. London reaches along the river fide to the weft, until the river leaves the bottom of the hill and turns to the fouth. Above this the river is confined between artificial banks on

I

both fides, and is lined with houfes till it runs through two old towns, Weftminfter and Lambeth, confifting moftly of ruinous houfes, exclufive of the river, about a mile in length and breadth.

London is furrounded, befides the houfes >v’hich line the roads, with many large vil-

lages ii

[ 249 ]

lages ; efpeclally from the weft by the horth to the fouth-eaft.

The river Thames runs through a valley upon a bed of gravel, and probably clay un¬ der it, for many miles above and below Lon¬ don. The valley is bounded on both fides by hills not exxeeding four hundred feet in height. Where the river runs in the middle of the valley, it is fecured by artificial banks on both fides, which have lafted longer than the memoxy of hiftory, extending in all more than thirty miles. Thefe banks, when the river walhes the bottom of the hills on either lide, are only continued on the oppofite fide. When not encreafed by either rains or the tide, the river is about a quarter of a mile broad, not more than twelve feet deep, and now and then in very dry feafons it has been forded by horfes. The tide in this river rifes above fifteen miles higher than London. At London it rifes at fpring tides from twelve to fourteen feet. The water is very pure fomeu miles above the town ; near the town it is mixed with mud, and contains a fufficient quantity of mucilaginous matter to putrify. When preferved in calks it purifies itfelf by putrefaftion, and remains afterwards more

pure.

[ 250 ]

pure, but it never putrefies fenfibly in the river, nor in the cillerns in which it is fome- times kept for a few days for ufe. At the lower part of the tow^n it contains a little fea- falt when the tide is at its height ; but this does not reach to the middle of the town. Its fpecific gravity is the fame with that of diftilled water. The inhabitants are fupplied with this water, which is pumped up by fe- veral engines, principally worked by fire, into their houfes.

The town is alfo fupplied with water by an aquedudl, which is brought' from more than twenty miles diftance from the north, through a canal of about fixty miles in length. The water of this aquedudl is alfo pure, and unlefs when heavy rains bring down clay, it is bright and clear, and does not putrefy on ■keeping. Its fpecific gravity is alfo the fame with diftilled water. This water, as well as the other, is carried in wooden pipes under the ftreets into the hoiifes of the inhabitants.

There are fprings found on digging every where in the town, which might yield •large quantities of water. Thefe were for¬ merly ufed, but are now little employed, be- caufe the fupply from the Thames and New 4 River

I

[ 251 3

River is much cheaper. The waters of thefe fprings contain a fmall portion of fea-falt, and a larger quantity of magnefia^ vitriolata, fo as ► to be fenfible to the tafte, and fo as in fome places to adl as a purgative. They alfo con¬ tain gas ; fome times in quantity fufficient to give them brifknefs, and render them agree¬ able to the tafte.

Rain water is never ufed, being always very impure from the duft floating in the air, and lying on the tops of the houfes.

The whole fupply of water from aquedufts and engines is 109,440 cubic feet in an hour.

The valley through which the Thames runs is gravelly, generally dry, and not marftiy till about a mile below the town, the water in the river being confined between its banks. .

The hills, or rifings, on which the princi¬ pal part of the town ftands, are moftly a mix¬ ture of clay and fand ; the fand or gravel ge¬ nerally being in rather the largeft proportion. In fome places the- foil is gravel.

• The winds from fouth-weft to north-weft, and from fouth-eaft to north-eaft are the moft prevalent. The wefterly winds blow over the great Atlantic ocean, pafling before they reach London over part of Great-Britain for about

two

[ 252

two hundred miles, and over Ireland when they veer to the north. They are generally moift, although much drier than when they ar¬ rive at the weft coaft of the ifland. The baro¬ meter is generally low when they blow. They are commonly moft prevalent in February, September, November and December. The eafterly winds blow over the large continent of Europe : they are alv/ays dry. The ba¬ rometer is high when they blov/. They are mofl prevalent in January, March, and the heginning of April. They are cold, except fometimes when they blow in July and Au- . guft, while the wefterly winds are almoft al- w^ays warm, except in 'November, if they verge to the north.

The heat of the air is very variable, feldom remaining equal for many daysj and every year differing entirely from the preceding ones, not only in heat, but alfo in moifture, and rain. Sorne times the winter is feverely cold, wdth froft from November till May with lit¬ tle interruption ; fometimes the water is not frozen for more than ten or twelve days. Moft commonly there is a little froft in No¬ vember and December, but otherwife thefe months are ufually very foggy and moift.

The

[ 253 ]

The principal froft generally Is in i January ; February is commonly a mild, open, moift month. March is generally cold and dry. The fummer months vary as much ; fome- times there are three months very warm, fometirnes not more than a week ; the latter half of July is commonly the hotteft. In Auguft heavy rains often fall, efpecially in the laft half of the month. The thermo¬ meter fometirnes rifes to above 8o“ of Fah¬ renheit’s fcale, very rarely to 86° j but the moft common fummer heat is from 65° to 75° : it fometirnes falls in the winter to 15°; it has been known to fall below the point marked o, but very rarely. The moft com¬ mon winter heat when it freezes is between 20° and 30°; the moft frequent when it does not freeze between 40° and 50°. •

The air when dry is always loaded with, and often obfcured by duft, which confifts of afhes and foot arifing from pit-coal, the fuel which is commonly burnt ; horfe dung pro¬ duced, and ground to fmall powder by the numerous carriages drawn by horfes, with which the ftreets are always crowded ; pow¬ der of granite and flints, which form the ftreets and roads, and 'are ground extremely

fine

[ 254 ]

fine by the wheels of the carriages. Thefe powders, with various others, penetrate the houfes every where, and undoubtedly enter the trachea, adhere to the furface of the lungs, and not uncommonly produce cough, with difficulty of breathing, in people on firft coming from the country.

The ftreets are generally wide ; few of them fo narrow as to prevent two carriages 'from paffing, and many of them wide enough to allow five or more to pafs, efpecially in new parts of the town, which form more than half of it ; they are from fixty to twenty feet wide, thofe of great comm.unication fel- dom lefs than thirty, in the old part of the town ; in the new part moft of them are not lefs than forty. In feveral places there are fquares of a confiderable fize, i. e. from about log to looo feet fquare. The llreets are well paved, and clean, potwithfianding the immenfe quantity of horfe dung conftantly falling upon them.

The houfes, except moft of thofe in the oldeft part of the town, which are not more than a fourth of the whole, have a ftory funk under the level of the ftreet. This contains the kitchen and other offices. Below the

level

[ 255 ]

level' of the bottom of this ftory a covered canal is dug under the ftreet, with which there is a communication from the houfes, and by which putrefcent matters fufficiently fluid are carried off. Allies, bones, &c. are conveyed away in carts twice a week. The greateft part of the houfes are of an uniform ftrufture ; in each ftory a large room in front, a fmaller room and the ftaircafe occupy the back part, and there is frequently a fmaller room added behind. There are commonly four ftories belides the one under the level of the ftreet.

The town is fully inhabited ; there is hardly a houfe unoccupied. The number of inha¬ bitants is very little known : calculations of various kinds have been made by many au^ thors i but thefe have been founded on ele¬ ments entirely conjeftural, and are therefore of no ufe. As far as my own opinion goes, and nothing better than opinion can be formed in this cafe, they are about a million. They confift of clafles living in very different manners.

The firft clafs Includes thofe living on their paternal fortune, or riches fuddenly acquired, comprehending a few merchants. The wo¬ men

[ 256 ]

men of this clafs live almoft conffantly in their houfes, which are very clofe, although the rooms are fpacious, and the whole houfe perfedlly clean and neat, or in carriages, with no labour and little exercife. This gives them a delicacy in their appearance hardly to be defcribed. As a flower brought forward by the cherifliing heat of a confervatory, where it is defended from the nipping winds, ex¬ ceeds any thing produced by nature alone, like it they too have a tendernefs of confli- tution, which fubjedls them to difeafe from the flighteft expofure to any caufe. Their lituation, however, prevents them from being often expofed to infedlion or hidden cold, which are the great caufes of violent difeafe in this metropolis. Their complaints there¬ fore are generally flight, and very irregular; nor can they bear medicines in any way of a rough nature. Their diforders mufl: therefore be touched with the flightefl; hand. This has often produced an imbecility of pradlice, not only in London, but throughout* the kingdom, which firfl: infedls the medical people who are immediately employed in the diforders of this clafs. Although there may Ibmetimes perhaps be found one or tw'^o

among

I

^ [ 257 ]

' among thefe who are not the moft learned or judicious practitioners, yet they are the richeft, which contributes not a little to the fpreading of this infection. Notwithftanding the dif- eafes of the women of this clafs are frequent, yet they are feldom fatal, fo that they often live to a great age.

The men of the firft clafs are much in the air in the morning, and ufe exercife. They live in the country part of the year, when they are^often occupied in hunting and fliooting. With fome exceptions, they are of conflitu- tions fufficiently ftrong, are feldom difeafed ; their difeafes are itrong and marked, and they bear the operation of powerful remedies.

The men who are menial fervants of this

t

\

clafs, like the domeftic flaves of the ancients, are idle, lazy, ufe little exercife, none when they can avoid it ^ they are thus rendered ir¬ ritable, and being often expofed to all the in¬ clemency of the weather, in the winter fea- fon often till three or four o’clock in the , morning, they are exceedingly fubjeCl to dif- eafe, particularly of the thorax ; and few of them attain to any great age, except thofe of the higher ranks,

S - The

/

- [ 258 I

‘The women fervants refemble in their con- llitu'tions their miftreffes.

,The clergy are fewer here than in'^almofl any other country in Europe. They are very apt to be affected with hypocondriacal com¬ plaints, perhaps from an idea that they do not occupy their proper rank in life. Being in general regular in their manner of living, they often attain to a great age.

The lawyers who are occupied- in- buCnefs, ar-c often, from their great attention and bour of miind, weak, and difordered imdteir primae Yfe.'’ Thofe who are not emiplbyed^ may-^be confidered as in the fame ftateiwith the independent ^gentlemen.

Phyficians are fo few,, thatv.itris: hardly worth enumerating them. • Thef^ are not xmich above two hundred in all, and hot -near half that number are employed in -pradiice. Except when they are cut off by infecftious fevers, before they are habituated to infec¬ tion, although often difeafed,^ phyficians ge¬ nerally attain a confiderable age.

Attornies and apothecaries are to be con- iidered in their manner of liff and conftitu- tions in the order of tradefmen.

Merchants

t 259 ]

Merchants and traders of confequence form the next clafs. The women of this, clafs live a regular life, going to bed generally before midnight, and rifing about nine in the morn¬ ing. Moft families have villas near town, where the women pafs much of their time, efpecially during- the fummer feafon. They are much more in the air, and confequently have neither the delicacy nor the irritability of the clafs we have firft enumerated, enjoy a much’ better ftate of health, their difeafes are more' regular, and they bear the aftion of powerful remedies. . Of the men of this clafs, fome lead a fed^ntary life, ; their tirrie is much employed in writing, generally leaning onr their breafts, fuch are .fubjeft to complaints in their primae vias ; others of them ufe ex- efeife^ efpecially bn horfeback, and often deep in the country: alhof them in point of eat¬ ing are luxurious. ' .

The lell^r tradefmen, Ihopkeepers, and ma- nufafturers, are alfo fober and regular in their manner of life s but they are much confined to their houfes, efpecially the women of this clafs, which renders them irritable and fub- )edi to difeafe, often violent and fatal. Nor is that part of the ^ men whofe bufinefs calls

S 2 them

[ 26o ]

them abroad lefs fubjed to morbid afFeftlon, fo that they rarely attain to great old age.

The laft clafs confifts of the working part of the mannfad:iirers, and labourers of all de¬ nominations - who, with fome exceptions, are the moft diforderly, profligate, debauched fet of human beings perhaps in the whole earth ; working hard, and being dextrous in their occupations, and of courfe earn¬ ing. large fums of money, which they fpend in drinking, expofing themfelves at the fame time to the inclemency of the weather ; al¬ ways idle while they have any money left, fo that their life is fpent between labour and at^ tention above their powers, and perfe(ft idlenefs and debauchery. Their women, alfo paffing from affluence to diftrefs almofl eveiy week, are forced, although foberly inclined, to lead a very diforderly life. Pulmonary complaints are more particularly common and fatal in this clafs, as well as all other difeafes.

London is fatal to infants in general. On a CQuiparifon of charity children fent to be nurfed in the environs, with thofe nurfed in town, it appeared the lofs in town, being thirty- nine, was only twenty-nine in the fame num¬ ber and time in the country. But if this lofs is

great

:[ 26 1 ]

great altogether, it is tremendous among the lowed: clafs, the mothers being almoft always obliged to labour for their bread, and often even robbed, by their hufbands, have no time left to take the care neceffary for the rearing of infants, lb that they are often left to wal¬ low in dirt, notwithftanding the general dif- pofition to cleanlinefs in this country; and can never receive that exercife, or purity of the air, which is requifite ; nor can their food be at all attended to. Add to this, a pernicious prad;ice of continuing to give them fuck for even two or three years, by which they hope to prevent their having charge of many children. This pernicious pradtice goes even to fome mothers of the ranks above this; while mothers in the higher ranks refufe the natural fuftenance to their infants, leaving them often to the care of d rangers, regardlefs of motherly afteffion. From all thefe caufes, the lofs of children in London is more than one half before they attain the fifth year of their age.

The fecond horizontal column in the fcheme, is marked the preceffion of the feafons, or the courfe of the preceding feafons.

s 3

This

as one

[ 262 ]

, This column is meant principally ground of -invelligating the caufes of epi¬ demics.

