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SURGICAL OBSERVATIONS.
SURGICAL OBSERVATIONS.
The Constitutional Origin and Treatment of
LOCAL DISEASES;
AND ON
ANEURISMS.
ON
DISEASES RESEMBLING SYPHILIS;

AND ON
Diseases of the Urethra.

BY JOHN ABERNETHY, F. R. S.
Honorary Member of the Royal Medical Society of Edinburgh, and of the Medical Societies
of Paris, Philadelphia, &c. Assistant Surgeon to St. Bartholomew's
Hospital, and Teacher of Anatomy and Surgery.
“ Chirurgó necessarium esse cognitioneum Physices, Chimiæ,
“ Logices, omnis (fere) ambitus Medicinæ; neque solo manus
« exercitio veros chirurgos fieri.” Herm. Boerhaav. Method.
Stud. Med. locupletata ab Alb. von Haller.
PHILADELPHIA:
PRINTED FOR THOMAS DOBSON, AT THE STONE HOUSE,
No. 41, SOUTH SECOND STREET.
Fry and Kammerer, Printers.
1811.
Taubman/Rare
302k & 3
-
+
3)
„дач
PREFACE.

THE best mode of obtaining and extending me-
dical and surgical knowledge is, in my opinion, to
pay that strict attention to diseases, which qualifies
us to note even the slightest shades of difference
that distinguish them from each other. Such dis-
crimination leads us to form some regular arrange-
ment of them, which, even if it be not correct, may
ultimately enable us to discover their natural series
and order. This method I have pursued from the
beginning of my professional studies. Whenever

attention to cases had impressed upon my mind, dif-
fered from those which seemed to prevail amongst
other practitioners, I published the facts, and the
inferences which I drew from them; because I
thought that the former at least deserved attention,
and that the latter would either be confirmed or
confuted by the result of general experience.
It is more, however, on account of the cases,
than of the conclusions which they suggested, that
I am desirous of republishing my surgical writings.
Various advantages result even from the publica-
tion of opinions; for though we are very liable to
error in forming them, yet their promulgation, by
exciting investigation, and pointing out the defi-
ciencies of our information, cannot be otherwise
than useful in the promotion of science.
The publication of the opinions which naturally
arise in the mind of the surgeon, from the cases
submitted to his observation, possesses the further
utility of rendering a prolix detail of circumstances

2
vi
PREFACE.
unnecessary. It would be almost impossible to re-
late every minute occurrence, that tended to im-
press certain conclusions on the mind of the ob-
server; or to relate every trifling particular of treat-
ment, by which the surgeon endeavoured to accom-
plish his object. Such a dull and tedious narrative,
which would weary and disgust the reader, may
indeed be well spared; because the practitioner
may, and must, repeatedly peruse the case at large
in the book of nature. The writer merely points
out those signs by which any disease may be dis-
criminated from others, and identified as one of the
particular class to which he is desirous of exciting
the public attention.
With regard to the cases, which I consider as
the valuable part of the book, I may observe, that
it is not to be expected that the records of them
will make so strong an impression on the minds of
the readers, as the observance of them has done
on that of the writer; but when the same occurren-
ces are met with in practice, then will the impres-
sion become more vivid, and knowledge arise, as
it usually does, from personal experience. If the
facts contained in these volumes occurred so rare-
ly, that others could not be expected to meet with
them, their relation would be of little value. They
may, however, not improperly be compared to
certain species of plants, by no means uncommon,
which are liable to be confounded with others by
an inattentive observer; but when their discrimi.
nating characters are once pointed out, they may
be so readily distinguished, collected and exa-
mined, at to render a more minute description of
them unnecessary. If diseases could, like other
objects which we mean to delineate, be placed in
various points of view, and illuminated at pleasure,
so as to show distinctly their different parts, one




wa fed

PREFACE.
vii
accurate representation would suffice; but we see
them obscurely, and as knowledge increases, it
serves, like light shining from different places,
to illuminate the various parts of the objects of our
examination.
For, as I have expressed it in the first edition of
these writings, “ in proportion as we advance in
knowledge, we are led to remark many circum-
stances in the progress of a disorder which had
before passed without notice; but which, if known
and duly attended to, would clearly point out the
nature of the complaint. Hence the records of for-
mer cases are of much less value; as the symptoms
about which we are now anxious to inquire, have
in them been entirely overlooked.” It, therefore,
becomes necessary that each writer should state
those circumstances to which he has been parti.
cularly attentive; nor need he further delineate the
case than by a general outline, so as to render it
intelligible.
· The relation of cases may be compared to the
representations which an artist gives of natural ob-
jects, and which are valuable only in as much as
they are correct or vivid delineations of reality.
Such portraits, sketched by a person of dull per-
ception, or by one whose optics are perverted by
prejudice and theory, are either valueless or decep-
tive; and hence, perhaps, has arisen that objection
to books of cases which I find to be very prevalent.
In the imperfect sketches which I have laid before
the public, my chief object has been to touch up
and bring into view some parts of the subjects
which have not been so clearly seen or strongly
delineated by former draftsmen.
When books of this kind are published, mutual
forbearance is requisite on the part both of the wri.
ter and the reader. The former should not expect



viii
PREFACE.
his work to be approved of, till the latter has ex:
amined whether his representation of diseases be
correct, and his conclusions legitimately drawn
from the facts which he has observed and collected.
Neither should the reader condemn the work till
he has examined the subject, and is in consequence
able to point out the errors of the premises or con-
clusions. The author's view of a subject may in-
deed be correctly formed from the facts which he
himself has witnessed; but it may differ from that
which more extensive experience would have sug-
gested. For this difference no blame can properly
be attached to him; he relates what has fallen under
his own observation, and invites others to attend
to the same facts.
I have been induced thus to offer my sentiments
respecting the design, mode, and probable advan-
tages of recording cases, not with a view of vindi.
cating the plan which I have pursued, for that in-
deed cannot be necessary, since it is the same that
has been followed by the best authors on surgery.
My object, by these remarks, has been to induce
others to reflect how they may most effectually pro-
mote medical knowledge. No one can have tho.
roughly studied his profession without perceiving
how susceptible it is of improvement, without dis-
cerning how inadequate the efforts of an individual
must be towards the accomplishment of this pur-
pose, and consequently without feeling an earnest
wish to engage general cooperation in this desira-
ble object.
In republishing my former writings, I have left
out all that part which relates to physiology. The
surgical facts contained in them, will now be found
incorporated with my later publications, under the
same general head of Surgical Observations. I
have also made those alterations and enlargements



PREFACE. . ix
which a greater share of experience has dictated.
The subjects have likewise been transposed. I have
put at the beginning of the book those cases which
show how much local diseases depend upon the ge-
neral state of the patient's health, because I shall
have frequent occasion to refer to this subject in
the succeeding parts of the work.
I feel much gratified in finding, that, though a
larger portion of experience has enabled me to add
some new and striking facts to this edition, it has
not shown me any thing that I ought to retract or
materially alter. This, indeed, must be the case in
a book containing only facts, and opinions not in-
cautiously deduced from them. Several of the pa-
ral and strong objection, which I considered as the
greatest compliment which could be paid to them.
For if the views which I had taken of various prac-
tical subjects were different from those of others,
and were ultimately found to be correct, the greater
was the necessity for their publication.



ON THE
CONSTITUTIONAL ORIGIN
AND

TREATMENT OF LOCAL DISEASES;
AND ON
ANEURISMS.


SURGICAL OBSERVATIONS.
ON THE
Constitutional Origin and Treatment
OT
OF
LOCAL DISEASES.
AN evil seems to me to have arisen from the ar-
tificial division of the healing art into the medical
and surgical departments. This division has caused
the attention of the physician and the surgeon to
be too exclusively directed to those diseases, which
custom has arbitrarily allotted to their care. The
effects of local disorders upon the constitution have,
in consequence, been too little attended to; and
indeed I know of no book, to which I can refer a
surgical student for a satisfactory account of those
febrile and nervous affections which local disease
produces, except that of Mr. Hunter. * The re-
ciprocal operation of constitutional disorders upon
local diseases has obtained still less attention. To
investigate more particularly some parts of these
subjects, and to submit them to public notice, are
the proposed objects of the present paper.
No part of the animal body can in general be
very considerably disordered, without occasioning
a correspondent derangement in other parts of the
system. Such disorder has been considered by Mr.
* Treatise on the Blood, Inflammation, &c.
A
On the Constitutional Origin and

Hunter as the result of universal sympathy. This
consent of the whole constitution with its parts
manifests itself, in particular instances, by a greater
disturbance of the functions of some organs than of
those of others; and from this circumstance diseases
have derived the appellations, by which they are
commonly distinguished. If the actions of the san-
guiferous system be principally disturbed, and the
temperature of the body subject to unusual varia-
tions, the disease is termed fever: if the nervous
system be chiefly affected, a state of vigilance or of
delirium may be produced: convulsions and tetanus
take place, when the functions of the muscular
system are more particularly deranged. Though the
disorder of particular organs thus give a character
and denomination to the disease, it is sufficiently
evident, in the instances adduced, that the whole
constitution is disturbed; while certain parts are
chiefly affected, perhaps from unknown circum-
stances relative to the nervous system, or from a
predisposition to disorder existing in the affected
parts. It seems to be ascertained, that persons of
particular constitutions are predisposed to those
febrile actions of the sanguiferous system, which
constitute the inflammatory fever; that there is a
propensity to convulsions in children; and to tetanus
in the inhabitants of warm climates.
It may be a fit subject for inquiry, whether it be
possible for particular organs to become affected
otherwise, than through the medium of the nervous
system in general. Though some instances of sym-
pathy are strange, and perhaps inexplicable, there
are strong reasons for believing that the inflam-
matory fever, the state of vigilance and delirium,
convulsions and tetanus, which arise in consequence
of injuries of the limbs, are produced by irritation
imparted to the brain, which, by a kind of reflected


Treatment of Local Diseases.

operation, occasions a greater disorder of some of
the organs of the body than of others, and thus
gives a character and denomination to the disease. *
That the stomach and bowels are disordered by
injuries and diseases of parts of the body, has been
remarked by various persons; but the subject has
never been extensively surveyed, nor viewed with
that accuracy of observation, which its high im-
portance merits. It has been observed that sprains
of tendinous or ligamentous parts produce sudden
sickness; and Mr. Hunter has attributed that
shivering which is consequent to accidents, and
attendant on some diseases, to the state of the
stomach. It is known that, in some local injuries
from accident or operations, the stomach has ap-
peared to be the part principally affected. But re-
marks on the affections thus induced in the di-
gestive organs have been made only in a cursory
* Mr. Hunter, who, with that patience and industry for
which he was so remarkable, collected and examined all the
facts which he had observed relative to the subject of sym-
pathy, has divided it into continuous,'contiguous, and remote.
It is the remote sympathies, according to his division, of
which I am now speaking.
The observations of Dr. Darwin on ocular spectra, and
indeed the consideration of the nervous functions in general
render it highly probable that sensation is not produced
merely by impulses made on the nerves, but by means of
actions excited by such impulses, which actions are continued
to the sensorium. Nervous actions, then, may take place
without the usually exciting causes; such actions may be
continued through the medium of the reticular communica-
tions of nerves, and thus physiologically we may explain the
continuous and contiguous sympathies. Actions also pro-
ductive of sympathetic sensations may be supposed to take
place through the media of ganglia or plexuses. In remote
sympathies, however, we must suppose the actions which
originate in an injured or diseased part of the body to be
continued to the sensorium, and there to excite the actions
of other nerves, &c.
On the Constitutional Origin and
manner; and it is my intention to examine tho
subject more particularly. It also appears to me
that the connexion of local diseases with the state
of the constitution in general is either not sufficient-
ly understood, or not duly regarded by the gene-
rality of practitioners; and I also mean to claim
their particular attention to this subject. I shall in
the first place select a case to show how the stomach
and bowels, or, to speak yet more extensively, the
digestive organs may be affected from local disorder.



Sudden and violent local Irritation will sometimes
produce an equally sudden and vehement Disor-
der of the digestive Organs.
CASE I.
A HEALTHY gentleman about twenty-five years
of age, was induced to submit to an operation for
the return of an adherent omental hernia, rather
in order to remove the inconvenience and appre-
hension which the disorder occasioned, than from
any urgent necessity; for any increased exertion in
walking or riding produced the descent of a portion
of intestine behind the thickened omentum, and
I obliged him to stop, and replace it: and he frequent-
ly could not accomplish the reduction without con-
siderable difficulty. The application of trusses had
been quite ineffectual in obviating these alarming
inconveniencies.
The patient's diet on the day preceding the ope-
ration was scanty, and consisted of fluid substances.
He took on the morning of the operation some Ep.
som salts and manna, which purged him twice and
seemed to have emptied his bowels. A portion of
- Treatment of Local Diseases. .

the omentum was cut off, and the remainder was
returned, after two vessels had been tied. The ope-
ration was followed by general disorder of the con-
stitution, manifested by a full and strong pulse,
furred tongue, great anxiety, restlessness, and total
want of sleep. The stomach was particularly affected,
being distended, uneasy on compression, and re-
jecting every thing that was swallowed. He was bled
largely in the evening, and took saline medicines,
but could not be prevailed on to swallow any thing
else, except some toast and water. The sickness
had in some degree abated on the next day. A so-
lution of magnesia vitriolata in mint water was pre-
scribed in small occasional doses, in order to relieve
the disorder and distention of the stomach, by
procuring some discharge from the bowels. * In the
course of the day he took an ounce of the salts,
which was not rejected by the stomach, yet he
could scarcely be prevailed upon to take any thing
else. The tongue was still covered by a thick yellow
fur; the skin was hot and dry, and the pulse frequent.
As there was no particular tenderness about the hy-
* It is most probably the disorder of the brain which affects
the stomach; but the reaction of the latter affection is liable
to increase and maintain the former, by which it had itself
been produced. The effects that result from the sympathy of
the whole constitution with local disorder vary greatly both in
nature and degree. Sometimes the brain is the part chiefly
affected; on these occasions the nervous energy appears to be
much impaired; and in some instances of this description,
the patient gradually sinks, little fever or reaction of the con-
stitution being observed; in other instances, however, there is
a low delirium, with a slight degree of febrile action; and in
others again, the delirium is more violent, and is accompanied
with a proportional increase of fever, subsultus of the muscles,
and convulsions. Sometimes other parts of the body or par-
ticular organs seem to be principally affected; indeed the
variety of effects produced under the circumstances alluded
to is such as to baffle description.

On the Constitutional Origin and
pogastric region, he was not again bled. The second
night passed without any sleep. As the salts had
produced no effect, the same medicine was ordered
in an infusion of senna, with the addition of some
of the tincture, which, by being given in very small
doses, was retained. When, however, it seemed
likely that no effect would result from this medicine,
a grain of calomel was given at night, and repeated
on the following morning. Still the loathing of food
continued. The third night passed, like the former
ones, without sleep and in great anxiety. On the next
morning, two pills, containing five grains of the pil.
colocynth. and the same quantity of the pil. aloet.
cum myrrhâ, were given every fourth hour. These
procured no stool, nor produced any sensation which
inclined the patient to believe that they would ope-
rate. Again he passed a sleepless night; but, towards
the morning, he felt his bowels apparently filling, to
use his own expression, and a profuse discharge
ensued. A dozen copious, fetid, and black evacu-
ations took place between five and ten o'clock, and
he had several others in the course of the day;
after which his appetite returned, his tongue be-
came clean, and a sound and continued sleep suc-
ceeded.
That the chylopoietic organs were the parts
chiefly affected in this case, can scarcely be ques-
tioned. The sickness, the tenderness of the parts in
the epigastric region, the aversion to food, and the
state of the tongue, all indicate that the stomach was
much disordered. The insusceptibility of the bowels
to the action of medicines, which would ordinarily
have produced discharges from them, and the pro.
fuse evacuations which subsequently relieved the
patient, prove that these viscera participated in the
affection. The black colour of the discharges shows,
I think, that the secretion of the bile was not healthy,
Treatment of Local Diseases.

and that the liver was affected with the other chy-
lopoietic viscera.
It may be supposed, that the injury done to the
omentum might contribute to produce the disorder
of these organs, rather than of others. We do not,
however, find that such effects commonly succeed
to similar operations. The consequences in the pre-
sent case were more severe than might have been
expected, if it were not known, that an operation
performed on a healthy patient is more apt to pro-
duceconsi derable disorder, than when performed on
one whose constitution has previously sustained the
irritation of a disease, for which the operation be-
comes necessary.
It is probable also that the restlessness and anx-
iety of the patient were aggravated, if not princi.
pally caused, by the state of the chylopoietic viscera;
since the relief which took place in those parts on
the renewal of secretions into them, certainly re-
moved the nervous and febrile symptoms. That the
discharges were the effect of secretion is proved by
the absence of alimentary matter in the bowels, in
consequence of the action of the purgative adminis-
tered on the morning of the operation, and the ab-
stinence both before and after that period.*
* Two instances are recorded in Mr. Pott's Works, of the
operation for the reduction of an hernia being performed
where no strangulation existed. See Pott's Works, Vol. III.
pp. 295, 299, edition of 1783.
* The operation in the case just related was undertaken upon
the authority of these cases, which were both successful. I
performed a similar operation on a patient, whose life had
been twice in imminent hazard from strangulation in a case
of adherent epiplocele, in which a truss did not keep up the
hernia, and the operation was followed by violent peritonitis,
which could only be subdued by such copious and repeated
venesection, as endangered the patient's life. These two
cases have made such an impression on my mind, that I should
be very averse in future to undertake similar experiments.

On the Constitutional Origin and
I could relate numerous cases in support of the
inferences, which I have drawn from the preceding
history; that local irritation acting on the nervous
system may affect the digestive organs in a very
serious manner, and thereby create great general
disorder of the system, which is afterwards allevi-
ated in proportion to the amendment that ensues in
the state of those viscera. Such consequences of
great local irritation must frequently occur to every
one; it is therefore unnecessary to adduce more in-
stances to support the opinions here delivered.
With respect to the treatment of cases of this
description it may be right to add, that the primary
object should be to produce secretion from the
irritable organs. In the case which has been related,
and in many others recorded in this volume, the
effect of secretions occurring from the disordered
organs in relieving their irritable state is very mani.
fest. In many instances opium will not prevent con-
tinual efforts to vomit, yet when by magnes.
vitriolat. or purgatives administered in the form
of pills, and clysters, stools are procured, the
vomiting ceases, the stomach retains both food and
medicine, and general tranquillity of constitution is
as suddenly restored.
A slighter Degree of continued local Irritation will
produce a less violent Disorder of the digestive
*Organs.
If then vehement local irritation can produce a
violent disturbance of the chylopoietic organs, it
may be expected that a less degree of a similar
casue will produce slighter effects of the same
nature. Indeed, the foregoing case was related not
Treatment of Local Diseases.

merely because it seemed worthy of record by it.
self, but chiefly to prepare the reader for the ob.
servations which are to follow.
The slighter degree of derangement occurs in
the advanced stages of lumbar abscess, diseased
joints, compound fractures, and all kinds of local
disease, which impart considerable and continued
irritation to the whole constitution. We also find a
less important disease, as for instance, a fretful
ulcer, keep up a disorder of the system in general,
and of the digestive organs in particular, which
subsides as the irritable state of the ulcer dimin-
ishes. But as practitioners in general may not per-
haps have so attentively remarked these circum-
stances as to be familiarly acquainted with them, it
may be useful to mention a very common occur.
rence, which cannot have escaped observation. I
allude to the effects of the irritation of teething
upon the health of children. The brain is some-
times so affected as to cause convulsions; the di-
gestive organs are almost constantly disordered.
The appetite fails; the tongue is furred; the secre.
tions of the liver are either suspended, diminished,
or vitiated. The bowels are either purged or costive,
and the fæces fetid. The fæcal matter is often mix.
ed with mucous and other secretions. There is also
frequently a very troublesome cough. Such symp-
toms generally subside when the local irritation
ceases, but sometimes the disorder of the digestive
organs, thus excited, continues and disturbs the
general health of the patient.
If local irritation be capable of disordering the
bowels, it seems natural to conclude that it acts
upon them through the medium of the brain. If
also the brain and nervous system should be disor.
dered, without any apparent local disease, similar
derangements may be expected to take place in the

10 On the Constitutional Origin and
functions of the digestive organs. In cases, where
some morbific poison has been absorbed, producing
effects similar to those of syphilis, we usually find
the irritation of the constitution which ensues to be
accompanied with this slighter disorder of the chy-
lopoietic organs.
Whenever, also, the nervous energy and general
powers of the constitution have been weakened and
disordered by any violent disease, as fever, small-
pox, measles, hooping cough, &c. the digestive or-
gans are frequently affected in consequence, and
such affection becomes, as will afterwards be ex-
plained, the cause of many secondary diseases.
In persons, likewise, who have naturally a weak
or irritable state of the nervous system, we find the
digestive organs disordered in a similar manner.
Improprieties in diet will also produce a similar
state of irritation, weakness, and disorder of the
functions of the digestive organs.
This slighter disorder of the chylopoietic organs
is, in general, manifested by a diminution of the
appetite and digestion, flatulence, and unnatural
colour and fetor of the excretions, which are gene-
rally deficient in quantity. The tongue is dry,
whitish, or furred, particularly at the back part;
this symptom is most apparent in the morning.
The fur is greatest at the back part, and extends
along the middle of the tongue to the tip, the edges
remaining clean. As the disease advances, a tender-
ness is felt when the epigastric region is compres-
sed, and the patient breathes more by the ribs, and
jess by the diaphragm than in the healthy state.
The urine is frequently turbid.
In this general enumeration of the symptoms,
several circumstances are omitted which occur oc-
casionally, and which may, when the subject shall
be better understood, denote peculiarities in the
Treatment of Local Diseases. 11

disease, and require corresponding peculiarities in
the medical treatment. I shall here notice a few of
them. The appetite is sometimes moderately good,
when the digestion is imperfect; and the latter may
not be defective, although the disease still exists.
In some instances, indeed, the appetite is inordinate.
Tenderness of the epigastric region on pressure, is
not always an attendant, even on advanced stages
of the disease. The bowels are alternately costive,
and lax even to purging. * The urine is sometimes
pale coloured and copious like that of hysterical
patients.
Patients affected in the manner above described
commonly declare they are in good health, except
that they feel disturbed by their local complaints;
yet they are found, on inquiry, to have all the symp-
toms, which characterize a disordered state of the
digestive organs. The mind is also frequently irri-
table and despondent; anxiety and languor are ex-
pressed in the countenance. The pulse is frequent
or feeble; and slight exercise produces considerable
perspiration and fatigue. The patients are sometimes
restless at night, but when they sleep soundly they
awaken unrefreshed, with lassitude, and sometimes
a sensation, as if they were incapable of moving.
Slight noises generally cause them to start, and they
are, to use their own expression, very nervous.
These circumstances seem to me to indicate weak-
ness and irritability of the nervous and muscular
systems; which, in addition to the disorder of the
digestive organs, that has been described, are the
* I have known persons whose bowels were ordinarily cos-
tive, and whose general health was much deranged by disor-
der of the digestive organs, though they were unconscious of
its existence, feel pleased that their bowels were in a comfort-
ably lax state; yet on observing the stools, they resembled
pitch in colour and appearance.


12 On the Constitutional Origin and
chief circumstances observable relative to the gene-
ral health of those patients, whose cases are related
in the following part of this paper. By correcting
the obvious errors in the state of the digestive or-
gans, the local disease, which had baffled all attempts
at cure by local means, has speedily been removed,
and the patient has acknowledged that such an
alteration has taken place in his general health, as
excited his surprise.
A Review of the natural Functions of the digestive
Organs, and an Inquiry into the Signs which de-
note them to be in a healthy or disordered State.
Before I proceed, I may be allowed to enter
more fully into a consideration of the symptoms
which denote disorder of the digestive organs; in
order to induce surgeons to pay that strict attention
to them, which the importance of the subject so
well deserves. It would indeed be impossible for
the reader to understand, without such prefatory
observations, my object in the treatment of the
cases which will presently be related, or the opin.
ions which I have formed, relative to their mode of
cure.
The changes which the food undergoes in the
digestive organs of the more complicated animals
are threefold; and distinct organs are allotted to each
of the three processes. Digestion takes place in the
stomach; chylification in the small intestines; and a
third process, hitherto undenominated, is performed
in the large intestines. It is probable that in some
cases, one set of organs may be more disordered
than the others, and of course one of these proces-
ses may fail more than the rest. For instance, the
Treatment of Local Diseases. 13
stomach may digest the food in a healthy manner,
although the intestines do not perform their share
of the changes which they ought to effect.
The food is converted in the stomach into a vis.
cid semitransparent substance called chyme; and
that this change is effected by the agency of the
succus gastricus, is a point as well ascertained as
any in physiology. In a state of health this conver-
sion takes place without any appearance of that na-
tural decomposition which animal and vegetable
matter would ordinarily undergo in a warm and
moist place. When, however, digestion is imper-
fect, gaseous fuids are extricated from the alimen-
tary matter. Vegetable food becomes acid, and oils
become rancid. Uneasy sensations are also felt, and
undigested aliment may be observed in the fæces.
Disorder of the stomach is however more readily
perceived by adverting to the state of the tongue,
which often indicates an irritable and unhealthy
condition of the stomach, when no manifest symp-
toms of indigestion occur. If there be no fever to
disturb the secretions in general, the change which
is visible in the tongue can be imputed to no other
cause than local disease, or a participation in a dis-
order of the stomach or lungs. Local irritation or
mental anxiety will cause a white and dry tongue;
but does not this effect arise through the medium
of an affection of the stomach? For although the
secretions of the tongue must partake of the gene.
ral disturbance which prevails in fever, their espe-
cial disorder may be, in that case, also, not impro-
perly attributed to the state of the stomach.
The state of the tongue is, in general, an infalli.
ble criterion of a disordered condition of the sto.
mach; butit does not point out the kind and degree of
that disorder. In recent and considerable affections,


14. On the Constitutional Origin and
where the appetite is lost, and the digestive powers
are greatly impaired, the appearances of the tongue
are by no means so strikingly unhealthy as in more
confirmed cases, where neither the appetite nor di-
gestion appear materially deficient. It is probable
that a continuance of irritation in the stomach may
so affect the tongue, as to render unnatural secre.
tions habitual to the part, and that these exist inde-
pendently of the original cause, or may be reprodu-
ced by trivial degrees of disorder. Nay, sometimes
the cuticle of the tongue seems to have lost its
transparency, and to become permanently white, in
consequence of continued irritation.
After making the allowances, which such circum-
stances require, we may in general be enabled to
detect a disordered state of the stomach by observa-
tion made on the tongue: and, as it is of consequence
to ascertain such disorder at an early period, when
the symptoms are probably slight, this organ should
be observed in the morning, when it will be found
much furred, particularly at the part next the throat.
Its appearance may vary in different parts of the
day from varieties in the state of the stomach, de-
pending on the excitement which is derived from
food, or a state of irritation arising from too long
fasting. The tongues of many persons with disor-
der of the stomach look moderately healthy during
the day, though they have been so much furred in
the morning, that it has been deemed necessary to
scrape them.
• A disordered state of secretion, either as to quan-
tity or quality, will be the natural effect of irritation
of a secreting organ. This is evidently the case
with the tongue; and we may, with great proba-
bility, conjecture that the same consequence also
takes place in the stomach. Since the juices of the
stomach are the immediate agents in digestion, that


Treatment of Local Diseases. 15
process must be disturbed in proportion as its se-
cretions are deficient or vitiated.
If undigested matter pass from the stomach into
the intestines, it can scarcely be supposed that their
powers are capable of converting it into chyle; and
it may become irritating to those organs in conse-
quence of the chemical changes, which it may then
undergo. When digestion is imperfect, animal and
vegetable substances experience considerable che-
mical changes before they leave the stomach; and
similar changes may continue to take place during
the time they are detained in the bowels, unless coun-
teracted by the powers of the digestive organs:
powers which seem chiefly to belong to the fluids
which are secreted into them.
The extent of the power which the intestines
possess of converting what they receive from the
stomach into chyle, or of preventing chemical
changes, is unknown. It is probable that much un-
digested matter is absorbed by the lacteals, when
the digestive powers fail in their functions. This is
apparently the case in diabetes, where the vegetable
matter floats in the serum of the blood, rendering
it turbid, and afterwards combines so as to form
sugar in its passage through the kidneys. The
strong odour, which various kinds of food impart
to the urine, indicates that different substances are
absorbed indiscriminately from the intestines. It is
probable that a turbid state of the urine, and varia-
tions from the natural odour of healthy urine, may
very frequently arise from a similar cause; viz. from
the imperfect action of the digestive organs, in con-
sequence of which, unassimilated matter is taken
up by the lacteals, and afterwards separated from
the blood in the kidneys. It may be reasonably
conjectured that the same powers, by which the
kidneys convert the old materials of our body into



16
On the Constitutional Origin and
that peculiar modification of animal matter, which
is dissolved in the water of the urine, and which
has been called by the French chemists urée, may
also enable it, in a healthy and vigorous state, to
dispose of much unassimilated substance in the
same way. The further consideration of this subject
would, however, lead to a discussion foreign to the
purpose of the present paper: it will be sufficient to
remark at present, that the state of the urine may
afford assistance in ascertaining the existence of
disorder of the digestive organs, and in indicating
its nature. It has been already mentioned, in the
brief account of the symptoms, that the urine is
frequently turbid. It should, however, also be ob-
served, that the quality of the urine greatly depends
on the state of the nervous system. It is frequently,
in the disorders of which I am speaking, pale
coloured and copious; which is probably owing to
a state of nervous irritation, such as exists in hys-
teria. It is not improbable that disorders of the di-
gestive organs, by causing the frequent secretion
of unnatural urine, may produce irritation, and sub.
sequent disease of the kidneys, and other urinary
organs.
Modern physiologists seem to agree in the opin-
ion that the succus gastricus is the agent, by which
digestion is effected; but they are not so unanimous
as to the immediate cause of chylification. It is not
improbable that the succus intestinalis is a princi.
pal agent, although its qualities have not yet been
inquired into; for, indeed, the investigation would
be attended with difficulties almost insuperable.
Since the bile and pancreatic liquor are poured
into the intestines at a small distance from the
stomach, it is natural to consider these fluids as
useful in effecting the change, which the alimentary
matter undergoes in the small intestines, namely,
Treatment of Local Diseases. 17

its conversion into chyle. The chyme, or aliment
digested by the stomach, being viscid, the pan-
creatic juice has been considered as an useful and
necessary diluent, and perhaps this fuid may have
other properties with which we are unacquainted.
The uses of the bile have of late much engaged
the attention of physiologists. Mr. Hunter observed
that it did not seem to incorporate with the chyle;
and it certainly cannot do so and retain its own
nature, since its colour and taste are so intense, that
it would impart these properties to the chyle, if mix.
ed with it in the smallest quantity. The difficulty of
conceiving that the two fuids can be agitated to-
gether by the peristaltic motion of the intestines,
without becoming incorporated, has led to an opi.
nion that the bile may combine with the alimentary
matter, and lose its original properties; but nothing
of this kind is ascertained. Fourcroy thinks that the
alkali and saline ingredients of the bile may com-
bine with the chyle, and render it more fluid, while
the albumen and resin may combine with the ex.
crementitious matter. It is, indeed, evident that the
bile combines either totally or partially with some-
thing separated from the chyle, and exists formally
in it, and in a state of health uniformly dyes it of
its peculiar colour; and therefore it has of late been
supposed, that the bile may serve to purify the
chyle, by precipitating and combining with its fe-
culent parts. *
It has been said in the brief and general recital
that has been given of the symptoms, which charac-
terize disorder in the chylopoietic organs, that the
* In the inquiry into the probable uses of the bile, it ought
to be observed, that in many persons, in whom that secretion
is either for a considerable time wholly suppressed, very de-
ficient, or much depraved, it does not appear that the nutri-
tion of the body is defectire.