It is well known that the fame fpecies of dif- eafe fometimes rifes and fpreads through a to wn^ a whole country, nay over a whole continent at one time ; . rages with violence for a certain period, and afterwar# ceafes : when this hap¬ pens, we fay the diieafe is epidemic. I do not mean to enter into the whole hiftory of fuch difeafes, but only to obferve that the different ftates of the human body arifing from the temperature, moifture, &c. of the atmofphere in which a man has lived for a length of time, renders him fubjedt to parti¬ cular difeafes often more than its prefent flate. The inhabitants of the fame town, nation, or even continent, fornetimes are expofed to the fame peculiar ftates of the atmofphere, and the conftitutions of the inhabitants in ge¬ neral are therefore rendered equally fufceptible of being affedted by the caufes of the fame difeafe. If fuch caufes, therefore, diould be generally applied, the difeafes will be univer- fal, or epidemic, over the whole country. If the caufes fliould be partially applied, the dif- cafe will be epidemic in that town or country

where

t 2'63 ]

where they are fo applied • and if they be ap¬ plied no where, the epidemic will not arife, notwithftanding the predifpolition.

For inftance, dyfenteric purgings are often brought on in the autumn by the moffturc and coldnefs in that feafon ; but in other au¬ tumns equally cold and moift, dyfenteric purgings do not happen in the fame number. In fome they are epidemic in an high degree, in others they hardly appear. It is not, there¬ fore, the ftate of the atmofphere at this fea¬ fon that is to be looked on as alone producing the epidemic ; for this would not have taken eifeft if the preceding fummer had not given the predifpolition. Hot and long fummers produce difpofition to dyfenteric purging.

Our fummers fometimes , begin in April, and %

continue till the end of Auguft, with un¬ equal, but fometimes great heat through the whole ; at other times they do not begin till the middle of June, and end in the beginning of Auguft, the heat hardly at any time reach¬ ing to 70“. In the laft cafe there are hardly any dyfenteric purgings' in the autumn, but in the lirft they are very frequent arid violent, efpecially if the cold and moifture of the au¬ tumn come on fuddenly or by fits. .But al-

S 4 though

[ 264 ]

I

though the fummer be hot and long, thefc purgings do not appear if the autumn be dry and warm.

How far we are to carry our refearch into preceding feafons is difficult to fay ; I think I have noticed effedls from three years back. The years 1779, 1780, 1781, for inftance, were years in which the fummers were long or very hot, at the fame time the winters were mild. It is well jcnown that living in warm air gives predifpofition to intermitting and re¬ mitting fevers. At the beginning of thefe three years fuch fevers were very rare, and hardly to be met with ; they began to appear in the fecond, and were very frequent at the end of the third, fo that I took thirteen of them at one time into St. Thomas’s Hofpital, and thefe had arifen in the environs of Lon¬ don, and we were never without many cafes of this difeafe

The courfe of former feafons maybe taken from journals, which are often kept with great care. Where they are kept by any public body, it is no way neceffary for a practitioner to keep them himfelf. A clock would keep

* Many cafes of people with intermitting fever come to the London hofpitals from marfliy parts of the country.

them

/

I 26s ]

them the heft If Mr. Cummins’s principle were adapted to the thermometer, quantity of rain, &c. as it is to the barometer, which might eafily be done.

By marking the courfe of the preceding feafons, it Is probable that great light might be thrown on the decline of difeafes, as well as their fpreading ; but it muft require a long time before much advantage will be gained.

The next column contains the prefent ftate of the atmofphere, which ought to be marked not only at and before the attack, but through¬ out the difeafe. This is difficult, on account of the various things to be attended to, many of which cannot be referred to public or pri¬ vate journals or clocks. The weight of the atmofphere may undoubtedly ; the general moifture may alfo. The wind, which is of con- fequence in this refpedl, that particular winds in particular countries have peculiar effedls. The eaft wind, for inftance, is in this country a drying wind, and produces cold by diffolving moifture, fo as to be felt in^the bed-chamber of a patient in rheumatifm, &c. as is well known. The purity of the air cannot be judged of by any thing external to the cham¬ ber in which the patient is, if he be confined

to

T ?66 ]

to Tiis bed or bed-chamber, 'with any degree of accuracy. Methods have been found lately of afcertaining the quantity of. pure air con¬ tained in the atmofphere,. but thete methods fliew the pure air to be in as great quantity in the atmofphere of a ward of an hofpital, where the infedtion is in the moft violent de¬ gree, as on the banks of a ftrea'm murmuring over pebbles in a gravelly foil.

It does not feem to be the quantity of pure air contained in the atmofphere that is to be fought after, but the various fubftances inter¬ mixed. In the fame manner as it is very dif¬ ferent to the drinker of water, whether he drinks it with a duft of plain fand or arfenic^

The marks of purity in the atmofphere in a room, or rather freedom from noxious va¬ pour or powders, or fmall drops of liquid matter, are very obfcure. A felon brought into a court of juftice, apparently in perfedl health, has, from his cloaths or perfon, fent out fuch a quantity of noxious matter, as to infedt half the perfons prefent with violent fever. Yet the men neareft him, nor in any other part of the court, have been fenfible of the leaft fmell, tafte, feel, or any other fen- fation whatfoyer j fo that unlefs it had hap- : 5 pened

C 267^ ]

pened more than once, or even if it had not happened frequently, no man would have fuf- pedted that the difeafe had arifen from that caufe. Juft as when the venei;eal difeafe firft broke out, no peribn fufpecfted that it arofe from coition, but from fome malignity of the air. The nuns therefore in Paris, in order to avoid this infection, were not clofe ftiut up in their convents, but houfes were fitted up for them in the country, out of the in¬ fection of the air of the town.

» The purity of the atmofphere from infec¬ tious or noxious matters in the bed-chamber of a patient, muft be taken from various cir- cumftances, which our prefent knowledge can give but little direction about. I have often feen a perfon already infeCted and at¬ tacked with fever, go through a fever with as mild fymptoms in a room where there were feveral people ill of the fame difeafe, as another who was kept in the pureft atmofphere that could be procured.- Yet if feveral perfons who had entered the room had been feized with fever, we 'might determine that there was febrile infectious matter. We are, there¬ fore, to take the purity of the atmofphere where the patient is, more from the clofenefs and fize

of

[ 268 ]

of the room, current of air, &c, but the fub- je£t: is not fo far inveftigated as to be capable of being farther gone into. The heat of the atmofphere of the room is of material impor¬ tance to be noted, both for the prefent go-^ vernment of the prad:itioner, and for the evi¬ dence of the difeafe. Heat in medicinal ef- fedt is not by any means to be judged of by the thermometer alone in the atmofphere in which the patient at prefent is. There muft be taken into confideration the temperature he has been 'lately accullomed to. When, therefore, we fay the air in a room is warm, we cannot fix to that idea the name of a de¬ gree in the thermometer. In winter in this country, 6o° of Fahrenheit's thermometer is warm, or rather hot; in fummer 73° is .a moderate temperature. In other countries it is different. There are places in India and 'Africa, where 90^ in certain feafons of the year is cold. Having firfl afcertained what is generally felt warm at feveral feafons in a year, we may then refer it to the thermometer. In London in the cold feafon 55'’ is warm, and in fummer 73°, varying in other feafons be¬ tween thefe two points. It is not here pro¬ per to enter into the effedl of hot and cold

atmo-

[ 2^9 ]

atmofphereS on difeafes. ’ I £ball only men¬ tion one inftance. jt In acute rheumatifm in winter, if the heat be 6o° we £hall rarely have; much metaftafis, while many fhall happen if it be 45° or 50°.

Phyflcians in all ages have been of opinion, that it is of great advantage to attend to the. epidemic difeafes which prevail, not only be- v ' caufe it is ufeful in cafes of the epidemic it- felf, but becaufe the fame caufes which influ¬ ence the body fo as to make it fubjedl to that particular difeafe, render it liable . to be af- fecfled in a peculiar manner when any other difeafe takes place. I might ground, there¬ fore, this column upon the authority of Hip^. pocrates, Sydenham, and various other phy- ficians of great weight. But perhaps it may be ufeful to make fome obfervations to deter¬ mine what particular epidemics are more ne- ceflary to be noted.

Fir ft then, there are certain infecftious dift* eafes that become epidemical. Thefe may arifc from an infedion which produces a dif¬ eafe, which, when it has once happened, does not recur during the life of the perfon, fuch as the fmall-pox. In this cafe it may be, that a community has guarded itfelf againft the

difeafe

C. 27a I

difeafe fo long, that a great number of pei*- fons are liable to the infection* Numerous cafes of fuch difeafe may arlfe on this account, if the infection fhould be. by any accident in¬ troduced into fuch community, (although there be nothing in. the air or the conrfe o£the fea- fons, or any other circumftance, which renw ders men in general at that tirhe more apt tp receive the infection fuch a difeafe becom-' ing epidemic in this manner is not of much ufe to be notedjin this column, as it will not govern in any degree any other, difeafe. But infrequently happens that infectious difeafes, whether they recur but once or oftener in the fame perfon, arife and fpread at times tlifongh a community which has not been guarded againft them,Nor but negligently, as in Lon¬ don, where there is always fmall-pox, and other' fuch infectious difeafes, which recur but once, yet fometirnes they, fpread them- felves much more univerfally than at others, and the fame thing happens in the plague, for the more perfecd hiftory of which phyli- cians are much indebted to Dr. RulTel, and in other difeafes which recur in the fame per- fon more than once. When this happens, there: mujft be fome peculiarities produceddn

the

[ 271 ]

* • ► * the bodies of men in general, which renders

them peculiarly liable to be infected. * Thefe

peculiarities may have confiderable irifltience

on any other difeafe that may arife, but they

have not been hitherto inveftigated with any

degree of precifion. It is, however, "the ob-

objed: of this fcheme of difeafe, to bring out

evidence, and therefore fuch epidemics fhould

always be noted. * "

Another fet of epidemic difeafesf arifing

from caufes that are very commonly applied; '

are not infeftious, therefore the difeafe only

afifes. more frequently in a commttiiity at a

f .

particular time, becaufe the bodies of meri^rt^ general are influenced fo as-^ to be^' rhbre eaiily alFeded by fuch caufesv-' 'Thus ih'lhe fpring^ the bodies of men are rendered fubjed to phlegmoiibus inflammations, in the autumn to dyfenteric affedions. ’ ' ' "

^ Gr there may be dileafes which may arife* either from infedion or without any mfedibn,* fuch as the eryfipeldtous fore throat; often called the putrid or ulcerated fore throat,' which is undoubtedly an infedious difeafe, but which likewife arifes often where there can be no kind of fufpicion of infedion. Thefe certainly become epidemic from their

being

[ 272 ]

being peculiarities produced in the bodies of men of a community, which renders them fubjedt to be affedted either by infedlion or any other caufe. In thefe cafes of epidemics almoft every difeafe incident to the human body is more or lefs influenced by the pecu¬ liarities which occafions the epidemic affec¬ tion, and therefore fuch require very particu¬ lar notice.

The next column Is meant to point out the temperament of the patient. Hippocrates conceived that there were four humours in the body ; blood, bile, black bile, and phlegm : hence men, according as one or other of thefe humours abounded, were faid to be of a fan- guineous, bilious, melancholic, or phlegmatic temperament. This dodlrine pervaded the whole of Greek medicine, and continued through the Arabian during the reign of the Abaflides, and came, with other Greek and Arabian medicine, into Europe. The modern knowledge of the fluids of the human body, fliews that the doftrine which treated of thefe fluids was without the fmalleft founda¬ tion. But it often has happened, that ap¬ pearances and differences , have been really marked by phyficians both in health and dif¬ eafe.

t 273 r ■'

eafe, and have been defcribed in words which were only applicable to the hypothefes of the > caufes on which they were fuppofed, to de¬ pend. Although thefe hypothefes are no^ true, yet the appearances which occafioned their formation are perfectly grounded. There does, for inflance,* exift in certain men, born, bred up, and living in all the circumftances of others of the fame community, a difpofi- tion to phlegmonous and general inflamma¬ tion. Thofe who have this difpofition, ' have likewife their difeafes influenced by it, and have been faid to be of a fanguineoiis tempe¬ rament. There are others in whom perfedt regularity takes place in all their difeafes ; dif¬ pofition to regularity is alfo evident in their natural functions. Such have been faid to be of a bilious temperament. Others there are in whom there is great irregularity both ia health and difeafe ; thefe have been faid to be of a phlegmatic temperament. In others there is a degree of intracfl:ability in all their difeafes, as well as in what happens in their healthy ftate ; thefe have been faid to be of a melancholic temperature. It would require a much longer diflertation than can • be allowed here, to point out the various paf-

T fages

[ 274 ]

fagcs ill the works of pradlitioners, to iliew that this was what produced the idea of tem-^ perament. A phyfician, whofe pradlice is in any degree extenlive, muft be very inatten¬ tive not to fee clearly thefe differences, which, however, run into one another in all kind of variety. It is much to be wiflied, that the antient names for them were abolifhed; in the fpecimen, therefore, I have not ufed the term phlegmatic temperament. But whether thefe antient names may be ufed, or whether new ones are to be fubftituted, or general de- feription is to be given, it is a matter of great confequence to be noted, as it "often governs many circumflances in the difeafe. As for example : we fliould expedl in the fmall-pox, -even before the eruption, a great degree of general inflammation during the time of the eruption, if a man had great difpofition to phlegmonous inflammation; but if the patient iliould be fubjedl to irregularity in natural things, we fliould expect that the difeafe, when the eruption took place, would exhibit vvatery puftules, forenefs, great frequency of the pulfe, and the other fymptoms of a difeafe which I have called, in the Elements of the Praftice of Phyfick, fymptoms of irritation.

Befides

[ 275 J

Befides thefe differences in the conflitutioii of the body, which have been marked by phy- ficians in ' alnioft all ages as' nearly general among mankind, there are in particular ha¬ bits peculiarities, which have been called idiofyncrafy, which may have influence in a great degree on the appearance of difeafe, and the effedbs of medicines. I have known, for example, many inftances where the pulfe, in- ftead of going on regularly, has been very ir¬ regular ; in feveral cafes without any other ir¬ regularity it has intermitted, and yet all the fundions of the bo'dy have been carried on perfectly. Perfons have been affeded by opium, purgatives, and various ’ other medi¬ cines, in a manner totally different from the effeds which they produce in mankind gene^ rally. Such circumftances often tend to mif- lead, if they are not known; therefore, form the next horizontal column.

It is fufliciently evident that it is neceffary to note the ufual manner of living of a pa¬ tient previous to the difeafe, as it has not only an influence on the difeafe itfelf and its ap^ pearances, but forms alfo a ground of prac¬ tice. For example : if a man had been ac- cuflomed to drink a large quantity of wine in

T 2 health,

[ 276 ']

health, if he fliould be felzei with a fever, and that fever go on till the ftrength be much exhaufled, wnne mieht be exhibited in con- fiderable quantity ; while if a man who drank no vinous liquor in the ordinary mode of his living, had an equal quantity exhibited to him, he would be intoxicated. Although the fa- fliion of fome pradlitioners at prefent is to keep patients in fevers intoxicated v/ith wine, in as far as I have been able to judge, the prad:ice is very detrimental. So if animal broths are to be exhibited in fevers at any time, it certainly would be more pardonable, to prefcribe them to thofe who have been much accuftomed to live on animal food, as is the cafe of the inhabitants of this country.

In the mode of living the points to be con- fidered are, the kind and quantity of food and

drink which is made ufe of. The times of

\

tiling food and drink. The defence from, or expofure to, the weather. The quantity and times of deeping. The degree and times of exercife.

The mode of living will therefore form the next horizontal column.

The next column of thofe containing things lo be marked previous to the difeafe, I have

called

‘ [ 277 ]

called times and contingencies. Thefe are, in the firft place, the age of the patient.

It is not of great confequence to mark the exaft age, that is, the exad: number of years a man has lived ; but great changes take place at different periods. The firft period may' be confidered as happening for the firff nine months. The fecond from the end of that time, to the end of the fifth year. During the whole of both thefe periods, while chil¬ dren are fubjecft to particular difeafes, they are remarkable for the irregularity which takes place in all their difeafes. The next period is from five to fourteen ; the moft healthy of the whole life-time of man, provided the fmall-pox, and other fuch infedlious difeafes, which happen but once, are either gone through before, or do not occur till after¬ wards, and provided alfo that there is no fcrofulous difpofition in the child. From fourteen to twenty-eight is the tiext period 3

• t

during this time there is inflammatory difpo¬ fition in men, and to women it is a very try-

«

ing one. From twenty-eight to forty- five is. again an healthy period. From forty- five to fixty is to be confidered as the next 3 and

T 3 after

after that time the fyftem is wearing out very faft.

In this column the ftate of the menftrual flux is alfo to be noted, as well as any difeafe the patient has formerly been afflifted with ; fince difeafes have influence, in many inftances, on thofe which follow them, as an intermit¬ tent will occafion a fubfequent fever, even after years, to break down into an intermit¬ tent of the fame type, as I have feen in fe- veral inftances. Laftly, any accidental cir-* cumftance is to be fet down.

The laft thing to be noted before the tak¬ ing place of the difeafe, is the application made to the fyftem which gives occafion to the difeafe, and which is its occalional caufe. It may be an application to any part of the body, or to the mind. The knowledge gf the occafional caufes of difeafes is of great confequence for the prefervation of health. In fo far it does not conftitute a part of the hiftory of a particular cafe of difeafe, there¬ fore has Inference to the fcience of medicine in general. The knowledge of the occafional caufe is often alfo of great ufe in pointing out the treatment of difeafes, in as. far as the

maxim

[ 279 ]

maxim that the caufe being removed the ef- fed: will ceafe, is true.

The knowledge of the occafional caufe of difeafe is extremely difficult,' and in many cafes by no means as yet afcertained. The difficulty arlfes from various caufes. The* firfi: is the uncertainty of the adion of every thing upon the human body, both caufes of difeafes and remedies. We have feen, for example, as in the cafe at the Old Bailey during Mr. Naffi’s mayoralty, a felon bring¬ ing infedion with him into a court of juftice, v/hich produced fever in a great number of thofe affembled in the court, while thofe af- feded fat promifcuoufly in every part of it \vith thofe who efcaped, and there was no human means of diflinguiffiing any difference in the conftitutlons of thofe infeded and thofe who efcaped. That a man, there¬ fore, has been expofed to an occafional caufe of difeafe who has not been afteded by it, is no proof that that particular application is not an occafional caufe of that difeafe ; yet this argument has been held by many praditioners of great eminence. Sir J. Pringle, for ex¬ ample, affirmed that the cloaths of a man be¬ ing moiftened with water while he wore them was nQt a caufe of catarrh or i^ieumatifm,

T 4 becaufe

I

•[ 280 ] ■

becaufe many men, even whole regiments of troops, have had their cloaths wet while they wore them, Vv^ithout either catarrh or rheu- matifm arifing. Neverthelefs it is certainly true, that I have feen more than two hun¬ dred patients at leaft, who, when in perfeft health, on having had their cloaths moift- ened while they wore them, were feized im¬ mediately with catarrh or rheumatifm, when there was no other the leaft apparent caufe of the difeafe applied. On the other hand, it is equally fallacious to fuppofe, that any ap¬ plication to the body, if followed immediately by a difeafe, was the occafion of it. If, for example, a man, after drinking a glafs of water, fliould be immediately feized with a fit of apoplexy, it would not follow from thence that the apoplexy was occafioned by drinking the water. But if a difeafe fliould be found to follow immediately upon any ap¬ plication made to the fyftem in a great num¬ ber of cafes by one practitioner, who was the only one who had accefs to fee fuch applicar tion made, there would arife a confiderable degree of probability that it was the caufe of the difeafe. If more practitioners than one had had occafion to fee fuch application made, and found that the difeafe immediately fol¬ lowed,

V •

[ 28l ]

lowed, the probability would increafe.' It would increafe the more if thefe practitioners had had no communication with one another ; and it would come almoft to a certainty, if it had been obferved by many pradlitloners dur- ' ing many ages, although the difeafe did not arife more than once in ten, twenty, or even an hundred times that the application had been made. Such, however, has the inat¬ tention to accuracy been, that many occa- iional caufes which produce difeafes imme¬ diately, are rather admitted from common confent than from fuch evidence as I have pointed out.

In the next place it happens undoubtedly, that in many cafes the occalional caufes of ^ difeafe do not operate immediately, but the perfon appears in perfect health for fome time before the difeafe comes on. As in the fmall- pox, after catching the infeftion, there is un^ doubted proof of the patient’s continuing ap¬ parently and adtually in perfect health before the difeafe takes place. Here the difficulty increafes in an immenfe degree. It is true, indeed, that fuch difeafes as never arife ex¬ cept from one well known caufe, fuch as the fmall-pox, and fome other infedtious difeafes, have that caufe well afcertained even when it

is

/

[ 282 ]

is not underftood in what manner it operated before its effedls became fenfible. But in other cafes, where a difeafe arifes from many caufes, it becomes extremely difficult to afcer- tain the application which has adtually pro¬ duced it. This has been the origin of greater confufion in medicine than any other circum- ftance whatever : for a pradtitioner, in relating either a fingle cafe, or the refult of his expe¬ rience in difeafe, has generally taken no man¬ ner of notice how long it was from the appli¬ cation of the fuppofed caufe to the beginning of the difeafe. It is, therefore, a ftrld: rule, that in filling this horizontal column, it fhall ' be fet down exaftly how long it was after the application of the fuppofed caufe before any jnorbid appearance was perceived in the fyftein.

When a difeafe arifes fbme time after its caufe has been applied, it is clear that that caufe muft have produced fome alteration, which became a caufe of the difeafe. The conjedlures with regard to this alteration, have formed the greateft part of the fallacies, hy- pothefes, and confufion in me(^icinie, they being almofi: entirely from conjedture, and not obfervation. It is, therefore, high time that thefe fijould be laid afide, and the inter-

piediaCc

[ 283 ]

mediate appearances, from the application of the caufe to the appearance of the difeafe, fhould only be noted. Perhaps it may not be overloading this differtation, already too long, to give one inftance. Sudden expofure to cold certainly produces difeafe in many cafes. The difeafes which it produces have been taken for granted to arife fome times at a diftance from the time when the cold was produced, and in this cafe it has been fup- pofed, from the matter of the infenfible per- fpiration being obftrudled, accumulated, noxi¬ ous, and capable of producing difeafe ; like- wife 'that it did adlually produce difeafes by its noxious qualities. Now of all this there is not the fmalleft evidence.

Thefe things are to be obferved with re-f gard to the evidence of the adtual caufes of difeafe. There is another circumftance to be attended to ; the effed: which the caufe pro¬ duces, if the application of it be continued 'during the courfe of the difeafe : for fome- times the caufe continuing, is the occaiion of the continuance of the difeafe. In this cafe the maxim is true, that dempta tolitur

effedliis ; as if a thorn be run into the flefh, it produces an inflammation, and keeps it up ; but if the thorn be fenioved before the in-

flamn^atioi^

[ 284 ]

fiammaticii arifes to a certain height, the in¬ flammation v/iW diminifh and ceafe. Yet it may alfo happen, that the occafional caufe being removed, the efFeft may continue, without any application of any new caufe produced by the fir ft, and the difeafe may go on. It may happen in medicine as in mo- , tion, that a body being impelled by a given power, will move on, although there is no new impulfe. If the caufe of difeafe con¬ tinue to be applied, yet no continuance of the cffeft may be produced, as I have endeavoured to fhow in a former paper in this volume on fever. Want of attention to this point has introduced an infinite number of hypothefes in medicine, fuch as the idea of fome error in the fluids being the occafion of the continu¬ ance of fever ; fuch error, or, in other words, alteration of properties can never be admitted, unlefs proved by experiments ; and although I myfelf have tried various experiments to determine the properties of the fluids con¬ tained in the blood -veflels during fever, as well as the fecreted fluids, I never found any properties exifting in them which do not oc¬ cur in perfect health ; nor has any perfon as yet found out a means of diftinguifhing tha

blood

t 285 ]

blood of a perfon affefted by fever, from that of a man in perfecft health, as far as has hi* therto been made public, except that in fome cafes of violent fever it does not coagulate fo firmly, the red particles are broken down, and there is an evident tendency to putrefac¬ tion, even fo as that there are initances upon /

record of its being foetid. But this putref* cency of the blood is the cifedl of the depref- fion of ftrength, for it happens only where there Is previous great depreffion of ftrength ; and when fuch depreffion arifes in any other cafe, the fame progrefs towards putrefaftion is always obferved.

There are difeafes, in which the difeafe once produced, goes on without any caufe at ail, as the motion of a mafs of matter being once produced, the mafs would continue to move on if in free fpace.

In the next place it is to be obferved, that this may be the cafe where the caufes pro¬ duce a difeafe immediately on their applica¬ tion, and alfo when the occafional caufe pro~ duces an effefl:, which effedl is or is not a difeafe itfelf, but the caufe of the difeafe finally produced.

I ffiall

[ 286 ].

I fliall jufl add, that difeafes appear to go on fimply, without any continuation of the application of any caufe : or one part of them may be a caufe of the other reciprocally, as feems to be the cafe in inflammations. But this is foreign to the prefent fubjedt.

Thefe are the things to be obferved before the difeafe takes place.

Thofe things which are to be obferved during the difeafe, are placed in perpendicu¬ lar columns, as may be feen in the fcheme, which will fufliclently explain Itfelf, as being the things laid down to be obferved by all authors who have pradlifed. There is only one column which requires explanation, thq day of the difeafe.

A day hffs been varioufly confidered, ac¬ cording to the purpofes for which time has been meafured. It is almoft fuperfluous to mention, that a day has been taken from the riling of the fun to the riling of the fun ; from the time the fun palTed the meridian, till the time of its next paflage over the me¬ ridian ; from the time of a fear's palTage over the meridian, until its next paflage over the meridian. All thefe meafurements of time, as well as others, have their particular ufes.

6

[ 287 1

It IS well known that almoft all the an- tlents, that is to fay, the Greek phyfi clans, have counted days in difeafe, as well as the Arabians, moft of the moderns, the Chinefe, and indeed almoft all nations in whom the ftudy of medicine has made any |olerable pro- grefs. Yet few authors have confidered when a medical day begins. It is true, that al¬ moft all have taken the period from the fun's paffing the meridian to the time of its next paffing the meridian, as the length of the day, which is unequal. It feems how¬ ever, notwithftanding, to be received with univerfal confent, that this inequality is not to prevent our confidering this period as , the length of a medical day. But the time of the beginning of the day is a point which, for accuracy, ffiould have been after tained from the firft. Suppofing two fevers in different perfons to begin at eleven o'clock in the forenoon on Sunday : in one of thefe the crifis takes place on the Sunday fol¬ lowing, at eight o'clock in 'the morning, and in the other at two o’clock in the af¬ ternoon ; if we count according to the ordi- naryVeckoidng of days, both crifes would hap¬ pen on the eighth day of the difeafe. But

if

[ 288 ]

If v/e begin the day at the time (of the attack of the fever, then that crifis which took place at eight in the morning, would be on the fe- venth day 5 and that which took place at two,

t

would be on the^ eighth. Therefore, unlefs this point be previoufly determined, every thing about critical days is thrown into con- fufion. Perhaps there fliould be two modes of counting the beginning of medical days ; one from the commencem.ent of the difeafe itfelf, whatever time of day it took place, which feems to have been adopted, and is proper, as far as I can judge, in pure phleg¬ monous inflammation, not attended with fe¬ ver But in the human body a natural evening attack of fever is fenfible in all man¬ kind, even in the moft perfect health, and this begins at five o’clock in the evening; therefore that hour, in many difeafes, mufh be accounted the beginning of a medical day.