On the Constitutional Origin and
stools are of an unnatural colour and odour. Medi-
cal men entertain various opinions respecting the
colour of the fæces: to me this property seems
generally to depend on the kind and quantity of the
bile. All the secretions, which are poured into the
alimentary canal, except the bile, are colourless or
white; if, therefore, this fluid were wanting, the re-
sidue of the aliment would be of the colour, which
might be expected to result from some of its undi-
gested parts combined together. When, for instance,
the secretion of bile is stopped by the irritation of
teething in children, whose diet is chiefly bread and
milk, the fæces are white; when this secretion is
obstructed in adults, the stools are pale like whitish-
brown paper.
In cases of disease, however, coloured excretions
may take place from the bowels. There is great
reason for ascribing the discharges in the disease
called melæna to a vitiated secretion from the sur-
face of the alimentary canal. I was intimately ac-
quainted with a patient who suffered repeated and
increasing attacks of constitutional irritation. When
the disorder was wrought up, as it were, to a crisis,
he was forewarned by a sensation, as if his stomach
wasfilling, of the occurrence that was about to take
place. In less than a quarter of an hour he would
vomit more than two quarts of a fluid resembling
coffee grounds in colour and consistence. Shortly
afterwards very copious discharges of a similar
darker coloured and offensive matter, took place
from the bowels: but a green viscid bile, appearing
distinct and uncombined, was intermixed with this.
These evacuations ceased in a day or two, and the
constitutional irritation disappeared with them.
I examined the bodies of several persons, who
died under attacks of this nature, and found the
villous coat of the alimentary canal highly inflamed,

Treatment of Local Diseases.
swoln and pulpy. Bloody specks were observed in
various parts; and sphacelation had actually taken
place in one instance. The liver was healthy in some
cases, and diseased in others. I conclude therefore
that these diseases, which were termed hæmateme. .
sis and melæna, arose from a violent disorder, and
consequent diseased secretion of the internal coat
of the bowels: and that the blood, discharged when
the affection was at its height, did not flow from
any single vessel, but from the various points of the
diseased surface.
Indeed I think it probable, that the profuse dis-
charges, which sometimes follow the continued
exhibition of purgatives, consist of morbid secre-
tions from the bowels themselves, and not of the
residue of alimentary matter detained in those
organs. Such evacuations, either occurring spon-
taneously, or excited by medicine, frequently re-
lieve irritation of the chylopoietic viscera.
It seems probable that the stools which resemble
pitch are principally composed of diseased secre.
tions from the internal surface of the intestines, since
they do not seem either like the residue of the food
or discharges from the liver. Can we suppose that
all the black and fetid matter which was discharged
from the bowels, in the first case, was poured forth
solely from the liver?
The subject of morbid secretions is however par-
ticularly illustrated by that well known alvine dis-
charge, which so much resembles yeast in colour
and consistence that it cannot be confounded with
fæces, with blood, or with a vitiated secretion from
the liver. A medical man of my acquaintance took,
for some disorder in his stomach and bowels, an
aperient medicine, which apparently emptied those
organs. He ate nothing but a little bread in broth for
his dinner, and a small quantity with his tea in the

20 On the Constitutional Origin and
evening. He experienced an uneasiness in his bow-
els, and an inclination to evacuate them after he
had gone to bed; but he resisted this desire till four
o'clock in the morning, when its urgency forced
him to rise. He then discharged, what he supposed
to amount in quantity to a gallon, of a matter exact-
ly like yeast, unmixed with any bile or fæces. When
he arose in the morning, he had a similar evacua-
tion of about a quart; and on the succeeding day
there was a solid stool, apparently of the same sub-
stance, coloured of a light green from an admixture
of bile. He had a natural stool the next day: his ap-
petite returned, and the uneasy sensations subsided.
An unhealthy colour of the fæces may further be
attributed to some degeneracy in the quality of the
alimentary matter; such as may be supposed to take
place when the digestive organs fail in the perform-
ance of their offices, and different alimentary sub-
stances are in consequence detained in the bowels,
where they may pass through chemical decompo-
sitions, and recombinations. But, though I am in-
clined to allow the full operation of these causes,
the following reasons lead me to believe that the
colour of the fæces generally depends on the kind
and quantity of the bile. In the natural state of the
digestive organs, when there is no peculiarity of
diet, and no medicine is taken, the bile alone colours
the residue of the food. The fæces voided during
a state of disorder of the digestive organs are some-
times partially coloured; which circumstance can-
not be well accounted for upon any other supposi.
tion than that of an irregular secretion of the bile.
Fluids secreted from the intestines do not usually
enter into combination with the fæcal matter, but
appear distinctly when excreted. Thus we find
mucus and jelly discharged from the bowels, un-
mixed with the fæces. Medicines which affect the
AN

Treatment of Local Diseases.
liver produce a very sudden change in the colour of
the fæces. Small doses of mercury, without any
alteration of diet, sometimes change the stools im-
mediately from a blackish to a light yellow colour,
which indicates a healthy but deficient secretion of
bile.
Healthy bile in the human subject is generally of
a deep yellow brown colour; the brown depending
on a concentration of the yellow colour. It resem-
bles the colour of wetted rhubarb; for, if a small
portion of either of these substances be put into a
large quantity of water, the water will be tinged of
a bright yellow colour; this appears therefore to be
the proper colour of these substances, but it is so
concentrated in the mass as to appear of a deep
brown. Sometimes, indeed, we find green bile in
the gall bladder, when the liver is not diseased. I
cannot, however, but think that the natural colour
is a yellow, so intense as to appear brown. Green
bile is usually poured out in circumstances, where
there is evident disorder of the digestive organs;
and we cannot well suppose that there are two kinds
of healthy bile. The quantity of this fluid should be
such as completely to tinge the excrement of its
peculiar colour. By attending, therefore, to the
colour of the fæces, the kind and quantity of bile,
which the liver excretes, may in general be ascer.
tained.
The colour of the alvine excretions in disordered
states of the viscera is various. Sometimes they ap-
pear to consist of the residue of the food, untinged
by bile. Sometimes they are of a light yellow colour,
which denotes a very deficient quantity of healthy
biliary secretion; they may also be of a deep olive,
of a clay brown, and of a blackish brown; all which
show a vitiated state of the biliary secretion. -
Any kind of brown, which dilution will not con.

92 On the Constitutional Origin and
vert into yellow, I should consideras unhealthy, since
the colour of healthy bile is a bright yellow, which
by concentration appears brown.
Such are the circumstances which I have collect-
ed from my own observation, and the reports of
others, relative to the alvine excretions, in the dis-
orders which have been described.
I have dwelt thus particularly upon the subject
of the biliary secretion, from a belief that its quan-
tity and quality can, in general, be ascertained by
inspection, and will therefore serve to indicate the
presence of disorder. Whether the foregoing opi-
nions be correct or not, it will, I think, be generally
granted that the excretions from the bowels com-
monly indicate the healthy or disordered state of the
digestive organs.
The effects, which medicine or diet may have
upon the colour of the fæces, ought, however, to
be considered. When the food is coloured, and this
colour is not altered by digestion, it will, of course,
appear in the fæces; hence if it should be thought
desirable to know accurately the state of the biliary
secretion, it would be right to restrict patients to a
diet that is not likely to colour the fæces. The green
colour of vegetables tinges the fæcal residue of the
food. Steel also is known to blacken the fæces. It
should also be remarked that the exposure of the
fæces to air after their expulsion, will, in some in-
stances, cause a considerable alteration in their
colour. In our endeavours, therefore, to ascertain
whether the liver is performing its office rightly, by
observing the colour of the fæces, attention should
be paid to these circumstances.
I conclude this review of the opinions entertained
respecting chylification, by observing that if the
succus intestinalis be an agent in this function,
disorder of the intestines is likely to affect its se-
Treatment of Local Diseases.

cretion, and thus impede this second important part
of the process of assimilation.
The residue of the alimentary matter, mixed with
the bile, passes from the small into the large in-
testines, and there undergoes a sudden change; it
acquires a peculiar fetor, and becomes what we
denominate feces. This change is so sudden, that
it cannot be ascribed to spontaneous chemical alte-
rations, (which would be gradual) but to some new
animal agency. If the contents of the small intes-
tines at their termination, and of the large at their
commencement, be examined, they will be found
totally different, even within a line of each other;
the former being without fetor, and the latter being
in all respects what is denominated fæces. Though
chemists then might speak of the feculent matter
of chyle as fæces, yet physiologists would rather
apply that term to the change in the residue of the
food, which takes place in the large intestines, and
which seems to be effected by the animal powers
of those organs. The fæces quickly suffer chemical
decomposition out of the body, although they often
remain in the bowels without undergoing the same
kind of change. Their chemical decomposition is
attended with the sudden formation of ammonia;
yet if they be examined when recent, they are found
to contain acids which ammonia would neutralize.
The inference, therefore, naturally arises, that this
third process, I mean the conversion of the residue
of the aliment into fæces, may, amongst other pur-
poses, be designed so to modify that residue, as to
prevent it from undergoing those various chemical
changes, which might be stimulating to the contain-
ing organs as well as injurious to the general health.
In a perfectly healthy state of the digestive or-
gans, probably no chemical decomposition, even of
the fæces, takes place; yet such changes happen,

On the Coinstitutional Origin and
in some degree, without apparently producing any in-
jurious consequences. To chemical changes we may
probably attribute the extrication of inflammable
air, and the various and unnatural odours of the
fæcal matter, which are observable in disordered
states of the digestive viscera.
The means by which this modification of the
residue of the food, which takes place in the large
intestines, is effected, are but little known. Analogy
leads us to refer it to the effects of a secretion from
the lining of those intestines in which it occurs.
Now if this secretion deviates from the healthy state,
in consequence of an irritated or disordered state of
those organs, we may reasonably expect a corres-
ponding derangement of the process, by which the
residue of the food is converted into fæces.
Further Inquiry into the Nature and Effects of that
Disorder of the digestive Organs, the Symptoms,
of which have been recited at page 10.
HAVING taken this general view of the functions
of the chylopoietic viscera, in order to facilitate the
forming a judgment relative to those circumstances
which indicate their derangement, I return to speak
more fully of that affection of them which I have
described, as arising from causes recited at page 10.
This subject, it must be acknowledged, is very im.
portant, if it can be shown that disorders of the diges.
tive organs are the cause of a great number of other
diseases. The inquiry would then not only lead us
to discover the source of many disturbances of the
constitution, which originate in those of the digestive
organs (for patients have no suspicion of any disor-
der existing in them), but would also lead to the
Treatment of Local Diseases. 25
prevention and cure of many secondary diseases of
a more vexatious and sometimes of a more fatal
nature, than those from which they originated.
If the tongue be furred at its back part in the
morning, when there is no fever, it is reasonable to
infer in general that the state of the tongue is owing
to its participating in the irritation of the stomach.
Such participation produces an alteration in the se-
cretions of the tongue; they are either deficient in
quantity, or vitiated in quality. A state of irritation
in any secreting surface is, indeed, likely to be at-
tended with the same consequences. It is, there-
fore, fair to infer that, when a general disorder of
the digestive organs takes place, those fluids, which
produce the changes that the food undergoes in
them, are deficient or depraved, and consequently
that digestion and the subsequent processes must be
imperfectly performed. The liver is likely to par-
ticipate in the disorder, and the biliary secretion to
be diminished or vitiated. This circumstance ad-
mits of ocular demonstration; and I have, therefore,
considered it as an evidence of a more or less ge-
neral disorder of the digestive organs. A very rea-
sonable objection may, however, be made to con-
sidering the derangement of the functions of the
liver as a criterion of those of the stomach and in-
testines; since the liver is independent of the latter
organs, and may be the subject of a disorder con-
fined to itself. In some cases, also, the alimentary
canal may be affected, without disturbing the liver.
Such circumstances may happen occasionally; but
they are not ordinary occurrences, and should be
considered as exceptions to general rules, which do
not militate against their common operation. In
general, affections of the former influence the func-
tions of the latter; and the state of the biliary secre-
tions affords a very useful evidence of a more or

26 On the Constitutional Origin and
less general derangement of the chylopoietic viscera,
and should excite our attention to investigate its
kind and degree.
I have stated, in describing the symptoms which
denote disorder of the digestive organs, that the
fæces are generally deficient in quantity. This cir-
cumstance may be accounted for in various ways.
It may be ascribed to diminished or unhealthy se.
cretion of bile, which does not precipitate the usu-
al proportion of feculent matter from the chyle.
Persons whose bowels are lax, and not inactive in
carrying downwards the feculent matter, void it
daily in deficient quantities. It may be supposed too
that, either from the deficiency of bile, and conse-
quent want of excitement, or from the effects of
disorder, a torpid state of the bowels may exist,
which causes them to carry downwards the feculent
matter in small quantities. This circumstance may
produce a greater absorption of the fæces than what
is natural, or an accumulation of them in the colon.
That the digestive organs in general were affect-
ed in the cases of local disease, which I am about to
record, is most evident; but I am aware that many
varieties of disorder may be included in the gene-
ral description of the symptoms, which I have given.
Future observations may lead to further distinctions;
but I see no impropriety at present in speaking of
the disordered state as general; since it is probable
that no material disorder can ordinarily take place
in one of the digestive organs without disturbing the
functions of the others. When digestion is imper-
fectly performed, the functions of the intestinal
canal will soon participate in the disorder of the
stomach. Under these circumstances, the secre-
tion of bile will also probably become irregular.
Should disease commence in the large intestines, as
about the rectum, it disturbs the functions of the

Treatment of Local Diseases. 27
stomach, and secretion of the liver, and becomes
augmented in its turn by its sympathy with these
parts. Should the liver be disordered in the first in-
stance, the stomach and bowels may not immedi-
ately sympathize, although they will probably soon
become affected.
I feel further warranted in considering the symp-
toms, which have been recited in the former part
of this paper, as arising from a general disturbance
of the functions of the digestive organs, from con-
templating the effects of blows on different parts of
the belly, which do not seem to have injured the
structure of any single abdominal viscus, but yet
produce effects denoting a general disorder of these
organs. The symptoms have varied in severity in
proportion to the violence of the blow received. In
the cases which were the consequence of the more
forcible injuries, the symptoms were, a furred
tongue; great vomiting, so that the stomach could
retain no food; difficulty of affecting the bowels by
medicine; great fever; and even delirium. Indeed,
all those effects were produced, which I have repre-
sented as arising from vehement local irritation of
remote parts of the body. The disorder has gene-
rally terminated by a profuse discharge of black and
fetid stools, after which the patient has perfectly
recovered. On the contrary, where the symptoms
consequent on the blow have been less violent, so
as not to claim such strict attention, the disorder
has continued. Persons who had been previously
in perfect health, have become hypochondriacal,
and have had all those symptoms of disorder of the
digestive organs, which have been already enume-
rated as arising from a less degree of local irritation,
with such consequent diseases as originate from such
disorder, and which will be mentioned in the sub-
sequent part of this paper.

28. On the Constitutional Origin and
In order to inquire more particularly into the
nature of this disorder of the digestive organs, I
have examined the bodies of a considerable num-
ber of persons who have died of diseased joints,
lumbar abscesses, and other great local diseases.
I knew that these patients had their digestive organs
disordered in the manner that I have described, and
that in many of them the secretion of bile had been
suppressed for a great length of time, and when it
was renewed, that it was very deficient in quantity,
and faulty in quality: yet, on dissection, no altera -
tion was discovered in the structure of the chylopoi-
etic viscera, which could be decidedly pronounced
to be the effect of disease. It naturally excites sur-
prise, that such a state of irritation, and imperfect
performance of the natural functions of these parts,
should exist for so long a time, as in many cases it
is known to do, without producing organic disease;
still I believe it may be set down as a truth, (which
has been verified byevery observation I have made,)
that a state of irritation leads to those diseased vas-
cular actions, which produce an alteration of struc-
ture in the irritated parts.
However, where the disordered state of the bowels
had been of longer duration, I have found the villous
coat of the intestines swoln, pulpy, turgid with
blood, and apparently inflamed, and sometimes
ulcerated; and these appearances have been most
manifest in the large intestines. Having observed
repeatedly in dissections of these cases, that the
large intestines were more diseased than the small
ones, it occurred to me, that the fact might be ac-
counted for in the following manner: If digestion is
incomplete, the undigested food must be liable to
chemical changes, and the products resulting from
this cause are likely to be most stimulating to the
large intestines. Indeed, in advanced stages of this

Treatment of Local Diseases. 29
disorder, mucus and jelly tinged with blood are
discharged, and it seems probable that a kind of
chronic dysentery may be thus induced.
In some instances, where the disorder had ex-
isted for many years, the bowels have been diseased
throughout their substance; the internal coat being
ulcerated, and the peritoneal covering inflamed, so
that the convolutions of the intestines were agglu-
tinated to each other. In these cases the liver, and
sometimes the spleen also, were much diseased,
beingtuberculated inevery part. Such is the result of
the information which I have obtained by dissection.
Accurate attention to the subject, especially in
medical cases, may lead to important subdivisions,
which I have not yet been able to make. But when I
find that irritation of the nervous system, however
it may originate, deranges the chylopoietic organs,
and affects the stomach, bowels, and liver, ap.
parently at the same time, I think it fair to infer,
that these organs are equally operated on by the
same cause. Disorders of the brain may affect the
chylopoietic organs; and it is well known that this
influence is reciprocal. The stomach is said to be
chiefly concerned in producing these effects; but the
causes of the sympathetic affection are probably
more general. A fit of passion has produced jaun-
dice; and the irritation of teething in children fre-
quently suspends the secretion of bile; so that the
stools are not in the least degree tinged with that
fluid. If the head can thus affect the liver, it is
reasonable to infer, that the liver may reciprocally
affect the head. It is very difficult to form an opi-
nion relative to this subject; for, in the instances
which have been mentioned, the affection of the
liver may take place, only because it forms a part
of the digestive organs, and not from a direct sym-
pathy existing between it and the head. Still, how-


f
30 On the Constitutional Origin and
ever, I do not think it unreasonable to conclude that
irritation of the other chylopoietic organs may, as
well as that of the stomach, disorder the source of
sensation.
To display how much hepatic irritation may affect
the sensorium and consequently the whole nervous
system, I insert the following case:
CASE II.
A gentleman applied to me with a thickened and
tenderstate of the periosteum of his tibia. This disease
had troubled him for more than a year, but became
at last so extremely painful that he declared he had
not slept for three months, and that his life was so
intolerable that he resolved to undergo a course of
mercury, even though in the opinion of those sur-
geons whom he had consulted, his disease was not
venereal. This duration of the disease, as it had made
no greater progress, induced me to coincide in the
opinion which had been given him. His tongue was
much furred, his appetite was moderate, and he was
not conscious that his digestion was otherwise than
good. His bowels were perfectly regular. I desired
him to take five grains of the pilul. hydrarg. every
second night; but before he took them to remark
the colour of the discharges from his bowels, and to
observe whether the medicine produced any change
of it. In a week's time he called upon me, and said,
I come to tell you the strangest thing that perhaps
you ever heard, which is, that I actually do not
know the precise spot where the lump on my shin
was situated, and doubtless these pills which you
directed are a most wonderful compound of opium.
The first gave me sleep, which I had not had for
three months. After taking a second, I have slept
soundly all night, and feel myself alert in the day.
Every other preparation of opium, which I have


Treatment of Local Diseases. 31
taken, failed in producing sleep, and made me ill
during the succeeding day. After all, continued he,
it cannot be the pills that have made me well, for
they have had no perceptible effect on me. I asked
him, had he, as I requested him, remarked the
colour of the alvine discharges? He replied, he had,
and that before he took the medicine they were
(to use the patient's own words) as black as his hat,
and now they were of the colour of a ripe Se.
ville orange. The great relief arising from the cor-
rection of the biliary secretion was not to me so
strange, as the patient expected. It is doubtless
such remarks that have impressed some medical
men with the opinion that the liver was the root
of the evil in all disorders of the digestive organs.
Cases like the present, (and several similar ones
will be found recorded in this work,) appear to me
highly valuable on many accounts. They show that
hepatic disorder may disturb the sensorium, either
immediately or intermediately, by disordering other
organs concerned in digestion; they show how dis-
orders of the abdominal viscera may become the
cause of various other diseases, by disturbing the
source of sensation and nervous energy; and they
further show that unirritating and undebilitating
doses of mercury have, probably by their local ac-
tion in the bowels, a great influence in correcting
the secretion of bile, and by this means of relieving
hepatic irritation.
Nothing in pathology is more generally admitted,
than the reciprocal operation of disorders of the
head and of the digestive organs on each other; yet
the exceptions to this general rule deserve to be
remarked in a comprehensive examination of the
subject. Some persons have great disorder of the
digestive organs, without any apparent affection of
the nervous system; and even diseases of a fatal na-



32 On the Constitutional Origin and
rez
ture may take place in the former organs, without
affecting the latter. Indeed, if we examine any of
the most evidently sympathetic affections, we shall
find the same exceptions. The stomach generally
sympathizes with disorder of the uterus, but it does
not invariably do so.
Many of the symptoms recorded in the descrip-
tion of the state of health of those persons who are
affected by disorder in the digestive organs, denote
a disturbance of the nervous and muscular powers.
When we observe this compound disorder we can
seldom determine which were the primarily affected
organs. General nervous irritation may have prece-
ded the disorder of the stomach and bowels, or may
have been caused by it. The history will generally
show, that the derangement of the digestive organs
is secondary. When it arises from local irritation,
it can be produced only through the medium of the
sensorium. When it is idiopathic, it frequently ori-
ginates in causes which affect the nervous system
primarily; such as anxiety, too great exertion of
mind or body, and impure air. Sedentary habits
and irregularities of diet are causes which may be
supposed to act locally on the organs themselves.
Nervous irritability and weakness are not perhaps
susceptible of a direct cure by medicine; but the
disorders of the digestive organs are more corrigible
by medical remedies. In practice, these require our
chief attention; and if their disorders be corrected,
all nervous irritation frequently ceases, and health
is restored. In many instances the nervous irritation,
which has induced the disease, is trivial, and would
soon cease, were it not kept up by the reaction of
its secondary symptoms.
Whether this disorder of the digestive organs be
primary or secondary, it generally produces irrita-
tion in the brain; and thus may cause in many in-

**
Treatment of Local Diseases.
stances actual disease of that organ, as will be stated
in the conclusion of this paper. But derangement
of the digestive organs arises, in many cases, from
established nervous disorder: indeed there is often
reason to suppose that it is dependent on, or con-
nected with, actual disease of the brain. In such
cases, the correction of the disordered functions of
the digestive organs cannot be accomplished; and
even if it were practicable, it would not cure the
nervous disease. It is however highly necessary
and advantageous to attend to the disorder of the
digestive organs, where it is only a symptom of
nervous disease. The relief of the former will often
mitigate, though it cannot cure the latter. *
The connexion of local disease with general dis-
order has been often remarked; it has been formerly
attributed to impurity of the fluids; a theory which
is not irrational. Imperfect digestion must influence
the qualities of the blood, and all parts of the body

** The ingenious Mr. John Bell has of late published an
opinion, that all nervous disorders depend on the circulation
of blood in the brain. The opinion is founded on this dogma;
the brain being insensible, there can be no such thing as ner-
vous irritation. Believing similar opinions to be prevalent in
the profession, I think it worth inquiring, whether, if the mo-
tion of a worm in the stomach produces temporary blindness
or convulsions, there be not some neryous irritation? If a man
has his leg amputated on account of a compound fracture, and
afterwards becomes delirious and dies; I grant that fulness
of the vessels of the head will be found on dissection; but was
not the vascular action caused by preceding nervous irritation?
The same fulness of vessels and signs of inflammation are
found in those who die of fevers; but do not the miasmata
which cause them affect the brain, and suddenly impair
and disturb its energy, and is not then the vascular action a
consequence? I would ask too, practically, does bloodletting
cure disorders in which there is a fulness of the vessels of
the head. It must be granted, that in many instances it tem-
porarily alleviates them, but in others it fails to relieve and
even aggravates them.
34 : On the Constitutional Origin and
may be affected from this source. But in accounting
for the reciprocal influence of disorders of the head
and the digestive organs on each other, the modern
explanation of these phenomena, by means of sym-
pathies, is perhaps preferable. Afflicting intelligence
will destroy the appetite and produce a white tongue
in a healthy person; and a blow on the stomach dis-
orders the head. These phenomena take place in-
dependently of the blood, and can only be explained
by admitting that disturbance of one organ imme.
diately affects another.
The writings of the ancients abound with passa-
ges, in which local diseases are attributed to affec-
tions of the abdominal viscera, and the same fact
has been noticed by several of the moderns. The
French surgeons appear to be very solicitous to
keep the bowels in a cool and tranquil state; and
Dessault ascribes the origin of erysipelas to a bili-
ous cause. The German surgeons, Richter and
Schmucker, attribute many local diseases to gastric
affections; and in Italy, Scarpa views the subject in
the same light. The English practitioners seem to
have been less attentive to this class of disorders;
insomuch that Fischer, a German, who published
an account of the state of medicine in this country,
expresses his surprise that the English should be so
little acquainted with gastric diseases. I know not
exactly what ideas these gentlemen may annex to
the terms gastric and bilious disorders, since they
do not particularly describe them. I have repre-
sented the subject in the foregoing pages, as it
has appeared to me on the most attentive examina-
tion.
There is also an excellent dissertation, in which
the effects and treatment of disorders of the diges-
tive organs are particularly described, inserted in
the eighth volume of the Memoires de la Société


Treatment of Local Diseases. 35

Royale de Medicine of Paris for the year 1806, at
page 310, entitled Reflections sur le Traitment de
la Manie atrabílaire comparé a celui de plusieurs
autres Maladies chroniques, et sur les Avantages
de la Methode evacuante, par M. Hallé. After de.
scribing the discharges from the bowels in atrabi-
liary mania, he observes, that a similar state of those
organs is found in other diseases, namely dropsy, hy.
pocondriasis, accompanied with difficulty of breath-
ing and palpitation, obstinate coughs, and a great
number of very different diseases; to all of which
the same treatment is applicable. That the extremely
prejudicial consequences of disorders of the stomach
and bowels have been noticed at all times by per-
sons of observation, and particularly by those who
are in the habit of judging of their state by their
excretions, is sufficiently evident. The ancients
sought to correct the error by purging with helle-
bore, and the moderns by more compound purges,
to use the words of M. Hallé, par le mélange de pur-
gatifs résineux et des mercuriaux. I have not, how-
ever, met with any physiological investigation of the
nature of these diseases, nor of the rational objects
of cure. It is to promote such an investigation,
that I have laid before the public the facts which
have come under my observation, and the reflections
to which they have given rise.
In investigating the connexion between local dis-
eases and disorder of the health in general, I can
perceive, that failure in the functions and irritation
of the digestive organs may act prejudicially on the
system in general in various ways. They may pro-
duce weakness, for strength and vigour seem to arise
from the conversion of our food into perfect blood.
They may produce an impure state of that fluid,
and they may produce great irritation of the brain,
and thus influence the whole body. However, what



36 On the Constitutional Origin and
-
-
I have to observe respecting the causes and cure
of local diseases will be most properly introduced
and best understood after the cases have been re-
corded, upon which the opinions have been founded.
The result of all these observations, which I have
been able to make, relative to this subject, has in-
duced me to believe that the disorder of the diges-
tive organs, caused by the various circumstances
which have been recited, consists in a weakness
and irritability of the affected parts, accompanied
by a deficiency or depravity of the fluids secreted
by them, and upon the healthy qualities of which
the due performance of their functions seems to
depend. This opinion is deduced immediately from
the consideration of the symptoms, and confirmed
by all the collateral evidence, which we can collect.
The duration of the affection, without fatal conse-
quences, shows that it is a disorder of functions,
and not a disease of structure. Dissections confirm
the opinion. Blows which excite general irritation
of the digestive organs, produce also the symptoms
which characterize the like disorder, when it arises
from nervous irritation, or is excited by intemper-
ance. I doubt not but every one will, on reflection,
consider the disorders of the digestive organs to be
of the first importance, and will perceive the pro-
priety of diligently inquiring into their nature, that
we may know them when they exist, and that our
attempts to remedy them may be conducted on
rational principles. This consideration will, I trust,
vindicate me for employing so much time in an
investigation which, perhaps, some may consider as
tedious and unprofitable.
Treatment of Local Diseases.
Occasional Effects of Disorder of the Digestive
Organs.
It is generally admitted, that disorders of the
chylopoietic viscera will affect the source of sensa.
tion, and consequently the whole body; but the
variety of diseases, which may result from this
cause, has not been duly weighed and reflected on.
. It may produce in the nervous system a diminu.
tion of the functions of the brain, or a state of exci-
tation, causing delirium; partial nervous inactivity
and insensibility, or the opposite state of irritation
and pain. It may produce in the muscular system,
weakness, tremors, and palsy; or the contrary affec-
tions of spasm and convulsions. It may excite fever
by disturbing the actions of the sanguiferous system;
and cause various local diseases by the nervous
· irritation which it produces, and by the weakness
which is consequent on nervous disorder or imper.
fect chylification. Or if local diseases occur in a
constitution deranged in the manner which I have
described, they will become peculiar in their nature
and progress, and difficult of cure. Affections of all
those parts which have a continuity of surface with
the stomach; as the throat, mouth, lips, skin, eyes,
nose, and ears, may be originally caused or aggra-
vated by this complaint. I must observe, before I
proceed to the relation of cases, that such a disor-
der of the digestive organs as I have described ex-
isted in every instance. I do not take upon myself
to say that it was the primary cause of the general
derangement of the constitution, with which the
local disease appeared to be connected; it might
have been the consequence, as indeed has been sta-
ted in these preliminary observations.




38
On the Constitutional Origin and
O
Treatment.
I shall now proceed to mention the plan which I
have pursued in the treatment of these disorders,
when they have been connected with surgical dis.
eases: with what degree of success, the following
cases will demonstrate. I do not feel altogether
competent to give full directions relative to this
subject; because I have never attended to medical
cases with that degree of observation which would
lead me properly to appreciate the efficacy of differ-
ent medicines, when administered either in their
simple or compounded forms. The subject is so
important, that the public would be highly indebted
to any practitioner, who would point out the varie-
ties of these diseases, and the appropriate modes of
cure. The method of treatment, which I have
adopted, is simple, and founded on the opinions I
have formed of the nature of the disease, and on
physiological views of the functions of the affected
organs. Believing the disordered parts to be in a
state of weakness and of irritability, my object has
been, to diminish the former and allay the latter.
Believing also that the secretions into the stomach
and bowels, upon the healthy state of which the
due performance of their functions depends, were,
in consequence of such disorder, either deficient
in quantity or depraved in quality; I have endeav-
oured to excite, by means of medicine, a more copi-
ous and healthy secretion.
In conformity to these views of the subject, the
patients have been recommended to be particularly
attentive to their diet. The food should be nutri-
tious, and easy of digestion: strong plain broths,
animal food of loose texture, milk, eggs, and fari-
Treatment of Local Diseases. 39
naceous vegetables, are the articles which appear
most advisable. But as custom and inclination have
so great an effect in regulating the actions of the
stomach, I have contented myself with recommend-
ing patients not to eat any thing, which it was pro-
bable that they could not digest. It seems reasona.
ble to suppose, that, if the food be properly diges-
ted, it will not irritate the intestinal canal; but that,
if digestion fails, the animal and vegetable matters
will undergo chemical changes in their passage
through the long tract of intestines, and thereby
maintain a state of irritation in those organs. I have
urged patients not to oppress the powers of the sto.
mach by too great a quantity of food, nor to take
a second meal, until time has been allowed for the
digestion of the first, and for the recovery of the
powers of the stomach. Whilst I have thus advised
patients to eat moderately and not too frequently,
I have also cautioned them not to let the stomach
become irritable by too long abstinence. I have
ordered five grains of powdered rhubarb an hour
before dinner, with a view of inviting secretions
into the stomach, and of preparing it for the office
of digestion. This gentle excitation perhaps induces
it to expel any residue of alimentary matter, and
creates a kind of artificial appetite; so that persons
habitually subject to indigestion experience very
considerable benefit from the practice. Where
rhubarb has disagreed, columbo has been substi.
tuted.
The quantity of food should of course be propor-
tionate to the powers of the stomach. If it receives
more than it can digest, no nourishment is obtained
from the superfluous quantity, and the undigested
aliment not only acts injuriously in the bowels, but
in the blood, and in the urine, as has been men-
tioned. There is also anotheſ view of the subject.