It would lead into a differ tation fai\ beyond my prefent purpofe, to lay down the obferva- tionsTrom pradtice and contemplation of the

* It is to be obferved here, that I do not mean by fever, heat, and frequency of the pulfe, but what is often called fimple

fever, and by Dr. Cullen fever ilridlly fo called,

*

works

[ 289 ]

wotks of medical authors, to give the reafons why I fix on five in the evening, much more fo to enumerate the difeafes in which the time of the firft attack of the difeafe is to be ac¬ counted the beginning of the day and the dif¬ eafes, in which five o’clock in the evening is to be confidered as the beginning of the day.

There is another circumftance with regard to the beginning of difeafe, which is obferved by De Haen, to wit, that it happens in cer¬ tain difeafes, as in fever for example, that fome flight flying appearances take place be¬ fore the actual attack of the difeafe, from whence its beginning is to be counted. It is alfo very neceffary to pay attention to this circumftance.

Obfervations on the Cafes inferted in the Scheme

as Examples,

It is to be obferved, that in one cafe with which the fcheme is partially filled up, there is a column marked the mouth and throat, which is a variable column, and is referved for the appearances which take place in a part of the body, if that part fhould be the feat of the difeafe.

Qs^

U

t 290 ]

One of the cafes, which I have felecSed as an example, may be confidered as not proper, on account of its not being fully defcribed ; but I chofe to take one lefs perfecfb, becaufe it often happens that the hiftory of the firft j^rt of a difeafe cannot be procured.

I did not fee the patient at the beginning

of the difeafe, therefore could only take the

firft days from report. I alfo chofe a fhort

difeafe, as not having it much an objefl; to

draw off the attention to the difeafe itfelf from • »

the general-view of the plan. I have alfo laid before the fociety a cafe of fever more full, and I have many others in the fame ftate. I have another reafon for chufing the firft cafe asacafe of eryfipelatous inflammation. In order juft to obferve, that although many praftitioners in this town are well acquainted with the life of cortex cinchonae, generally ' called Peruvian bark, in eryfipelatous inflam- tnatioft, yet the knowledge of its virtues in fuch inflammations Is not general. It is not of much confequence who has made any in¬ vention in the fcience of medicine, for the fatisfadlion arifing from being able to relieve ‘diftrefs by the application of a new medicine, or one already known in a new manner, or 'for* new purpofcs, is a fufficient recompence.

I do

[ 291 ']

I do not mean, therefore, to difpute the pri-’ ority of the application of this medicine with any perfon who fhall confider himfelf as the inventor of it, I only mean to fhow by what progrefs I have brought it in evidence that it is the moft powerful remedy in eryfipelatous inflammation. By eiyfipelatous inflammation I mean inflammation of the Ikin when it is only inflamed, or inflammation of the furface of an ulcer where the very furface only is fore and inflamed ; or inflammation of the mucous membrane, when there is little fecretlon from the mucous glands. It was in the year 1759 that I firfl: applied this bark in the quantity of an ounce in twenty-four hours in a phy- mofis, where there was much inflammation of the Ikin of the whole penis, having ob- ferved this kind of inflammation to be in- creafed by evacuants. The difeafe gave vv^ay in lefs than forty-eight hours. Afterwards, in the year following, I juft came to fee my friend Dr. Balfour RulTel die of what is called the putrid fore throat, or fore throat attended with ulcers by Dr. Fothergill. Dr. Fother- gill attended him from the beginning of the cafe, along with his brother. Struck with the inefiicacy of the treatment by ftimulants ufed in this cafe, and at the fame time know-

I

U 2 ing

I

[ 292 ]

ing from many cafes I had feett (for at that time I had applied myfelf for ten years par¬ ticularly with a view to medicine) that the' evacuations by bleeding, and other anti-phlo- giflic treatment. Was very improper, I con¬ ceived that in this fpecies of eryfipelatous in¬ flammation likewife, Peruvian bark in larcfe quantities might be employed with fuccefs. 1 ufed it in the firft cafe I met with of the difeafe, and with great advantage. As the difeafe was not uncommon, I had feveral op¬ portunities of feeing its effedts, which I found always fuccefsful, and ventured accordingly to extend its ufe to other cafes of eryfipelas, liich as happen frequently in the face, and often in other parts of the body. I w^as fo far convinced of its power, that I ventured to recommend it to my pupils, and publifh its ufe in the eryfipelatous fore throat in my Elements of the Pradlice of Phyfic, although with that diffidence a young pradlitioner fhould obferve in the introduftion of any new prac¬ tice. In the year 1771 I was chofen phyfi- ; cian to St. Thomas’s Hofpital, wdiere there i is great opportunity of afeertaining the effir • cacy of medicines in all difeafes. Here I have had an opportunity of verifying to myfelf as well as to my prefent colleagues, that in all

I cafes

[ 293 ]

cafes of eryfipelatous inflammation Vv^hlch are pure, that is unmixed with phlegmonous in¬ flammation, or increafed fecretioh from the mucous glands, even in fome cafes of the lat¬ ter intermixture, Peruvian bark is the moft powerful remedy that can be employed, and is almoft always fuccefsfuL It fliould be ex¬ hibited in fubjflance if the patient’s flomach will bear it ; and in this difeafe it will almoft always bear it, and In as great quantity as the patient’s ftomach will bear, which is com¬ monly to the quantity of a drachm every hour.

I believe there are many praftitioners in this country who ftill adhere to the treatment of eryiipelatous inflammations, and thofe of the mucous membrane when pure, by bleeding and other evacuations, which I have always found hurtful ; and I do not think the ufe of Peruvian bark is at all known abroad,, e^tcept- ing in gonorrhoea, from the chapter of my Text-book on the Lues Venerea being tranf- lated for the ufe of the ftudents in fome of the medical fchools in France This pradtice requires only to be tried to convince any one of its. utility.

* Montpelier and Grenoble,

u 3

XVII.

[ 294 ]

XVII. Obfervations ^ and Heads of Inquiry y on Canine Madnefsy drawn from the Cafes and Materials colledled by the Society y refpeditng that DifeafeC 5^/ John Hunter, M.D.

' F. R, S. and Phyfcian to the Army. At the Defre of the Society.

'The fociety having colleded many cafes, and other valuable information, refpefting hydrophobia, or canine madnefs, it is judged that a fhort abftradl of the refult of their in¬ quiries would not be unacceptable to the pub¬ lic. It will fhew the prefent ftate of our knowledge refpedting that very extraordinary difeafe, and, it is hoped, be the means of faggefting improvements both in its preven¬ tion and treatment.

I. Of the generation of the poifon.

It would be of great importance, if we could afcertain the manner in which the poi- fon producing canine madnefs is generated. For fhould it appear that it did not arife fpontaneoufly among dogs, but was commu¬ nicated by infection, as the fmall-pox is in

the

[ 295 ]

the human fpecies, it would then be poffible either intirely to eradicate the difeafe, or greatly check its progrefs, by regulations fimilar to a quarantine. The following fadls, though they will not prove that the difeafe never arifes fpontaneoufly, yet are fufficient evidence that it is moft commonly the.refult of infeftion. Dogs are more numerous in the ifland of Jamaica, than perhaps in any part of the world. It is the ambition of every negro to be mailer of a dog ; yet not- withllanding their great numbers, particularly in the towns, forty years have elapfed with¬ out a dog being known to go mad. The in- fular fituation of the country fecures to it, in fome degree, the advantages of a quarantine ; and the rare occurrence of the difeafe proves that it feldom, if at any time, originates of itfelf. The length of the voyage from this country to Jamaica is fuch, that it would fcarcely be carried in the dog kind from Great-Britain, for in them the* difeafe gene¬ rally proves fatal in three weeks ; but North America is much nearer, and it is from that quarter, when the difeafe has made its ap¬ pearance, that it has been fufpedled to come,

U 4 The

[ 296 1

The moft eminent fportfman ^ In this country, to whom the prefervation of his kennel from madnefs was an objed: of great importance, has, for many years, preferved his dogs from the difeafe, by making every new hound perform a quarantine before he was allowed to join the pack. From thefe fads we may fafely infer, that the difeafe, if not always, yet, certainly in the far greater proportion of cafes, even among dogs, is communicated by infedtion.

n. 0/ the fymptoms of the difeafe in the dog

kind.

From the above confiderations we are na¬ turally led to an inveftigation of the difeafe as it fhews itfelf in dogs, in order that it may be known early, and with certainty, and pre¬ vented from fpreading, by the confinement or death of the animal. '

-v

Dogs fuffer a change in their natural man¬ ners, and become dull and heavy. They grow peevifli and fnappifh, and are eafily of¬ fended. They rather take offence at fuch things as come acrofs them, than run in

^ Mr. Mejnell,

I

[ 297 ]

fearch of objefts to attack them ; yet they are more apt to quarrel with ftrange dogs,, and to run after fuch domeftic animals as • they have been ufed to hunt, as fov/ls and hogs. In this ftate the dog ftill minds the call of his mafter; and can be retrained by him } but, as the difeafe advances, he difre- gards him, appears not to know him, and will bite him if he is near him. It is pro¬ bably about this period of the difeafe, when his recolleffion of perfons is nearly oblite¬ rated, that he drays from home, and follows any path or road he happens to meet with, feem/ngly without purport or defign. In this ftate he only bites or fnaps at fuch animals as come in his way, giving apparently but little attention to external objedts, fo that it is eafy to avoid him. If he be confined in this ad¬ vanced ftage of the difeafe,. he bites and gnaws every thing near him ; is furious for a moment when approached ; and his chops are covered with tough frothy faliva. With thefe fymptoms he foon expires. Before death there are fwellings about the throat, and alfo of the tongue in fome cafes. He can fwallow both folids and liquids during the whole difeafe, and readily eats what is offered

him*

[ 298 ]

him. He has no fear of water, for he never avoids it. It is faid that dogs know, and avoid by inftindt, one that is mad ; and there appears fome foundation for this opinion : for dogs of fuperior courage and ftrength have been known to run, after the firft encounter, from thofe that are mad, as if ftruck with horror.

There is probably fome variety in the dif- eafe, as it fliews itfelf in dogs ; one out of twelve or fifteen that were bit, and all died, had no marks of wildnefs or fury about him, never offered violence to any thing near him, and expreffed pleafure at the fight of

t

his mafter, by fhaking his tail, a little before he died.

The progrefs of the difeafe in the dog is, in general, very uniform, yet it would appear to admit of exacerbations and remifiions in fome degree ; for a dog, after leaving home, will return again ; and, after being enraged at his mafter, will become fubmiffive.

There is no circumftance that contributes more to fpread the difeafe, than the difpo- fition which the dog has to leave home, and wander about ^ and, on this account, all ftray dogs fliould be approached with caution, and never with familiarity. It is a remark

deferving

[ 299 ]

defer vlng the moft ferioas attention, that, in a large proportion of the cafes collefted by the fociety, the infedfion was communicated by taking familiar notice of ftrange dogs.

III. What animals co7nmiinicate the difeafe.

All domeftic animals, birds, as well as beafts, are fufceptible of the poifon of the mad dog ; and, indeed, our experience has not yet taught us that there is any race of animals exempted from its efFed;s. Whether every animal labouring under the difeafe is ca¬ pable of infeding others, or whether this power is confined to a few only> we are yet to learn.

The difeafe has been communicated to the

human fpecies by dogs, cats, wolves, and

foxes. The dog, the wolf, and the jackal,

have, by the late inquiries of naturalifts %

been afcertained to be of the fame fpecies ;

and therefore it is probable, from analogy, that

the latter is capable of communicating the

infedfion as well as the two former. The fox

alfo has a fhrong affinity to the dog, and is by

Linnaeus counted of the fame srenns ; but the

^ )

* Mr. Hunter's paper, Phil. Tranf, vol. Ixxvii. page 2 C5.

dif-

I

[ 300 ]

diftinfilons of natural hiftory will not avail us here ; for the cat, an animal of a very dif¬ ferent genusy has often produced the hydro- ' phobia in the human fpecies. Many ,other animals are reported to have the power of in- fedting others, by biting them while labour¬ ing under the difeafe themfelves ; but the fadls hitherto colledled are very vague, and lead to -nothing conclufive on this head. Were we to judge from analogy, from feeing two animals fo different from each other as the dog and the cat, capable of infeding others, we might be led to infer, that every animal fufceptible of the difeafe had the power of communicating it, provided their natural habits led them to bite and tear with their teeth fuch animals as came in their way while in an enraged ftate. But, though there are inftances of men labouring under hydropho¬ bia biting fome of thofe employed in taking care of them, no ill confequences have been known tc follow. From this, however, we can draw no pofitive inference, for it is but a fmall proportion of fuch perfons as are bit by dogs undoubtedly mad, who are infeded with the poifon.

The bite only ferving the purpofe of ip- cculation, the danger arifing from it will be

various^

[ 301 ]

various, as It happens to be In a part more or lefs vafcular ; or as the teeth are more or left loaded with the poifon. There is the greateft danger from bites In the face, and the fymp- toms come on fooneft; bites in the hands ahfo, which arc generally bare, are full of danger. In other parts of the human body the cloathing, by wiping the teeth, greatly leifens the danger of infedion. The bite is not effentially neceffary for the application of the poifon : a dog, by licking a fore, pro¬ duced the hydrophobia ; but he licked it till it bled, fo that the poifon came in contad with the newly divided blood- vcfiels. This circumftance, if we may judge from the ana¬ logy of other poifons, is probably of impor¬ tance in giving efficacy to the poifon, yet it is not clear that it is elTential ; for there are two cafes of the difeafe mentioned in the Phi- lofophical Tranfadions which arofe from put^-ing the hands in the mouth of a poppy that was mad, but when there was no bite ; and there is a fimilar cafe in the -f* Memoirs of the Royal Academy of Sciences of Swe¬ den. It is true, various other modes of in- fedion are narrated by writers, but in all of

* Phil. Tranf. vol. xxiii. p. T074* t Anno 1777.

them

[ 302 I

them there is much appearance of fabulous credulity. There is good reafon to think that tetanus has fometimes been miftaken for hy¬ drophobia, and given rife to the accounts of the difeafes proceeding from the bite of a cock, the claw of a cat, and fimilar hiftories.

Dogs are much more fufceptible of the in- fedlion than the human fpecies. Four men and twelve dogs were bit by the fame mad dog, and every one of the dogs died of the difeafe, while all the four men efcaped, though they ufed no other means of prevention but fuch as we fee every day to fail. There is alfo an inftance of twenty perfons being bit by the fame mad dog, of whom only one had the difeafe.

There is a queftion which naturally pre- fents itfelf here ; does the difeafe ever arife fpontaneoufly in the human fpecies ? The fadls relating to this queftion involve many doubts. Francis Stannier ^ died in Novem¬ ber 1787, with the fymptoms of hydropho¬ bia, though it was not known that he had ever been bitten by a mad dog ; and fimilar cafes are related by writers. Yet as a large bite is no way necelfary to communicate the infedtion, the patient abovementioned may

* London Medical Journal, vol. ix. p. 256.

have

[ 303 ]

have been llightly bit, without knowing it, as he was often drunk, and frequently in the ftreets at night. There is good reafon to believe that the difficulty of fwallowing, which fometimes occurs in tetanus, has been miftaken for hydrophobia in fome cafes ; and there may be other fpafms about the throat and the oefophagus, which may fo far re- femble hydrophobia, as to give rife to errors on this fubjedl. Something of this hind oc¬ curred once to Dr. John Hunter, in an hy- fterical woman. Were we to be guided by analogy in deciding the prefent queftion, we fhould be led to deny the exiftence of fpon- taneous 'hydrophobia ; for where is there ah example of any of thofe difeafes which de¬ pend upon a fpecific poifon, as the* fmall- pox, the venereal difeafe, or the meafles, arifing fpontaneoufly ? But the full decifion of this queftion muft be left to future expe¬ rience and obfervation. -

IV. Effects of the poifon on the hitman fpecies.

' In obferving the operation of the poifon upon the human fpecies, we find, that from the time of the bite till the difeafe appears, there is no derangement of health, nor any 4 pel*-

[ 304 ]

perceptible change in the conftitution> pro¬ vided the perfon bitten be not under the in¬ fluence of fear. The effedls of that paffion have, in fome cafes, been fo great as to pro¬ duce an imitation of many of the fymptoms of the difeafe ^ ; the patient adlually imagin¬ ing that he could not fwallow, and fuffering all the horrors of extreme defpondency, till it has been difcovered that the dog was not mad by which he had been bitten.

The wound has nothing to diftinguifh it from the bite of a dog which is* not mad, and heals as foon ; there are almoft always, how¬ ever, pains in and about the wound, and fometimes fwelling, and even a frefh dif- charge from it, fliortly preceding the hydro -

The interval between the infedlion and the appearance of the difeafe, varies from thirty- one days to feventeen months, in the cafes laid before the fociety. The moil: common period appears to be about forty days. There is a cafe given in the Philofophical Tranfac- tions, in which the fymptoms appeared nine¬ teen months after* the bite -f-. The difeafe is

* Vid, Philofopb. Tranf. vol. xliii. p. 257#

+ Ibid. vol. xl, p, 5,

reported

[ 305 ] ‘

reported to occur fometimes in a few days, as four or five, after the bite ; but fuch cafes have fomething doubtful in them, and are probably to be referred to tetanus, or fome other convulfive difeafe

The pains and difagreeable feelings about the part where the wound was, are generally defcfibed as paffing towards the head or heart, and the hydrophobia follows foon after. The dread of fwallowing liquids, though the moft fingular fymptoin of the difeafe, and from ' which the name has been given to it, confti- tutes but a fmall part of the malady. It is true that none, or very few, recover who ‘ have this fymptom, yet they certainly do not die in confequence of the difficulty of fwal- v lowing liquids ; for the human body could eafily exifl: double the tim.e in which the dif¬ eafe ufually proves fatal, v/ithout food or

*

drink. But the fick can often fwallow fub- ftances that are nourifliing in a pulpy ftate, without, however, having their life prolonged from it. It is not, therefore, the difficulty or impoffibility of fwallowing liquids, but the effecfts of the poifon upon the conftitution a.t large, which occafion death.

* Vid. Medical Tranf, vol. ii. p. 222.

X

The

I

[ 306 ]

The ufual progrefs of the fymptoms is as follows ; the flieht oains about the wound are

O 1

foon fucceedcd by great depreflion of fpirits, anxiety, reftleiTn'efs, extreme fenfibility to all impreffions, and great difficulty, or an utter impoffibility of fwallovving any thing liquid. This Lift fymptom is generally difcovered ac¬ cidentally, on attempting to drink, and, after a few trials, is accompanied with fuch hor¬ rible fenfations, that any thing which after¬ wards recalls to the mind even the idea of drinking, excites violent agitation and inex- preffible averfion. Of the lick who are more compofed, and can, therefore, better deferibe their own fenfrtions, fome fay, that, upon attempting to fwallow a mouthful of any li¬ quid, they feel fomething rifmg from the ftor mach which obftrudls the paffage ; others tell you, that they have a fenfe of choaking or fuf- focation ; and it is very obfervable, that the attempt to pafs the liquid over the root of tlie tongue, excites convulfions in the larynx and pharynx, and even in the mufcles of the cheft and abdomen. They complain of no pain. There are, moreover, watching, inquietude, a countenance expreffive of extreme mifery, and fits of great irritability and almoft fury, from

9 trifling

[ 307 ]•

trifling caufes,as the fick themfelves readily al¬ low, and even wonder at when more compofed. There Is often a fenfe of great oppreilion at, the breaft, which the fick generally call a dif-. Acuity of breathing, but it is properly the anxietas pracordiorum, which probably is an affedlion of the heart ; for they figh often,, and make deep irregular infpirations, and find fome relief from motion, as running' and walking, which fliew the lungs not to be the feat of the oppreffion.

The extreme fenfibility of the fick to all . imprefiions, appears ' in the difpleafure they exprefs at even the air blowing upon them ; in their diflike to’a.ftrong light; in their averfion to new faces, or even the fight of their friends and relations ; and in the terror they exprefs at being touched, which almoft threatens to throw them into convulfions.

As the difeafe advances, the mind is more filled with dreadful fears and apprehenfions ; the- fits of fury become both more frequent and more violent, and mifery and horror are more deeply marked upon the countenance. Thedaliva grows thick and ropy, and would appear to be fecreted in larger quantity. The miferabie fuiferer, not daring to make the ,

X 2 fmalled

/

[- 3<^8 ]

fmallelt attempt to fwallow it, fpits it out iu« eeffantly, which he does With much vehemence and difficulty, and with frequent retchings and vomiting. What he brings up is a little phlegm, tinged with brown or yellov/ bllc.^ In this flate the flighteft catife excites con- vulfive tremors all over the body. They fometimes call out they are fuffocated, turn black in the face, and expire In convulfions^ It is not uncommon, however, for the ftrength to fink fuddenly, the patient to become quiet and calm, as if nature gave up the flruggle, and to die without a groan. -

The pulfe in the beginning is not quick, nor is the fkin hot ; and there is none of the mufcular debility fo remarkable in fever ; but in the progrefs of the difeafe there is Ibmie feverifli heat, and, as death approaches, the pulfe becomes extremely quick and tremu¬ lous.

The duration of life from the appearance of the hydrophobia till death, varies from thirty- fix hours to four or five days ; the moft common period is from two to three days.

There is confide rable variety in the fymp- toins 1 they are more or lefs violent, and in proportion prove fatal in a fhorter or a longer

6 time.

[ 3'>9 ]

time* The hydrophobia, or dread of uval- lowing liquids, is in very different degrees : in fome cafes the patient can not only make the attempt, but even force down a mouthful or two ; in others, the firft approach of* any thing liquid for the purpofe of drinking, ex¬ cites the moft violent commotion in the whole frame.

There is no part of the difeafe that admits of greater variation than the degree of men¬ tal derangement, which in fome does not amount to more than extreme irritability and impatience ; while in others it rifes into fits of the mofi: violent rage and fury, in which they bite and tear themfelves, and every thing near them. This difference would ap¬ pear to depend a great deal upon the natural temper and difpofition of the mind.

The difagreeable feelings in the wound are defcribed by the fick fometimes to pafs to¬ wards the head or body, and when they reach thofe parts they produce head-ach, or pain in the breaft. In fome, though rarely, there is a confiderable degree of fever. There are inftances of the fiek having attacks of fits a good deal refembling epilepfy. Priapifm is a fyfnptQm of the difeafe in fome cafes.

X 3

It

[ 31° I

It fometimes happens that all the fymp- •toms admit of remiffions and exacerbations, and ‘ that with - fome degree of regularity. Under thefe cireumftances the virulence of the poifon would appear to be fomewhat leffened ; and it may be a queftion, whether the difeafe does-^ not at times fhew itfelf in a milder form, as in the cafe defcribed by %Iorgagni -f*, and in fome of the patients of "wdiom the late Dr. Garden communicated an account to the fociety.

' It^ deferves to be remarked as a lingular ^tiling in the operation of a poifon fo de- ftrud;ive to life, that it afteds the mufcular ilrength but'little. In two cafes the pant¬ ing and difficulty of breathing, as the patients -called it, were remarkably relieved by run¬ ning; one of them found himfelf relieved by "running rouhd Smithfield, which is nearly a ' quarter of a mile, a few hours before he 1 died. i -

^ DiffeBions. ‘ -

Many exarninations^of the bodies of thofe

. who have died of hydrophobia have been

>

communicated to the fociety. An appear-

■f De S'edibus Sc Caufis^MorborunnfJ epiff. 6i. 14.

‘ ; X ' ance

[ 3II J

ance has in general beeii feen on the inner coats of the ftomach, near the cardia, fimi- lar to what is found in the bodies of perfons v/ho have had flight inflanimation, that is^ a greater number of red vefiels with fmall fl-reaks of red blood. In fome inftances there •has been an increafed vafcularity of the pia mater, or flight watery effufion on the furface of the brain. In fome dogs that died of the difeafe, the appearances upon the inflde of the ftomach were fimilar to what have been al- readv defcribed : but there was no unufual ful- nefs difcovered in the veflels of the brain, or its memb;:anes. Thefe appearances are ho ways adequate to account for the iymptoms of the difeafe.

Morgagni though he has not himfelf examined the body of any that has died of this difeafe, yet has colledted the obfervations of his friends, and compared them with fuch as are to be found in medical writers. In no particular do they agi*ee ; and the change in the human ftrufiiure upon which the difeafe depends, -would appear to be beyond the reach of anatomical inveftigation.

* De Sedibus & Caufis’ Moib, epift* 8* i >.

X 4 VL ijf

[ 312 ]

VI. . Of the prevention of the difeafe.

We have as yet difcovered no remedy, that has any efFed; in the cure of this moil extra¬ ordinary difeafe ; the means of prevention become, therefore, an objed of the firft con- fequence. Whatever has hitherto been done in this way is principally, if not altogether, to be referred to the local treatment of the wound, or part to which the poifon has been applied. It is true, indeed, that numerous prophyladics have been propofed, and many are in general ufe, which are fuppofed, by their effeds upon the conftitution, to coun- terad or expel the poifon ; yet, upon fairly weighing the proofs of their efficacy, not one appears in titled to the fmalleft credit. None has been held in higher eftimation for a great length of time than fea-bathing, though there is fcarcely a cafe of hydrophobia publifhcd of late years in this country, that does not con¬ tain full proof of its inefficacy. The Orm- fkirk medicine is in precifcly the fame pre- - dicament. Mercury too has had a fair trial, nor has it been more efficacious than the others. It is hardly neceffary to take notice

of

4

[ 3^3 ]

of the inefficacy of the puhts antilyffus or of the Tonquin medicine -f*. The queftion may here be afked, admitting the frequent failure of thefe remedieSj have they not fome- times prevented the difeafe ? The anfwer would certainly be in the affirmative, if every perfon bitten by a mad dog, who did not ufe fome means of prevention, were feizeel with the difeafe. But this is not the cafe ; fpr in' the human fpecies the proportion of thofe bitten, v/ho are feized with hydrophobia, is much lefs than of thofe who efcape, even where no means of prevention are employed: we can, therefore, infer nothing in favour of thefe prophyladtics, becaufe they have been given in cafes in which no hydrophobia has fupervened. There can be little doubt, that if in any cafe the virtues of thefe fpecifics were fufficient to overcome, or counteradl the poifon, they would often be ftrong enough either to retard the appearance, or mitigate the fymptoms of the difeafe, like to what we fee from mercury in the venereal difeafe, or bark in intermittents ; but nothing of this kind is obferved, and the poifon produces its

* Compofed of the lichen cimierus ierrjiris ^ piper nigrum, t Compofed of mufk and oinnabair.

peculiar

7

[ 3H ]

peculiar efFedls equally foon and equally vio¬ lent, when thefe prophylactics have been ufed, and when they have not.

The prevention of the difeafe therefore depending upon the local treatment of the wound, various modes have been made trial of, either with a view to procure the dif- charge, or infure the deftrudlion, of the poi- •fon. Cupping-glafles have been applied to the wound, and it has been kept open by ir¬ ritating applications for a great length of time. The part has been deftroyed by cauftics, and by the adtual cautery; and it has been cut out. There is good reafon^to believe that all thefe have, at different times, been ufed with ‘ ; advantage ; but the fadls before the public,

. as well as thofe collected by the fociety, con- ; tain full evidence of the failure of every one of them, except the lafl mentioned, that is, cutting out the part.