40 On the Constitutional Origin and
Moderation in diet not only insures the complete
digestion of the aliment, but it prevents the blood-
vessels from being overloaded and kept in a state
of action exhausting to their strength. When also
important organs may be in a state of nervous irri.
tation and disorder of function, if there be a pletho-
ric state of the bloodvessels at the same time, those
vascular actions are likely to ensue, which may pro-
duce an alteration of their structure, and irremedia-
ble disease.
The function of digestion will not, however, go
on well, even where these circumstances have been
attended to, if the stomach be deprived of a stimulus
to which it has been long accustomed. Uneasy sen-
sations will be experienced, denoting, if I may so ex-
press it, a discontented state of this organ, and a
want of the expected stimulus. It is on this account
injurious wholly to restrain those patients from the
use of wine who have been in the habit of taking
it. A moderate quantity of such a stimulus may be
allowed after dinner, to prevent uneasy sensations
and to promote digestion; but strong fermented
liquors must be injurious at any other period. It is
wrong to stimulate the stomach when it has no task
to perform.
Even our food must be considered as exerting a
medicinal influence in disorders of the stomach,
when that organ is irritable. A vegetable diet and
abstinence from fermented liquors may tend to tran-
quillize it. On the contrary, when it is weak as
well as irritable, that aliment which is most readily
digested is to be preferred, and cordials are some-
times beneficial. The effects of food and medicine
can never be considered as resulting from their
operation on the stomach solely, but from their
conjoint influence upon the nervous system in gene-
ral. Irritability of the stomach may arise from that



Treatment of Local Diseases.
of the brain, and unstimulating diet may tend to
tranquillize the latter organ, and thereby alleviate
the disorder of the former. On the contrary, a more
generous diet may, by exciting the nervous system,
produce that degree of energy in its actions, which
invigorates the stomach, and tranquillizes its disor-
der. It may further be observed in some cases, that
the kind of medicines or diet which is serviceable
to the stomach, may aggravate the nervous disor-
der; and on the contrary, that those means which
seem to tranquillize nervous irritation tend to di-
minish the powers of the stomach.
Bark and steel are not uncommonly given in
these diseases to increase the powers of the sto-
mach: they ought, I think, to be administered in
small doses, and never when the tongue is dry; as
they seem to suppress those secretions, which in
many cases are already deficient; and the increase
of which would tend to relieve irritation in the af-
fected organs. I mention this opinion, however,
rather to account to the reader for these medicines
not having been prescribed in the subsequent cases,
than from any other motive; as I do not feel per-
fectly competent to decide upon their degree or
kind of utility.
Vegetable diet-drinks appear to me very useful
in tranquillizing and correcting disorders of the sto-
mach and bowels, for this is the manner in which
they seem to be efficacious in the cure of local dis-
eases. The vegetables prescribed in the different
formulæ are so dissimilar, that we can scarcely sup-
pose that they act specifically upon the local disease.
Even sweet-wort has obtained considerable cele.
brity. When diet-drinks fail to correct the disorders
of the digestive organs, they also fail to produce any
amendment on local diseases. Such observations
have induced me to believe that they have the utility,

42 On the Constitutional Origin and
S
which I have ascribed to them, of tranquillizing and
correcting disorders of the stomach and bowels. It
is allowable to form an opinion from such observa-
tions, though I am sensible of their invalidity as
arguments to prove its truth.
A regular diurnal evacuation of the bowels is
particularly necessary, since the detention of the
fæces must prove irritating to these organs. Pur-
ging medicines sometimes relieve unpleasant sensa-
tions; but they do not in general produce even this
effect; and all active purges seem to me to increase
the disorder. It is natural to suppose that strong
stimuli will aggravate the unhealthy condition of
weak and irritable parts.
I have expressed my opinion of the manner in
which the continued exhibition of purgative medi-
cines, in such doses as do not immediately purge,
relieve disorders of the digestive organs, by produ-
cing morbid secretions which afford considerable
relief, either when they occur spontaneously or are
thus induced. This plan of practice is what Dr.
Hamilton has suggested, and the utility of which
he has so successfully elucidated. I am aware that
laxative medicines may relieve irritation merely by
augmenting the natural secretions of the viscera,
and thus unloading their vessels; and also by deter-
mining the fluids from the head, when the nervous
symptoms are aggravated by a plenitude of the
vessels of the brain. As I have found the lenient
plan of treatment, (that of exciting the peristaltic
action of the bowels, so as to induce them to clear
out the whole of the residue of the food; without
irritating them, so as to produce what is ordinarily
called purging,) particularly successful, I have
rarely deviated from it. I am not, therefore, war.
ranted from experience in speaking decisively res-
pecting the more free use of purgative medicines.
Treatment of Local Diseases.
43

It is difficult, in many cases, to regulate the ac-
tions of the bowels either by diet or medicine.
They are costive for a time, and then fits of pur-
ging come on. The former state must be obviated, in
order to prevent the latter. Medicines which excite
a healthy action of the bowels in one person, are
either inert or too active in ancher. Doses, which
would have no effect in a state of health, become
purgative in this disorder; a circumstance which
shows that the bowels are irritable. There are some
rare instances of the contrary, in which it is ex-
ceedingly difficult to excite the actions and secre-
tions of these viscera. The object which I have had
in view, in all cases, is to excite the peristaltic
action of the bowels, without irritating them, so as
to induce them to pour forth and evacuate their own
fluids. The administration of purgative medicines
in very small doses, at regular intervals, is in many
cases the best mode of effecting this purpose.
In giving purgative medicines I have endeavour-
ed to combine them, so as to excite and strengthen
at the same time. Rhubarb, columbo, and kali
vitriolat. have been given together; or an infusion
of gentian with senna or tincture of rhubarb. When
the infusion of gentian with senna has been given,
it has been prescribed in the subsequent cases, ac-
cording to the following formula, which is in use at
St. Bartholomew's hospital:
B. Infus. gentian. comp. 3j.
Infus. sennæ, 31j.
Tinct. cardamom. comp. 3j. M.
Fiat haustus, bis quotidiè, vel pro re natâ, sumendus.
It is sometimes necessary to increase the quantity
of infusion of senna. I have found in some cases,
that the purgative medicines and spices dissolved
in spirit and water, have answered better than any

On the Constitutional Origin and
thing else, in producing a sufficient, but not toocopi-
ous discharge from the bowels. Equal parts of com-
pound tincture of rhubarb and senna is the formula
to which I allude. When irritation in the large in-
iestines has been denoted by the mixture of mucus
and jelly with the fæces, and sudden and urgent
calls to void them, I have advised oily and muci.
laginous medicines as aperients: as castor oil, mixed
with a large proportion of mucilage. My sole object,
however, has been to regulate the state of the bowels;
and when they have been regular without medicine,
I have rarely recommended any.
At the same time, I have not been inattentive to
the error in the biliary secretion, which exists in
the greater number of these cases. I have endea-
voured to correct this error by the administration of
such small doses of mercury, as do not irritate the
bowels, and are not likely to affect the constitution,
even though persevered in for a considerable time.
In this state of the digestive organs, calomel, in
small quantities, sometimes proves irritating. I have
combined it, as in Plummer's pill, and have given
one grain every other night. Where this dose pro-
duced uneasy sensations, or acted as an aperient,
five grains of the pil. hydrarg. were substituted in
its place; and even this quantity has been diminished
in some cases. When it appeared necessary, on
account of the biliary secretion, and when the calo-
mel did not irritate the bowels, I have increased
the dose. The relief, which arises from the increase
or correction of the biliary secretion, in the majo-
rity of these cases, shows how much the liver is
concerned in causing or aggravating the symptoms
in these diseases.
There are numerous and undoubted proofs of the
utility of mercury, in correcting and augmenting
the biliary secretion; but the mode of administering

Treatment of Local Diseases.
it has not, perhaps, been sufficiently attended to.
I have known patients, who had voided nothing
but blackish stools for some months, discharge
fæces of a light yellow colour, denoting a healthy,
but deficient secretion of bile, upon taking such
small doses of mercury. The effect of this change
on the constitution and spirits has been surprisingly
great; though the state of the stomach did not ap-
pear to be altered. The use of mercury by inunc-
tion, sometimes acts beneficially, in correcting the
biliary secretion; but if the constitution be irritated,
and weakened by that medicine, the actions of the
liver are disturbed; and the digestive organs in
general, become deranged. Mercury, in my opinion,
acts most certainly and efficaciously, when taken
into the bowels, and a much smaller quantity will
suffice, when its application is in this manner ren-
dered chiefly local. **
Although experience has made me think very
highly of the efficacy of small doses of mercury, in
exciting and correcting the biliary secretion; yet it
ought to be mentioned, that in some few cases, this
medicine fails to produce its usual effects, and that
the biliary secretion becomes healthy without its
administration.
Facts are wanting, to enable us to ascertain,
whether mercury meliorates and augments the se-
cretions of the other digestive organs, as it does that
of the liver. The stomach frequently appears worse
during its employment, whilst the stools are con-
siderably better; I have, in such cases, discontinued
the medicine, and returned to it again if the state
of the liver made it necessary. When benefit is ob-
tained from a small quantity of medicine, we natu-
rally expect an increased advantage from an aug-
mented dose; this is so natural an error, that an
admonition against it appears necessary. I have ob-


46 On the Constitutional Origin and
served in some instances, where small doses of mer-
cury have unexpectedly affected the mouth, that con-
siderable benefit seemed to arise from this circum-
stance. Yet it is wrong, in general, to augment the
dose of the medicine, so as to create even local irri.
tation in the bowels by it. The various effects of
mercury in disorders of the digestive organs cannot,
I think, be understood, but by considering, not
merely its local operation on these organs, but also
its action on the constitution at large. When we
see the biliary secretion corrected by a few grains
of the pilul. hydrarg., as in the second case, we can.
not but believe its action to be local. When the
medicine is given in larger doses, it exerts an influ.
ence on the whole constitution, and alters the state
of the nervous system. It thus controls diseases
dependent on an irritable and disturbed state of the
nervous functions: this I think I shall be able to
show by cases related in that part of this book which
treats on diseases induced by the absorption of mor-
bific animal poisons; and thus mercury may relieve
disorders of the digestive organs by relieving the
nervous disorder which caused them. But when
mercury is given in still larger doses, as it is for the
cure of syphilis, it never fails to irritate and weaken
the constitution, and thus to disorder the digestive
organs. Persons who are salivated have, as far as I
have remarked, the functions of the liver and diges-
tive organs constantly disturbed by that process.
I cannot, therefore, but think that it is wrong to use
mercury in hepatic affections to that extent, which
would disorder the functions of the liver, if they
were previously healthy. In the majority of cases
the disorder has existed for a long time, and has
become habitual; therefore it is not likely to be
cured suddenly. For this reason, we should adapt
our treatment to the more rational expectation of

Treatment of Local Diseases.

effccting a gradual recovery than a sudden cure.
The most judicious treatment will not remedy the
disease, if the exciting causes continue to operate;
such as improprieties of diet, agitation of mind,
sedentary habits, or impure air.
The following cases will afford sufficient testi.
mony of the efficacy of such simple treatment, as I
have recommended. In some inveterate cases, appa-
rently depending on established nervous disorder,
it has been ineffectual. Under such circumstances,
the nervous affection appears to require the princi-
pal attention.
When the state of the health required it, or the dis-
ease did not yield to the treatment which I have
described, I have referred the case to the physician;
under whose direction benefit has been obtained by
medicines of more activity than those which I had
ventured to recommend, conjoined with tonics, and
those medicines which are usually termed nervous.
In investigating the treatment of these disorders,
it is necessary to ascertain, not only what medicine
is beneficial, but also what change it produces in
the circumstances of the disorder. The administra-
tion of a medicine may in one case be succeeded
by a discharge of bile, and a striking relief from
long continued and distressful feelings: yet the same
medicine may be given in many other instances
without the same consequence. Was the change,
then, in this instance accidental? or must it be attri.
buted to some unnoticed peculiarity in the disease
or constitution?
I have generally explained to the patients the
objects which I had in view, in correcting disor-
ders of the digestive organs, by saying that there
are three things which I consider as right and ne-
cessary to the cure of disorder. First, that the sto-
mach should thoroughly digest all the food that is

48 On the Constitutional Origin and
put into it. The patient perceiving the necessity of
obtaining this end, becomes attentive to his diet,
and observes the effect which the quantity and
quality of his food and medicines have upon his
feelings, and the apparent powers of his stomach.
Secondly, that the residue of the food should be
daily discharged from the bowels: here too, the
patient apprised of the design, notes what kind and
dose of purgative medicine best effect the intention;
and whether it answers better if taken at once, or
at intervals. Thirdly, that the secretion of bile
should be right, both with respect to quantity and
quality. In cases wherein the secretion of bile has
been for a long time deficient or faulty, I recom-
mend, as I have said, unirritating and undebilitating
doses of mercury to be taken every second or third
night, till the stools become of a rhubarb colour.
This mode of exhibiting the medicine has at least
the advantage of being innocent, and if months
elapse before the object is accomplished we cannot
wonder at the tardiness of the cure, when we con-
sider the probable duration of the disorder, prior
to our attempts to correct it. The patient is relieved
in proportion as the end is accomplished, which
feelingly induces him to persevere in such innocent
measures. By thus engaging the cooperation of
the patient, the practitioner will, in my opinion,
derive considerable advantage in the treatment of
the case.
Whenever circumstances would permit, I have
recommended the patients to take as much exercise
as they could, short of producing fatigue; to live
much in the open air; and, if possible, not to suffer
their minds to be agitated by anxiety, or fatigued
by exertion. The advantages of exercise in nervous
disorders, upon which those of the digestive organs
in general so greatly depend, appear to me very

Treatment of Local Diseases.
striking. It were to be wished that we had some
index to denote the strength and irritability of the
nervous system, serving as the pulse does with
regard to the sanguiferous organs. Perhaps the
strength, agility, and indefatigability of the muscles
may be regarded as the surest evidence of energy
of nervous power and bodily vigour. If this were
granted, however, it would follow that many per-
sons, possessing great nervous power, have never-
theless great nervous irritability. Many people,
who are extremely irritable and hypocondrical,
and are constantly obliged to take medicines to
regulate their bowels whilst they live an inactive
life, no longer suffer from nervous irritation, or
require aperient medicines, when they use exercise
to a degree that would be excessive in ordinary
constitutions. The inference which I draw from
cases of this description is, that nervous tranquillity
is restored in consequence of the superfluous energy
being exhausted by its proper channels, the mus.
cles. When, on the contrary, the nervous system
is weak and irritable, exercise seems equally bene.
ficial; but caution is here requisite as to the degree
in which it should be taken. A weak and irritable
patient may not be able to walk more than half a
mile without nearly fainting with fatigue on the
first day of the experiment; but by persevering in
the effort, he will be able to undergo considerable
muscular exertion without weariness. Does not this
imply a considerable increase of bodily strength?
and is not the acquisition of strengh the chief de-
sideratum in the cure of many disorders? The ner-
vous irritability also when dependent on weakness
alone will proportionately diminish with its cause. In
the latter case, the nervous energy seems to be aug.
mented in consequence of our increasing the des
mand for it. I am induced to make these observa.
tions, from a belief that exercise is not employed

50 On the Constitutional Origin, &c.
as a medical agent, to the extent that its efficacy
seems to deserve. When the disorders, which have
been the subject of this paper, have been long con-
tinued, they do not admit of a speedy cure; hence
attention to diet, air, exercise, and mental tranquil.
lity, are more decidedly beneficial than medicines.
Surgeons in London meet with frequent and con.
vincing instances of the efficacy of pure air. Patients
under the irritation of a local disease, who scarcely
eat or sleep in town, recover their appetite, diges.
tion, and sleep, so suddenly on their removal into
the country, as to leave no room for doubting, that
the change of air has produced this beneficial alte-
ration in their health. The whole of the plan of
treatment which is here recommended is so simple,
and apparently so inefficient, that its power might
reasonably be doubted, did not facts attest its utility.
I should not have thought it right to have thus
related it in detail, but for the purpose of avoiding
repetition in the recital of the cases which are to
follow; and also because it seemed right to state as
explicitly as possible to the younger part of the
profession what are the curative intentions in dis-
orders of this nature. *
* After I had written the above account of the treatment,
which I had found the most successful in the correction of
disordered states of the digestive organs, I was much grati-
fied by the perusal of Dr. Hamilton's publication on the
Effects of Purgative Medicines. I think there is a great coin-
cidence in the mode of treatment which I have described,
and that which is sanctioned by his more extensive experi-
ènce. He prescribes purgative medicines to act as eccopro-
tics, to excite but not to stimulate the bowels; and he com-
bines with them generally unirritating doses of mercury.
Dr. Hamilton's plan of treating these diseases also accords
very much with that of M. Hallé, to whose Memoir I have
referred the reader,

CASES.
SECTION I.
On Nervous and Muscular Disorders.
Long before my attention was excited to disorders
of the digestive organs, I had remarked that there
was a paralytic affection of the lower extremities,
resembling that which is produced by a disorder
of the medulla spinalis, in consequence of disease
of the bodies of the vertebræ. This paralytic affec-
tion also appeared to me to vary with the state of
the patient's health.
. These observations led me to propose a method
of treatment, which proved successful in the cases
of two young ladies, who were affected in this man-
ner. The issues, which had been ineffectually kept
open in the back, were healed; and the state of the
health in general was amended by country air,
exercise, attention to diet, and a few simple medi-
cines. The use of the limbs returned in proportion
as the health became established. Such were the
observations which I had made relative to this sub-
ject, when I met with the following cases.
CASE III.
A young lady, whose stomach and bowels were
disordered in the manner already described, became'
gradually affected with weakness of the lower ex.
tremities, and pain in the loins. The pain became

52 On the Constitutional Origin and
at length very severe, and was aggravated in a man-
ner almost insupportable by the agitation of a car
riage. This lady could scarcely walk, and gave a
description of the state of her limbs, so exactly re.
sembling that which is sometimes consequent to
diseases of the vertebræ, that I thought it right to
examine the spine. I struck with my finger the
spinous process of each lumbar vertebra, and upon
touching one in particular, the patient complained
of great pain; but pressure on the contiguous ver-
tebræ also caused much uneasiness. Under these
circumstances I placed a blister on each side of the
spine, and kept up a discharge from the surface by
dressing it with savine cerate. These means, with
rest, relieved her sufferings; but, as her health de-
clined, she went into the country, where she soon
became much better. The blisters were now suf-
fered to heal, and she shortly afterwards had recov.
ered so much, as to take long rides on a rough.
going horse. She returned from the country in
good health, and was both muscular and fat. About
a year afterwards she was so ill, in the same way,
that she wished to have issues made in the back:
but I would not consent to this, from knowing that
the bone could not be diseased. Of this return of
pain in the back, and weakness in the lower extre-
mities, she again got well, upon amendment of her
health in general. Since that period, now five years
ago, she has been, sometimes, very well, at others,
pale and emaciated; and these changes have cor-
responded with the natural or deranged state of her
bowels.
CASE IV.
I was consulted on the case of a young lady,
who had been blistered severely for a pain at the
bottom of her back, which was chiefly felt at the
Treatment of Local Diseases. 53

junction of the ilium and sacrum. It was supposed,
that disease had taken place in the bone from some
injury, and had affected the sacral nerves: for she
could not stand without support, so great was the
weakness in the front of the thighs. There was no
projection of the vertebræ. If the sacral nerves had
been affected, the leg ought to have suffered the
greatest share of pain and weakness; but that was
not the case. She had no appetite; her tongue was
greatly furred; her bowels costive; and pulse gener-
ally 110. I strongly objected to making issues in
this case; but as the patient's sufferings increased,
it was done. She went into the country, and died
in four or five months. The bone was found, upon
examination, to be perfectly healthy; but the me-
senteric glands and lungs were diseased, and it
was concluded that she died of consumption. I
could not learn the state of the liver, nor do I know
whether its appearances were particularly atten.
ded to.
CASE V.
A young lady had been confined about six months
to her chamber, on account of pain in the loins, and
weakness of the lower extremities, which preven-
ted her from standing or walking. The weakness
of her limbs had been gradually increasing for a
year and a half, before it became so bad as to make
her incapable of moving about. Issues had been
kept open, during that time, on each side of the
spine; but, as the patient received no benefit, my
opinion was asked respecting the seat of the disease
of the bone: for it was concluded, that the issues
had only failed from not having been made in the
right place. I found, upon inquiry, that the chief
seat of her pain was in the posterior edge of the
liver. Indeed, that viscus was enlarged, so as to

54 On the Constitutional Origin and
be felt in the epigastric region, and was so tender
as to cause much pain on being compressed, at any
part, along the cartilages of the ribs. Her tongue
was furred; her appetite deficient; digestion bad;
bowels costive; and stools black, or else untinged
with bile. I had no hesitation in advising, that the
issues should be discontinued; and that attention
should be chiefly directed to rectify the disorder
of the chylopoietic viscera. Mild mercurials and
aperients were given, by which, with other means,
she got materially better in health, and was able to
walk about as well as ever. The gentleman who
attended this patient, met me accidentally, two
months afterwards, and informed me that she was
quite well. I said, that as her disease had been a
long time in forming, it could hardly be expected
that she should recover so suddenly. He consid.
ered this expression as implying some doubt of his
accuracy, and, therefore, sent the patient to me in
the morning. She came from Lambeth, in a hack-
ney coach, and looked very well: she observed;
that long before her confinement, she could not
have borne the agitation of a carriage; but that now,
she did not feel it. I have been informed, by seve-
ral intelligent students, that similar cases have oc-
curred in the hospital: as I was not a witness of
these, I shall not relate them. I shall, however,
mention one, which I saw, and superintended my-
self; although it is, in some measure, imperfect, as
the patient quitted the hospital suddenly, without
our knowing where he went to.
CASE VI.
Thomas Crighton, aged twenty-three, was ad.
mitted into St. Bartholomew's Hospital, on account
of a palsy of his limbs. About a year before, while
the use of his limbs was yet unimpaired, he was
- Treatment of Local Diseases. 55

attacked repeatedly with violent pain in the bowels;
uniformly preceded by costiveness, and generally,
terminated by a copious discharge of loose, fetid,
black stools. The relief afforded by the diarrhæa
was speedy and uniform. In the course of six months
his lower extremities became affected with occa-
sional twitchings, and he found that he could not
regulate their motions in walking: this increased
to such a degree as to make him incapable of taking
any exercise. He had, at the commencement of his
illness, a confusion of vision; anda constant and vio-
lent pain in the head. The formersymptom increased
so much, that he could discern no object distinctly;
a candle, for instance, although held near him, ap-
peared as large as the moon. The sensation of his
lower extremities continued perfect; but the actions
of the bladder were no longer under the control
of the will; the urine sometimes flowing involunta-
rily; and, at others, being retained for some hours,
with considerable pain. He afterwards, began to
lose the use of his upper extremities: the left hand
and arm were more affected than the right; but there
was no difference in the affection of the leg on the
same side. His speech, also, became much im-
paired; he hesitated and faltered considerably, and
the tones of his voice were irregular, so that,
at length, he could scarcely make himself under-
stood. At the time of his admission into the hospi-
tal, there was an entire loss of voluntary motion of
the lower extremities, and a great diminution of
that of the upper. The bowels were deranged; there
was constant head-ache; the speech was very indis-
tinct; and vision so imperfect, that he could not
read the largest print. An issue was made in the
neck, and some medicines were prescribed, under
the direction of the physician. As the treatment
did not prove beneficial, I was desired to examine


56 On the Constitutional Origin and
the spine, and found such a curvature and projec-
tion of the spinous processes of the upper lumbar
and lower dorsal vertebræ, that I thought, the
bodies of those bones must be diseased. I was,
therefore, inclined to attribute the paralysis of the
lower extremities to this disease of the spine; and,
consequently, directed, that issues should be made
on each side of the projecting vertebræ. As this
supposition would not account for the paralytic
affection of the parts above, and as the bowels were
deranged, I ordered two grains of calomel with
eight of rhubarb, to be taken twice a week, and
some infusion of gentian with senna, occasionally.
After using these medicines, for about three weeks,
his bowels became regular, the biliary secretion
healthy, and his appetite good. He could move his
hands and arms nearly as well as ever; and his eye.
sight was so much improved that he could read a
newspaper; indeed, it was nearly well. The func-
tions of the bladder were completely restored; *
his speech became articulate; and his general health,
in every respect, much improved. He remained in
the hospital about two months, but with very little
amendment in the state of the lower extremities,
when his friends suddenly removed him, on ac-
count of some disagreement with the nurses, and
I was unable to learn whither they had conveyed
him.
The history of the preceding case was taken by
Mr. Cruttwell, now practising as a surgeon in Bath,
who had been for several years a most industrious
student at the hospital, and whose accurate obser.
vation and extensive information induce me to
*** I have seen several cases which induce me to believe that
the weakness of the sphincter vesicæ, which occasions young
persons to void their urine during sleep, very frequently arises
from the same cause.

Treatment of Local Diseases. 57
place entire confidence in any statement of a case
which I receive from him. To that gentleman I
am, also, indebted for the following particulars re-
lating to a patient, who died some little time ago
in the hospital, and whose body was examined.
The dissection serves still further to elucidate my
present subject.
CASE VII.
Elizabeth Griffin, twenty years of age, was ad-
mitted into St. Bartholomew's hospital in August
1805, on account of an inability to move her lower
limbs; which was supposed to originate from a
disease of the spine. On examination, however,
there were no appearances, which indicated caries
of the vertebræ. Her voice was, at times, consid.
erably affected: and she was subject to occasional
attacks resembling, in some degree, epileptic pa.
roxysms. The affection of the limbs was liable to
considerable variations. At times, as she assured
me, she could walk across the ward with very little
difficulty; at others, she could not even stand with-
out assistance. Her tongue was extremely, and, I
believe, constantly white; her pulse natural. Her
bowels were, generally, costive, and it was neces-
sary to employ active medicines in order to pro-
cure stools, which were always of a dark colour.
A slight temporary diarrhæa sometimes happened,
and she invariably remarked, that the ease or diffi-
culty with which she could walk, and the pain in
her head with which she was troubled, were in
exact conformity to the state of the bowels, all the
symptoms being relieved by the diarrhea, and re-
turning as the bowels became again costive. There
was an appearance of irritability and languor in the
eye, which I have before observed in these cases,
and the pupils were generally much dilated. After
H

58 On the Constitutional Origin and
the patient had continued in the hospital about
seven weeks, she was attacked with fever, and
died. To this brief account of the symptoms, I
now subjoin the dissection.
No diseased appearances were observed in the
brain, though it was examined with the most par-
ticular attention: neither was there any disease of
the vertebræ. No disease, in short, was observed
except in the abdominal viscera. The chief morbid
appearance, in them, consisted in an ulcerated state
of the villous coat of the ilium near to its termina-
tion in the cæcum. The ulcers were numerous,
and situated where the mucous glands are chiefly
found. The internal coat of the large intestines,
also, appeared inflamed.
The liver was healthy in its structure. In the
gall bladder about one ounce and a half of a light
green serous fluid was found, which had not in
the least degree the soapy, or mucilaginous feel of
bile.
Cases, like those which have been related, are
not, if I may judge from my own experience, at all
uncommon. They sufficiently prove, in my opinion,
that local nervous disorders and muscular debility
may arise from a general disorder of the health, in
which the digestive organs are chiefly affected.
This disorder, as has been stated in the preliminary
observations, may, sometimes, be the cause, and
sometimes the effect, of the nervous affection. In
either case, however, its correction is of high im.
portance in the medical treatment of the disease.
In the fifth and sixth cases; a disorder of the diges-
tive organs must, I think, be allowed to bc the
cause of the nervous affection, from the sudden
and complete cessation of the latter, when the cure
of the former was accomplished. Decisive instances
like these are particularly valuable; they show what

Treatment of Local Diseases. -
59
great nervous disorder may be produced by that of
the digestive organs, and consequently how much
the latter disorder is likely to aggravate the former,
when it occurs even secondarily as its effect. I
have seen a considerable number of such cases,
which I cannot relate with precision, because I had
not sufficient opportunities of observing the pa-
tients, to enable me to note the progress of the dis-
ease with accuracy.
Of these I can only observe, in general terms,
that I have seen several instances of pain, imbe-
cility, and wasting of the muscles in one of the
lower extremities, which were considered as the
effect of disease about the hip joint; yet the event
proved that there was no organic affection of that
part. The complaint was connected with that state
of constitution which I have described, and was
amended as the health in general improved. I have
also seen several instances of wasting of the mus-
cles of one of the upper extremities in children;
so much indeed were the muscles shrunk, that the
bones and joints could be as distinctly examined
as in a skeleton. The local affection in these cases
came on suddenly. I lately saw a little boy, who
had an attack of this kind in his left arm several
years ago, and on whose case I was at that time
consulted. The bowels had been violently disor-
dered previous to the paralytic affection, and were,
at the time I saw him, in an extremely unhealthy
state. I recommended that the chief attention
should be paid to correct the disorder of these
organs, and that the arm should be supported by a
sling. The limb gradually recovered, and though
it is not at present quite so large and strong as the
other, yet the difference is so slight, that it would
not attract the attention of a common observer.
About six months ago I saw a little boy in very

60 On the Constitutional Origin and
similar circumstances, and in his case, the arm
quickly recovered its powers of motion, as the
state of the digestive organs became healthy.
I have also seen cases in children, in whom, after
some general disorder of the health, accompanied
by derangement of the stomach and bowels, an
affection of the muscles of the extremities has taken
place, like that which produces the varus and val-
gus; I mean a predominance of the actions of some
muscles over others, producing distortion of the
limb. I have seen this happen sometimes in one,
sometimes in both the lower extremities. I have
also seen the arm similarly affected.
That the local symptoms in these cases, as well
as in those which have been more fully detailed,
arise from a nervous affection of the brain, and not
from any cause acting locally on the nerves of the
affected part, will, I believe, on due consideration
be granted. I suspect however that some persons
may hesitate to admit such an opinion, from the
belief that disorder of the brain must operate gene-
rally, and not partially, on the nervous system.
Perhaps the contemplation of the consequences of
slight apoplectic effusions in the brain, may assist
us in forming just notions on this subject. Such
slight effusions of blood, occurring in various parts
of the brain, have been known to paralyse one leg
or one arm, or the muscles of the tongue, or of one
half of the face, without affecting the rest of the
nervous or muscular system.
Another opinion which I wish to be considered
is, whether, when there is considerable and con-
tinued paralysis, there must necessarily exist some
pressure or organic disease in the brain. That this
exists in many instances is undoubted; but the
number of cases in which the paralytic affection is
merely nervous, and independent of visible disease,

Treatment of Local Diseases.
is in my opinion very considerable. The instances
which have been related warrant this conclusion,
and show such cases to be more frequent than is
generally supposed. When there is organic disease
of the brain, the case is very hopeless; and proba.
bly, no considerable alleviation of the symptoms
will take place, by that attention to the state of the
digestive organs which I have recommended. In
dubious cases, and such, on the first examination
of them, the majority of these instances will pro-
bably be, it seems right to try the effect of correct-
ing disorder of the digestive organs, with a view
to alleviate nervous irritation, before we proceed
to those severer methods, which the belief of the
existence of organic or vascular disease in the brain
would induce us to institute. For if bloodletting
and counter irritation be employed, in order to
diminish vascular action; or if mercury be em-
ployed to some extent in order to induce the ab-
sorption of deposited substance; these measures
must aggravate that disorder of the general health,
upon which, in many instances, the nervous affec-
tion depends.
My object, in the recital of the foregoing cases,
is to point out a cause of paralysis in particular
muscles, which from its locality would, I suspect,
be generally attributed to some local disorder of
the nerves of the affected part, and therefore be
treated erroneously. If my opinion of the nature of
these cases be correct, they can only be success-
fully treated by means which operate upon the
constitution in general. I have particularly recom-
mended that our efforts should be directed to cor-
rect any errors that may exist in the functions of
the primæ viæ, for reasons that have been stated in
the preliminary observations. Of the efficacy of
such endeavours I have seen many more instances

62 On the Constitutional Origin and
than I have brought forward; indeed the propriety
of such attempts seems so obvious, that I doubt
not but they will be made, and the effect of them
will, by that means, be generally demonstrated.
It is right however to mention, that in some cases
to which I have attended, I have been foiled in my
endeavours to correct, by the simple measures
which I have related in the introductory remarks,
the disorders of the digestive organs; probably be-
cause their derangement depended on some estab-
lished disease in the brain.
In other cases, when the functions of the diges-
tive organs had been partially restored, the nervous
and muscular affections were mitigated but not
cured. I have also met with one instance, in which
the bowels became moderately correct in their
functions, without any evident amendment in the
state of the limbs; and I have known two instances
of persons, who were suddenly seized with paraly-
sis of the lower extremities, apparently dependent
on general nervous disorder, in which the digestive
organs scarcely seemed affected.
In several of the cases which I have related, there
were nervous pains in the affected limbs. That this
symptom may arise from general nervous disorder
seems to me very probable; at least, I can affirm,
that I have known such pains cured by correcting
the state of the digestive organs. In the cases of
tic douloureux, which have fallen under my obser-
vation, these parts have been greatly deranged;
and I have cured patients of such complaints, by
correcting this disturbance.
I wish finally to excite the attention of surgeons
to the state of the bowels in tetanus. The occur.
rence of this disorder occasionally, when the wound
which produced it is healing, seems to indicate
that the effects which have been produced by its
WA

Treatment of Local Diseases. 63
irritation, continue. It has been, I think, fully shown
that local irritation may disorder the digestive or-
gans; which disorder continuing, and aggravating
the affection of the sensorium, may possibly lead to
the production of tetanus, at a time when the wound
is no longer irritable. In four cases of tetanus, in
which I had an opportunity of inquiring into the
state of the bowels, the evacuations from them were
not like fæces. I wish to propose, in investigating
the cause of tetanus, as a question, What is the
state of the bowels between the infliction of the
injury and the occurrence of that dreadful malady?"
* Such cases as I have related, with others that it would be
foreign to my present purpose to mention, have impressed
the opinion on my mind, that disorders of the digestive or.
gans may originally cause, or may secondarily aggravate, a.
nervous disorder; and produce, as has been “ mentioned, in
the nervous system, a diminution of the functions of the brain;
or a state of excitation causing delirium, partial nervous inac-
tivity, and insensibility; or the opposite state of irritation and
pain: in the muscular system, weakness, tremors, and palsy;
or the contrary affections of spasms and convulsions." Could
these circumstances be proved, it would be scarcely neces-
sary to add, that those painful affections of parts, to which
perhaps some predisposition exists, may be excited in a simi-
lar manner: such as gout and rheumatism. Indeed rheuma-
tic pains are very usually concomitant upon that state of con-
stitution, which existed in the patients, whose cases I am
relating.