In confidering the local treatment, the fol¬ lowing things appear to deferve attention : iff. The removal of the poifon by wafliing the part fimply ; adly. The deffroying the part by cauftic ; and, 3dly, the cutting of it out.

It

/

[ '315 ]

It has been recommended to wadi the •part with cold water repeatedly poured upon it, which is to be continued for fome time. The pradlice is fafe, and may poffibly do good, particularly if made ufe of immediately after the bite. Cold water is better probably than warm, as warmth increafes the fenfi- bility, and quickens the adtion of all living parts, which might render the lacerated fur- faces of the wound more fufceptible of the eifedls of ' the poifon. Though much ftrefs cannot be laid on this mode of prevention, yet, as cafes may occur where there may be infurmountable objections to more effectual fteps^ it ^may deferve a trial ; and it would probably be more fuccefsul, if, after wafliing- copioufly with cold water, the cauftic alkali was to be added to the water. In fuch pro¬ portion as the part could eafily bear, and the wafhing to be continued v/ith this for fome time.

Cauftics may be admiffable in fome cafes, where the knife cannot be ufed ; and though they have failed in certain inftances, yet that • was probably owing to their not having been applied to all the infeCled furfaces. Late ex-

♦ London Medical Journal, vol. x. p. 295.

. periments

[ 3i6 ]

periments have indeed taught us, that all cauftics do not counteradl the effedls of poi- fons applied to the human body. It would appear, however, that the beft cauftic has not been ufed, which is probably the cauftic vegetable alkali in a folid form, the kali rum of the London Pharmacopoeia ; both as it ads more fpeedily, and alfo more completely deftroys and diflblves all animal ftibftances. By applying it to the various furfaces of the wound, and immediately removing with a fpatula the parts upon which it has aded and diffolved, it may again be applied, and the part deftroyed to what depth may be deemed neceffary : the furgeon feeing all the time the ' extent to which the cauftic goes.

What has been faid under the two preced¬ ing heads on waflring off the poifon or deftroy- ing it by cauftic, muft be underftood to ap¬ ply only to thofe cafes where there are infur- mountable objedions, either from the place where the bite is, or other caufes, to cutting out the part. Whenever the part can be cut ' out, it ought always to be done, as the only •certain means hitherto employed of prevent¬ ing the difeafe. In perforiming this operation

* Vid. Foutaaa, v&l, ii. p, 5* aud Appendix.

care

[ 3i7 ]

cafe muft be taken to cut out every part witb which the dog’s teeth have come in con tad:, for the fmalleft portion left might produce the difeafe. It becomes, therefore, neceflary for the operator to examine accurately the part, and to afcertain to what depth, and in what diredlion, the teeth have penetrated, keeping- in his mind the iituation of the parts in the adt of biting, in which the fkin and the flefe are pinched up, and therefore put out of their natural pofition before the teeth penetrate them

The fooner the operation Is performed it mu ft be fo much the fafer * but there arifes a queftion of confiderable importance, that is, how long after the bite can the part be cut out, fo as to prevent the difeafe ? Nothing could determine this fullv but exneriments

•/ J;

made upon the poifon, an arduous undertake

* Mr. Hunter in one cafe removed the parts, as he thought, freely, and there vyas nothing on the under furface of the piece cut out, tliat led him to fuppofe he had not cut beyond the bite. But on examining the furface of the wound, he found a part in the middle which was hollow underneath, which fhewed he had not gone deep enough, but had left a ridge, as it were, over part of the paffage made by the dog’s teeth, and which could only have been difeovered by examination after the ope~ ration. This is mentioned, to (hew the care that is requifite in cutting out the part, i<nd alfo the neceffity of going to a proper depth.

I

[ 3^8 ]

iiig, and not without much danger ; yet not to be defpaired of, if w^c advert to the expe¬ rimental inquiries concerning poifons, which a thiril: after knowledge has produced of late years. Till fome thing of that kind is done, the queftion can only be anfv/ered imperfedlly from a few fcattered fad:s, and conjedtureSi From the fadls before the fociety it appears, that the part has been cut out ^ thirty hours after the bite, and in one cafe as late as the fifth day.

In one of the patients, an account of whom has been communicated to the fociety, the bite immediately inflatned and feftered, and on the fifth day an abforption took place, as appeared by the fweiling of agland in the arm-pit, which was followed by a confiderable degree of fever, that lafted fome days ; but none of the fymp- toms of hydrophobia appeared till the ufual period, and after figns of a fecond abforption, when the difeafe proved fatal. From this and fimilar fadts in the animal ceconomy, it is pro¬ bable that the poifon lies long in the part, as in

r

fome other cafes of inoculation, and would ap-

* Dr. John Hunter direifted the part to be cut out, and it was done in his prefence by Mr. Foote, who has publiflied the cafe, but appears to have forgot the operation, for he flates that the . tooth perforated the part of the Ikin cut out, which if it had, the operation would have been of no ufe.

pear

[ 3^9 ]

pear to be Incapable of afFed;ing the conftitu tlon^ till it had produced a previous change in the part. If a conjedlure might be allowed on this point, it would feem that the pains about the wound riling towards the head or body, indicated the abforption of the poifon ; and that the poifon had been confined to the wound till a day or two before the fymptoms of the difeafe appeared. On this fuppofition the part might be removed, even weeks after the bite : but we mu ft wait for further infor-^ mation and experience before we can come to a pofitive conclufion on this head.

VII. Of the treaUnent of the dfeafe.

After the lymptoms of hydrophobia have appeared, no medicine or remedy that has hi¬ therto been ufed has relieved, much lefs cured the difeafe. On this confideration it may feem unneceflary to enumerate the- various things that have been tried ; but, without a knowledge of what has been attempted, much time mu ft be loft in ufelefs trials and fruitlefs repetitions ; and in fadl, the want of preconcerted order and method in inveftigat- ing the cure of this difeafe, is very apparent in all the writers upon theiubjeeft, and is pro-

bably

[ 320 ]

bably a principal caufe that no progrehi has been made in that important enquiry. In ftating fliortly the various remedies that have been tried, opium defervedly claims the firfl place* Reafoning from analogy, there is no article in the materia medica that would ap¬ pear fo peculiarly adapted to the relief or cure of "^11 the fymptoms of hydrophobia, as opi¬ um. It has therefore, in various ihapes and forms, had the moft full and ample trial, and has been found to do no good ; and it can only be imputed to the want of method and order abovementioned, that this medicine ftill continues to be given in almofl every cafe of this difeafe. It is evident that, however much might have been expected originally from opi¬ um, there are at prefent few articles in the catalogue of medicines, that have not a bet¬ ter chance of curing hydrophobia.

Mercury has alfo had a fair trial, both with a view to prevent the difeafe, and likewife to remove it after it had adlually taken place* But In neither cafe has it done any good.

Bleeding, the warm bath, alfo bliflers and cantharides have been ufed, but with no bet¬ ter effedt-.

In order, therefore, to avoid a repetition of medicines, which can be produftive of no

good,

[ 321 ]

good, we ought to have preconcerted various new methods of treating the difeafe, which may be tried as circumftances may indicate. In moft difeafes the doftrine of the juvantia and Icedentidy as It has been called, affords fome direftion refpedting the treatment; in hydro¬ phobia there is fcarcely any thing obferved to afford even a temporary relief. Among the cafes colledted by the fociety there are two, in which the relief obtained by running was very remarkable ; in one the amendment was fo confiderable, that the patient did not look like the fame perfon after running about a quarter of a mile. This fuggefls an experi¬ ment, which might be eafily tried. It would probably be made to beft advantage in the open air, in a quiet, retired, and fhaded place. It would foon appear, whether it were better to run brifkly for a fhort time, with frequent flops between ; or to take a flower pace, that could be continued for a greater length of time; If the patient found relief, there would be no difficulty in getting him to perfevere.

All the cafes of the difeafe laid before the public contain proofs of the fnfferings of the patients in attempting to fwallow liquids ; it is, therefore, an experiment that fhould not

Y be

[ ]

6e wantonly, and out of mere curloii ty, mzie upon them. At the fame time it is an ob- jedl of 'much confequence to fupport by non- rhhment and cordials a body labouring under the influence of fa deflruftive a poifon. Food, therefore, in a pulpy ftate, fliould be got down as much as poflible ; and if mixed with wine it would probably.be the better. Bread or bifcuit foaked in wine would anfwer this defcription. But if nourifhment could not be got down, broths, or warm wine and water, might be adminiflered by clyfter. Some plan of this kind would be abfolutely necefiary, if motion was found to give confi- derable relief.

It has been flated, that the means of pre¬ vention confifted chiefly in the local treat¬ ment of the wound .; and it may be a queftion? how far fom^ething of the fame kind might not prevent an aggravation of the Aymptoms, after the difeafe has come on. There is reafon to fufpeft that the poifon is confined to the part bitten till within a very fhort time of the appearance uf the difeafe ; and probably the moment the poifon is conveyed into the general circulation by the abforbents, the fymptoms begin. Judging from the analogy

of

[ 323 ]

of foilie other poifons; the greater quantity that is conveyed into the blood the more vio¬ lent will the eftedis be-; good, therefore, might arife from leffening this quantity. With this view numero'us and deep fcarinca- tions might be made where the wound was, and cupping-glaffes applied repeatedly. Li¬ gatures may be applied. Might not ice, or a freezing mixture be applied fo as to be¬ numb the part, and arreft for a time all mo¬ tion, and of courfe that of the lymphatics?

There is fome times an appearance of peri¬ odical remiffions and exacerbations in the lymptoms ; and there is fome reafon to fuf- peft that fuch cafes are of a milder 'nature, and that fome of them recover. Upon this ground the Peruvian bark might be tried.’ It might be fwallowed in an eled:iiary, and alfo thrown up by cly-ler.

In the Eaft-Indies, in the Carnatic, there is a pill in ufe, faid to be a fpccific againil the poifon of ferpents, and alfo the bite of a mad dog. The principal ingredient has been afcertained to be arfenic. It may feem ftrange to propofe as a remedy in any cafe, a fub- ftance that is a moft deadly poifon ; but we know that arfenic can produce not only very

Y z great.

t 324 ]

greaty but alfo very falutary efFeils upon the conftitution. The moft obftinate intermit- tents have been cured by a few drops of a fo- lution of it. It might be tried in the fame form, and in a dofe fomewhat increafed, in hydrophobia, as it is in agues. One tenth of a grain diflblved in water is given in agues three times a day ; this dofe might be doubled.

It would not be difficult to enumerate va¬ rious other adlive fubftances in the materia medica, which might be tried againfl the hy¬ drophobia ; but every one may readily chufe for himfelf ; for our grounds of trying one in preference to another are merely hypothetical.

Nothing would probably contribute fo much towards afeertaining a proper treatment of the difeafe, as experiments made upon the poifon. It is true the undertaking would be both dif¬ ficult and hazardous ; yet the danger is pro¬ bably greater in apprehenfion than it would be in reality. Dogs known to be mad are often confined till they die ; and in this ftate there would be no great difficulty in collect¬ ing a portion of the faliva, or poifon. The point of a lancet would probably introduce the infection as certainly as the tooth of the

[ 325 ]

dog. By experiments upon dogs, the feve-.- ral ftages of the difeafe might be known ; the lateft period at which the contaminated part could be cut out with fuccefs, might be afcertained ; aud various counter poifons might be applied to the wound/ or adminiftered in¬ ternally. It might be determined, whether the faliva of other animals, befides thofe for¬ merly mentioned, had the power of commu¬ nicating the difeafe, while labouring under it. An experiment with the faliva of an hydro¬ phobic patient might ealily be made upon a dog. It might be afeertained whether any of the humours of the body of an infedled animal poflelTed the poifonous quality, except the faliva. The liver of a dog that has died mad is reputed tg be a fpecihe againft the poifon, and as fuch is eaten in fome parts of the world ; but we cannot ahfolutely infer from this that it is exempt from the poifon, for the digeftion of the ftpmach deftroys fomp

vm.

[ 526 ]

VIII, Of the antiquity of the difeafe.

In the days of Plutarch ^ it was a quef- tion, whether canine niadnefs were not a new difeafe. The fame point is difciiffed by Cos- lius Aurelianus •f' ; but their mode of treating the queftion affords little fatisfadtion to a mo¬ dern enquirer ; their arguments turn upon fpeculative and metaphyfical points, and they negledt to examine into the matter of fadf, the only ufeful information. But though we are much farther removed from the origin of the difeafe, fuppofing it to be a new one, we are probably in a better condition to deter¬ mine the queftion, from the ample expe^ rience that later times have furnifhed of new difeafes. In the courfe of the lafl: eight or nine centuries there have appeared many new difeafes ^ and it is remarkable, that they are not only all infedlious difeafes, but are capable of being produced by infection alone, at leaft as far as our experience goes. Of the infec¬ tious nature of canine madnefs there can be no doubt, and there is reafon to fufpedt, as

* Sympofiacon, lib. viii. probl, 9, Acut. Morb, lib. iii. cap. 15.

[ 327 ]

has been flated above, that it Is only com¬ municated by infection ; in both particulars, therefore, it ao;rees with what mav be called the new difeafes of modern times. The quef- tion limply of the novelty of a difeafe muft be a thing of little confequence, but wdien that is connected with the manner in which it is pro¬ pagated, it becomes a confideration of impor¬ tance ; and if it Ihould appear that there is reafon for believing the hydrophobia to be a new difeafe, it may be an additional proof of the opinion already advanced, that it is only propagated by infedlion.