CASES.
SECTION II.
On the Effects of Disorders of the digestive Organs
uttending Injuries of the Head.
I shall next speak of those cases, in which local
disorders of the head, produced by blows, are kept
up and aggravated by affections of the digestive
organs. After what has been observed respecting
the reciprocal influence of the diseases of the brain,
and of the chylopoietic viscera, it will readily be
admitted, that an injury of the former may disturb
the functions of the latter. Thus, concussion of the
brain occasions vomiting as one of its immediate
consequences, and will also be found to produce
almost constantly, at a more remote period, that
disturbance of the digestive organs, which I have
described in this paper. If the disturbance be only
moderate in degree, but continued, it will often
react upon the head, so as to occasion an irritable
state of the injured parts, and impede their re-
covery.
In many cases of blows upon the head, a slow
inflammatory affection continues in the parts chiefly
injured, and ultimately produces destructive dis-
eases. The bone sometimes becomes diseased, or
an exostosis grows from its internal table; the dura
mater becomes thickened, or matter slowly collects
on its surface. Such local disorders produce others
Treatment of Local Diseases. 65

of a more general nature, and destroy the patient.
These occurrences are however, in my opinion,
rare in comparison with the cases first described;
in which a painful state of the injured parts is kept
up by means of disorder existing in the digestive
organs. The necessity for an accurate discrimina-
tion between these disorders, must strike us on the
most superficial view of the subject; for the lower-
ing treatment, which is necessary in the first and
rarer case, would be detrimental in the second and
more frequent ones. By attending to the state of
the digestive organs in these dubious cases, we
may be enabled to form a probable opinion of the
nature of the local complaint; for, if there be nothing
wrong in the general health to excite or maintain
it, we may reasonably conclude that it was merely
local; on the other hand, the inefficacy of evacua-
tions in curing the local disease would naturally
suggest the opinion, that it proceeds from irritation,
and is dependent on a disorder of the health in
general. It should be further observed, that when
the local disease is of an inflammatory nature, and
likely to induce morbid alterations in the struc-
ture of the affected parts, still it may be maintained
and aggravated by disorder of the digestive organs.
I have very frequently seen patients suffer so se-
verely as to warrant a suspicion, that local disease
of the most formidable nature existed; in these the
usual methods of treatment were ineffectual; and
they recovered suddenly or slowly, in proportion
as the state of the digestive organs was corrected.
I shall relate some examples of the disease under
consideration, which will enable the reader to iden:
tify the case, when it occurs in practice.

66
On the Constitutional Origin and
* CASE VIII.
A young gentleman, about ten years of age, fell
out of a window, six feet high, and struck the back
part of his head against some stones. He was stun-
ned by the blow, but perfectly recovered from the
effects of the accident by bleeding, purging, and a
low diet. He caught the scarlet fever about six
weeks afterwards; and recovered from that also.
But, whilst he was convalescent, the pains return-
ed in that part of the head which had been struck,
with so much violence, as to induce the belief that
some serious local mischief would ensue. After
they had continued without abatement for a few
days, I was desired to see him. He was lying in
bed, and could scarcely be prevailed on to lift his
head from the pillow. The integuments of the oc-
ciput were so tender, that he would hardly allow
me to examine the part; I ascertained, however,
that there was no fluid under the scalp, nor any in-
equality in the bone. He dozed a good deal, and
lay in a comatose state, but was occasionally rest-
less. His pulse was very frequent, his skin hot and
dry, and his tongue covered with a thick yellow
fur. He breathed almost without moving the dia.
phragm, and complained much if the epigastric
region was compressed. He loathed food; his bow.
els were costive, and his stools of a blackish colour.
He was ordered to take small doses of calomel at
night, and draughts with rhubarb and kali vitriola.
tum in the morning. The tongue soon became
clean, and the stools natural; his appetite and spirits
returned, and he no longer complained of any un-
easiness in the head.
This case presents us with a striking example
of what I believe to be a common occurrence; I
mean, a disordered state of the digestive organs
Treatment of Local Diseases.

taking place subsequently to a considerable febrile
affection. Indeed, when we reflect in how weak and
irritable a state the brain must be left upon the
subsidence of such a disorder, and how much the
chylopoietic viscera must suffer from the impaired
and disordered energy of the brain, we might natu-
rally expect such a derangement of the functions
of the digestive organs to ensue. When such dis-
order happens in this manner, it frequently produ-
ces many local diseases, to which the constitution
may perhaps be predisposed; a circumstance I shall
speak of in a future part of this paper. In the pre-
sent case, it brought on a painful state of parts re-
cently injured, with a considerable degree of fever.
That the morbid state of the stomach and bowels
was the cause of both is fairly to be inferred from
their ceasing so immediately, when the disorder of
the digestive organs was corrected. A case of this
kind, presenting an example of sudden recovery,
is particularly valuable, because it clearly demon-
strates the cause and the effect in such diseases.
The cause can indeed be seldom so suddenly re-
moved; and the gradual cessation of it under any
plan of treatment leaves room for a variety of con-
jectures, as to the mode of cure or of recovery
from those disorders which I have considered as
effects. I could relate many cases of similar but
less severe symptoms produced by the same cause,
which gradually got well, in proportion as the dis-
orders of the digestive organs were corrected. As
it does not, however, appear to me necessary to
accumulate instances to prove so obvious a fact, I
shall content myself with adducing two more cases,
to exhibit such effects in different points of view.

On the Constitutional Origin and
CASE IX.
A lady fell down in frosty weather, in conse.
quence of her feet slipping from under her, and
the occiput struck against a smooth stone pave-
ment. She was stunned by the fall, but soon re-
covered; nor had she for some weeks the severe
symptoms, which appeared in the sequel. This
circumstance shows that there was nothing produ-
ced by the blow that necessarily caused the subse-
quent symptoms; which must therefore be attri.
buted to inflammation or irritation taking place af-
terwards. When some weeks had elapsed from the
time of the accident, the parts which had been struck
became extremely painful; and the pain extended
forwards over the scalp to the right eye, the sight
of which became imperfect. The integuments upon
which the blow had been received were extremely
tender, and the patient became faint when they were
examined even slightly. These circumstances na-
turally induced a belief that some disease was taking
prevent its progress. The symptoms were mitigated
for a time by these means, but they quickly return-
ed with as much severity as before. After three
months the patient came to London, fully persuaded
that nothing but an operation would be of perma-
nent benefit. When I first saw her, she tottered in
moving from one chair to another, and replied to
questions with hesitation and effort. Her eyesight
was so much affected, that she could not read; and
she entertained an apprehension that she should
lose her senses. Her tongue was but slightly furred;
her bowels were habitually costive, and the stools
dark-coloured. It was evident where the injury had
been received; for the aponeurosis had been sepa-
rated from the pericranium by an effusion of blood;
Treatment of Local Diseases.
69.

and, though this blood had been absorbed, the de.
tachment of the scalp was distinguishable by the
touch. No inequality was perceptible in the surface
of the bone. When I mentioned my suspicion that
these symptoms were rather the effect of irritability
of constitution, dependent on the state of the sto-
mach and bowels, than of local mischief, she gave
not the least credit to the opinion; but said she was
persuaded that the bone was started, and that three
fissures extended in different directions. I ordered
her to take five grains of the pilul. hydrarg. every
second night, and a draught twice a day, contain-
ing one ounce of the compound infusion of gentian,
two drams of the infusion of senna, and one dram
of the compound tincture of cardamoms. These
medicines produced a considerable purgative effect.
On the second day there was but little pain in
the head; the patient walked about the room very
steadily, and had read a newspaper in the morning.
When I asked her opinion of this surprising altera-
tion, she imputed it to the evacuations which had
taken place; but she was still persuaded that the
bone was injured, and still apprehensive that, with-
out some operation, she should ultimately lose her
senses. The medicines were continued in such
quantity as to procure only one alvine evacuation
daily. A fortnight elapsed under this plan of treat-
ment, during which the stools became nearly of a
natural colour, and the patient's health was con-
siderably amended. There were times when no
uneasiness was felt in the head; and, during some
nights, the pain was so trivial as to give but little
interruption to her sleep. It was, however, occa-
sionally disturbed by pains, which were, in her
opinion, as intense as at any former period of the
complaint. Her pulse was good, and her muscular
strength greatly improved. The occurrence of the
pain in paroxysms strongly impressed me with the

70 On the Constitutional Origin and
belief that it was nervous, rather than depending
upon local disease. Under these circumstances all
ideas of an operation were dismissed from my mind,
but it was far otherwise with respect to the patient.
Being obliged to return into the country, she con-
sidered the possibility of a relapse with horror; and
was so convinced that the bone had been injured,
that she earnestly requested it might be examined,
were it merely to ascertain what was the fact. I
saw no objection to this examination, but thought,
on the contrary, that advantage might possibly
arise from an incision, which would loosen the ten-
sion of the scalp, and produce a discharge that
might relieve the irritation of the part. I accord-
ingly made an incision of a semicircular form, ex-
tending farther back than the part which had been
struck, and turned up a portion of the scalp, so as
to see the bone, covered by its pericranium, to the
extent of a crown piece. The bone was uninjured,
and, together with the pericranium, appeared per-
fectly natural. The scalp being replaced, the wound
was dressed superficially, without any attempt to
favour the union of the parts. If they united under
these circumstances, there would be an additional
reason for believing, that neither the bone nor the
subjacent parts were diseased. The pain was as
severe for the two first days and nights after this
examination as it had been at any former period;
it abated when the wound began to discharge, and
had entirely ceased on the fifth day. This state of
tranquillity continued as long as the patient re-
mained in town, which was about three weeks af-
ter the division of the scalp. The wound at that
time had nearly healed. She has since had occa-
sional returns of pain in the head when her general
health has been disordered, but never to that de-
gree as to induce a suspicion that any local vascu-
lar disease existed.
Treatment of Local Diseases. 71

To exhibit the effects of the reaction of disor-
ders of the digestive organs upon those of the head
in another point of view, I subjoin the following
case.
CASE X.
May 29, 1805, a labouring man, aged forty-five,
fell from a considerable height upon his head, and
was immediately brought to St. Bartholomew's
hospital. No fracture of the skull could be discern-
ed: and the patient seemed to labour under the ef-
fects of violent concussion of the brain. By vene-
section, and other antiphlogistic means, he soon
recovered his senses. Every thing went on very
favourably for three days, when he was attacked
with shivering, nausea, pain in the head, impatience
of light, and other symptoms, which usually are
considered as denoting inflammation of the mem-
branes of the brain. He was consequently bled; and
had a blister applied on the head. He was suddenly
seized in the evening with a more excruciating pain
in the head, which, after lasting half an hour, was
succeeded by convulsions, so violent that three
men could scarcely hold him. When the fit abated,
he expressed himself much relieved, and said that
he was easier than before its accession. Some calo-
mel and rhubarb were given to obviate a costive
state of his bowels. On the next morning (June 2d)
he had a return of the pain and convulsions; and
the symptoms were so violent, that he was bled
four times in the course of the day. This treat-
ment, however, had no effect in diminishing the
pain and other symptoms, and another fit of con-
vulsions took place in the evening. The purgative
operated on the succeeding night, and brought
away a large quantity of highly offensive feculent
matter of a light greenish-yellow colour. On the 3d

72 On the Constitutional Origin and
of June his breath was extremely offensive; his
skin hot and dry; his pulse quick; his tongue
thickly furred; and he had great tenderness in the
epigastric region, and right hypochondrium. He
was ordered to take two grains of calomel imme-
diately, and a saline medicine at intervals; this pro-
duced two motions in the course of the day. By
pursuing this plan for a few days, the state of his
bowels was rendered more regular, and the dis-
charges acquired a healthy colour; in proportion
as this was effected, the tenderness of the abdomen
was removed, and the tongue became clean. He
had no return of convulsions, the pain and other
symptoms subsided, and in a short time, when the
digestive organs had been restored to a natural
state, he went out of the hospital perfectly well.
Cases of this description have been noted from
the earliest ages. Many passages in the works of
Galen show that he was well acquainted with the
circumstances that have been stated in this section.
Bertrandi* has related instances of abscesses taking
place in the liver, consequent to injuries of the
head. Andouillét relates additional cases, and
makes further observations on the same subject.
Of late, Richterf has delivered similar opinions,
and has directed the practice which should be pur-
sued, when the head is disordered by the reaction
of affections of the digestive organs. Still however
these circumstances seem to me to be stated rather
as occasional, than as occurrences which are com.
mon and naturally to be expected; and I therefore
think myself warranted in supposing, that they
* Mémoires de l'Academie de Chirurgie, tom. iii. p. 484.
+ Ibid. p. 506.
* Chirurg. Biblioth. b. viii. p. 538.
Treatment of Local Diseases.

have not made a sufficient impression on the minds
of surgeons, in this country at least. *
I beg leave, in the conclusion of this section, to
repeat what was said in the former one, viz. that I
consider the disease as depending on nervous irri-
tation in the parts affected, which is either caused,
maintained, or aggravated by disorders of the di.
gestive organs. Yet as the local disease must be
regarded as chiefly nervous, it might, in some rare
instances, exist independently of any manifest dis.
order of those organs. I may further add, that much
nervous irritation in any part generally excites vas-
cular action. It becomes therefore highly important
to attend to the nature and cure of such disorder,
as it might ultimately lead to the production of
organic disease, which would destroy the patient.
* In Doctor Cheston's Pathological Observationis, however,
cases of this description are noticed.

CASES.
SECTION III.
On undefined and undenominated Diseases arising
from Disorder of the Constitution.
The next class of cases, to which I shall call
the reader's attention, is that of unhealthy indura-
tions, abscesses, and sores. Sometimes but one
local disease of this description exists, but in gene-
ral they break out in succession in different parts
of the body. The circumstance of their successive
formation is, I think, a proof that they depend upon
some error in the health in general; and I have ac-
cordingly observed that they are seldom, if ever,
unattended with disorder of the digestive organs.
The imperfect history which the patients generally
give of their previous state of health, will not ena-
ble us to determine with certainty, that the disor-
der of the bowels was the cause of their ill health
and subsequent local diseases; but I can confidently
affirm, that those diseases in general become tracta-
ble, in proportion as the disorder of the viscera is
corrected; and that frequently no new local symp-
toms occur, after some attention has been paid to
the state of the digestive organs. The diseases, to
which I allude, have not been described in books
of surgery; and indeed it is scarcely possible to de-
lineate with precision their various appearances. It
would be quite impracticable to describe all the
diseases, which make the subject of the present

Treatment of Local Diseases. 75
section; namely, unhealthy indurations, abscesses,
and sores. They may be compared, not improperly,
in variety and number, with the infinitely diversia
fied combinations and shades of colour. Yet a brief
and general description of them will assist to recall
them to the remembrance of the experienced sur-
geon; and to enable the inexperienced practitioner
to recognise them, when they occur.
Some of these affections are quite superficial,
occupying merely the skin. The first that I shall
describe is, I believe, well known to surgeons, as
a disease, which is frequently, though not con-
stantly, cured by giving mercury to such an extent
as slightly to affect the constitution. A small indu-
ration or tubercle takes place in the skin, and this
is followed by the successive formation of others
at small distances from the orignal one. The skin
between these tubercles becomes thickened. Chord-
like substances, which are probably indurated ab.
sorbents, may sometimes be felt, extended along
the thickened skin. The tubercles ulcerate, and
form foul ulcers, which heal slowly and break out

again.
Another species of superficial or cutaneous ulcer.
begins generally in one point, and extends in every
direction. The chasm of the ulcer is formed either
by a very sudden ulceration, or by sloughing. A
sore is left, which first secretes a sanious, and then
an ichorous fluid. Granulations afterwards arise,
and the sore heals. The granulations are however
indurated and unsound; and when the patient sup-
poses that the sore is cured, it is suddenly repro-
duced by a process similar to that by which it was
originally occasioned. After some time the ulcer
again heals, and again breaks out. Whilst these
processes are going on in the middle, the sore en-.
larges in its circumference; the edges, which are
thickened, become at times highly inflamed, and

76 On the Constitutional Origin and
either ulcerate or slough. The disposition to dis-
case is aggravated by fits, and there are intervals
when it is apparently tranquil. When this sore has
enlarged to a considerable extent, in the manner
already described, the central parts, which have
healed unsoundly, break out into separate ulcers;
and thus present an appearance of several sores,
connected with each other by indurated skin or
newly formed substance.
I shall briefly mention some of the principal cir-
cumstances relating to the last sore of this descrip-
tion, which came under my care. The patient, who
had been ill for more than two years, and had taken
a great deal of mercury, came from the country in
very bad health, and with his digestive organs much
disordered. The sore was so painful, particularly
at night, that he was in the habit of taking large
doses of opium to procure rest. It occupied the
back of the hand and wrist. He had had somewhat
similar sores on his head and face; but they were
nearly healed, though disposed to ulcerate again.
By that attention to the state of the bowels which
I have described, and by dressing the sore with an
aqueous solution of opium, the greater part of it
was healed in the space of three weeks; and the
remainder was so much amended, and so little
painful, that he had left off his opium shortly after
the commencement of this treatment. As the pa.
tient's circumstances made it inconvenient to him
to remain in town, he went into the country, where
the sore broke out again. He then applied to a per-
son who sold a famous diet-drink; and before he
had taken twelve bottles, the sore was perfectly
healed, and has not since broken out. The diet-
drink, he says, had no sensible operation; but his
bowels became regular and comfortable, and his
appetite amended by taking it.
Another variety of these sores originates in a

Treatment of Local Diseases. 77
more deeply seated disease. The cellular substance
under the skin becomes thickened, and an un.
healthy abscess follows; after the bursting of which,
a foul sore is formed. In consequence of this pro-
cess, the fascia of the limb is sometimes exposed
to view, and seems to have sloughed: when the
slough has separated, the disease may get well
slowly. In many cases, however, there is no expo.
sure, nor separation of the fascia. Sometimes the
sore does not extend beyond the limits of the origi-
nal induration, but heals slowly; while other dis.
eases of the same kind occur in succession in vari-
ous parts of the body. In other cases, the ulcera.
tion of the original sore spreads along the contigu-
ous parts, whilst those which were first affected
get well; and thus the sore assumes an herpetic
character. In many cases the ulceration extends
from the whole circumference of the sore, and
thus the scar and ulcerated edges have a circu-
lar or oval form; in others, the disease is propa-
gated in particular directions, so that the ulcerated
surface presents the most irregular and singular
figures.
These diseases sometimes are small in extent in
the beginning, but enlarge considerably before the
skin gives way; and, when this happens, it proves
a kind of crisis to the disease, which afterwards
heals slowly. In these cases it becomes the object
of surgery to bring the disease to a crisis, whilst
it is yet of small extent; which may be effected
by producing ulceration of the skin by means of
caustic.
Some of these sores are formed from diseases
beginning in the absorbent glands; in which case
the gland, having first been indurated, suppurates
and bursts, and ulceration ensues. When this cir-
cumstance has taken place, in an absorbent gland

78 On the Constitutional Origin and
of the neck for instance, another ulcer may form,
in the manner above stated, in the skin and subja-
cent parts, without any gland being involved in it.
A third ulcer, having a diseased gland for its cause,
may form in the vicinity; and thus the disease pro-
ceeds without any regularity.
I once thought it a necessary but most difficult
task for a surgeon to remark the varieties of these
diseases, in order to understand his profession, and
contribute to its improvement. But, since I have
found that these diseases indicate some disorder of
the health in general, the correction of which is
the great object in their cure and prevention, I
have perceived that there is less necessity for un-
dertaking this most arduous investigation; which,
indeed, could never be accomplished without very
extensive opportunities and indefatigable diligence.
It will be found in the majority of these peculiar
diseases, that the patient had been indisposed for
some time before the occurrence of the complaint,
and, that afterwards the health had become more
evidently deranged. The digestive organs are dis-
ordered. The tongue is furred at the back part,
chiefly in the morning; and the biliary secretion is
deficient or depraved. My attention has been di.
rected to the correction of this disorder; and the
most beneficial effects have resulted from this at.
tention. The sores have healed readily in some
instances; and, in those cases where many had pre-
viously formed in succession, no new disease has
in general taken place. In some few instances, new
sores have formed after the medical treatment of
the disorder had commenced, and even after it had
been for some time continued. This probably arises
from the difficulty, which is experienced, in cor-
recting an habitual and long continued constitu-
tional disorder. In some still rarer cases I have
· Treatment of Local diseases.
79

found similar but much milder diseases arise, after
the disorder of the digestive organs had been in a
great degree corrected.
Whilst I am writing this, there are four patients,
whom I have attended in St. Bartholomew's hos.
pital, with these diseases; which I mention, to
show the younger part of the profession how fre.
quent they are. The health of these patients has
been surprisingly amended in a very short period,
by employing the means which I have described;
and the sores have healed rapidly, although nothing
but simple dressings have been applied to them.
It is not meant by these observations to depre.
ciate the utility of topical applications to unhealthy
ulcers, but merely to show how much they depend
on the state of the health in general; for some of
them, which have remained uncorrected by a great
variety of local applications, will get well under
simple dressings, when the state of the constitution
is amended. It is not, however, to be expected that
this will generally happen; for local diseased action
having been excited, becomes established, and may
continue, independently of the cause which produ-
ced it. Topical remedies will, under these cir-
cumstances, be employed with the greatest advan-
tage. Again, topical applications are of the highest
utility in general practice, because an irritable sore
affects the whole constitution, and aggravates and
maintains that disorder by which it might have
been originally caused. The disorder of the diges-
tive organs cannot in many instances be corrected,
till the fretful state of the local disease is dimi-
nished. I may further mention, with relation to this
subject, that I have seen patients, who scarcely
ever slept from the pain of the local disease, whose
stomachs were greatly disordered, and who had a
distressing purging, which could only be control-

80 Or the Constitutional Origin and
led by opium, sleep without interruption during
the night, regain their appetite, and have their
bowels become tranquil and regular, when, after
various trials, a dressing has at last been applied,
which quieted the irritable state of the sore. It is
right however to mention, that the effects of such
an application are not, in general, permanent; but
after a time the sore becomes again fretful, and re-
quires some new dressing to soothe or control its
irritability.
I have seen some cases of such diseased sores
as I have described, in consultation with other
surgeons, who have become convinced that my
opinions are well founded. Others have occurred,
even in the persons of medical men, whose feel-
ings cooperated to render their conviction more
strong.
Having thus, from general observation, acquired
the opinion that the peculiarities of local disease
depend chiefly on the state of the constitution, I
shall relate some cases, which were treated in con-
formity with the principles which such an opinion
would naturally suggest. I must, however, previ.
ously caution the reader against inferring, that I
attribute all local diseases to some general error in
the state of the health. I have seen local diseases,
which could not be deduced from any general in-
disposition, nor corrected by remedies which act
simply on the constitution at large. I wish to guard
against the suspicion of being inclined to make
general assertions; while I avow at the same time,
that my observations induce me to believe, that the
peculiarities of local disease generally depend upon
constitutional causes. Reason also suggests the
same opinion; for if sores of the same character
break out in succession in different parts of the
body, can we doubt that they arise from the state
of the health in general?
Treatment of Local Diseases.
81
There appears to me a combination of nervous
irritability and weakness, and to such a combina-
tion I am inclined to attribute the peculiarities of
these variable and unclassed local diseases. Perhaps
I may explain my meaning further, by adverting
to what happens not unfrequently in cases of vene-
real and other buboes. The part and the constitution
have been both weakened by the disease that has
occurred; they have been further debilitated by
the mercury employed for its correction. The dis-
ease subsides, but a new disease and action com.
mences; a trivial wound frets out into a phagedæ.
nic sore, which is very difficult of cure. The sores,
in different cases, are nearly as various in appear-
ance, as those of which I have been speaking. To
what are we to attribute these dissimilar, perplex.
ing, peculiar sores, if not to irritation occurring in
weak and irritable parts? As the peculiar diseased
actions of these sores originate chiefly from the
weakness and irritability of the parts, induced by
the previous disorder which they have undergone;

the best instance, that can perhaps be adduced, of
a peculiar local disease existing independently of
constitutional disorder. It is true they affect the
health in general; but it may, by attention, be kept
in a moderately right state, and yet the sore re-
mains unamended. The diseased actions of these
sores sometimes gradually, and sometimes sud-
denly cease; when healthy actions succeeding, the
sore heals. I remember a sore of this description,
to which almost every variety of dressing had been
tried without benefit. It was very extensive, and
had burrowed in various directions beneath the
skin. The ulceration at length became stationary;
but after nine months the sore still remained as
foul and fretful as it had been for a considerable


82 On the Constitutional Origin and
time; when in the course of one week it perfectly
cicatrized, leaving the hollows which I have de-
scribed; for it had thrown out no granulations to
fill these chasms.
Having thus stated the opinions, which I have
formed, relative to these kinds of local diseases;
and which have been deduced from cases too nu-
merous to record, of which I have preserved no ac-
curate accounts, I proceed to relate some cases trea-
ted in conformity to these opinions, which will, I
trust, be sufficient to exemplify and illustrate the
present subject.
CASE XI.
A gentleman's servant, between thirty and forty
years of age, was sent to me with a bad ulcer in his
cheek, situated between the nose and under eye-
lid. The surrounding parts were inflamed, swoln,
and indurated, so as to rise fully half an inch above
their natural level. The sore was of an oval figure;
measuring about an inch and a half in length, and
half an inch in breadth and depth; indeed I could
scarcely see its bottom. The surface was covered
by adhering matter of a greenish hue. The cuticle
round the margin was thickened, and had in some
parts scaled off. The patient had been rubbing in
the mercurial ointment for this complaint. He de-
clared that he had had no chancre for many years,
but had contracted a gonorrhæa about a year before
his present disorder. His health was much dis-
turbed; he had no appetite; his tongue was much
furred and tremulous; his bowels alternately costive
and lax; his fæces blackish. I advised him to take
five grains of rhubarb about an hour before dinner,
and five grains of the pil. hydrarg. every second
night, with castor oil or senna tea occasionally, so
as to procure a motion daily. The sore was dressed
Treatment of Local Diseases. 83

with spermaceti cerate. I saw him again in three
days; when he said that he felt himself under the
greatest obligations to me. He had been entirely
free from pain and distressful sensations, since he
began to take the medicines; although he declared,
that before that time, he should have been thankful
to any one who would have destroyed him. I men-
tion this, because I have often remarked in these
cases, the surprisingly great relief and comfort
which have arisen from a change, produced by
means apparently insignificant and inadequate. The
bowels now acted regularly, and the stools were
more copious and of a more natural colour, and to
this correction of the biliary secretion I am inclined
to impute that relief, which he so forcibly depicted.
The sore had discharged profusely; the surround-
ing swelling and inflammation were much lessened.
He pursued the same plan of treatment for a month,
during which time he recovered his appetite; his
tongue became clean; his bowels regular, and the
biliary secretion natural. The sore had contracted
into a small compass, but without the appearance
of granulations; and the surrounding parts were
not swoln, though still red. His health became at
this time again much disordered, in consequence
of his catching cold, from exposure to rain. He
had pain in the bowels, with a slight purging; his
appetite failed; his tongue was furred; and he had
a severe cough, attended with copious expectora.
tion. The sore on the cheek also enlarged to about
one half of its former size: and the surrounding
parts became tumid. I had the patient admitted
into St. Bartholomew's Hospital, where he took
the decoction of cascarilla with squills. His cough
became materially better in a short time: the state
of his stomach and bowels also greatly improved.
The sore again diminished in size. About a fort-


84 On the Constitutional Origin and
night after his admission into the hospital, an erup-
tion came out over his whole body. The spots were
of a copperish hue, but rather smaller, and more
elevated, than venereal eruptions generally are. *
Some of the eruptions gradually disappeared; and,
in about a fortnight, it was certain that many were
entirely gone. About this time he began to com-
plain of his throat; and an ulcer, of the size of a
shilling, formed in each tonsil. The edges of these
sores were elevated, and uneven, without any ap-
pearance of granulations; the surface was covered
with yellow adhering matter. The patient now
again caught cold: he was attacked with pain in the
bowels, and purging, which obliged him to get up
frequently in the night, and to remain for some
time out of bed. The cough and expectoration re-
turned: he lost his appetite; and he had a furred
tongue. Dr. Roberts, whom I meat at the hospital,
did me the favour to prescribe for him. In a day
or two afterwards, an erysipelatous inflammation
appeared on the right side of his face, opposite to
the situation of the sore. The eyelids were so tumid
that he could not open them: the erysipelas spread
to the other side of the face; and the other eye was
equally closed. The fever also ran very high, and
the patient became delirious; so that he was obli-
ged, for many days, to be confined by a strait waist-
coat. These symptoms gradually abated, and he
recovered, so as to be in better health than I had
ever seen him. He was discharged in about six
weeks, in a state of convalescence; and attended
Dr. Roberts as an out-patient. The eruption and
sore throat had entirely disappeared; the original
ulcer was firmly healed; and the contiguous skin
* Many persons who saw the patient did not entertain a
doubt but that all the symptoms arose from syphilis; it was
their progress alone which evinced the contrary.
Treatment of Local Diseases. 85
had become soft and natural, though it was still
discoloured. A year has since elapsed, and he has
had no return of his complaints.
It is, I think, sufficiently evident, in the present
instance, that the peculiarities of the local diseases
had their origin in the state of the constitution.