It is faid in Plutarch, that the hydropho¬ bia was firft feen at Rome in the days oiAf. fkpiades ; arid no mention is made of the dif^ eafe in Hippocrates, or in any preceding or contemporary writer. It is a diftemper fo fingular and ftriking in its appearances, that it could never be feen without leaving the 4eepeft impreffion upon the mind ; and the filence of Hippocrates is a ftrong prefump^ tion that it did not exift in his time, It has been alledged that Homer was acquainted with the difeafe, becaufe he ufes the word Avo-o-cjo ; but it is evident that he means to ex-*- prefs the anger or fury of a dog from paffion,

Y 4

[ 328 3

and not from difeafe ; though the term was very naturally afterwards applied to the difeafe. A fimilar derivation is to be obferved in the French name of rage, Ariftotle ^ is the firft writer who exprefsly mentions the difeafe. He fays that all animals belides man, were infedled by the bite of a mad dog 5 and that it proved fatal to every animal except man. imperfedt

ftate of his knowledge is a proof, that in his time the difeafe was recent. It has been remarked before, that a fmall proportion only of thofe of the human fpecies who are bitten, are feized with the difeafe j; and Ariftotle might have feen feveral who received no in-r jury from the bite of a mad dog. Again, the difeafe not appearing till long after the in- fedtion, and. the fymptoms in man differing greatly from thofe in the dog kind, in which there is no difficulty pr averfion to fwallow cither liquids or folids, fome tinic might elapfe, and many cafes of hydrophobia occur, before it was referred to its true fource. But

f- ' N. '.V

a period of no great length of time muft have been fufficient to clear up all thefe doubtful points; and when we advert to the total

* De HiiT:or, Animal. lib. viii. cap. zi.

iilence

I

[ 329 ]

filence of Hippocrates, the Imperfeft know¬ ledge of Ariftotle, and the familiar manner in which fubfequent writers fpeak of the dif- eafe, we are tempted to conclude that canine madnefs did not exift in Greece till a- fhort time before the days of Ariftotle, that is, about two thoufand one hundred years ago.

* i ‘

v

XVIII.

[ 330 ]

f

3CVIII. So7ne Obfervations on Wcers* By

Everard Home, Efq-, F.R.S, AJjiJlant

Surgeon to St. George's^ Hofpital.

)

i

As the management of ulcers is one of the moft common offices of furgeiy, the appli¬ cations employed for that purpofe, are almoft without number. Yet the ufual modes of treating fuch complaints, when fituated on the flower extremities, have been fo unfuc- cefsful, that they are regarded, not unjuftly, as the opprobrium of the art.

Ulcers generally confidered, vary in many refpedls, according to the conftitution of the patient, and the parts on which they are fituated; the modes of treating them can, therefore, be collected only from a field of pradice of confiderable extent, and form a topic of enquiry, much too various and im¬ portant, for the limits of this paper. It i§ not my intention at prefent to enter minutely into the fubjed ; a few obfervations pn the treatment of fuch fores as are of no fpecific nature, but from weaknefs, indolence, or long habit, have no difpofition to ficin, will be all that I fhall now bring forward.

The

' ' [ 331 ] '

The ufual mode. of treating ulcers of this kind is by ftimulating, or by fedative appli¬ cations ; when neither of thefe are thought neceffary, dry lint is commonly applied to the furface of the fore, to abforb the mat¬ ter, and fome uniSuous covering is laid over it, to prevent evaporation, and more readily admit of the removal of the dreffings.

Stimulating medicines are commonly mixed up with fome of the exprefled oils, and ap¬ plied in the form of an ointment ; but thofe applications that are intended to adl as feda- tives, are ufually combined with water, and made ufe of in the form of fomentations and poultices,

' Both thefe modes of applying medicines to an ulcer, experience has proved to be im¬ proper as a general pradlice. Undtuous drelT- ings are found not unfrequently to difagree with the furrounding Ikin, and, when brought in contadl with the furface of an ulcer, be¬ come extremely irritating. W atery dreffings, from the weight which is neceflary for their conflant application, are in many inftances . f)oth inconvenient and hurtful ; and, when ong continued, give the granulations a difpo*^ ^ion to be luxuriant aud flai^by.

Froim

[ 33^ ]

From the knowledge of thefe fadts, which are I belive fufiiciently eftabliflied, furgeons have, for fome years paft, applied their minds to ftrike out fome improvement ; and various fubftances in the form of powder have been propofed, as fubftitutes for the comnion dreffings.

In the courfe of thefe laft fourteen years,'! have had frequent opportunities of attending to cafes of this kind, and have made ufe of a variety of fubftances, in different forms, as external applications. I have not only tried thofe powders recommended by others, but have ufed fome which had not before been thought of. Of the latter kind, a few ap¬ pear to me to defervc particular attention^ my experiments and obfervations upon which, I have thrown together in this paper.

As the application of powders to ulcers in general is a pradice not yet much known, it may not be improper firft to mention the re- fult of my experiments on fuch fubftances as have not been found to anfwer, that others may not lofe time in ufelefs trials.

Tartar emetic, in the form of powder, has been recommended, and I have ufed it in a variety of inftance*'s ^ in fomp it produced no

vifible

[ 333 ]

yifihle effefts, and in others fuch as evidently were unfavourable ; nor in any cafe could I effedt a cure, by perfifting in the ufe of it*

Chalk has had its advocates, but experiejU:e does not authorife me to give my teftimony in its favour; it may anfwer in fuperficial fores, where nothing in fadt is neceflary to be done. This powder, when firft applied, does not feem to produce the fmalleft irrita¬ tion ; but if it be long continued, the fore in general, although not alaways, becomes foul.

r

Plaifter of paris is an application I was led to niake ufe of feveral years ago, from an idea that it would abforb the matter of a fuperfi¬ cial fore as faft as it was fecreted, and forna a cruft, which, fimilar to a fcab, would in¬ duce the parts underneath to ikin over ; ex¬ perience, however, proves that this is not the cafe, and the edges of the fore, in many inftanccs, are much irritated by this applica¬ tion.

Lapis caliminaris, in the form of powder, has had a character with feveral furgeons for having the power of difpofing fuperficial fores to ikin over ; I therefore thought it deferving of a trial. I ufed it in a great many in-

9 ftances.

t 334 ]

fiances, arid no one circumftance lias occiitrcA from which I could conclude in favour of its

effiacv. '

•/

That each of thefe four fubftances has been found, in particular inftances, to fuc- ceed, I am very ffeady to believe ; but, as far as my own obfervations lead me, I am in¬ clined to think that ^ they are- not to be fet down as applications on which dependence can be placed in the cure of ulcers.

- - The ufe of thefe mineral fubftances in pow-^ der having proved unfuccefsful, I was led to confider^how far the vegetable medicines could be applied in that form with advan¬ tage; and I was encouraged in this enquiry from having, in many inftances, experienced the good effefts of the carrot and caftada poul¬ tices which are nothing more than the powder of thofe roots in a moift ftate. ;

During the laft war, Twas eight months in* the.iiland of St.^Lucia, in the Weft-In¬ dies, where ulcers on the the legs of the worft kind - were exceedingly numerous ; and the application from 'which they appeared to de¬ rive the greateft benefit, was the caffada- root grated into a powder, and moiftened with

* The calTada is- the fafropha manihot of Linnaeus.

^ watei%

t 335 ]

Water. It did not at that time occur to me, tliat it might be ufed in a dry ftate.

As rhubarb has confid^rable powers in ill- ^ mulatirig the villou^" internal furface of the llomach and iiiteftines, which in appearance is not very diffimilar to that of a granulating fore, I made choice of this powder as an ex¬ ternal application.

I began my e]i?:perlments by covering the furfaces of feveral ulcers with the powder of rhubarb, very thinly fpread over them, and afterwards dreffing them with a pledget of common ointment. Thefe applications were renewed once in twenty-four hours. Under this treatment the fores mended for feveral days, and then feemed to be at a itand, al¬ though they retained a healing appearance. This circumftance was not readily accounted for, but as the pledget was exceedingly greafy, and came in contadl with the edges, and many other parts of the fore, it was attributed to that caufe, and a piece of lint v/as therefore interpofed between the powder and the unc¬ tuous covering, after which the granulations became difpofed to form Ikin, and the fores were gradually healed.

Encouraged

t 336 ]

Encouraged by thefe trials, I made ufe of this powder under a variety of circumftances, with a fimilar refult. In fome cafes it ap¬ peared, after being continued fome time, to lofe its efFed: upon the ulcer. But even in thefe inftances, the applying it twice in the fame day was fufficient to reftore the firft ef- fed. In other cafes the rhubarb feemed to be too violent an application, in fome degree difpofing the granulations to ulcerate; this effed was however prevented, by adding to it the powder of opium, in the proportion of a drachm to an ounce. By thefe means the application of this medicine may be adapted to the degree of indolence or irritability in the fore to which it is applied.

' Having afeertained the eiFeds of what is commonly called Indian rhubarb, I made

comparative trials With that imported from Turkey, but could not difeover any difference that appeared material. Rhubarb in the form of ^ tindure did not by any means produce limilar efFeds ; on the contrary, the fores to which it was applied, when irritable in their

* The tindure ufed in thefe experiments, was made by pour¬ ing proof fpirits upon the powder of rhubarb, and, after letting it remain three or four days without adding any other ingre¬ dient, the tindure w^s feparated for ufc.

nature.

[ 337 3

nature, put on a foul appearance ; when in¬ dolent they were lefs aifefled, but did not acquire the fame healing difpofition that the powder ufually produced.

After confining my experiments to rhu¬ barb, and having this fuccefs, I was natu¬ rally led to try the effedts of other vegetable powders. It feemed neceflary to determine whether this healing property was peculiar to rhubarb, or, if it be in other vegetable fubftances, in which of thefe it exifted in moft perfedtion.

With 'this view I feledled the following powders, as proper fubjedls for my experi¬ ments, and {hall {late, in as few words aa poflible, the refult of my obfervations upon them.

Ipecacuanha appeared to irritate the gra¬ nulations to which it was applied, giving the fore a foul appearance

The flour of muilard, applied by itfelf, not only irritated the granulations, but exco¬ riated the furrounding {kin ; to prevent thefe effedls, it was mixed with the farina of lint- feed meal in different proportions. Thus

i

■* Equal parts of ipecacuanha and rhubarb make an ufefuj jnild efcharotic for deftroying warts.

z

weakened

. [ 338 ]

weakened I applied it to feveral fores, but did not find its general efFedls fufficiently fa¬ vourable to induce me to continue this ap¬ plication.

The gentian and chamomile were ufed feparately, in a variety of cafes. The fores under this treatment went on tolerably well,

I

and the granulations put on a florid and heal- ing appearance ; but the procefs of forming new fkin was extremely flow, when com¬ pared with the cfledls of rhubarb. Compa¬ rative trials of thefe powders with rhubarb on the fame fore, afforded fufiicient evidence of the inferiority of their powers in difpofing ulcers to heal.

The powder of the columba-root appears, from its effects, to bear a greater refemblance to the rhubarb than any of the other fubftances which were made trial of. In feveral cafes where the fores had become ftationary under the application of the rhubarb, changing it for the columba produced a difpofition to heal, which continued till the fores got well. This certainly is in favour of the columba, but is no prcof of its fuperiority, fince all medi¬ cines lofe their effeds from being long con¬ tinued, and, when that happens. Amply 1 leaving

[ 339 ]

leaving them off may produce a cure, of dif- pofe the parts to get well under applications which before had failed.

My experience of the effedls of this medi¬ cine being lefs extenfive than of thofe of rhu¬ barb, I am unwilling to fay more refpedling it ; but in ufing columba, the granulations fometimes rife above the furface, a circum- flance which does not occur when the rhu¬ barb is ufed.

It will hardly be necelfary to mention here the difficulties which muft occur to every me¬ dical pradlitioner, in afcertaloing the effects of a medicine ; the only fatisfaftory mode of doing which, is to compare a number of re- fults, obtained under different circumftances,, deducing our conclufions from the aggregate.

In determining the effeds of local appli-

r

cations, the furgeon is often milled by fome circumftances which are not, I believe, fuf- ficiently attended to ; thefe, therefore, I (hall briefly mention.

It fhould be obferved, in the firfl: place, that almoft all fores appear for a time to re¬ ceive benefit Amply from a change in the dreffing, although the new application be by no means better than the former. In the

Z 2 fecond>

[ 34° ]

fecond, that all local applications lofe their effcd's upon a fore^, whatever they may be, after long continuance.

The circum fiances of the patient are alfo to be taken into the account, before we can well afcertain the effects of our treatment. A man who has been fuifering all the diftreffes of poverty, when taken into an hofpital, where he is kept quiet, and well taken care of, will mend under any treatment ; and in many inftances would get well without the affiftance of medicine. In all ulcers, on the lower extremities particularly, reft alone is of

the utmoft benefit. To thefe and fimilar cir-

\

cumftances, attention muft be ftridtly paid, with due allowance for their natural effedls, in all experiments that are attempted on this fubjeft.

Having given a general view of the effedts of rhubarb as an application to ulcers, and ' compared them with thofe of other vegetable and mineral powders ; I fhall add only a few obfervations upon the particular ' changes which moft commonly occur in fores while under this treatment.

In mentioning rhubarb as a dreffing, it is not meant to bring it forward as one that will 5 in

' [ 341 ]

in every cafe fucceed ; but only to introduce it into pradlice, as a mode of treatment fu- perior to fome now in ufe : as one which will be found riot unfrequently to give the granu¬ lations a healing difpofition, and, when they have arrived at the external furface, difpofe them to form {kin.

In the courfe of the lad; twelve months I have ufed this drefiing almoft conftantly in St. George’s Hofpital, in a large infirmary, where ulcers in the legs are very numerous, and in private practice. From the different cafes which have occurred in thefe fituations, I have been led to make the following re¬ marks upon the effedls of this medicine.

When the rhubarb is firfl applied, the fore is commonly more painful than it was before, and the whole furface becomes of an uniform red colour. In foul ulcers, where the mat¬ ter is principally compofed of coagulable lymph, adhering to the furfiice, a change is produced in the difcliarge ; it becomes more like true pus, which feparates from the fur¬ face, and expefes the granulations to our view.

In fores where the granulations are large^ fpongy, and femitranfparent, under this treat-

Z 3 meat

i; 342 ]

ment they become fmall, firm, very pointed at the furface, and of a florid colour; they are alfo fenfible to the touch, making the fore extremely tender.

The granulations, as foon as they have rifen to the level of the fl^in, feem to have a Ifop put to their growth ; and thofe that are next to the furrounding cutis lofe their irre¬ gular pointed appearance, become fmooth, fhining, and of a more florid colour than the refl: of the fore. In this way a margin is formed, about one- eighth of an inch broad, which is afterwards covered by a cuticle, con¬ tracting the fize of the fore ; and this procefs goes on till the whole is fkinned over.

This circumftance of the granulations be¬ coming ftationary when arrived at the level of the flcin, is fo general an effect, that in an hundred cafes, many of thefe fores nearly equal to fix inches fquare, no one inftance ’ to the contrary has occurred.

When the fore is beginning to heal, or has in part fkinned over, the powder adheres firmly to the edges, and fometimes to the furface of the granulations, forming a crufl over thefe parts. This fhould be carefully removed at each dreffing, as it confines the matter,

which

■ [ 343 ]

which is often produdlive of mifchief, and always retards the progrefs of the cure. • From thefe fadls, which have been afcer- tained by experiments too frequently repeated to admit of much fallacy, I venture to re¬ commend the rhubarb as an application, which will be found ufeful in the treatment of ulcers ; leaving it to a further and more complete experience to determine the exadl place it is to hold among the applications now in ufe.

i

Z 4 INDEX.

IWIWi

I N D E X.

N »

Abscess of the internal coat of the veins. Page 1 8

Aneurifm, obfervations on, 120, 123, 131, 139

" ■ ■ - popliteal, Mr. Hunter's method of operating

in, 138, 158

■■■■ — ■■ operations for, 172, 174, 178

. . cured wifhnut an operation, 756

— ■ of the femoral artery, operation for, 166

Ani, prolapfus, remarks on, 112, note Antimony, tartarifed, mode of preparing of uniform ftrength, 32

not a good application for ulcers^

332

: - - i-

B;.. i ■ -

Bark, Peruvian. Bee Cinchona Bladder, urinary, fnigular ftru^lure of an, 189 Blood, death perhaps occafioned by pus mixing with the, 24, 26

- - obfervations on the, 230, 284

Blood-veflels, lingular appearances of difeafes in, 119

- 'v - - on the obliteration of, 125

■ ' . . . . offification of, 133

'■■■ ■■ capable of fecreting air, 206

Bone,

INDEX.

Bone, fracSlured, want of difpofition to unite in, Page 233 Brain, unufual formation of a part of the, 212

I

)

C

Canine rriadnefs, obfervations on, 294 Carotid arteries, poffibility of living without any circula¬ tion through a part of the main trunks of both, ‘124 Cartilages, loofe, found in joints, remarks on, 229 Caffada poultice, utility of, in ulcers of the legs, 334i Chalk of little ufe as an application for ulcers, 333 Camomile powder applied to ulcers, 338 Cinchona, bark of, utility of, in eryfipelatous inflamma¬ tion, 290

Columba root, powdered^ utility of, applied to ulcers,

338

Contagion, remaiks on, 1 1

I

.■> -'r' ■ ; V

^ . i '

Day, in n(i^icine, ' on the! proper time of -beg4 lining- the, 286

Deglutition, palfy of the mufcles of, cured, 182

- - - on difHcuIty of, Wd,

Difeafe, uncommon appearances of, in blood-veflels, 119

Difeafes, advantages of remarking Angular appearances

in, ibid. ^ ■ " ' : \ -

- — . ’direiSlionsi for drawing- up hiftories of, * 244

- - - epidemic, remarks on, 262, 269

. ■■ ■— on the occafiohal caufes of, 278

. . — ^ time of commencement of, 288

> -■ . — - new, appear to be ail ftridtly infedtious, 326

Dogs, hydrophobia feldom if ever generated fpontaneoufly

ill, 294'

Dogs,

(

I N D E X,

Dog5, fym'ptoms of hydrophobia' in, Page 296 Dyfentery, obfervations on, 263 ' ^

V

Emphyfema not proceeding from local injury, caufes of, ' .202, 208 . ,

Epidemic difeafes, remarks on, 262, 269 ^

Eryfipelatous inflammation, remarks on, 290 Evidence, medical, , attempt to improve, 243

Fallopian tube, fatal haemorrhage from laceration of the,

215 \ . ■

Fever, obfervations on, il

- epidemic remittent, of “Buflbrah, cafe of, 53

Foetus, extrauterine, cafe of, 216

i

- - membrana decidua of the, formed in the uterus,

222

Fra6lures,‘ compound, ^remarks bn, 29 ' * •

- - - - peculiar circumftances attending, 233

G J ^

Generation, organs of, cafe of extraordinary flru£!Ure of the, 189

- - — . . — remarks on the, 223 >

Gentian powder applied to ulcers, 338

H

Heat, intenfe, at BulTorah, 57

Hemorrhage, fatal, from a laceration of the Fallopian jtube, 215

Hydatids

INDEX.

Hydatids' between the re6lum and neck of the bladder, cafe of, Page 34

~ on the growth of, 39

- different kinds of, 41, 49

— . — — mercurials recommended in cafes of, 47

Hydrophobia, on the generation of the poifon of, 294, 302 '

■ . . fymptoms of, in dogs, 296

■ . . — . — - the human fpecies, 306

- - - precautions to be taken againff, 298, 314

* ■ ■■ - how communicated, 299

I' . . . -- effe£ls of the poifon of, on the human fpe-

cies, 303

- - - on the prevention of, 312

- - - - treatment of, 319

. . . . . . antiquity of, 326

; I.

Inflammation of the internal coat of the veins, 18

- - -a-, after venefedlion, remarks on, 20

. — remarks on, 26

_ eryfipelatous, obfervations on, 290

Inoculation of fmall-pox, remarks on, i . . . .1 - - - beft mode of performing, 8

_ _ ~ . . . does not communicate other

difeafes, lO.

Infanity, peculiar kind of, 88 Introfufception, obfervations on, 103

■M — - cafes of, 107, 108, 1 15

- - - - - treatment of, 1 1 3

Ipecacuanha powder, efcharotic, 337

Joint, new, formed in confequence of fradlure, 235

Joints, on the loofe cartilages found in, 229

K

INDEX.

K

Knee, operation for extrading loofe cartilages from the. Page 239

Lapis calaminaris of little ufe applied in powder to ulcers,

333 • ‘

London, medical topography of, 247

M

Medicine, attempt to improve the evidence of, 243 Mercurials recommended in cafes of hydatids, 47

— - - ufelefs in hydrophobia, 320

Muflard, flour of, applied to ulcers, 337

O

/

Opium of no eiHcacy In hydrophobia, 32® - efleds of, externally applied, 336

Palfy of the mufcles of deglutition cured, 182 Pericardium, inftance of the want of, 91 Peruvian bark. See Cinchona ^ .

Plafter of Paris not a good application to ulcers, 333 Pregnancy, remarks on ficknefs during, 224' Preparation, remarks on, 9 Prolapfus ani, remarks on, 112, note Pus mixing with the blood perhaps a cau^e of death, 24, 26

R

INDEX;

R

I

RheumatiTm, obfervations on, Page 269 Rhubarb, powdered, beneficial efFedls of, applied t® ulcers, 335, 339, 340

9 '

•S

Sheep, hydatids of, 49

— - - difeafe called the Jlaggers in, produced by hydatids,

51

Small-pox, on inoculation for the, i

- - violence of, proportionate to quantity- of

matter abforbed, 6 '

Stomach, artificial mode of conveying food into the, j86 ' ,

Structure of organs may be confiderably varied without injury to their fundtions, 214 Suicide, inclination to, fymptom of a fever in Turkey, ,62, 86

T

\

Tartar, emetic. Bee Antimony tartar ifed Temperament, obfervations on, 272 Tunica decidua formed in the uterus, 222

\

U

/

Ulcers, obfervations on, 330, 339 — on the application of various powders to, 332 'Urinary bladder, extraordinary ftrudlure of an, 189 •

Urine,

INDEX.

Urine fuppreilion, fatal cafe of, P^e 34 Uterus, tunica decidua formed in the, v*'hen no foetu-s prefent in it, 222 ,

I

■ - - V

« I

Veins, internal coat of, liable to inflammation and abfcefs-^

^ • *

18

- - inftance of offification of, 134.

Vena cava inferior, changed into a ligamentous fubHancc-,; 127

- - azygos, double, 128

Venefedtion, inflammation after, 20'' ' ' ‘

- - directions for performing, 27

> ♦

W ' '

* ■ * r -

Warts, good efcharotic for> 337. mU

F I N I S.

I

\

/

X

• • ‘

V '

\

I

)

(

. ' ERRATA,

J

' } .

f» 93. 1. 8. f, b. for fai r. foi,'

' 1. 9. f. t. far on r. in.

I ' ' ' f

127. 1. 5. dele in.

142, note, 1, 1 1, f. h,for fteddying r, /teadylhg, 364. I. 2. f. for cacrfully r, carefully.

191. laft line, for glands, r. glans.

J94. 1. 9.yor mufcular r. vafcular,

>212. I.,4. f. \t. for falceform r. falciform. ' 220. 1. 2. f. h, for inrpregnated r. unimpregnated 301. 1. y. f. b.y^r when r.. where.

317, note, 1. 6. from b. for ridge r, bridge.

331 1, 2. f. h.forong r. long 333,1^ II. f. t, for alaways r. always.

], y. f. b. for Caliminaris r, Calaminari*. 334, note, yor fatropha r, jatropha. . ^

I

t

7

C A S E I.

L

Cilmate

' London'.

Preceffion of the feafons

[two very long and' cold winters, followed by fummers alfo cold, but mikf autumns, particularly the laft.-

Prefent temperature

Epidemics

Temperament

Peculiarities

Mode of living

Times and contingencies

Ocfcalional caufes

1787

Jan.

6 p. m.

T'p.m.

Boon

		day	Pulfe.
		Df
		dif-
		eafe.	-
12	F.	I
13	S.		between
		1 Sc 2	80 and
			90
- 14	Sun.	zSc 3	about
		1 00 }
15	M.	3^4	•> about
		/	1 10
. 16	T.	r 4	1 24
17	'• W.	“ 5	96
			•c

Jry

irequent inflammations of the Ikin, or red eruptions, fometimes accompanied withxrifypelatous fore throat,- fornetimes without ; they particularly affedfed that part of the town, rather fmall- in ftature, and delicate. Her pulfe in health fmall and weak, and eafily rendered frequent. , i

as women of a middle rank; regular as to hour of fleeping.

aged 29 ; menflrua regular, not much in quantity ; had been married four years without being pregnant; fhe had been affefted two years before with a nervous fever, which continued nearly four weeks,

.none apparent. -

I by the Ther¬ mome¬ ter un¬ der the I tongue.

105

moifl

and

natural

100

Heat feel	Heat on	.Mnfcles*	Eyes.	Tongue.	Mouth &	Refpira- j tion.	Stomach,	Food and	[nteftines. 1	Urine. (	Sleep.
of the	touching				throat.		drink..
patient.	the Ikin 3v the				-
	phyfician.		M				-	•
		} ' ■!			began to		appetite	t refrained
					feel the		not loft	Tom ani-
		^ !			uvula.			mal food
not hot			•		throat	natural	appetite	tea and	natural	not ob-	difturbed
	•» —				fore		oft	water-	evacua-	erved
								gruel	tion in the
	N,						-	morning
not hot .	/		-	foul	fore, red.	rather af-	lick	beef-tea.	no evacu-	ditto	verylittle.
					and be-	fefted		barley-	ation		drow fy
					ginning			water.
	■	i			flpughs	•		&c.
hot	■	' \ t	jj:-. • ; .	fouler	floughs	not m.uch	naufea	the fame	evacua-	ditto	the fame
		<	-		increafed	affedled			tion in the
							s		morning
hot	moderate	in noways	dull	a thick	flough of	not per-	naufea.	fago, pa-	evacua-	fomewhat	dofing and
	*	tenfe		yellowilh	an a(h co-	fedlly eafy	which fhe	nada, &c.	tion as	of a whey
			; -	brown	lour CO-	from the	aferibes	with '	ufual in	appear-	drowfy
				mucus	vered the	afleition	to the me-	wine.	the morn-	ance
				formed a	whole	of the	dicines	lemonade	ing
				triangle,	right ton-	throat
				the bafe	fil, round
	• ^			to the	which the					>1	■
				throat	membrane	-		/			,
					wasnotred					\
temperate	moderate	natural	brighter	mucus ■ crufl; lefs	membrane red about	more dif¬ ficult	naufea gone, but	the fame	the fame	higher co¬ loured,	:ftill dofing and
					the edge	from the	no appe-		r *	with a	drowfy N. .
			1		of the	throat	kite			cloud
/				-	flough^			..
			X		which be-	-		*•		-
•	V				gins to fepargte				•
'		!4	a						.

Mifceilaneous Obfervations,

excepting for the feel of the uvula no complaint

felt generally difordered

Medicines.

linimentum volatile guttura

pul vis jacobi- vefperer

miflura falina c, tart, emet;- gr. i fextis horis

I faw her for the firH time in this difeafe

th:! flougli fell off th^ evening of the 1 8th, and fhe recovered

R cort, Peruv, 9iji tertiis hof.- tii^. myrrh. 3ij. mel. rofar,- ^ij. aquas puras Jviij. m. fub-' inde utendum pro gargifmate’

R aq. menthi vulg. Jjfs. core. Per. pulv. 33*. fp. lavend. c.- 3j. ft. hauit fecunda q hora- fum.

R ol. olivar.' Jij. alkal. volat.- c. jij. pro liniment, guttur^' applicandum R tinduras rofar. |vj, myrrh. |ij. pro garg.

medicines continued-