CASE XII.
I was consulted, by a medical gentleman in my
neighbourhood, on the case of a lady about forty
years of age, who had been long subject to dys-
pepsia, and severe headaches. Her present and
chief complaint had been of about three months'
duration. It began with weakness, and an apparent
irregularity in the motions of the lower extremi-
ties, attended with considerable pains resembling
rheumatism, and rigidity of the calves of the legs.
These symptoms increasing, she was unable in the
course of a month, to move about at all; but was
obliged to be lifted in and out of bed. At this time
an induration of the muscles of the calf of each leg
had taken place. The indurated substance was
about three inches in length, and between two and
three in breadth. It was severely painful at times,
and the integuments covering it were occasionally
inflamed. There was also some pain and swelling
in the ham. Leeches, sedative lotions, and mercu-
rial ointment had been applied; cicuta and tonics
had been given, but without alleviating the symp-
toms. I first saw the patient about six weeks after
she had been obliged to keep her bed entirely; and
the peculiarities of the present case led me at once
to refer its origin to the state of the health in gene-
ral. The appetite and digestion were impaired, the
tongue was much furred, and the fæces blackish..
I merely recommended fomentations to the indu.
rated parts, considering it the primary object to

86 On the Constitutional Origin and
correct the morbid state of the digestive organs.
With this view the compound infusion of gentian
with the infusion of senna and tincture of carda-
moms was given, in such doses as to procure an
adequate evacuation daily, and five grains of the
pil. hydrarg. were taken every second night. These
simple medicines were completely successful: after
taking them a short time, the discharges from the
bowels were natural, and properly coloured with
bile. The appetite returned; the tongue became
clean, and the pains almost immediately ceased.
No cutaneous inflammation, indicating a disposition
to suppuration, appeared again over the indurated
parts, which gradually recovered their natural
state. In a fortnight the patient could go about with
a stick, and in two months could walk as well as
before her complaint. She has enjoyed better health
since this time, than for many years before.*
CASE XIII.
A gentleman, thirty-two years of age, who had
been subject for several years to occasional attacks
of severe pain in the bowels, was seized, about the
end of August, with a violent purging, which con-
tinued for a fortnight, and was attended with fever.
About a month afterwards, he felt pain in his leg
at night, which gradually became continued even
during the day, and obliged him to confine himself
to bed. In the beginning of October a swelling was
* The state of the indurated muscles in this case, was such
as would lead to the belief that suppuration would take place
in different parts of the hardness; indeed, I have seen many
cases less formidable in appearance terminate in that man-
ner. Seeing how much the irritability of muscles is disordered
by that state of constitution which I have been describing, I
think it is allowable to conclude that most of the organic dis-
cases of muscles originate from this cause.
Treatment of Local Diseases. 87

perceived near the inner ankle, which suppurated,
and was opened on the twentieth of the same month.
Two large teacups' full of dark brown matter were
evacuated. The discharge continued profuse for
some time, and afterwards diminished. Four other
small gatherings then took place in succession, and
bursting, continued to discharge; each aperture
fretting out into a foul sore. About the beginning
of February I first saw this case, which was con-
sidered as a disease of the bone. The five sores had
apertures in them leading to sinuses, which com-
municated with each other. A probe introduced
into one of these, near the bottom of the tibia, could
be moved upwards and downwards along the sur-
face of the bone, which was not, however, denuded.
From an upper ulcer the probe could be passed
behind the bone, and under the muscles of the calf;
this indeed seemed to be the original seat of the
abscess, from which the sinuses proceeded to their
different outlets. The integuments were ædematous
and firm to the touch, so that I could not distinctly
feel the outline of the tibia; but I thought that the
bone was not altered either in form or size. The
firmness with which the patient stood upon the
limb, and the want of aching pain in the bone con-
tributed also to make me believe that it was not
diseased, and that the whole disorder consisted in
an unhealthy abscess, the discharge from which
issued from the various sinuses in the manner
already described. I could not but attribute such a
disease toa general disorder of the health, and indeed
the patient's countenance and appearance indicated
a constitution much weakened and harassed by ill-
ness. His tongue was furred, and the discharges
from the bowels were irregular, deficient in quan-
tity, and of a blackish colour. With a view to the
correction of these symptoms, I directed the patient
to take five grains of the pil. hydrarg. every second


88 On the Constitutional Origin and
night, and the infusion of gentian with senna, so
as to procure one motion daily. But little benefit
was obtained by these measures; and in about a
fortnight afterwards a thickening of the integu-
ments took place over the fibula; a considerable
swelling gradually arose, and another abscess
formed, which burst in about three weeks, and
discharged a considerable quantity of brownish
matter mixed with blood. During this time the
limb was merely poulticed, and the patient could
not leave his bed. His pain was extreme, and he
had no rest at night. The use of opium was neces.
sary to alleviate his sufferings, and opening medi-
cines occasionally to procure stools. He took but
little nourishment, and his health greatly declined.
The disordered state of the stomach and bowels
was much aggravated by this local irritation. In-
deed the situation of my patient was now particu.
larly perplexing. The local disease made the gene-
ral health worse; and the aggravation of this general
disorder, which appeared to have been the cause of
the local disease and of its continuance, proportion-
ately increased the latter malady. The confinement
to bed afforded an additional obstacle to recovery;
yet it was impossible to remove him in his present
state, on account of the pain which motion occa-
sioned. The leg was insupportably painful in a de-
pendent posture. As change of air and exercise
seemed essential to his recovery, I was induced to
try if Mr. Baynton's excellent bandage, by sup-
porting the weakened vessels, would prevent their
distention, and the consequent pain. The sores were
dressed, after as much matter had been expressed
from the sinuses as could be done without occa-
sioning pain. Strips of sticking-plaster were ap-
plied after the manner of a many-tailed bandage;
and the limb was afterwards rolled with a calico
roller. The patient felt comfortable, and found his
Treatment of Local Diseases. 89
limb strengthened. He was directed to wet the
roller, if the parts became heated. The effect of
this treatment was surprising both to the patient
and myself. The pain, which had been constant
before pressure had been employed, ceased from
the time of dressing till five o'clock on the follow-
ing morning; but from that time it gradually in-
creased till noon, when the dressings were renewed.
The cause of this occurrence now became mani.
fest; for, upon opening the bandage, more than a
teacupful of matter was discharged from the dif.
ferent sinuses. I dressed the limb as before, cutting
holes for the escape of the matter opposite to two
of the chief sinuses. I desired the patient to put his
leg to the ground, in order to ascertain the effect of
the perpendicular position when the vessels were
supported; and he experienced no inconvenience.
The second day passed as the former, without pain;
and as the matter poured into the sinuses readily
escaped, he had no uneasiness from its detention.
I recommended him to sit up, and put his leg to
the ground several times in the day, in order to
accustom it to that position. After I had dressed it
on the third morning, the patient stood up, and
took two or three steps very feebly; but this was
rather the effect of general weakness than of par-
ticular infirmity in the diseased limb. I now advised
him to go a little way out of town in a carriage. The
air and exercise, together with the freedom from
pain, produced a very beneficial effect. He began
to recover his appetite, to sleep at night, and ac-
quired so much strength, that he was able in a
week to go about his house, and to resume his at-
tention to business. The discharge from the sinuses
was very trifling, and the sores looked much better.
The patient now undertook to dress his leg himself,
and hired a lodging out of town, so that I only saw


M
90 On the Constitutional Origin and
him occasionally. His limb was so much amended
in the course of a fortnight, that it caused no more
trouble than that of daily dressing. But his health
was not good. His countenance had the same ex-
pression of illness as when I first saw him; his
tongue was white and dry; his bowels costive; and
the stools of an unhealthy colour. I therefore re-
commended him to take again the same medicines
which I had formerly ordered him. His health now
improved; his tongue became moister, and less
furred; the bowels more regular; and the fæces
coloured with a more healthy bile. He continued
recovering till the middle of April, when he began
to complain of the trouble of applying the sticking-
plàster, and used the calico roller alone. I did not
see him for three weeks, and then found him in a
very desponding state. He complained of the tedi-
ousness of his confinement, which had lasted more
than half a year, and said that he would willingly
submit to have the sinuses laid open, if that would
make him well. I found his leg well, excepting two
orifices near the tibia; three ulcers which formed
the apertures of as many sinuses, had healed; the
outline of the bone could be distinctly felt; and
there was no alteration of it in form or size. I was
unable at first to account for this despondency un-
der such favourable circumstances; but I soon dis-
covered that it was the effect of hypochondriacism.
For his tongue was much furred and dry; and at
the same time that he left off the bandage, he had
also discontinued his medicines. I urged him to
return to them immediately; and called on him
again in ten days, when he perceived clearly the
absurdity of his late despondency, as well as its
cause. He called on me on the 10th of July, with
a new swelling near the upper part of the tibia,
which threatened to form an abscess, similar to

Treatment of Local Diseases. 91
those which had formerly taken place. I covered
the limb with the bandage of sticking-plaster, as
at first. The new disease disappeared entirely; and
the old ones were so much benefited by the exact
and equal pressure, that the patient felt nodifference
between the sound and the affected limb. The ul-
cers gradually healed, and his health is better than
it has been for some years; yet still there is an evi-
dent tendency to disorder of the digestive organs.


CASES.
SECTION V.
On more defined Diseases, as Carbuncle and Scrofula
arising from Disorder of the Constitution.
IF, upon an extensive and accurate examination
of the subject, it were to appear, that many very
peculiar and very dissimilar local diseases originate
from a common cause, namely from weakness and
irritability of the system in general, our inquiry
would be further extended, and we should feel
anxious to know whether similar causes may not
operate in the production of more common and
more frequent local disorders. As far as my late
observations have enabled me to determine, that
state of the digestive organs, which I consider as
denoting constitutional disorder, exists prior to the
formation of a carbuncle; and is exacerbated during
the progress of that disease. This opinion indeed
will appear probable, if we consider the kind of
persons who are attacked with carbuncles, and the
considerable derangement of health, which even a
trivial local disease of this nature occasions. I shall
mention but one case in support of this opinion,
though I have made similar remarks in several
other instances.

On the Constitutional Origin, &c.
93
CASE XIV.
I attended a gentleman, who was afflicted with
carbuncles, during three successive attacks, at the
interval of about a year between each. I made an
incision through the indurated skin, down to the
subjacent sloughy cellular substance, and thus
brought the local disease to a crisis. This treat-
ment was sufficient in the two first attacks; the
extension of the disease was prevented; the sloughs
separated, and the wound healed. The patient,
whose mode of life was intemperate, had cough;
difficult respiration; fulness and tenderness of the
parts situated in the epigastric region; unhealthy
secretion of bile; and in short, all those symptoms
which denote a very considerable degree of disor-
der of the digestive organs: it is probable indeed
that some organic disease of the chylopoietic vis-
cera existed. After he had recovered from the car-
buncle, I told him that the most important disease
still existed; and urged him to be attentive to his
diet, and to the directions of his medical atten-
dants. He still however continued to live intem-
perately, and his disorder increased. He was indeed
nearly dying from diseased viscera, when he was
attacked with carbuncle for the third time. The
division of the parts produced a temporary cessa-
tion of the disease; but it began again to spread
in every direction from its circumference, and he
died.
It will not, I believe, be doubted, that boils are
a slighter degree, with some variation, of the same
disease, which causes anthrax and carbuncle; and
it is almost unnecessary to remark, that some per-
sons are subject to a successive formation of very
large and troublesome boils from the least irritation

94. On the Constitutional Origin and
of the skin. I have seen many persons thus affected;
and there has been, in every instance, disorder of
the digestive organs, the correction of which has
prevented the return of these vexatious local dis-
eases. One gentleman, who had been tormented
for many years by the quick successive formation
of boils as large as eggs, has been free from them
for some years; though he has had other disor-
ders, which denote such a condition of the consti-
tution, as it has been my object to describe in this
paper.
I have remarked in many instances that diseases
of the absorbent glands, such as are usually and
justly denominated scrofula, occurring in adults,
have apparently originated from the disorder which
I have described. In several cases the local disease
was of long duration, and had become worse rather
than better under various plans of medical treat-
ment; yet it amended regularly, and sometimes
even quickly, in proportion as the state of the di-
gestive organs was corrected. I need not detail any
cases on this occasion, since every surgeon must
know them familiarly. The patients are commonly
sent to the sea-side, or into the country; where
enlarged glands subside, and those which have
suppurated and ulcerated heal; and the local dis-
ease recovers, in proportion as the health in gene-
ral is amended.
There are cases of scrofulous diseases occurring
suddenly, and in various parts of the body at the
same time, which seem to originate in that state of
the constitution which is occasioned by disorder
of the digestive organs. I have chiefly observed
these cases in children; and they have followed
some violent febrile affection. In two cases which
I shall particularly mention, the smallpox was the
antecedent disease. I have already stated, that


Treatment of Local Diseases. 95
when the health has been considerably disordered
by some violent disease, the digestive organs may
become subsequently affected; and that this disor-
der proves a cause of many secondary diseases.
CASE XV.

A child of two years old had the smallpox, from
which he did not seem to recover, but, on the con-
trary, fell into a very bad state of health. The ab-
sorbent glands on the right side of the neck became
enlarged in succession, so as to form altogether a
very considerable tumor, which extended down
to the collar bone. The axillary glands then became
affected in the same manner; the swelling was unu-
sually great, and seemed to extend under the pec-
toral muscle, elevating it, and forming by this
means a continuation of tumor with the glands of
the neck. These swellings had partially suppurated,
and had broken in two places, viz. in the neck,
and about the margin of the pectoral muscle: but
no relief followed; on the contrary, the mass of
disease seemed to be rapidly increasing. The child
was bowed forwards, so that the spine was much
curved in the loins; the left leg appeared paralytic,
and a swelling was perceived in the abdomen, which
I could not but ascribe to an enlargement of the
external iliac glands. The child was extremely
emaciated; his skin felt hot and dry; his tongue
was covered with a brown fur; and the stools were
black and highly offensive. As there was no expec-
tation that he could survive this desperate state,
those medicines only were prescribed that seemed
likely to correct the state of the digestive organs;
such as occasional doses of calomel, and rhubarb.
A strict attention to diet was also recommended.
Under this treatment the stools gradually became
natural, and the tongue clean. The disease seemed
96 On the Constitutional Origin and

to stop immediately. As the heaith was restored,
the swellings rapidly subsided; and the child be.
came one of the healthiest and stoutest of the
family.
CASE XVI.
A female child, after having had the smallpox,
got into bad health from disorder of the diges-
tive organs. She was then suddenly attacked with
a scrofulous affection of the knee and elbow of the
opposite sides of the body. Two collections of
Muid had taken place beneath the fascia of the leg
and thigh. The joints were greatly enlarged, and
the swelling was apparently caused by an increase
in the size of the bones. Had I seen either joint,
as a single case of disease, I should have said that
it would leave the child a cripple. It was manifest,
in the present instance, that these local diseases
were the consequence of general ill health; and that
the first object was to correct the disorder of the
system. The functions of the digestive organs,
which had been deranged, were restored to their
natural state by employing the same diet and medi-
cines which had been so signally successful in the
preceding case. By these means the health was
reestablished, and the local diseases gradually dis-
appeared.
I have heard it remarked by surgeons of great
experience, that patients often recover when many
scrofulous diseases appear at the same time; al-
though some of them may be so considerable, that
they would seem to warrant amputation had they
appeared singly. The cases which I have related
afford a most clear and satisfactory account of the
mode of recovery. General irritation and weakness
bring on diseases, to which perhaps a predisposi-
Treatment of Local Diseases.

tion may exist, in several parts of the body; these
cease when their exciting cause is removed.
Of late indeed I have been equally surprised and
rejoiced to see swellings of the absorbent glands
in children readily dispersed by that medical atten-
tion to correct errors in the functions of the diges-
tive organs, which I have described. Some of these
swellings came on rapidly, and some slowly, but
these were so large and so much inflamed, that if
any person had formerly told me they might be
dispersed by such measures, I should have thought
the assertion an absolute absurdity from its direct
contradiction to my former experience. From
amongst a considerable number of cases I shall
relate the following:
CASE XVII.
The son of one of my friends had gradually fallen
into a very bad state of health. The child was about
six years of age, and had been unwell for several
months; when, in conclusion, two glands in the
neck became gradually enlarged, till each had
attained the size of a large walnut. The child's
tongue was much furred, his appetitę very defi-
cient, and capricious; his bowels had a costive ten-
dency; his stools were never of a proper colour.
His flesh was wasted and flabby, his countenance
pale, his pulse feeble and frequent; and his general
demeanor languid and irritable. I told his father,
that I could advise nothing as a local application
better than bread and water poultice; and that the
chief object of attention was the correction of that
disorder under which he had long laboured, so that
his constitution might regain its natural tranquillity
and strength. Upon this subject I promised to
speak to the gentleman who had hitherto attended
the child. In about two days a deep redness came
98.' On the Constitutional Origin and

over the most prominent part of each gland, deno. ,
ting, as I concluded, a disposition in the internal
parts to suppurate. The child took half a grain of
calomel with five of rhubarb every second night,
and ten drops of the acid: vitriol: dilut: three times
a day. In about a week, an evident amendment
was observed in the appetite, spirits, and colour of
the excretions from the bowels. In a fortnight, the
spirits of the child became, to use the words of the
parents, ungovernable; and an evident amendment
of the health in general took place. In a month, the
child might be said to be well; though he still re-
mained thin. After another fortnight, he discon-
tinued all medicine, except the occasional use of
the powders, for at this time all vestiges of enlarge-
ment in the glands had disappeared. I do not relate
this case as extraordinary, for I have seen several
worse cases cured by the same means; and as I
have said, some of the swellings have come on
tardily and others rapidly. It is related merely,
because in the same family another child had sup-
puration of the glands; which left a sore that healed
slowly.
It cannot indeed be proved that these cases would
have been strumous; it can only be said, that to
all appearance they were the same as others which
I have formerly seen suppurate, and form sores
slow in healing, and such as are generally denomi-
nated scrofulous.
CASE XVIII.
A slender child about five years of age had five
swollen glands on the right side of the neck, and
three on the left. Their magnitude was considera-
ble, and the child's appearance sickly; and the dis-
order had so threatening an appearance, that the
gentleman who attended the family requested the
Treatment of Local Diseases. 99
parents to take some additional opinion on the case.
The tongue was furred, and the bowels so habitu-
ally costive, that sometimes a week elapsed with-
out any alvine evacuation. As the child was fever-
ish, he took at first some saline medicines in a state
of effervescence, which was afterwards changed
for the diluted vitriolic acid. He also took half a
grain of calomel, every second night, which gradu-
ally brought about a regular secretion of healthy
bile, and in about three weeks the child might be
said to be well, for his bowels acted regularly when
no medicine was taken, and the discharges from
them were properly tinctured with bile. The use
of calomel was now only recommended, if the
appearance of the stools varied from the rhubarb
colour. The swollen glands disappeared, nothing
but a bread and water poultice having been ap-
plied to them. The bodily powers of the child were
considerably augmented, and his aspect became
healthy

CASE XIX.
A boy between seven and eight years of age had
a lameness about the hip, which was so considera-
ble as greatly to alarm his parents. There was no
tenderness when the joint was compressed either
in front or from behind. The tongue was furred,
and he had been subject to slight paroxysms of fe-
ver, resembling an intermittent. I recommended
half a grain of calomel with a few grains of rhubarb
every other night. In a short time the lameness so
entirely disappeared, that I was no further consulted
on his case. About eight months afterwards, how-
ever, I was desired to see him with three consid-
erably enlarged absorbent glands on one side of his
neck, and two on the other. They had for many
days continued to increase. He was at that time

100 On the Constitutional Origin and
feverish, and I now became more acquainted with
the state of his health in general. I learned that he
eat rather voraciously, and could not be restrained
from taking very highly seasoned food; that though
his bowels regularly enough evacuated the residue
of the food, the stools were of various, and always
of faulty colours, and very offensive; that he perspi-
red profusely upon the slightest exertion. His skin
was covered every where with scurf and eruptions;
and his hands were hard, harsh, and chapped. He
took the medicines, as in the preceding case, for
about the same length of time, when the glandular
complaint was well. He continued the half grain
of calomel, however, for three months, for the
secretion of bile had not even in that time become
healthy in quantity and quality. His skin was, how-
ever, perfectly smooth and free from eruptions.
His hands only retained in a slight degree their for-
mer feel.
I have also seen instances of sores apparently
scrofulous left after the suppuration and ulceration
of diseased glands, which had continued for more
than a year, heal rapidly under the same kind of
treatment. I have however seen other instances, in
which the sores did not appear to be amended by
such constitutional treatment.
I have also observed several instances of stru-
mous affections of the fingers in children get well
in proportion as the general health has become
established by correcting disorders of the digestive
organs. I need not however detail them. These
diseases were, in my opinion, strictly scrofulous.
The nature of the disease in the following case
will not I think be doubted, and on this account I
relate it.
Treatment of Local Diseases.
101

CASE XX.
A child about five years of age, after having had
the measles, got into a bad state of health, and had
several scrofulous abscesses form on the fore-arm.
They became sores of various sizes, but in general
about that of a shilling; the surrounding skin was
thickened and of a purplish hue. The sores were
foul and without granulations. In this state they
were when I first saw the patient, and had con-
tinued with occasional amendment and deteriora.
tion for two years. Being consulted on the case,
and perceiving the child appeared out of health, I
examined his tongue, which was furred; inquired
respecting his appetite, which was deficient, and
the state of his bowels, which were costive. The
same medicines were prescribed as in the former
cases. In about six weeks the child got into re-
markably good health, which it had not enjoyed
from the time of its first indisposition, and the sores
rapidly and soundly healed.
My observations have led me to believe, that
most local diseases are preceded by general indis-
position, of which the disordered state of the diges-
tive organs is an evidence, and may have been a
cause. The relief arising from the correction of
this disorder is indeed surprising, and the general
knowledge of this fact I have deemed my duty to
promote to the utmost of my power. When the
appetite has been deficient, I have been accustomed
to recommend acids as medicines, when on the
contrary it has been good, and the digestion diffi-
cult and imperfect, I have recommended bitters
and alkalies.
I mention this to account for my giving the
vitriolic acid in these cases. It is in addition to its
medical properties, so pleasant, that even spoiled
102 On the Constitutional Origin, &c.
children will take it without agitating themselves,
and distressing their parents. It pleases me to be
able to give proofs of its utility; because, I think,
they will be allowed to disprove that any specific
good arises from the administration of alkalies:
Alkalies may be useful occasionally in dyspeptic
cases; but that they have no specific action in the
cure of scrofula, I have long thought from some
experiments which I made on this subject at the
hospital. In cases of scrofulous glands, I gave
soda in doses which were gradually increased till
they affected the qualities of the urine, without
perceiving any benefit to accrue to the local dis-
ease from their use. The pleasure which I feel
in thus endeavouring to disprove the specific
virtues of alkalies arises from this circumstance:
That if I am right in my notion, that they are
chiefly useful by their operation in the stomach
and bowels, it shows how much better it is to be
informed of what ought to be done for the cure of
diseases, than of the means by which it may occa-
sionally be accomplished; or in other words, it
shows how much superior the rational is to the
empirical practice of medicine.
After having attempted to show that many non-
descript diseases arise apparently from the state
of the constitution, and that carbuncle and scro-
fula are sometimes consequences of the same
cause; it may be inquired, whether, if the same
general disturbance of the health can produce so
many varieties of local disease, it may produce
many others, and even every variety. Even in
cancer, disorder of the digestive organs appears
to be antecedent to the local disease, and aggra-
vated by its existence; but whether this disor-
der be the effect or cause of the constitutional
diathesis cannot, I think, be at present deter-
mined.


CASES.
SECTION IV.
On Diseases of various Glands, arising from Disor-
der of the Constitution.
I have also observed that diseases of particular
organs, seem to originate, in many instances, from
disorder of the system in general. The testis of the
male subject, and breast of the female, have fur-
nished me with examples of this observation. In
the cases to which I allude, the testes were alter-
nately affected, enlarging considerably, and then
subsiding. * I have met with numerous and inte-
resting cases of such diseases of the breast; how-
ever, the relation of a few will be sufficient to in.
form the reader of all that I know concerning this
subject.
CASE XXI.
A lady came to London, to submit to the re-
moval of a diseased breast, if it should be judged
necessary. The disease had existed for more than
two years. The breast of the affected side was one
* The cause which excites and maintains alternate irrita-
tion and disease of the testes, generally resides in the urethra;
but there was no disease of that part, in the cases which I now
mention. The patients first became unhealthy, and disorder
of the testes followed. Similar affections are not uncommon in
pseudo-syphilis.

104 On the Constitutional Origin and
third larger than the other; indurated in several
parts; and so much enlarged and hardened in one
place, that this might have been taken for a distinct
tumor on a hasty and inattentive examination.*
This part was situated near the margin of the pec-
toral muscle. The disease had resisted the various
means employed with a view to disperse it, such
as leeches, lotions, mercurial ointment, &c. It was
occasionally painful, and caused the patient so much
mental anxiety, that the surgeon, who attended her
in the country, thought it should be removed. The
mammary gland of the opposite side was far from
being in a perfectly healthy state; which circum-
stance appeared to forbid an operation, since the
same disease might take place afterwards in the
opposite breast. The patient's general health was
much impaired, her tongue was furred, her appetite
deficient, her digestion imperfect; the biliary secre-
tion was disordered, and the bowels costive. I or-
dered her to take a compound calomel pill every
other night, five grains of rhubarb half an hour
before dinner, and the infusion of gentian with
senna, so as to procure a sufficient evacuation of
the bowels daily. Linen moistened in water was
applied to the part in the evening, or when it felt
painful and heated. This plan of treatment reduced
the bulk of the diseased gland by at least one third
in the course of a fortnight. The patient went after-
wards into the country, still employing the same
medicines; and was entirely free from the disease
in three months, though she felt occasionally shoot-
* It may not be improper to observe here, for the instruc-
tion of the younger part of the profession, that if a breast con-
taining a portion which is particularly indurated be examined
with the points of the fingers placed circularly, the disease
will feel like a separate tumor; but if the flat surface of the
fingers be moved over it, its true nature will become manifest.
Treatment of Local Diseases. 105
ing pains, which probably indicated that her health
was not completely reestablished.

CASE XXII.
A lady consulted me on account of a considera-
ble swelling of the breast, attended with much pain.
It had come on suddenly, and had been painful
about a week; but she thought that a lump had
existed previous to this time. The principal tumor
was on the side next the sternum, and was as large
as an hen's egg; it seemed to be distinct, yet there
was a general swelling, with partial induration of
the substance of the gland. The tongue was furred,
the bowels costive, and the pulse frequent; and she
was, to use her own expression, very nervous. I
directed her to use the same means as were men-
tioned in the preceding case. Small doses of mer.
cury act beneficially on the bowels, by inducing
regular and healthy secretions; and I know no bet.
ter method of administering it as a discutient. The
general induration of the breast and tumefaction of
the integuments subsided quickly under this treat-
ment, and left the lump in the same state which I
supposed it to have been in before the attack of
general swelling and pain. In another week this
apparently distinct tumor was flattened on its
surface, diminished in size, and confused with the
substance of the mammary gland. Its form varied
each successive week; it first became oblong, and
afterwards seemed to separate into two parts; but
in less than six weeks no trace of it could be felt.
CASE XXIII.
"A medical man, who resides in the country,
brought his daughter to town for advice. She had
apparently a tumor in her left breast, between the
106 On the Constitutional Origin and

nipple and the axilla; in which part she had felt a
good deal of pain. The swelling was of very con-
siderable size, and the breast so tender, that I could
not exactly make out whether it arose from distinct
tumor, or from a partial enlargement of the mam-
mary gland. Want of time prevented the patient's
father from showing the case to another surgeon.
I could only give him this opinion; that in the pre-
sent circumstances, no one would think of an ope-
ration. I recommended the application of the lotio
ammon. acetat. when the part felt heated; and as
the patient had disorder of the stomach and bowels.
to a great degree, that the chief attention should be
paid to the state of these organs. A grain of calo-
mel was directed to be taken every second night;
rhubarb before dinner, and infus. gentian and sen-
na, if necessary.
About two months afterwards, having occasion
to be in that part of the country where the patient
resided, I called on her. Her father then told me
that the swelling had subsided considerably, after
his daughter's return in the country; and that of
late he had not examined the complaint, as she
told him she felt no uneasiness from it.
When I now examined the breast, I could not
perceive any difference between it and the other.
No vestige was left of a disorder, which had been
of such a magnitude, as to occasion considerable
alarm; a circumstance that excited the greatest
surprise in the mind of her father, who was a prac-
titioner of much experience. *
Before I had paid attention to those complaints
which arise from, or are aggravated by, constitu.
tional causes, I could not have believed that such
* I have also known cases of induration and suppuration of
the salivary glands, apparently caused by the same general
disorder, and cured by the same treatment.

Treatment of Local Diseases. 107
considerable local diseases, after resisting various
topical and general means, should give way so
readily and completely to small doses of medicine.
It is only by considering the manner in which this
effect is produced, that the subject can be placed
in a proper point of view.
An attention to the state of the bowels is indis-
pensably necessary, even in the common practice
of surgery. A simple cut of the finger frets into a
bad phagedænic sore, which resists every local
remedy so long, that amputation is at last proposed.
This is the consequence of bad health, which in its
turn is aggravated by the irritation of the sore. The
patient has a furred tongue, with other symptoms
of disordered digestive organs. An attention to this
disorder corrects the painful state of the sore, which
now heals rapidly under simple dressings.
A patient has a disorder in the urethra, almost
too trivial for surgical attention; yet producing
much inconvenience. The functions of the diges-
tive organs are impaired, and he is hypochondri-
acal. He consults a physician, under whose care
his general health is amended, and he no longer
feels or thinks of the local disease.
An erysipelatous inflammation of the leg is im-
puted to some trivial cause; as for instance a gnat-
bite. It becomes worse under the common reme-
dies. The health has been long declining, and the
chylopoietic viscera are obviously deranged. The
erysipelas is quickly cured by medicines prescribed
for that disorder.
A patient has a trivial sore on his leg, which the
surgeon finds a difficulty in curing by the usual
methods. The patient feels indisposed, and has a
manifest disorder of his digestive organs. The sore
begins to slough, and becomes very painful. The
disorder of the stomach and bowels is augmented;
108 On the Constitutional Origin and

so great is the indigestion, that the small quantity
of food which the patient thinks it necessary to
swallow for sustenance, feels weighty and uncom-
fortable in the stomach; and the vegetable food
becomes almost corrosively acid. Opium fails to
procure sleep, or even to give ease. When the
mortification has spread so as to occupy almost
one fourth of the integuments of the leg, several
very copious pultaceous stools of a greenish brown
colour are discharged from the bowels in the course
of the night, and the patient's feelings undergo an
entire revolution. Before this, the stools procured
by medicine were watery and dark-coloured. The
patient now sleeps like one long harassed by pain
and watching; his stomach is tranquil and willingly
receives aliment, which now produces no uneasy
sensations. The skin which had been hot and dry,
becomes moistened with a gentle perspiration, and
the pulse beats with its natural frequency, and in
a tranquil manner. The effects of this favourable
crisis being maintained by medical treatment, the
sloughs are thrown off and the sore heals with a
rapidity indicative of considerable vigour of con-
stitution, and further demonstrative of the slough-
ing not having been the effect of vascular weakness,
but of nervous irritation. I could relate numerous
cases of erysipelatous inflammation terminating in
sloughing, in which the disease arose from a simi.
lar constitutional cause.
A patient supposes that his knee is strained; for
pain and inflammation of the joint suddenly come
on, with deposition of fluid into the articular cavity;
this attack is attended with fever, furred tongue,
and unnatural discharges from the bowels. Leeches,
cooling washes, and poultices; in short, all topical
applications are unavailing. It is a case of rheuma-
tic inflammation, for which a physician is consul-


Treatment of Local Diseases.
100
ted. Five or six weeks elapse without any abate-
ment of the disease, the patient being almost unable
to stir in bed. An alteration in the health suddenly
takes place; the tongue becomes clean, the bowels,
regular, and biliary secretion healthy; and there is
no longer any pain in the knee. All the fluid is
absorbed from the joint in two days, and the patient
walks about his chamber. Or there may actually
have been some local injury; but the consequences
are very considerable and violent, and quite incom-
mensurate to the cause. Such occurrences can only
be explained by imputing the effects to the state of
the health in general. *
A case like that described in the preceding sketch
would, I believe, be acknowledged by every one
to be dependent on the state of the constitution in
general; but I could bring forward a great number
of instances of chronic affections of joints, incura.
ble by local measures, which were evidently cured
by correcting those errors in the state of the diges-
tive organs, which were the cause or effect of gene-
ral disorder of constitution. In diseases of joints, we
find three distinct kinds of cases. First a scrofulous
disease of the bones, which ultimately affects their
articular surfaces; secondly, an inflammatory affec-
tion of the joint, producing effusion of Auids into
its cavity and ulceration of the cartilages and liga-
ments; and in this case, the most perfect rest, and
most strenuous efforts by local means to put a stop
to inflammation are requisite; and thirdly, an in-
flammation dependent on constitutional causes.
This inflammation is sometimes of an active and
* As operations are injuries, so we ought not to perform
them, if it can be avoided, when the constitution is much dis-
ordered. I could relate several instances of the wounds made
in operations, assuming diseased actions from such a state of
the constitution.

110 On the Constitutional Origin and
painful nature, and sometimes of a more indolent
and chronic character; but whatever form it may
assume, it is less prone to injure the structure of
the joint, and little susceptible of cure by local
measures, whilst it yields to those means which
tend to improve the health in general. When a dis-
eased joint is so situated as to become an object of
examination, these circumstances will be suffi.
ciently evident. I am induced to mention them
chiefly on account of such variety of affections oc-
curring equally in the hip, as well as in the other
joints, in which case the benefit accruing from dif-
ferent modes of treatment is less demonstrable to
the sight and touch.*
* As I know of no treatise on diseases of the hip in which
the distinction of cases is" made; and as, from what I have
seen, I cannot but consider the subject to be very important;
so I think I should do wrong to forego the present opportu-
nity of relating as succinctly as possible two of a considerable
number that have come under my observation, in order to
cxcite attention to this subject.
CASE I.
A boy about twelve years old was sent from school to Lon-
don, being supposed to have a lumbar abscess. There was a
considerable collection of fluid beneath the fascia of the thigh;
but it received no impulse when the patient coughed. The
boy limped in walking as if he had a diseased hip, scarcely
bearing on the affected joint. When pressure was made on
the front of the orbicular ligament, it gave him acute and
considerable pain. He was kept perfectly quiet in bed, blood
was taken by leeches repeatedly from the integuments oppo-
site to the inflamed joint, and linen wet with diluted ay: am-
mon: acet: constantly applied, till pressure no longer occa-
sioned pain. A blister was then applied over the joint, and the
cuticle being removed, the sore surface was dressed with
savine cerate. This dressing produced considerable inflam-
mation and ulceration beyond the blistered part, and caused
the surface of the skin which had been deprived of its cuticle
to mortify, Near a month elapsed before the sore healed. At

Treatment of Local Diseases. 111
this time no fluid was discoverable beneath the fascia; no
uneasiness was felt when the joint was compressed; and the
boy could not be prevented from getting up, because he felt
as competent to walk about, as before the occurrence of his
disease. He went to school again in the country, and after
two years was put into a merchant's employ; in which situa-
tion, he was obliged to be constantly walking about the town.
He then again became lame in the same manner, but not to
the same degree. There was, however, no effusion of fluid
beneath the fascia of the thigh. A month's rest with similar
treatment seemed to have cured this relapse; and I then told
his father that he must change the employment of his son:
observing, that though the joint might recover sufficiently to
endure common exercise, without injury, it was not to be ex-
pected that it would ever be able to sustain violent exertions
with impunity. I urged him, also, to let me know immedi-
ately if there was any return of lameness. About three months
afterwards, I met the father and his son in the street, and ob-
served that the youth limped in walking very much. I asked
why I had not been informed immediately, as I had requested,
of return of lameness; and further inquired, whether the boy
still continued in the same situation. Being told that he did so,
I felt so much hurt at the cruel and absurd conduct of his
father, that I declared I would no longer interfere in their
concerns, nor was I asked to do so.
All that I can further relate of this case is, that a large ab-
scess formed and broke behind the trochanter, and that I once
afterwards saw the poor lad lying in St. Bartholomew's hos-
pital with his thigh bone dislocated in consequence of the de-
struction of the ligaments of the joint.
CASE II.
A young lady of a delicate and susceptible constitution, who
had suffered much uneasiness of mind on account of some of
her friends, became so excessively lame in the left hip that
she could not move a few steps without support. Pressure on
the front of the joint occasioned considerable pain. Her
longue was much furred, and her bowels greatly disordered,
and she had fits of agitated and difficult respiration. I re-
commended. nothing but tepid fomentations to the hip,
and explained to her physician what I thought would be
right to be done with regard to the state of the digestive
organs.
As she became better in health, her power of moving about
increased, and she went to the sea-side. After two years

112 On the Constitutional Origin, &c.
there still remained some tenderness, when the hip joint
was compressed and some thickening of the parts which
covered it. She, however, eventually got well, though no
local applications of any moment were made to the diseased
parts. I need scarcely add, that the means employed in the
first case, with such striking success, would have been prée
judicial in the latter, whilst those which were serviceable
in the last case, would have been futile and nugatory in the
former.

CASES.

SECTION V.
Disorders of Parts which have a Continuity of Sur-
face with the Alimentary Canal.
I had formerly observed spasmodic strictures of
the esophagus to disappear under various modes
of treatment, in a manner which I did not under-
stand. Mercury seemed to effect the cure in three
instances. Many cases have occurred to me lately,
in which the irritation in the æsophagus seemed to
be first excited and afterwards maintained by dis-
order of the digestive organs. It will be readily
allowed, that spasmodic strictures of the æsopha-
gus, when long continued, may cause a thickening
in the affected part of the tube, and thus the stric-
ture may become permanent. One instance will be
sufficient to illustrate and verify this view of the
subject.
CASE XXIV.
A lady, who had been in bad health for many
years, and was supposed by her medical attendants
to have a stricture of the esophagus, became at
last incapable of swallowing any food, except in
very small quantities; she was even then obliged to
drink some fluid after each morsel, to facilitate its
descent into the stomach. Some mucus and blood
rose into the mouth after vomiting, which very
114 On the Constitutional Origin and

generally followed the taking of food. Under these
circumstances, I was requested to pass a bougie, in
order to ascertain the state of the esophagus; but I
declined this examination, on account of the disor-
der which existed in the stomach. The tongue vas
greatly furred; the parts in the epigastric region
very tender: the bowels much disordered; the se-
cretion of bile either very unhealthy, or entirely
wanting; every symptom, in short, which indi.
cates an aggravated form of disorder of the di-
gestive organs, existed in a striking degree. The
stomach and bowels were brought into a better
state by such medical attentions as I have already
so often described; and the æsophagus partook of
this amendment: for moderately sized morsels of
food could now be swallowed without the necessity
of washing them down by liquids. The general
health also improved, and she became fat. But
the disorder of the digestive organs, which had
been of long continuance, was not completely sub-
dued; she was still subject to relapses, and in
some of these the difficulty of deglutition again
occurred. *
The throat and mouth are the parts next in or.
der; but it is unnecessary to relate additional cases
under this head: some of the instances already re.
corded will be sufficient to confirm my sentiments
on this subject, and the propriety of the practice
which I have recommended.
That diseases of the nose may be caused or ag-
gravated by irritation arising from the stomach is
a proposition, which will, I think, be readily grant-
ed. Indeed it seems surprising that the operation
of this cause has been so little adverted to in books
of surgery; since the phenomena which prove the


* This patient has now for more than four years been free
from this disorder.

Treatment of Local Diseases. 115

fact are so well known. Are the monstrous noses,
caused by excessive drinking of vinous and spiritu-
ous liquors, to be otherwise accounted for, than
by irritation arising from the stomach? And do not
worms in children cause a teazing sensation in
the extremity of the nose? I had seen, in private
practice, several cases of irritation and swelling of
the end of the nose, in some instances accompania
ed with small ulcerations of the pituitary mem-
brane. In these cases, the skin over the nose,
which was tumid, became rough and discoloured:
the middle of the discoloured part became sound;
whilst the circumference retained its morbid ac-
tions, the disease there spread in a small degree.
In these cases the tongue was furred; and there were
evident indications of disorder in the stomach and
bowels. The disease was checked, and cured, by
attention to this disorder. I was strongly impressed
with the opinion, that if these cases had been ne-
glected, they would have terminated in that herpetic
ulceration, which so often affects the end of the
nose. I have also seen several instances of that her-
petic ulceration in its confirmed state more mate-
rially benefited by medical attention to correct
the disorder of the digestive organs than by any
local application: and I feel confident that it may be
frequently cured by such endeavours.
I have observed, in all the cases of that noisome
and intractable disease, ozæna, which have come
under my care lately, that the stomach and bowels
have been disordered; and more benefit has been
obtained by endeavouring to bring these organs
into a healthy state, than by all the local applica-
tion, which had been previously tried. I stated to
a medical friend my opinions respecting one pa-
tient, who came from the country, and begged to
know the effect of the treatment which I had pro.
posed. He informed me, after some months, that
116 On the Constitutional Origin and

he had not been able to succeed in correcting the
visceral disorder; and after relating the means which
had been used, he adds, “The patient was now at-
tacked with a bilious disorder, to which she had
formerly been subject, and for which I gave her
six grains of calomel in a bolus, which soon re-
lieved her. During this attack the nose seemed
well; there was no fetor in the discharge, and she
recovered her sense of smelling.” However the
disease returned afterwards as before.
I have known several instances of persons who
have for a long time been subject to polypi of the
nose, in which the polypi ceased to grow after
some attention had been paid to correct a disorder
of the digestive organs.
In farther confirmation of the opinion, that dis-
eases of the nose depend much upon the state of
the stomach, I shall mention the case of a woman,
who had a disease of the nose, which I expected
would, at least, prove very tedious and very trou-
blesome, but which got well speedily under sim-
ple dressings, in consequence, as appeared, from
the effect of internal medicines.


CASE XXV.
This patient was between thirty and forty years
of age; had a furred tongue, bowels alternately
costive and lax, and the discharges discoloured.
An enlargement of the left ala nasi, caused by a
great thickening of the parts covering and lining
the cartilage, had gradually taken place. The skin
was discoloured, and an ulcer, about the size of
a sixpence, had formed on the under surface of the
ala. The sore was deep, with a sloughing surface,
and uneven and spreading edges. Spermaceti ce-
rate was employed as a dressing; and the external
Treatment of Local Diseases. 117

skin was frequently bathed with Goulard's wash.
She was ordered to take internally five grains of
rhubarb an hour before dinner, five grains of the
pil. hydrarg. every second night, and the infusion
of gentian with senna occasionally. The sore ceas-
ed to spread, the swelling gradually subsided, and
all diseased appearances were removed in the
course of a month. The patient also found her
health considerably amended.
In most cases of deafness, there is probably a
state of irritation, and a tendency to inflammation,
throughout the passages of the ear. The external
meatus may be unusually sensible, the secretions
being either suppressed, or discharged in an un-
natural quantity. The lining of the eustachian
trumpet is thickened; and hence it becomes par-
tially obstructed. It must be admitted that such a
state of the organ is likely to be aggravated by a
cause, which maintains or produces irritation in
the nose. When dulness of hearing also depends
on a torpid state of the nerves, it may be caused
by the same circumstance, which is known to af.
fect the sensibility of other nerves.
Indeed, I have remarked that the hearing of
many persons has considerably varied with the
state of their health in general; so that I felt no sur-
prise from the occurrence related in the following
case.
A gentleman applied to me on account of some
pseudosyphilitic symptoms, which I told him
would gradually become well. I advised him, at
the same time, to be particularly attentive to the
state of the digestive organs, which were gener.
ally disordered by the effects of the poison. He
took five grains of the pil. hydrarg. every second
or third night. The disorders for which he had
consulted me were all removed in the course of

118 On the Constitutional Origin and

two months; when I received a letter from him,
saying, that he thought it a duty he owed to me and
to the public to inform me, that the lenient course
of mercury, which I had recommended, had cured
him of a considerable degree of habitual deafness.
It is well known that ophthalmy frequently arises
from constitutional causes; and in such cases
the digestive organs are generally deranged. The
health will be most speedily restored, and the local
disease most effectually diminished, by correcting
the disordered state of the abdominal viscera.
There is no necessity for enlarging upon this sub-
ject; yet it may be useful to state what I have ob-
served respecting those ophthalmies, which take
place subsequently to gonorrhæa, and which have
generally been ascribed to a retropulsion of that
disorder, or to the accidental application of the
discharge to the surface of the eye. In the worst of
the cases, which I have seen lately, there was con.
siderable redness and irritability of the eye, lasting
nearly a fortnight. The digestive organs were de-
ranged in all the instances, to which I allude; and
I attribute the comparative well-doing of these pa-
tients to the attention which was paid to their cor-
rection. In other cases, which I had formerly been
witness to, where 'evacuations by bleeding and
purging, &c. were employed, the disorder was ex-
tremely obstinate; nay several patients lost their
sight.
The cases of ophthalmy connected with gonor-
rhæa appear to be of two kinds. In the worst case,
and that which I have happened to meet with most
rarely, there is, I think, reason to suppose that
some of the discharge from the urethra has been
accidentally applied to the surface of the eye. This
circumstance may be inferred from the copious
and puriform discharge which takes place from


Treatment of Local Diseases. 119
the conjunctiva which is continued for about three
weeks, and from the disease not yielding to any
remedies which usually relieve other ophthalmies.
The milder and, to me, more commonly occurring
case, seems to be the result merely of irritability
of constitution. With relation to this subject I may
mention that I know a patient who has several
times had discharge from the urethra and inflamed
eyes alternately with each other; and both appar-
ently arising from constitutional causes. I shall
also add the following striking instance of ophthal.
my connected with gonorrhæa, in which the in.
flammation of the eyes can neither be supposed to
be the effect of local contamination nor of metas-
tasis.


CASE XXVI.
"A gentleman, having a gonorrhæa and being in
a remote part of Scotland, felt himself obliged to
go to the west of England with the greatest expe-
dition. He came to London by the mail coach, and
during the journey his eyes became greatly inflam-
ed, and he was much tormented with dysury; he
was indeed so ill, upon his arrival in town, as to be
unable to proceed on his journey. His eyes were
exceedingly red and painful, and the lidstumid. He
had frequent and urgent desire to void his urine.
The discharge from the urethra was very copi-
ous. His tongue was much furred; his bowels had
a costive tendency; the stools were blackish and
offensive; his pulse frequent, and neither full nor
strong; his skin hot and rather dry. He said that
formerly having a gonorrhea, he had been affec-
ted with ophthalmy in the same manner. He was
directed frequently to bathe his eyes with a luke-
warm decoction of poppies; but the chief attention
was paid to the state of his stomach and bowels.
A
day
120 On the Constitutional Origin and
He took five grains of the pilul. hydrarg. every
night, and other medicines to procure a sufficient
alvine evacuation daily. On the third day he had
severe rheumatic pains in his shoulder. On the
fourth, his knee became affected with rheumatism,
and so much swollen that he was incapable of mov.
ing about, though his eyes were much better, so
that he was able to sit up and bear the window
shutters of his chamber to be left open, which he
could not before have permitted. On the fifth day,
though better, his eyes were still much inflamed,
his dysury troublesome, and he was unable to walk
from the rheumatic affection of his knee. The dis.
charges from the bowels had been regularly ob-
served, and they still continued of a very wrong
colour, till the evening of this day, when he had a
stool properly tinctured with healthy bile. He now
felt a sudden and surprising amendment which
appeared equally so to others on the following day;
for I found him walking about with very little
lameness, his eyes requiring no further attention
than wearing a green shade, and he had no dysury.
In two days he pursued his journey, nor did he
experience any relapse.
There is a chronic ophthalmy, which is, I be-
lieve, generally considered to be venereal, proba-
bly from the difficulty of curing it, and probably
from mercury being frequently beneficial to it.
As cases of this description evince how much
ophthalmies are likely to depend upon constitu-
tional causes, I shall briefly relate the following to
identify the kind of disease to which I allude.

CASE XXVII.
A gentleman had for more than two years been
more or less subject to a chronic ophthalmy.
When he was very bad, he had twice used mercury
Treatment of Local Diseases. 121

for its cure, and with temporary success. The
last mercurial course was a considerable one, as
the relapse of his disorder was attributed to the in.
sufficiency of the former one. The ophthalmy,
however, returned with as much, if not with more
severity than formerly. The eye was extremely
red, very irritable, and his vision very imperfect.
I found the patient shut up in a close and dark
chamber, from which he rarely ventured to stir,
lest he should catch cold. His tongue was furred,
and his biliary secretion faulty. I directed small
doses of mercury every second night, merely as
probilious medicines, and requested him to pay
attention that his bowels were kept clear without
being what is called purged. I also urged him to
go out into the air and use active exercise. By
pursuing these measures, the ophthalmy was
nearly well in about three weeks. He now either
caught cold or fancied that he had done so; his ge.
neral health became disturbed, and his ophthalmy
returned. It got well, however, as the disturbance
of his constitution wore off; and though he had two
or three times, during a year, some trivial returns
of ophthalmy, yet they were always induced by
general disorder, and readily got well by measures
directed to correct disorders of the alimentary
canal.
|_That cutaneous diseases * are much connected
* It may perhaps be right to advert to the direct and sud-
den sympathy which exists between the skin and the stom-
ach. In affections of the latter organ, the skin is dry and cold,
moist and cold, hot and dry, or moist and dry; and it suddenly
changes from the one to the other condition, as the state of
the stomach varies. When the digestive organs are disordered,
the irritable state of the skin is manifested by the effects of
blisters and other irritating applications. A blister produces
a tormenting local disease, and even a Burgundy pitch plas-
ter causes extensive erythema. Indeed, when the constitution

122 On the Constitutional Origin and
with the state of the stomach, is generally known.
Hence various medicines have been recommended
to correct disorders of that viscus, with the view
of removing the more evident, but consequent dis-
ease of the skin. The account, which I have given
of disorders of the digestive organs, may lead to
a more rational and less empirical treatment, and
to the more just appreciation of the value and mode
of action of remedies, which are sanctioned by ex-
perience. It is almost superfluous to relate any
case to authenticate so well known a fact; the fol-
lowing, however, may be found interesting and in-
structive.
A patient in St. Bartholomew's hospital had an
herpetic disease of the skin. This had healed in
the middle, and spread in the circumference to
such a degree, that it occupied nearly the whole
length of the leg, and included two thirds of its
circumference. The skin had recovered a moder-
ately sound state in the centre. The disease was
propagated in the circumference by an ulceration,
which threw out a projecting and firm fungus of a
tawny colour, of about half an inch in breadth. A
small groove or channel separated this fungus
from the surrounding inflamed skin, which had
not yet ulcerated. A similar disease occupied the
back part of the arm; this was of an oval figure,
and resembled, in every circumstance, that which
I have already described upon the leg. These dis-
eases had existed for nearly two years, and con-
tinued to spread in opposition to every mode of
treatment. Mercury had been employed, even to
is irritable, all the modes of counter-irritation, which sur-
geons employ under other circumstances with success for
the cure of local diseases, are likely to do harm; and thus
these curative methods obtain discredit in consequence of
their ill-timed employment.
Treatment of Local Diseases.
123

salivation, without any marked alleviation of the
local complaint. I immediately perceived that the
digestive organs were greatly deranged: upon
correcting this disorder, the skin surrounding the
disease became pale; and all disposition to spread
ceased. The fungus, however, still projected, and
did not heal; it was therefore dressed with a weak
solution of kali arsenicatum. This remedy seemed
to subvert the diseased actions, which had pro-
duced the fungus; so that, in less than two months,
the patient was discharged from the hospital per-
fectly well.
I have seen similar herpetic diseases, of much
less extent, succeed to the absorption of matter
from sores upon the genitals. These have got well
when the patient has gone into the country, and
appeared again when he has returned to town.
They have healed under a course of mercury, and
broken out again when it was discontinued.
In this review of disorders, occurring in parts
having a continuity of surface with the digestive
organs, I have traced them from the stomach. An-
other set of diseases may originate from the same
source. The large intestines suffer more in ad-
vanced stages of these disorders than the smaller
ones; hence disorders of the rectum, and particu-
larly many irritable diseases about the orifice of
that bowel, are deducible from this cause. I shall
not, however, prolong the account by the relation
of cases; but content myself with assuring the
reader, that the opinion has been derived from
facts, and not from preconceived notions of the
operation of such disorders.

124
On the Constitutional Origin and
SECTION VI.

IN this section I shall mention what information
I have obtained by dissection, relative to the causa-
tion of other diseases by those of the digestive or-
gans. The reciprocal sympathy, which exists be.
tween the brain and the digestive organs, is gene-
rally admitted; but the kind and the degree of the
effects arising from this sympathy, is not, perhaps,
in general, sufficiently understood. These organs
mutually increase each other's disorder; till the af.
fection of the sensorium leads to the greatest dis-
turbance of the nervous functions, and even those
of the mind.
All this may happen without any visible disease
of the brain. Dr. Kirkland particularly directed the
attention of medical men to nervous apoplexy; and
the observations, which have been made since his
time, have proved, that not only a general derange-
ment of the functions of the nervous system pro-
ducing apoplexy, but also partial effects of a simi-
lar nature causing hemiplegia and paralysis, may
take place without any visible change of structure in
the brain. I have met with numerous instances of
this kind; but could not determine whether the af-
fections were merely nervous, or whether they
were produced, or aggravated by disorder of the
digestive organs. I only know, that the patients
died affected by apoplexy, hemiplegia, or more
local paralysis, without any derangement in the evi-
dent structure of the brain. I may also mention,
that I formerly examined the brains of three per-
sons who died in a comatose state, in consequence

Treatment of Local Diseases. 125

of the metastasis of rheumatism. In these cases no
morbid appearance was observed in the brain, ex-
cept some slight marks of inflammation of the pia
mater. It therefore appears clearly to me, that dis-
order and a considerable diminution of the nervous
functions may take place, without any organic af-
fection of the brain. The perfect recovery of pa-
tients, which sometimes happens, after such dis-
orders, may also be considered as additional evi.
dence of there having been, in such instances, no
organic disease of the brain.
There can be no doubt but that epilepsy may in
like manner take place without any morbid altera.
tion of the structure of the brain, or its membranes.
Some of the persons whose heads were examined,
without the discovery of any disease of those parts,
had been subject to attacks like those of epilepsy.
Dr. Henry Fraser has, of late, published a decisive
instance in proof of this fact. A patient died of epi-
lepsy, and his brain was examined with particular
attention by Mr. Cooper, without any morbid al-
teration of structure being discovered. * In gen-
eral, however, morbid appearances are evident in
the brains of those persons who die of epilepsy.
Tubercles are most frequently met with. There
is, however, a disorder of structure which I wish
briefly to mention, as I do not find that it has been
noticed. In two persons, who died of epilepsy, I
found the medullary substance of each hemisphere
altered from its natural structure; it had lost its
natural firmness, and smoothness of surface, and
appeared like thick curdled cream.
Now, if disorder of the digestive organs is ca.
pable of causing or aggravating nervous disorder,
even to the production of those effects which have
been mentioned, when there is no alteration of
* See Fraser on Epilepsy, page 39.
126 On the Constitutional Origin and

structure; it must be granted that such a state of
irritation of the sensorium may lay the foundation
of an excitement of the vascular structure of the
brain, and thus very frequently produce organic
disease. When this has occurred, it will aggravate
and establish the nervous affection, and thus per-
haps render it insusceptible of cure.
Such are the general observations which I have
made, by means of anatomical inquiry, relative to
these subjects. With respect more especially to the
investigation of my present object, I have exami-
ned the bodies of six patients, in whom disease
most certainly began in the abdominal viscera, and
was continued in them to the conclusion of their
lives. Nevertheless the patients seemed to die
rather of nervous disorder, than of disease of the
parts first affected. One of the patients died affec-
ted with apoplectic symptoms, and five with hemi.
plegia.
In all these cases the liver was greatly diseased,
and the bowels also exhibited diseased appearances.
In three of the cases there was considerable inflam-
mation of the membranes of the brain; and a good
deal of water in the ventricles. In two of them no
morbid appearance of the brain was discovered. I
have also examined a child, who was supposed to
die of hydrocephalus, accompanied by great dis-
order of the stomach and bowels. In this case the
bowels were inflamed, the liver sound, and the
brain perfectly healthy in appearance; yet there had
been so great a diminution of sensation and motion,
as to leave no doubt of the existence of hydroce-
phalus. I am aware, that great opportunities of ob-
servation, accurate attention to the history of dis-
eases, and anatomical examination of fatal cases,
are requisite to enable us to form just notions re-
lative to the present subject. I thought, however,
Treatment of Local Diseases. 127

that it might not be improper to state what had
been the result of my own inquiries by dissection,
in order to promote a more general attention to the
subjec
When my attention was first directed to the sub-
ject of sympathetic affections of other organs, caus-
ed by disorder of those concerned in digestion, my
primary object was, to endeavour to ascertain, by
dissection, how far pulmonary diseases originated
from such a source. I have, in the course of my
inquiries, had several opportunities of examining
the bodies of patients who apparently died of phthi-
sis combined with diseases of the digestive organs.
In these cases both the history and dissection tend-
ed to prove, that the chylopoietic viscera were the
seat of the greatest and most established disease,
and that the pulmonary affection was a secondary
disorder. The liver was greatly diseased, and the
lungs were also beset with tubercles; yet a consid-
erable portion of those organs was sound. But dis-
sections can never conclusively ascertain the truth
of the opinions which I have stated; for the same
disposition to disease existing in the constitution
may equally affect both the pulmonary and diges-
tive organs. Nay, observations made in dissection
in general, would tend to disprove the opinions al-
luded to; for diseases of the lungs are very com-
monly met with in dead bodies, while those of the
liver and bowels are much less frequerit. Yet con-
siderable disorder of the digestive organs does
exist, and may continue for many years, without
any organic disease being apparent: it is possible,
therefore, that such disorder may excite disease of
the lungs, and thus produce a worse disease in the
latter organs, than what existed in the former. In
short, the opinions, which I have delivered, cannot
be either ascertained or refuted by anatomical re-
searches alone.
128 On the Constitutional Origin and
Accurate attention to the state of the digestive
organs may determine this important subject, and
lead to the prevention and cure of the sympathetic
diseases which I have mentioned. The attention al.
luded to is not of that general kind, which adverts
only to the quantity of the ingesta, and the periodical
expulsion of the egesta, but one that more strictly
observes whether the viscera are free from irrita-
tion, and whether their secretions are healthy or
otherwise. My opportunities of acquiring practical
information on this subject must necessarily have
been very limited; yet I have seen many cases which
to me, appeared to prove, that pulmonary irritation
sometimes proceeds from disorder of the digestive
organs. In cases of surgical diseases, accompanied
by disorder of the digestive organs, I have also
occasionally observed a cough attended with ex-
pectoration to cease, upon the correction of the
disorder of those organs.
A case, which happened about five years ago,
strongly impressed these opinions on my mind. A
servant of mine told me, that his wife was dying of
a consumption, which had been rapidly increasing
for six months, and had baffled all attempts to re.
lieve it. Thinking that I could procure her some
medical assistance from the hospital, I went to see
her. The case, however, seemed past hope. She
was extremely emaciated; her pulse beat 140 in a
minute; her face was flushed; she had a most dis-
tressing cough; and spit up more then a pint of
mucus, mixed with pus and streaked with blood,
in twenty-four hours. The circumstance, however,
which most disturbed her was a continual purging
of black and offensive matter. She told me that her
bowels were first disordered; that an unhealthy
state of those organs had preceded the pulmonary
affection, and was indeed habitual. I thought it un-

Treatment of Local Diseases. 129
necessary to trouble my medical friends in so
hopeless a case; and ordered some pills, containing
one grain of opium, to be taken in such a quantity
as was necessary to stop the purging. As she in-
formed me that the disorder began in the bowels,
I added to each pill half a grain of calomel. By
these means the purging was so much checked,
that she did not find it necessary to take more than
two pills in twenty-four hours; and when she had
taken twelve, the mercury, very unexpectedly, af-
fected the mouth. From that period, the stools be-
came of a natural colour and consistence; the
cough and expectoration ceased; and she was soon
sufficiently recovered to go into the country; from
whence she returned apparently in good health.
Now if it were to be ascertained, that pulmo-
nary irritation, which might of course produce pul-
monary disease, sometimes arises from disorder of
the digestive organs;* it would be right to inquire
further, whether it produces such effects, by the
nervous disorder it occasions, and by its operation
on the health in general; or by means of a more im-
mediate sympathy existing between the pulmonary
and digestive organs. I do not mean to insinuate,
by what has been said, that pulmonary diseases do
not arise originally and idiopathically; but only to
suggest that they may arise sympathetically, or in

* In the second part of my surgical and physiological essays
in which I related experiments, made with a view to ascer-
tain the functions of the skin, I mentioned that as it was mani-
fest the skin and lungs were both engaged in the function of
throwing forth carbonic acid gas, it followed, that when from
vicissitudes of the atmosphere or weakness of the sanguifer-
ous organs, the circulation and secretion of the skin were
much diminished the lungs would be liable to plethora, and
have to perform more than their ordinary duty, which cir-
cumstances were likely to induce irritation, and perhaps con-
sequent disease of those organs. Those experiments, as they
are not of practical importance, I shall not reprint.
130 On the Constitutional Origin and

consequence of disorder of the digestive organs.
The proportionate number of cases, in which they
originate in this manner, can only be determined by
very extensive experience. That the stomach and
bowels are disordered, during the progress of phthi-
sis, will, I conclude, be readily admitted; and that
an attention to correct such disorder is requisite,
must be acknowledged, from what has been said
relative to the influence of such treatment upon
various local diseases.
The actions of the heart seem to me also to be-
come disordered from sympathy with the stomach.
That palpitations, and feeble or intermitting ac-
tions of that organ arise from this cause, is prov-
ed by their ceasing, when the state of the stomach
becomes changed. The palpitations which take
place after eating, in cases where the heart is irri-
table, further evince the sympathy which exists be-
tween these organs. Surgeons are occasionally con-
sulted on cases of palpitations of the heart, which
the patients mistake for aneurisms; and I have seen
many instances, where the great degree of palpita-
tion led to a belief, that some organic affection ex-
isted. This has ceased on an amendment of the
general health, apparently arising from an amelio-
ration of the state of the digestive organs, and the
patients have continued in perfect health. I have
not collected any accurate narratives of the cases
that I have seen: none at least which I could pro-
perly present to the public as a proof of the fact.
There is nothing, however, of which I am more
perfectly convinced; for I have felt it to be true in
my own person. After considerable and unusual
fatigue, I was seized with pain, and a sensation of
coldness in the region of the stomach. I had no ap-
petite, and the biliary secretion was suppressed.
Whilst this disorder continued, which was for many
Treatment of Local Diseases.
131
weeks, my pulse intermitted very frequently, and
I was distressed with hypochondriacal sensations.
Upon an alteration in the state of the digestive or-
gans, and a renewal of the biliary secretions, which
happened very suddenly after taking five grains of
the pil. hydrarg. my pulse became perfectly regu-
lar, and my mind tranquil.
The observations, which I have made in sur-
gical cases, lead me also to attribute many hemor-
rhages, and particularly those from the nose, to a
sympathetic affection of the heart and arteries, ex-
cited by disorder of the digestive organs.
If such a state of the system in general, as I have
described, and which is manifested by circum-
stances denoting the digestive organs to be in an
unhealthy state, and the nervous system to be like-
wise disordered, may, in some instances, cause va-
rious local diseases of parts not essential to life, the
care of which custom has consigned to the sur-
geon; and may, in other instances, produce disor-
ders of organs essential to our existence, the care
of which is allotted to the physician; the subject
must be allowed to be of the highest importance.
Of late, indeed, I have been inclined to consider
these circumstances as the cause of the complicated
diseases which are met with in man, so much more
frequently than in animals. In man the brain is
more sensitive, and liable to be disordered by men-
tal affections. In man the digestive organs are liable
to be disordered by stimulating and unnatural diet.
Sedentary habits and impure air cooperate to ag-
gravate these disorders. The affections of the brain
and digestive organs mutually increase each other;
and thus a state of constitution arises, which is pro-
ductive of the most general and complex diseases.
But even these do not seem to me to be the most
calamitous terminations of such causes. The dis-


132 On the Constitutional Origin and
order of the sensorium, excited and aggravated by
the means which have been described, frequently
affects the mind. The operations of the intellect
become enfeebled, perplexed and perverted; the
temper and disposition irritable, unbenevolent and
desponding; the moral character and conduct ap-
pears even liable to be affected by these circum-
stances. The individual in this case is not the only
sufferer, but the evil extends to his connexions and
to society. The subject, therefore, appears to me
of such importance, that no apology need be offer.
ed for this imperfect attempt to place it under gen-
eral contemplation. * *
I have endeavoured to show, in the introductory
observations, that a state of nervous disorder and
a disorder of the digestive organs, may reciprocally
produce each other; and that when both occur,
they become mutually increased, and thus derange
the constitution in general, so as to prove the ex-
citing or predisponent causes of numerous dissimi-
lar and important local affections. I shall, in con-
clusion, for the reasons mentioned in the preface,
offer the opinions which the consideration of the
foregoing and similar cases have impressed on my
mind. When I find in diseases that the functions
of the digestive organs are impaired and disturbed,
I consider this disorder as the cause or effect of a
more general derangement of the system at large.


* The ancients, who formed their judgment of the nature
of disorders by observing the excretions, denominated an ir-
ritable and desponding state of mind, Hypochondriasis; and
when a more fixed and irrational dejection took place, they
deemed it an atrabiliary disorder, and called it Melancholia.
There can be no doubt of the correctness of their observa-
tions; for if the disorder began in the nervous system, it
would generally produce and become aggravated by that dis-
order of the digestive organs, from which they denomina-
ted it.

Treatment of Local Diseases. 133

When it seems to be the cause, and when it can be
speedily corrected and removed, then the relief and
cure of those local diseases which may have taken
place, is in many instances so sudden and surpris.
ing, that I think it impossible to consider the dis-
order of the general health and the local disease, in
any other relation but that of cause and effect.
The cure of local diseases by means that cannot
be supposed to act otherwise than by correcting
errors in the functions of the digestive organs, in-
cline me to differ in opinion from those who con.
sider the local diseases alluded to, as the effect of
impurity of the fluids, and to coincide with others,
who consider them as the result of general irrita-
tion, frequently induced by that of the abdominal
viscera.
When I see the same local diseases removed by
the same means, though more slowly, I do not
wonder at the tardiness of the cure; and perceiving
that the amendment of the local disease is propor-
tionate to that of the health in general, I feel war-
ranted in forming the same opinion as to the mode
in which the cure is effected. When I see local dis-
eases disappearing and reappearing as the consti.
tution in general is tranquil or disturbed, I feel
confirmed in my opinion concerning their origin.
If the actions of any part of the body be excited,
and increased by accidental causes, it may reason-
ably be inferred, that in a state of health they will
be simple and common, unless the stimulant be of
a peculiar nature; but if the actions be specific and
diseased, we may naturally conclude that the cause
of their becoming so is constitutional, The occur.
rence of similar local diseases in different parts of
the body, furnishes an additional proof that the
cause of such diseases is constitutional.
134 On the Constitutional Origin and

It must indeed be very difficult to ascertain the
causes of the peculiarities of local diseases; but
when I see such a variety of them cured, some-
times suddenly, by means which tend only to tran-
quillize and invigorate the contitution, I become
confirmed in the opinion that a similar state of
health may lead to the production of dissimilar lo-
cal diseases.
I have further observed with respect to this sub-
ject, that persons who have been out of health,
but with no other distinguishable errors in their
constitutions than such as I have described, I mean
nervous weakness and irritation, with a marked dis-
order in the functions of the digestive organs, have
been liable to a succession of dissimilar local dis-
eases. In such instances, I have seen in succession
enlargements of absorbent glands, boils, rheumatic
affections of joints, and dysury: yet all local dis-
eases have ceased as the health became reestab-
lished, by attention to correct the disordered func-
tions of the digestive organs. I have seen also in
the same patient enlargements of absorbent glands,
rheumatic disease of a joint, and an eruptive
disease of the skin, which have all equally got
well as the general health improved, by similar
medical attention. Nay, the continuance of local
diseases in some instances, after the disorder of
the constitution has been relieved or cured, does
not in my opinion invalidate the foregoing conjec-
tures respecting their origin. Local diseases, how-
ever induced, may have become established by
habit, or continued from that state of disorder into
which they have reduced the part that they have
attacked. A local disease, however excited, may,
as we know from experience, be of such a nature
as that its actions never cease, and as we have not
succeeded in curing. I allude to cancer, which oc-
Treatment of Local Diseases. 135
curs, in conclusion, in such constitutions as I have
endeavoured to describe.
It has been said that I have been hasty in drawing
these conclusions. Yet, as may be seen in my first
publication, I mentioned, in speaking of disorder
of the digestive organs as exciting or aggravating
nervous irritation, and thereby causing local dis-
eases, it followed that the nervous irritation might
exist, and produce disease, without this usually
exciting cause. I then, too, brought forward in-
stances of local diseases produced by local causes,
in order to establish our opinions of the indepen-
dent nature of local diseases. I further remarked,
that constitutions disposed to local diseased ac-
tions, might naturally be supposed to be liable at
the same time to a manifest disorder of the nervous
system and of the digestive organs; and from
thence, as I observed, might have arisen that con-
nexion between local disease and general disorder,
which I have so continually remarked. I likewise
added, that though the cases related naturally sug-
gested an opinion, that there is some constitutional
cause for the production of local diseases, they ap-
peared to me insufficient to prove it. After having,
however, drawn the opinions which I offered from
a very considerable number of cases, and having
been solicitous to state both sides of the question
as fairly as I was able, that the reader might judge
of it for himself, I trust no imputation of haste
can properly be attached to my conduct. In my
own opinions I place very little confidence; yet it is
impossible to avoid forming them, and I think it
proper to relate them, for the reasons which have
been stated in the preface.
That such opinions as have been delivered in the
four paragraphs preceding the last, are deduced
from a partial, though most commonly presenting

136 On the Constitutional Origin and
view of the subject, I now readily repeat; because
I have seen instances of local diseases, in which I
could not trace any disturbance of the nervous sys-
tem, or of the digestive organs; apparently ade-
quate to their production. With respect to some
of the striking cases which I have related, wherein
the suddenness of the cure made it, I think, evi-
dent that the local disease was the effect of ner-
vous disorder, induced by that of the digestive or-
gans; it may be further inquired, how is it possi-
ble, that a similar cause should produce such va-
rious effects? Is it because a state of weakness and
irritation having occurred, those local diseases
ensue, to which there is a predisposition in the
constitution? And are we to consider the general
disorder of the system, as the exciting or predis-
ponent cause of the local disease?
Granting it were ascertained, that local diseases
generally arise from disturbance of the constitu-
tion at large, and consequently, (as it has been
my chief object to state,) may be most readily and
effectually cured by measures which tranquillize or
invigorate the constitution, still it would be very
improbable, and contrary to common observations,
to suppose that local diseases might not arise with-
out any material constitutional disturbance.
Though I am strongly impressed with the opin-
ion, that the primary causes of local diseases, are,
in general, such as I have represented, yet I think
it probable, that there may be adjunct circumstan-
ces at present but little understood, which by their
cooperation lead to the peculiarity of such diseases.
In our present state of knowledge, therefore, I
think it better to consider the disturbance of the
system in general, as merely the exciting cause of
local diseases. With this view of the subject, the
cases recorded show how suddenly local diseases


Treatment of Local Diseases. 137
are frequently cured, when the exciting cause is
removed; how generally they decline in proportion
as the exciting cause is diminished: and thus they
indicate how they may be prevented by a timely
attention to mitigate and remove that cause.
It may not be improper further to state the opin-
ions which I have formed respecting the origin of
diseases of particular organs, and which may be
considered as local diseases, though they are not
generally alluded to when that term is employed.
If we may be able to trace the origins of diseases
of the absorbent and salivary glands, of the breast
and testes, to constitutional causes, why may we
not reasonably expect that similar circumstances
may produce diseases of the lungs, liver, and kid-
ney? It seems to me improbable that so complex a
structure as the human body, should be so correct-
ly formed, as that every part should possess its due
proportion of vessels and nerves, endowed with an
exact degree of natural and relative strength; or in
other words, that there should be no such thing as
comparative weakness or irritability of the differ-
ent organs of the body, such as should predispose
them to disease,
We may therefore account rationally, and in con-
formity to acknowledged facts, for the production
of diseases in vital organs, by supposing, that a
state of general weakness and irritability being in.
duced, the naturally weak parts suffer in the great-
est degree, and in consequence they most readily
become the subjects of disease. But when diseases
of vital or other organs occur, it is probable that
another cause contributes to their production; that
is, the sympathy which each organ has with the
disorders of another. If, then, the organ thus sym-
pathetically affected be naturally disposed to dis-
ease, its structure may be irremediably spoiled ir

138 On the Constitutional Origin, &c.
consequence of vascular actions, excited through
the medium of nervous irritation. If this opinion
be correct, it is highly important, as the medical
indication in this case is to remove the exciting
cause, and our attention becomes directed to an
organ in which perhaps there is but little manifes-
tation of disorder, or if there be, which is likely to
be overlooked when the attention is so forcibly at-
tracted to an apparently far greater evil.*
* See the case beginning at page 128.
*

ON ANEURISMS.
The exposure of a portion of an artery, and tying
it in order to stop the current of blood into an
aneurismal sac, as proposed by Mr. Hunter, may
be said to have been a new operation, at least in
modern surgery. It is not therefore surprising
that errors were at first committed in the mode of
performing it. The hemorrhages, which took place
after the operation in the first cases in which it was
performed, arose from the ulceration of the artery
that had been tied. The vessel in these cases was
laid bare and detached in some degree from its
surrounding connexions, and the middle of the
detached portion was tied by a single ligature. An
artery thus circumstanced must necessarily inflame;
which it would do in different modes and degrees,
accordingly as the state of the constitution, or of
the part was more or less healthy; and this inflam-
mation produced the ulceration of the vessel.
The occurrence of hemorrhage led some sur-
geons to adopt a practice which cannot but be con-
sidered as injurious. They applied a second ligature
above the other, leaving it loose, but ready to be
drawn tight of the first should not answer. The
second ligature, however, must not only keep a
certain portion of the artery detached from the sur-
rounding parts, but must also'give additional irri-
tation to the inflamed vessel; and on both these
accounts it is more likely to make the inflammation
end in suppuration or ulceration."
The mode of performing the operation for the
aneurism, which Mr. Hunter's judgment and ex-

140
On Aneurisms.
perience taught him to adopt, was to expose and
disturb the artery as little as possible, and after
having tied it to bring the surrounding parts into
contact with it again. Though an experienced and
skilful operator may accomplish this object with
very little disturbance of the artery from its natural
situation and connexions; yet I cannot but suspect
that surgeons in general may not be so successful,
especially in cases where, from the deep situation
of the vessel, the surrounding it with a ligature
depends more on feeling than on sight. * Also,
though when the artery is sound and the constitu.
tion healthy, ulceration may not ensue, even though
the artery is in some degree separated from its sur-
rounding connexions, and tied by a single ligature;
yet it is surely proper to guard against those cir-
cumstances which tend to produce its ulceration.
As large arteries do not ulcerate when they are
tied upon the surface of a stump after amputation,
it occurred to me that it would be right to tie them,
in cases of aneurism, as nearly as possible in the
same manner and under the same circumstances.
The large vessels on the surface of the stump con-
tinue to possess all their natural surrounding con.
nexions, whilst they are left in a lax state, in con-
sequence of their division.
To accomplish this object in cases of aneurism,
I propose that the operation should be performed
in the following manner:--- The operator should
divide the immediate coverings of the artery, till
* It can neither be considered as a compliment to Mr.
Home, nor an affront to any other surgeon, to suppose that
no one can perform the operation for an aneurism after Mr.
Hunter's method better than he does. Yet in a series of cases
published in the second volume of the Transactions of a So-
ciety for the Promotion of Medical and Chirurgical Know-
ledge, hemorrhage from ulceration of the artery appears to
have been a frequent occurrence.

On Aneurisms.
he has fairly exposed its surface. When he can
touch the bare vessel, he will not, I believe, find
any difficulty in separating from it, by means of
his finger and thumb, or the blunt edge of an aneu.
rismal needle, the cellular substance that connects
it to the contiguous parts. This part of the opera-
tion is not painful and should be performed slowly.
The firm sides of the vessel enable the surgeon
clearly to distinguish its surface, and by keeping
the finger in exact contact with it, a passage may
be made completely round the artery. Care should
be taken not to elevate the artery more than can
be possibly avoided, because the artery would be
stretched in its longitudinal direction by so doing;
and care should also be taken not to injure the con-
tiguous veins and nerves. When the operator has
thus gently insinuated his finger between the vessel
and its surrounding connexions, so that an inch of
its surface is every where exposed, two ligatures
may be put under it, one of which is to be carried
upwards, and the other downwards, as far as the -
artery is detached, and then tied as firmly as pos-
sible. The artery should then be divided by a probe-
pointed bistory in the interspace between the two
ligatures, but nearer to the lower ligature than to
the upper one.
In my opinion, large arteries should always be
tied with moderately chick ligatures, because we
may then draw the noose as tightly as possible,
without apprehension of cutting or tearing the coats
of the vessel, or of breaking the ligature. The latter
occurrence would in many cases prove a very em-
barrassing circumstance, and it might be very in-
jurious on account of the jerk communicated to
the artery to a considerable distance. Also, when
an artery is tied with a thick ligature, the com-
pression made by it is not so great as to produce a

142
On Aneurisms.
speedy mortification and separation of the end of
the vessel, so that the ligature remains, in general,
a fortnight before it is detached, and therefore, time
is allowed for the consolidation of the sides of the
vessel prior to its separation.* When an artery is
thus tied in cases of aneurism, it possesses its natu-
ral surrounding connexions and support, and is left
loose, in consequence of its division. It appears,
indeed, in most respects, similarly circumstanced
* Doctor Jones, whose numerous and accurate experiments
have thrown much light upon the natural means by which
hemorrhages are suppressed, thinks that the ligatures should
be round and firm; because such cords are most likely to cut
the internal coats of the artery. I am solicitous that they
should be strong and moderately large; because as far as I
have remarked, large ligatures remain longest on the arteries
before they are detached; and in examining the stumps of
patients who have died after amputation, I have frequently
seen the sides of the artery unclosed, even though the liga-
tures have fallen off from them.
Though ligatures when applied to the principal arteries of
amputated limbs are scarcely ever known to slip or become
projected from their situation, yet it has been apprehended
that such an occurrence might take place in cases of aneurism,
from the greater determination of blood into the arteries of
the limb in such cases. To obviate such an effect, Mr. Henry
Cline suggested the following method of securing the ligature
in its situation. His suggestion was adopted by Mr. Cooper,
who thus describes the operation in which it was instituted.
6 An incision being made on the middle of the inner part
of the thigh, and the femoral artery exposed, the artery was
separated from the vein and nerve and all the surrounding
parts, to the extent of an inch, and an eyed probe armed with
à double ligature, (each cord of which was armed with a nee-
dle,) was conveyed under the artery and the probe cut away.
The ligature nearest the groin was first tied; the other was
separated an inch from the first and tied also; then the needles
were passed through the coats of the artery, close to each
ligature, and between them; the thread they carried was tied
into the knot of the ligatures which had been already secured
around the vessel: and thus a barrier was formed in the artery,
beyond which the ligature could not pass.” See the first num-
ber of the eighth volume of the Medical and Physical Journay.

On Aneurisms.
· 143
to an artery tied upon the surface of a stump, and
as I never knew hemorrhage from ulceration of
the vessel take place after the operation for aneu-
rism, when it was accomplished in this manner, I
cannot but continue to practise and recomntend
this method of securing the artery. That the ope-
ration for the aneurism will succeed when only a
single ligature is employed has been proved by
experience; but as hemorrhages, independent of
ulceration of the artery, so frequently arise from
an inflammatory action of the vessels, every thing
tending to produce a tranquil state of the wounded
parts cannot but deserve to be put in practice, and
the relaxation of the artery by its division, must, I
think, contribute to this effect
The cases of aneurisms which I am about to
recite, are not however intended to illustrate any
mode of conducting the operation, but merely to
show the powers which nature possesses of carry-
ing on the circulation, and maintaining the limb in
its pristine state of vigourand strength, even though
so large an artery as the external iliac may have
been tied, and thereby rendered impervious.
CASE I.
Feb. 1796.---James Lindsey, aged thirty-four,
about a year ago perceived a swelling beneath the
calf of his right leg; and soon afterwards, whilst
walking, he suddenly felt, he said, “ as if he had
.“ been struck on the part by a cannon ball,” the
pain being so great that he could not move for
several minutes. The pain, however, gradually
abated; but the swelling of the leg had continued to
increase since that time. The whole calf was now
lifted up by a quantity of blood effused beneath it.
The muscles appeared thin, and were so extremely

On Aneurisms.
tense as to occasion great pain, accompanied with
considerable erysipelas of the whole leg; so that a
speedy ulceration and sloughing, or sudden rupture
of the distended part, was hourly to be dreaded.
Under these circumstances, tying the artery above
the aneurism, was the only means of relieving the
patient from his present suffering, and of preserving
him from sudden death. But what was particularly
discouraging, both to the patient and surgeon, was
the discovery of another aneurism, situated in the
femoral artery of the opposite limb. No preternatu-
ral pulsation, however, could be felt in any other
part of his body. The operation was performed
Sir Charles Blicke in the following manner: An
incision about three inches in length was made
through the integuments of the middle of the thigh,
so as to expose the inner edge of the sartorius mus-
cle and the fascia covering the artery, which was
divided to the extent of somewhat more than an
inch. The artery was separated from its connex-
ions for one inch of its length. Two ligatures were
put under it, and firmly tied, and the artery was
divided in the interval between them. The lips of
the wound were then brought together by slips of
sticking-plaster. This patient's limb was for some
time much colder than the other, and nearly three
days elapsed before it had regained its natural de.
gree of warmth; but the tension, pain, and erysi-
pelatous inflammation quickly subsided. The di-
vided integuments united above and below the
ligatures, but not between them; and there was
also a large discharge from the wound: which cir.
cumstance was probably owing to the state of the
patient's constitution, which was much reduced in
point of strength. This man, however, did not
complain of the least throbbing, tension, or pain in
the wounded part; and this entire exemption from

On Aneurisms.
145
the sufferings of other patients, I could not but
attribute to the division of the artery. The upper
ligature came away on the tenth, and the lower on
the fifteenth day; after which the wound healed
gradually, though very slowly.
About five weeks after this operation, the aneu-
rism in the opposite thigh was almost ready to
burst; the tumor having acquired a pyramidal
form, and the skin covering the apex having yielded
so much as to form a kind of process from the tu-
mor. Indeed the integuments at this part were
so thin, that we every hour expected them to give
way. The aneurism was situated so high, as to
make it probable that the disease extended above
the place where the arteria profunda is sent off.
The patient had hitherto refused to submit to the
operation; but on reflecting that if the tumor
should burst in the night, he must perish unless
the bleeding vessel could be immediately secured,
he consented to let me tie the artery in the groin,
whilst we had daylight and proper assistance. The
tumor approached so near to the groin, as to pre-
vent us from compressing the artery against the
bone; for, in attempting this, the compress occu-
pied the place where the incision ought to be made,
and our endeavours to make a compression still
higher were ineffectual; they weakened, but did
not interrupt the pulsation of the tumor. As the
artery was so imperfectly compressed, hemorrhage
took place during the operation, which, though not
dangerous to the patient, proved extremely embar-
rassing to the surgeon; for in attempting to lay
bare the fascia of the thigh, I divided, by the very
first incision, so many small arteries supplying the
inguinal glands, and also so many veins, that the
blood which was poured forth, completely filled
the space made by the incision, and overflowed the


146
On Aneurisms.
sides of the wound. The application of the sponge,
the usual resource on these occasions, was of no
avail; for the wound was instantly filled again, so
that the whole operation was to be done upon parts
covered with blood, where the only guide in its
performance was the feeling. I did indeed see some
exposed inguinal glands, and found that I had di-
vided two of them in trying to get at the fascia of
the thigh. As soon as I could distinctly feel this
part, I made a small opening through it, and intro-
ducing my finger, I divided it upwards as far as
Poupart's ligament, and downwards as low as the
aneurismal sac would allow me. The pulsation of
the artery now served as my guide. Laying aside,
therefore, all surgical instruments, I made way
with my finger, in a perpendicular direction, till I
could touch its coats, and then, with my finger and
thumb, separated it from its connexions, so as to
be able to grasp it alone between them. I then pas-
sed two ligatures under it by means of an eyed
probe, and drawing one of them upwards, and the
other downwards, as far as the space would permit,
I tied them firmly. The upper ligature was about
half an inch from the os pubis, and the lower one
the same distance from the arteria profunda, which
vessel I had distinctly felt before I tied the liga-
tures.
There are, perhaps, few situations of aneurism
where the artery can be tied so separately and dis.
tinctly as here; the pulsation directs the surgeon
to the precise situation of the vessel; and if he only
keeps sufficiently close to its sides when he passes
the ligature round, neither the vein nor the nerve
can be included. I did not divide the artery be-
tween the two ligatures; it was suggested that it
were better not to do so; and I knew that I could
obtain all the advantages of a relaxed state of the

On Aneurisms.
147
vessel, by merely bending the thigh upon the pel-
vis. The patient did not, after the operation, suffer
any kind of pain from the wounded parts; which, I
think, shows, that the artery did not inflame much
in consequence of the ligature. The suppuration
was moderate, and everything relative to the
wound went on as well as could be expected. The
limb, and particularly the foot, was colder than that
of the opposite side; but in about three days, it
gradually acquired its natural temperature; and it
all along retained a perfect state of sensibility,
which I considered as a proof that it was sufficiently
nourished. To prevent the heat from being carried
off faster than it was generated, the limb was wrap.
ped in flannel; but I avoided the application of any
artificial warmth, lest its stimulus should prove in-
jurious, by exciting action when the powers of life
in the part might have been considerably dimin
ished.
| The blood in the aneurismal sac did not appear
to have coagulated before the operation; for the
bulk of the tumor could be greatly lessened sy
pressure, whenever the patient would allow the
attempt to be made, so that I conclude the limb
had received a considerable quantity of blood
through the femoral artery, until that vessel was
tied. The tumor diminished greatly after the ope-
ration, and the blood contained in it became coagu-
lated. This reduction of the swelling, I think, was
owing to a considerable part of the blood passing
onwards through the femoral artery: and I regretted
afterwards, that, at the time of the operation, I had
not endeavoured to press all the blood from the
aneurismal sac; which experiment would have
shown how far it was fluid or coagulated.
Every thing, with respect both to the state of
the limb, and the patient's general health, went on


148
On Aneurisms.
well till the fifteenth day, when the upper ligature
separated, and the blood gushed in a full stream.
from the open extremity of the vessel. This fortu.
nately happened during the attendance of the sur-
geons at the hospital, and the bleeding was stopped
by pressure until their arrival. The stream of blood
which flowed upon any remission or wrong appli-
cation of the pressure, was so large, that we did
not dare to remove the patient even from the bed
in which he lay. Mr. Ramsden undertook, in this
situation, to prevent the further escape of blood
from the vessel, whilst I proceeded to tie the ar-
tery above Poupart’s ligament. Accordingly, I first
made an incision, about three inches in length,
through the integuments of the abdomen, in the
direction of the artery, and thus laid bare the apo-
neurosis of the external oblique muscle, which I
next divided from its connexion with Poupart's
ligament, in the direction of the external wound,
for the extent of about two inches. The margins
of the internal oblique and transversalis muscles
being thus exposed, I introduced my finger be-
neath them for the protection of the peritoneum,
and then divided them. Next, with my hand, I
pushed the peritoneum and its contents upwards
and inwards, and took hold of the external iliac ar-
tery with my finger and thumb, so that I was thus
enabled to command the flow of blood from the
wound. It now only remained that I should pass a
ligature round the artery, and tie it; but this re-
quired caution, on account of the contiguity of the
vein to the artery. I could not see the vessels; but
I made a separation between them with my fin-
gers. Having, however, only a common needle
with which to pass the ligature, I several times
withdrew the point, from the apprehension of

On Aneurisms.
149
wounding the vein. * After having tied the artery
about an inch and a half above Poupart's liga-
ment, I divided that part, and thus laid the new
and former wound into one. I traced as well as I
could with my finger, the continuation of the ar-
tery, from the place where the ligature was now
made, to that where it was formerly applied. I
wished to have divided the artery, and to have suf-
fered it to retract behind the peritoneum; but I
found it so attached to the surrounding parts, as
to render such division difficult, and perhaps not
advisable.
* The lips of the wound were brought together
with sticking-plaster, and one suture only was made
opposite to the natural situation of Poupart's liga-
ment. The peritoneum was pressed back into its
place, and the protrusion of it restrained by bringing
together the integuments with straps of sticking-
plaster.
No perceptible alteration occurred in the state
of the limb after this second operation; but the pa-
tient's health was considerably reduced, by his
having suffered from the complaint nearly twelve
months, by having undergone three operations,
and by the loss of a considerable quantity of blood.
* It would be, I think, an useful addition to our surgical
instruments for such purposes, to have needles made with
handles of pure, and consequently flexible, silver, and with
steel points that have edges just sharp enough to pass
through the cellular substance; but neither so pointed nor so
sharp, as to endanger the wounding any parts of consequence
that may be contiguous to those round which they are pas-
sed. When the points of these instruments were once passed
underneath the vessel, the surgeon could bend their bandles
so as io accommodate them to the space they have to turn in,
and thus avoid an inconvenience which, I believe most sur-
geons must have experienced; I mean, the great difficulty of
turning a common needle in a deep and narrow wound.

150
On Aneurisms.
No adhesion took place between the divided parts;
the edges of the wound were open and sloughy;
the wound was painful, discharged a great deal of
pus, and was so extremely tender, that he could
not bear it to be touched. Still no greater mischief
appeared till the fifth day after the operation, when
a hemorrhage of arterial blood took place in such
quantity, that there was no doubt but that it arose
from the principal artery; though the ligature with
which it was tied still remained firm. The patient's
health was now so impaired, and his weakness so
great, that an attempt at tying the artery still higher
up, would have appeared like torturing him with-
out any hopes of ultimate success. The wound was
therefore cleansed and dressed; some compresses
were applied upon it, and bound down by the spica
bandage. By this treatment the hemorrhage was
stopped; and the attendants were ordered to make
a pressure on the bandage if any fresh bleeding
should occur. The compresses were renewed for
three succeeding days; and though occasionally the
wound bled, yet it was not profusely, or in such
quantity as to destroy the patient: his strength how-
ever gradually declined; a troublesome cough oc-
casioned extreme pain in the wound, and in the
course of the eighth day after the last operation, he
died.
Dissection.
No marks of disease were discoverable in the
aorta, or in the internal iliac artery. The external
iliac was covered by a great number of lymphatic
glands, which prevented it from being readily dis-
tinguished; yet, when separated from these, it did
not appear diseased. For nearly two inches above
the part which was tied, the lymphatic glands cov.
ering the artery were considerably enlarged, having

On Aneurisms.
151
no doubt become additionally swollen from the ir-
ritation excited by the ligature. The external sur-
face of one of them next the wound, had ulcerated;
and the ulceration penetrated through the gland,
and communicated with the artery, as was after-
wards made evident by slitting open that vessel. It
was through this aperture that the blood had esca-
ped; for the ligature still remained firm upon that
part of the artery which it had inclosed. From this
ligature to the place where the vessel had formerly
been tied, the artery was so closely connected with
the surrounding substance, that dissection was re-
quired to separate them. The parts of the artery
from which the former ligatures had separated,
were about half an inch asunder, and the canal of
the vessel appeared perfectly open. The whole of
the vessels from the bifurcation of the aorta, to the
aperture in the tendon of the triceps muscle, were
now removed, and carefully dissected; and after
being stuffed, and hardened by spirits, they were
cut open to show the state of them internally. A
coagulum of blood, about two inches long, was
found above the part where the last ligature was
made. At what time this coagulum had been form-
ed, is perhaps difficult to ascertain; it did not seem
to have taken place after death, for above it the ar-
tery contained no blood; and if it had occurred im-
mediately after the operation, it is probable that it
would have prevented the hemorrhage. I have al-
ready remarked, that the man did not bleed for
some time previous to his death; in which interval
perhaps, this coagulum had been formed. The ul.
cerated opening from the artery through the dis-
eased gland, admitted the passage of a moderate-
sized bougie. The ligature, which still firmly in-
closed the artery, had brought its sides in contact,
so as to render it probable that they would have

152
On Aneurisms.
united. All the other parts of the femoral artery
were quite open, so that a large bougie could be
passed from the lower end of it, through the aneu-
rismal sac, to the place where the ligature now re-
mained. About half an inch of the artery was want-
ing, which had been, as it were, cut out by the lig.
atures in the first operation. The sides of the ar-
teries below the part which was tied were thicker
than natural, and their internal surface was rough,
and of a yellowish white colour. The arteria pro.
funda was filled with coagulated blood, and had
become reduced to less than the natural size. The
sides of the artery of the opposite limb had firmly
united at the part where it had been tied. No co-
agulum was found in it, and it had not diminished
in size in any remarkable degree above the part
which was closed..
It may be inquired in this case, why the artery
did not heal, but upon the separation of the liga-
ture remained widely open. That the ligature was
tightly applied is, I think, evident from its suppres-
sing all hemorrhage till its separation on the 15th
day. I am inclined to attribute the want of union
in the artery to its unhealthy state, which opinion
is confirmed by the dissection, which showed that
even the lower orifice of the artery had not healed,
whilst the artery in the other limb which was tied
much further from the aneurism, and where the
vessel was more likely to be sound and healthy,
had become firmly united. The event of this case
would induce me to tie the artery as remotely from
the seat of aneurism as could with propriety be
done.
In this first operation of tying the external iliac
artery, I was urged to perform it by the impulse
of the moment, for the death of the patient would
otherwise have been inevitable. In this case. I
per un

ter
reno

On Aneurisms.
153
thought, I disturbed the peritoneum too much,
and tied the artery higher than was necessary. As
the limb, however, did not appear to suffer materi-
ally, I felt it a duty to perform a similar operation in
the following case. The vessel was tied lower down,
so that it was brought into view at the time of the
operation. It was tied with two ligatures and divi.
ded in the interval; it afterwards firmly united at
each extremity, and the ligatures came away at the
usual time: neither did there appear any deficiency,
in the nutrition of the limb. These circumstances
afford reasonable expectations of success in future
óperations of this kind, yet in the present instance
the operation appeared to have been too long de-
layed, and the patient to have died from an event
which was not foreseen, but which might perhaps
have been prevented.
CASE II.
- -Wrungel, a German, by trade a sugar-
baker, of a sickly aspect and slender make, about
5 feet 7 inches high, and near 40 years of age, was
admitted into St. Bartholomew's hospital, on ac-
count of an aneurism in the femoral artery, close to
Poupart's ligament. This he imputed to a strain
about three weeks before. The tumor at the time
of admission was of the size of a small orange, and
the blood contained in it was fluid; for it could be
entirely expressed from the aneurismal sac. At a
consultation on the treatment of this case, I said
that I did not think a surgeon warranted in tying
the external iliac artery, till he was in some mea.
sure compelled to it by the progress of the disease,
for the following reasons. 1st. An aneurism, in pro-
portion to its increase and duration, obstructs the
passage of the blood through the natural and prin-
cipal channels, and obliges it to circulate by other
154
On Aneurisms.

courses, which are enlarged according to the exi-
gency of the case. It seems highly probable, that
in proportion to the size of the artery which is tied,
and the magnitude of the part to be nourished after
that operation, so will be the degree of previous
enlargement in these collateral channels, which is
necessary to ensure its success. On this account
the operation should be delayed longer in an in-
guinal aneurism than in any other.
edly. The operation of tying the external iliac
artery must, in the present state of our knowledge,
be considered as very serious in its nature, and un-
certain in its event. I had then only once tied this
vessel when a man would otherwise have bled to
death from the femoral artery; and though the limb
was nourished, the artery ulcerated. The operation
was done a second time in London, and the limb
mortified; but no fair practical inference can, I am
told, be drawn from the latter case, as the operation
was postponed till mortification was as it were im-
pending.
3dly. There is some chance in aneurisms of a
cure spontaneously occurring from the closure of
the artery above by the coagulation of the blood.
To cite those instances only which have come with-
in my own knowledge, and which it seems right to
mention, as it increases the stock of facts before
the public; I have known such a spontaneous cure
take place twice in the popliteal artery, once in
the arteria profunda femoris, and once in the axil-
lary artery. For these reasons it was agreed to post-
pone the operation in the case of the vresent patient
till circumstances should appear to demand its per-
formance. *
* There was about twelve months ago a soldier in the York
hospital, who had an aneurism of the femoral artery, but the
external tumor had so much overlapped Poupart's ligament

On Aneurisis.
155
Our poor patient therefore lay in the hospital du-
ring two months, in which time his disease gradu-
ally increased, and his health declined. Towards
the latter part of the time he suffered a great deal
of pain in the front of his thigh, which deprived
him of rest, and the whole limb was largely ede-
matous. These symptoms would naturally arise
from the pressure which the aneurism must make
on the anterior nerves and absorbents of the thigh.
The tumor had advanced towards the surface, and
the skin had become slightly inflamed, yet the pro-
truding part of the tumor was not of greater ex-
tent than when he was first admitted into the hos-
pital, and no judgment could be formed of that part
which was more deeply situated, on account of the
general swelling of the thigh. The blood could
even now be expressed from the prominent part of
the tumor, and I felt anxious, lest the obstruction
to the circulation in the main artery should not
have been sufficient to have obliged the blood to
circulate by other channels. It deserves to be re-
marked, that the aneurism may extend considera-
bly beneath the fascia of the thigh, causing pain
and edema by its pressure, and yet that part which
advances towards the surface may be of no great
magnitude. ?
The patients sufferings increased considerably
during the week preceding the operation, so that
he declared his present state was almost insupport-
able, and solicited that something might be done
to change it either for the better or the worse. He
and interposed itself between the integuments and the fascia
of the external oblique muscle, as to render an operation very
difficult, if not impossible. In this case the integuments mor-
tifying, occasioned a simultaneous coagulation of the blood in
the artery, for though the coagula came out, yet there was no
resh hemorrhage, and the patient recovered. -
156
On Aneurisms.

never, however, was able to explain the cause of
this uncommon degree of anxiety and inquietude.
The operation was undertaken on Saturday che
24th of October. An incision of three inches in
length was made through the integuments of the
abdomen, beginning a little above Poupart's liga-
ment, and being continued upwards; it was more
than half an inch on the outside of the upper part
of the abdominal ring, to avoid the epigastric artery.
The aponeurosis of the external oblique muscle
being thus exposed, was next divided in the direc-
tion of the external wound. The lower part of the
internal oblique muscle was thus uncovered, and
the finger being introduced below the inferior mar-
gin of it and of the transversalis muscle, they were
divided by the crooked bistory for about one inch
and a half. I now introduced my finger beneath the
bag of the peritoneum, and carried it upwards by
the side of the psoas muscle, so as to touch the
artery about an inch above Poupart's ligament. I
took care to disturb the peritoneum as little as
possible, detaching it to no greater extent than
would serve to admit my two fingers to touch the
vessel. The pulsations of the artery made it clearly
distinguishable from the contiguous parts, but I
could not get my finger round it with the facility
which I expected. This was the only circumstance
which caused any delay in the performance of the
operation. After ineffectual trials to pass my finger
beneath the artery, I was obliged to make a slight
incision on either side of it, in the same manner as
is necessary when it is taken up in the thigh, where
the fascia which binds it down in its situation is
strong. After this I found no difficulty in passing
my forefinger beneath the artery, which I drew
gently down, so as to see it behind the bag of the
peritoneum. By means of an eyed probe two liga-
On Aneurisms.
157

tures were conveyed round the vessel; one of these
was carried upwards as far as the artery had been
detached, and the other downwards: they were
firmly tied, and the vessel was divided in the space
between them. Nothing further remained than to
suture, and some strips of sticking-plaster. The
threads of the upper ligature were left out of the
wound above the suture which closed its edges,
and those of the lower beneath.
A few remarks on this operation may be per-
mitted. To divide the parietes of the abdomen,
push aside the peritoneum, and tie the external
iliac artery by the side of the psoas muscle, is an
operation more formidable in sound, and on its
first proposition, than it is in reality. It is perform-
ed almost without shedding blood, so that the prin-
cipal circumstances of it are very evident. When
I formerly performed this operation, I was urged
to it by immediate necessity: I tied the artery
much higher than in the present case, disturbed
the peritoneum in a greater degree, and, contrary
to my own principles, I did not divide the artery.
In the present case, having time to deliberate upon
the steps of the operation, I detached merely so
much of the peritoneum as enabled me to reach
the artery, as far as I conveniently could above
Poupart's ligament; but not so far as to make it dif-
ficult to ascertain that I surrounded the artery only
with my finger, without injuring any of the adja.
cent parts, nor so far but that I could draw down
and distinguish the artery which I included in the
ligature. The remembrance of the swelling in the
external iliac glands, and of the ulceration of the
artery in the former case, led to this difference of
conduct.
158
On Aneurisms.

The poor man was greatly exhausted by the ope-
ration, and his leg which had been chilled by ex-
posure during the operation, continued very cold
for a long time afterwards. It was wrapped up in
fannels, to prevent the dissipation of its own heat;
but I would not apply any artificial warmth to re-
store its temperature lest it should act as a stimu-
lant.
A ra 18 na
He could not compose himself after the opera-
tion, nor did he sleep during the night, so that on
the following day his state was very unpromising.
His pulse beat 160 inta minute; his tongue was
covered by a dark brown fur; he looked agitated,
and a purging took place, which was not restrained
till the following night by a cordial and opiate mix-
ture. Respecting his pulse, it is proper to mention
that it beat 120 most days in the week preceding
the operation.
His thigh was as warm as that of the sound side,
his leg cooler than the opposite one, and his foot
many degrees colder. He had however perfect sen-
sation in his toes, and power of moving them. The
leg and foot were rubbed with oil three or four
times a day, in order to prevent any stagnation in
the veins, and to diminish perspiration. It was well-
covered as before by flannels.
On Monday, the 2d day (Oct. 26) the pulse was
less frequent: he had slept a good deal during the
night, and seemed stupified by the opium; but was
on the whole so little better, that I concluded he
would gradually sink in consequence of the shock
of the operation. The temperature of the limb was
a little increased. The man however took bread
and milk and other food in moderate quantities,
whenever it was offered to him: the purging having
ceased, the quantity of the opiate was diminished.
He rather improved in the evening, and rested well

On Aneurisms.
159

2
during the night; so that on (Oct. 27) the third
day after that of the operation, every circumstance
wore a favourable aspect. His pulse did not exceed
100, and was moderately firm and full; his appe-
tite had increased: the temperature of the limb was
a good deal augmented, so that his foot was scarce-
ly colder than that of the sound side; and the ede-
ma of the limb was considerably diminished. I now
dressed his wound, in which he had not complained
of pain, nor of any tenderness, when the surround-
ing parts were compressed. The incision appeared
but as a line, except at the neighbourhood of the
ligatures, where it was a little open, and from
whence there issued a moderate quantity of as
healthy pus as I had ever seen. The surrounding
parts were perfectly natural both in appearance and
sensation. On the fourth day (Oct. 28) he was still
better: his pulse 90; his appetite good; his sleep
sound; and his limb lessening in size, and increas-
ing in warmth. The students at the hospital had
dressed the wound before my arrival, and reported
that the discharge was tinged with blood.
On the fifth day (Oct. 29) he was still better, his
pulse being but 80 when I counted it. The wound
and contiguous parts looked remarkably well, but
a bloody sanies was discharged, which I felt unable
to account for.
On the sixth day (Oct. 30) the state of his health
and limb continued as well, if not improving. The
bloody discharge however had increased in quan-
tity, insomuch that it ran through the coverings of
the wound and soiled the bed; it had also become
fetid. From the first occurrence of this bloody
discharge I felt considerable uneasiness respecting
it. I could not believe that a healthy wound would
secrete such a sanies, and I felt apprehensive lest
the wound should spread from disease. Nothing
160
On Aneurismis.

however took place to confirm this idea. It seemed
probable also that if the aneurismal sac were not
entire, some of the blood being exposed to the air
might tinge the discharge from the wound, and
grow putrid. I frequently pressed on the tumor,
but could press no blood from the wound. In this
state of uncertainty it was, however, pleasing to
observe, that the patient's health continued in
every respect better than could reasonably have
been expected.

much the same during the seventh and eighth days
after the operation. On the morning of the ninth,
(Nov. 2) when I came to the hospital, I met Sir
Charles Blicke, who told me that the poor Ger.
man was dying; intelligence which equally surpri.
sed and shocked me.
He was indeed in a dreadful state, appearing like
a man far advanced in typhus fever. His pulse was
150; his tongue covered with a brown fur; his in-
tellect waivering, and the action of his muscles tre-
mulous. On examining the wound with a view to
discover the cause of this great and sudden altera-
tion, and pressing on the tumor beneath Poupart's
ligament, I forced out a great quantity of blood,
rendered fluid and highly fetid by putrefaction, in-
somuch that it instantly blackened the probe with
which it accidentally came in contact.
The cause and circumstances of the bloody dis-
charge were now made clear; the surface of the
exposed coagulated blood of the aneurism had at
first tinted the discharge from the wound, and then
had, by gradual dissolution, been more plentifully
commixed with it, and given it a degree of putrid-
ity. Till, however, the whole mass had become
putrid, and had been converted in consequence
into a fluid, it could not be forced out from be.


On Aneurisms.
161
neath Poupart's ligament when pressure was made
on the tumor; nor did it till that period excite
inflammation in the surrounding parts by its acri-
mony, or derange the constitution by its absorp-
tion.
After entirely expressing the putrid blood, I
washed out the cyst with warm water, till it re-
turned untinged. The relief which was by these
means afforded to the poor man was very striking
and considerable. His pulse became moderate, his
intellect clear; he had some refreshing sleep, and
again took food in moderate quantities. On the
following day, when the integuments beneath Pou.
part's ligament were compressed, a considerable
quantity of fetid discharge and air were forced out.
It was not however at all tinged with blood, and
appeared to me to be merely the secretion from the
cyst which had contained the blood. I directed that
this discharge should be pressed out, the cavity
syringed, and a poultice applied three times a day;
but finding a considerable quantity of fetid fluid
still lodged in the cyst, I thought it right to make
an opening into it beneath Poupart's ligament, to
afford it a more ready exit. No abatement in the
quantity, or alteration in the quality of the dis-
charge, was however remarked; it seemed to be
such as a sloughing sore commonly furnishes. --
This fever came on in the evening of the eighth
day (Nov. 1) after that of the operation; and I am
convinced it would have speedily destroyed the
patient, had not the cause been detected and re-
moved. The powers of his constitution rallied
again; his pulse was firm, and often not more than
100; he took sufficient food, and slept moderately
well. But the part, as has been said, did not go
en well, and seemed to prevent any increase of
strength. For a week I was not without opes that

162
On Aneurisms.
some favourable change might happen, but after-
wards I lost all such expectations, as his already
much reduced powers were still further declining;
nevertheless, he held out more than another week.
when he died on November 16, the twenty third
day after the operation. A few days before his death
both ligatures came away with the dressings.
Dissection.
A very slight adhesion had taken place between
the sigmoid flexure of the colon and that part of
the peritoneum which was opposite to the wound,
but there was no other appearance of that mem-
brane, or of the bowels, having suffered any in-
flammation in consequence of the operation. The
peritoneum was separated from the loins, and from
the posterior half of the left side of the diaphragm,
by a considerable collection of blood, which exten-
ded downwards to Poupart's ligament, and com.
municated under that ligament by a small aperture
with the aneurismal sac. This opening was situated
in the direction of that crevice which is found be-
tween the internal iliac and psoas muscles. The
only rational explanation that can be given of the
formation of this collection is, that the blood had
burst its way from the aneurismal sac in the va-
cancy between the muscles just mentioned; after
which it would readily and extensively separate the
peritoneum in the manner described. I am inclined
to attribute to this circumstance the undefinable
disturbance of health which the poor patient suf-
fered during the week preceding the operation. It
may, perhaps, excite surprise that this collection
did not become putrid.
No particular account can be given of the aneu-
rismal sac beneath Poupart's ligament, since it and

On Aneurisms.
163
the contiguous parts had sloughed in consequence
of the irritation of the putrid blood. A small aper-
ture had been made by this sloughing in the front
of the orbicular ligament of the hip joint, and a
small extent of the thigh bone was, by the same
cause, deprived of its periosteum.
A bougie was passed from the lower end of the
femoral artery into the sac. A
The extremities of the external iliac artery,
which had been divided in the operation, were
united together by a firm new-formed substance;
the sides of each extremity were perfectly closed,
and a small plug of coagulated blood was found in
each.
Having thus given as brief an account as I am
able of the circumstances of this case, as they ap-
peared to me, I cannot conclude without mention-
ing the observations of others, particularly as they
may assist in suggesting rules of conduct for future
operations on similar cases. It has been said that
the irritation of the aneurismal bag was probably a
spontaneous occurrence, and not the effect of the
acrimony of the putrid blood. But the suddenness
of this attack, the manifest existence of a cause suf-
ficient to produce it, and the total absence of such
an occurrence in all other cases of anuerism, render
this supposition highly improbable.
It has also been imagined that part of the dis.
charged blood might have returned from the lower
end of the artery. This latter opinion is very im-
probable, since, after the complete removal of the
blood, none returned by that channel: and in the
first case which I have related, none returned by
the inferior part of the artery, though the area of it
was still of its natural dimensions, and unobstruct-
ed. This latter observation had tended to diminish
my confidence in the powers of the communicating

164
On Aneurisms,
channels, and made me wish to defer the perform-
ance of the operation as long as possible. It seems
evident that in the present instance it was too long
delayed.
It would be desirable in future to perform the
operation before an extensive diffusion of blood
had taken place; indeed, could the adequateness of
the collateral arteries for the supply of the limb
be established, it would be proper to operate at an
early period of the disease.
It deserves to be considered whether, in cases
where it is probable the blood has become diffused,
it might not be right at the time of the operation to
open the aneurismal bag, and remove the blood. I
should, however, be inclined to postpone this at-
tempt; for, perhaps, no necessity might exist, as
putrefaction might not take place. A few days will
determine the degree of life of the limb, and would
make a wound less likely to ulcerate or slough.
Should signs of the putrefaction of the blood en-
sue, or the probability of such an occurrence be.
come evident, I should think it necessary to make
a small opening into the aneurismal bag for the re-
moval of the contained blood. This being done, if
no blood came from the lower orifice of the artery,
there would be no necessity for tying it.
CASE III.
Jane Field, aged 40, who had been in the habit
of drinking to excess, was admitted into St. Bar-
tholomew's Hospital, with a very large femoral
aneurism, reaching as high as Poupart's ligament.
The whole limb was edematous, but in no very
considerable degree. She was quite incapable of
using the least exercise, or of sitting upright; and,
even in bed, she suffered continual pain, which was

On Aneurisms.
165
ZA
much aggravated during the pulsation of the aneu-
rism. The pain was so violent as to preclude sleep.
She had no appetite; her pulse was feeble and fre-
quent, generally exceeding 100; but her tongue
was not furred; and her bowels were regular.
On Saturday, 11th October, 1806, the operation
was performed in the same manner as in the last
case. An incision, about three inches in length,
was made through the integuments of the abdo.
men, in the direction of the artery, beginning just
above Poupart's ligament. Having divided the skin
and aponeurosis of the external oblique muscle, I
introduced my finger between the margin of the
internal oblique and transverse muscles and the
peritoneum. I then divided their lower edges up-
wards, in the direction of the external wound, to
the extent of an inch and a half, with a probe-
pointed bistory. Having thus made room for the
admission of my finger, I put it down upon the ar-
tery, felt its pulsations, and gently insinuated it
beneath the vessel; and then, with the aneurismal
needle, passed under it two moderately thick liga-
tures, carrying them upwards and downwards, as far
as the detachment of the artery permitted, and ty.
ing them as firmly as I could. I next divided the
artery in the interval, but much nearer to the lower
ligature than to the upper one. The wound was af-
terwards closed, in the middle by a ligature, and in
other parts by a sticking-plaster. Upon removing
the patient to bed, she complained of great pain
in the wound, and in her head; and was very rest-
less and ungovernable. She wished for something
to procure sleep, and I gave her twenty-five drops
of laudanum. This, instead of having the desired
effect, made her much more restless; she was con-
tinually changing her position in bed, and com-
plained of violent headach. At night she became

1166
On Aneurisms.
more tranquil. The one foot was much colder than
the other; but the limbs at the knees were nearly
of an equal temperature.
Sunday, 12th. I visited her early in the morn-
ing, and found that she had been moderately quiet
during the night; that she had suffered much pain
in her foot, but none in the wound. The pain in
the limb she described as having first attacked the
thigh, next the leg and afterwards the foot, which
last pain had now ceased. The foot was warmer
than it was the preceding evening, and in a state of
perspiration: It was four degrees of heat lower, by
Fahrenheit's scale, than that of the healthy limb.
The superficial veins of the leg were filled with
blood. Her pulse was 96. She had nó appetite. I
left her with a promise to visit her again at night,
recommending her to lie quiet, and take some sim.
ple nourishment. About noon, one of the dressers,
observing that her skin was hot, and the tongue
dry, gave her some saline medicine, with a small
quantity of antimonial wine, which occasioned vor
miting, and such continual nausea, that she refused
all kinds of food. The limb, at night, continued in
the same state as in the morning. She was free
from pain; her pulse 120. As she was without an
evacuation, I gave her a pill, containing two and a
half grains of pil. aloet. e myrrh. with the same
quantity of extract of colocynth, ordering it to be
repeated in the morning, if necessary.
Monday, 13th. The foot was nearly of the same
temperature with the other. She had had two stools,
and felt much more comfortable. Still, however,
she had an aversion to all kinds of nourishment.
Her pulse was 150 and 160, at different times of
the day. I may here mention, that every subse-
quent day, she had one or more stools, without
having recourse to opening medicine; and when-

On Aneurisms.
167
ever she'was more irritable or disturbed than usual,
she had a tendency to purging. In the evening of
this day, I inquired if she had a wish for any par.
ticular kind of nourishment; and, at her suggestion,
gave her half a pint of porter with some ginger and
toasted bread. This seemed to agree with her sto.
mach, as she slept the whole night, and awoke much
refreshed the next morning. Her tongue was then
clean; she took some tea and muffin for breakfast,
and broth and bread, in moderate quantities, in the
course of the day. Half a pint of porter was allow.
ed her at dinner and supper. Her pulse this day
(Tuesday) was 95. The foot warmer than the
other. The wound was dressed for the first time;
it appeared well closed, and discharged but little.
Wednesday, pulse about the same number; had
slept during the night, but not so soundly as on
the preceding one. The wound and contiguous
parts were tender; there was a considerable dis-
charge, which was fetid; the lower ligature came
off the artery. The artery, as I have mentioned,
was divided very near to the lower ligature; and it
is probable, that, in the restlessness of the patient
subsequent to the operation, the motions of the
limb had drawn the artery from out of the ligature. *
* I have never made use of the expedient suggested by
Mr. Henry Cline, for securing ligatures upon arteries since
I never felt its necessity; and because I have always thought
it right to tie a large artery with so thick a ligature, that it
would have been unsuitable to the practice which he has re-
commended. One advantage arising from tying a large artery
with a thick ligature is, that it may be drawn as tight as pos-
sible, without apprehension of cutting the vessel, or of its
speedily coming off from it. Should I, in any future instance,
think it right to oppose any inechanical obstacle to the liga-
tures's coming off the vessel which it encircles, I should do
it in the following manner. Having tied a large knot at one
end of a small thread, I would pass it, by means of a common
sewing needle, through the middle of the artery, in front of

168
On Aneurisms.
Thursday. The wound very tender, and the skin
had inflamed very much; pulse 84.
Friday. The discharge from the wound less in
quantity, and more puriform; pulse the same in
number, but very feeble.
Saturday. The patient had been seized in the
middle of the night with severe headach and shiv-
ering, and in the morning she could eat no break-
fast. Her tongue was rather dry, and slightly cov.
ered with a brown fur; pulsė 95, and feeble. Half
a pint of wine was allowed her in sago, in addition
to the porter; and she took the infus. menth. vitriol.
of the hospital, with some tincture of gentian.
Sunday. She was much better; tongue moist and
clean, and her appetite much improved. She dis.
liked the bitterness of the medicine, peppermint
water was therefore substituted for the common
mint water, and the tincture of gentian was omitted;
pulse 82; skin cool.
- Monday. In the same state as yesterday; granu-
lations appeared in the wound below the ligature,
which closed it in the middle. This part of the
wound is now about an inch in breadth, and a third
more in length. The wound above the ligature
about one fourth of an inch across; and the new
flesh, by which it is united, of a tawny colour, and
flabby texture. The surface of the skin, to a con-
siderable extent from the wound, red and excoria-
ted-
: Tuesday. She had a return of headach, with loss
of appetite; her pulse 96. There flowed from the
wound a considerable discharge, of an offensive
the ligature which encircles it; I would then form a second
thick knot on the thread, close upon the surface of the ves-
sel. These two knots would, I think, present a considerable
obstacle to the slipping of the circular ligature from off the
end of the artery.
0

On Aneurisms.
169
smell, and seemingly irritating to the skin over
which it passed. She complained of having had a
restless night; and observed that, in general, she
found herself well or ill, as the preceding night had
passed comfortably or otherwise. Thinking it prob-
able that the irritable state of the wound might con-
tribute, in a great measure, to prevent her from
sleeping, I dressed it with an aqueous solution of
opium, and smeared the excoriated skin with lard,
to prevent the acrimonious discharge from affect-
ing it. All appearance of granulations in the wound
had vanished. I ordered her fifteen drops of lau-
danum in her night draught; and, instead of the
infus. menth. vitriol. I gave her decoct. cinchon.
Zij, with zj of tinct. card. comp. every four hours.
Wednesday. She had a comfortable night, with
much sleep; her pulse 80. The wound greatly
amended. The discharge puriform, less fetid, and
smaller in quantity. The new flesh above the liga-
ture florid; and granulations appeared again on the
sides of the wound, below the ligature. The same
treatment was continued.
Thursday. She had not rested so well, and com-
plained of headach. The wound, however, was
rather better than on the preceding day. I cut out
the ligature which closed the wound in the middle,
thinking it might tend to keep up irritation. She
attributed the pain in her head to the opium she
had taken; to ascertain this point, I ordered the
dose to be increased to twenty five drops.
Friday. She had slept well, and was free from
headach; her pulse under 80. This day, the ligature,
from the upper part of the artery, came away with
the dressings. The excoriated skin had healed; the
redness was inconsiderable. The wound, in every
part, had a healing appearance. It seems unne-
cessary to detail particularly the subsequent part

170
On Aneurisms.

of the case. She was kept in bed to the end of the
third week, when she was allowed to sit up, that
her bed might be made. I thought this caution re-
quisite, from knowing that ligatures are detached
from arteries before the sides of the vessel are uni.
ted. I also confined her to bed during the whole of
the fourth week; but advised her to move the limb
about frequently. The wound healed like a healthy
wound; and was nearly closed in a month after the
operation. During the third week, when the wound
no longer proved a source of irritation, her pulse
did not exceed 75 strokes in a minute; it was gen-
erally lower, and once I found it to be only 68.
At the expiration of the month, she got up daily,
and walked about the ward; although, on her ad-
mission into the hospital, she was incapable of walk-
ing at all. There was not the least edema of the
limb. Its circumference, at the calf, was but one
third of an inch less than the opposite side. Having
walked many times the length of the ward, she be-
came tired, and thought that the limb which had
been operated on, felt more fatigued than the other.
The aneurismal tumor remains at this time of a
considerable size. It is certainly more than one
third less than at the time of the operation. I have
related the case thus particularly, in order that the
reader may judge of it for himself. To me it ap-
pears, from this and the former cases, that, in an
advanced state of femoral aneurism, the artery may
be tied above Poupart's ligament, with as little de.
triment to the circulation of the limb, as in other
cases of aneurism, where the operation is attended
with very constant success. The symptoms imme-
diately subsequent to the operation, appear to me
to have arisen entirely from the irritable and weak
state of the patient. She had pain in the head from
the operation; and so she had afterwards, whenever

On Aneurisms.
171
her health was disordered by irritation. Her pulse,
prior to her taking the medicine which acted as an
emetic, was 96; but the subsequent day it was
150 or 160. This appears to be the result of the
state of the stomach, for that becoming tranquil.
the pulse was again reduced to 95 or 96. In a con-
stitution so weak and irritable, a wound was not
likely to heal kindly; and all the subsequent cir-
€umstances of the case are satisfactorily explained,
as the effects of an irritable wound, acting upon an
irritable constitution. Upon the wound becoming
healthy, at the expiration of a fortnight, all varia-
tions of the constitution ceased. I cannot, there-
fore, but consider the perplexing circumstances
that succeeded the operation, as the effect of the
patient's peculiarity of constitution, and not as
arising from the operation itself, or from the state
of the limb consequent to such an operation. A
similar operation has lately been performed by Mr.
Frere, of Birmingham, with success. The patient
being healthy; the wound healed without difficulty.
Mr. Tomlinson, of Birmingham also performed
a similar operation with equal success, so that it
seems proved that the external iliac artery may be
tied, in the case of a femoral aneurism, with as little
detriment to the limb, as occurs from tying the
femoral artery in a case of popliteal aneurism. I
lately saw the woman who was the subject of the
last case which I have related, and there is no dis-
tinguishable difference in the size or strength of the
two extremities. -
CASE IV.
J. Peterson, a Swedish sailor, about forty years
of age, was admitted into St. Bartholomew's hos-
pital, on account of an aneurism of the femoral
artery, just below the groin. He was a thin man

172
On Aneurisms.
but had strong muscles. He had a languid appear.
ance; and his pulse was small and feeble; his appe-
tité, according to his report, moderate, and bowels
regular; his tongue, however, was much furred.
As the up er and most prominent part of the aneu-
rismal tumor was ascending above Poupart's liga-
it might overlap the ligament, and render the
operation difficult, delay was inadmissible, and the
operation was performed on Saturday, 25th Feb-
ruary, 1809. It was accomplished as in the prece-
ding case. I put my finger behind the peritoneum,
and clearly distinguished the cylindrical form, and
firmness of the artery; but I could not perceive its
pulsation. I pressed on the vessel, and the beating
of the aneurism ceased; I remitted the pressure,
and it was renewed. Having thus ascertained that
I had my finger upon the artery I tried to separate
it, so as to get my finger round it; but I could not
succeed. I then tried with the point of the aneurism
needle, carrying it close to the artery from with-
out, towards the cavity of the pelvis; but the vessel
yielded so considerably, that I did not accomplish
it. I tried in a contrary direction, and though the
artery receded from its situation, as I think, fully
half an inch, yet by perseverance I accomplished
my purpose. I then passed another aneurismal
needle, threaded with a double ligature, through
the track that I had made, and tied each ligature
firmly. I have related these circumstances, that
the reader may know why the artery was not tied
as it was in the preceding case. I could not bring
the artery into view. I might have done so lower
down nearer to Poupart's ligament; but the appre-
hension of producing any communication between
the air and the blood of the aneurismal bag, which
might occasion its putrefaction, made me tie the

On Aneurisms.
173
artery at some distance above the ligament. The
recession of the artery in this case, before the pres-
sure made by the aneurismal needle, was so con-
siderable as to excite my surprise.
The patient lay upon his side with his thigh bent
upon the pelvis, and for the first three days after
the operation without pain, or any apparent distur-
bance of his constitution. He was fed with bread
and tea, and bread and broth, and his bowels were
regular. The wound seemed closed by adhesion,
except at its lower part, where the ligatures came
out. On the fourth night, he was seized with vio-
lent and distressing pain in the epigastric region,
and on the left side of his chest; he had not the
least sleep, and felt very anxious, and disturbed.
His pulse beat the next day 130 in a minute; his
skin was hot and dry, his face flushed, and his
tongue covered with a dry brown crust. Two
grains of calomel were given to him, and efferves-
cing saline draughts were taken every four hours.
The calomel produced a purging stool during the
night, which had not a drop of bile in it. The fol-
lowing day his pulse exceeded 100 only by a few
strokes, his skin felt temperate, his tongue was
moist, and not so brown or incrusted. His pain
also, was much diminished, though the epigastric
region was still tender. His saline draughts were
continued, and he was directed to take five grains
of the pilul. hydrarg. each night. The next day he
was still better; his pulse 90, his skin moist, and
his tongue cleaner; he took food without disgust,
though not with much appetite. As he had no
evacuation from his bowels, a little opening electu-
ary was given him, and the saline draughts were
changed for the infus. menth, vitriol. with a little
tinct. cardam. He had a stool in the night, which
was of a light ochre colour; that is, a light brown,
0

174
On Aneurisms.
which dilution would not convert into a yellow. He
continued the same medicines till the tenth day
after the operation, with an evident amendment in
his health; though the alvine discharges which we
contrived to procure daily, were still of the colour
above described, though somewhat deeper.
On the tenth day, after observing his tongue and
pulse, &c. those who saw him, joined with me in
opinion, that he was in better health than when he
was admitted into the hospital.
During this constitutional disturbance, the up-
per part of the wound became open, and the dis-
charge was offensive and irritating, and excoriated
the skin over which it flowed. I therefore greased
it with fresh lard at each dressing, to prevent as
much as possible the discharge from acting upon
it. Some swelling of the parts on that side of the
wound next the ilium also took place. Still there
was nothing very materially wrong, and the state
of the wound gradually amended as the patient's
health became tranquil.
On the tenth day, the ligatures came away, and
then the patient first complained of a pain on the
inside of his thigh, just above his knee. A
On thc 11th day he repeated his complaints, and
said that the pain disturbed him, and prevented his
sleeping during the night. I knew not to what to
attribute it; I thought it might indicate some irri-
tation of the anterior crural nerve; however as the
patient remained pretty well, I gave no directions
respecting it.
On the 12th day, when I visited the patient, I
was shocked at his appearance. His countenance
expressed great anxiety and despondency; and his
pulse was more than 120. His tongue was covered
with a brown fur. He had missed his regular evacu-
ation from the bowels. Being clear that the calo.




On Aneurisms.
mel had been of essential service before, I gave
him two grains of that medicine, and ordered again
the effervescing draughts.
On the 13th day, he was no better; but more
languid. The calomel had produced two copious
loose stools, scarcely tinted with an ochre colour.
I requested Dr. Roberts to see him, who directed
him to take a grain of opium at night; ordered him
sago and wine for food; and the infusion of carca-
rilla with tinct. of columbo.
Fourteenth day. He neither seemed better nor
worse; he had slept four hours in the night. A slight
blush of the skin appeared on the inside of the thigh,
such as indicates inflammation of the absorbing ves-
sels. Fomentations and poultice were directed to
this part. Dr. R. also ordered half a grain of calo-
mel, with five of cicuta, to be taken night and morn-
ing.
Fifteenth day. He was considerably better,
though his leg continued painful; the pain how-
ever was diminished. He was directed to continue
the same medicines; and to insure a good night, if
one grain of opium failed to give him rest, he was
allowed to take another after four hours.
Sixteenth day. Not quite so well. He had had no
evacuation for the last twenty-four hours. He took
a little opening electuary.
Seventeenth day. He had a stool during the night,
and was better. His thigh was edematous but not
painful. The pain was descending towards his an-
kle. Dr. Roberts wished him to take the blue pill
in preference to the calomel. Five grains were there-
fore given each night.
Eighteenth day. He was better, and continued
gradually to improve till the twenty-fourth day,
when he declared he felt quite well, and had had
six hours' comfortable sleep. The colour of the
176
On Aneurisins.

stools had been gradually improving, and on that
day, when such a marked amendment took place,
the siool might be said to be nearly properly tinc-
tured with bile, and of a proper consistence.
During this time an abscess had formed on the
inside of the thigh, a little above the knee, where
the absorbents of the limb began to inflame, and
the matter had been discharged by a puncture made
with a lancet. Swelling in the ham likewise took
place, and was apparently caused by the irritation
of the absorbents in that part, but no matter formed
in it, and the leg also became edematous. The
wound made by the operation had healed firmly
and all tumefaction about it had subsided. As the
patient's bowels acted regularly, no medicines were
now given him.
After about a week had elapsed, he was seized
as before with pain in the epigastric region, rheu-
matism in the right shoulder, and inability to move
the right arm. His countenance again expressed
despondency and disturbance; his pulse was fre-
quent and his skin hot; the abscess also was pain-
ful and discharged copiously, and became distend-
ed with matter, so that it seemed necessary to en.
large the aperture, which had nearly healed. His
tongue was much furred, and his stools had no bile
in them.
He again took calomel at first, and afterwards
the pilul: hydrarg: and the secretion of bile was
gradually renewed and increased, as in the pre-
ceding instances, which produced a proportionate
amendment in his general health. His limb also
was so much improved as to enable him to walk
about the ward, and to go out occasionally into the
air.
Believing that living in a better air would greatly
contribute to the restoration of his health, he was

On Aneurisms.
177
soon afterwards discharged from the hospital; look-
ing as well as he did on his admission, and capable
of walking but with little infirmity. He was advised
to take the pilul: hydrarg: every second night, till
the secretion of bile was right, and to take them af.
terwards whenever he perceived it to be deficient
or faulty. He was also enjoined to keep his bowels
regular in other respects.
The cases which I have related and referred to
show that the current of blood through the exter-
nal iliac artery may be stopped, without occasion-
ing any material, or even evident diminution of
the powers of the limb. It also appears to me that
this operation does not disturb the constitution
more than a similar one performed upon arte-
ries of less magnitude. It is true that considerable
disorder of the constitution took place in the cases
which I have related, but it seemed to have arisen
from the peculiarities of the state of health of the
patients, and not as a necessary consequence of the
operation. In the last case, every thing went on fa-
vourably till a disorder of the digestive organs oc-
curred. To such disorder it cannot be doubted that
there was a strong predisposition; and of which, the
operation by its effects on the mind as well as the
body, confinement in an hospital, and great altera-
tion of diet may be considered as the exciting
causes. I think it probable that the state of the
constitution might have greatly contributed to pro-
duce the general irritation of the absorbents of the
limb, which was first observed on the day when the
ligatures came away. I cannot doubt but that the
inflammation of these vessels did, as indeed it ge-
nerally does, greatly disturb the constitution and
aggravate its disordered state. These conjectures
appear to me to be verified by the last occurrence
which I have related. When the wound was healed,
178
On Aneurisms.

and the limb so well as that it probably could im-
part no irritation to the general system, from leav-
ing off the mercurial medicine, disorder of the di-
gestive organs recurred and produced the effects
which I have described.
That the femoral aneurism, when it occurs near
to the groin, may, like other aneurisms sometimes
be cured by the processes of nature, is proved by
experience; yet this is not likely to be the common
event of such cases. I knew two instances of pa-
tients dying of hemorrhage from such aneurisms.
The sufferings both of body and mind, in these
cases, were shocking. The patients were unable
to move, and the distention of the integuments,
and pressure on the nerves occasioned great pain
and irritation. The patients also lay apprehensive
and uncertain of the hour when their sufferings
might be terminated by a fearful and fatal hemor-
rhage. I think myself therefore fortunate that I was
first, as it were, compelled to perform an operation,
which I trust, may be found to diminish the suffer.
ings, and preserve the lives of those afflicted with
this disease.



SURGICAL OBSERVATIONS
ON
DISEASES RESEMBLING SYPHILIS;
AND ON
DISEASES OF THE URETHRA.
BY JOHN ABERNETHY, F. R. S.
Honorary Member of the royal Medical Society of Edinburgh, and of the
Medical Societies of Paris, Philadelphia, &c.
Assistant surgeon to St. Bartholomew's Hospital, and teacher of Anatomy
and Surgery.

SURGICAL OBSERVATIONS.

On the Origin, Symptoms, and Treatment of Dis-
eases produced by the Absorption of morbific Ani-
mal Matter, and which in Appearance frequently
resemble Syphilis.
SECTION I.
INTRODUCTORY REMARKS.
SINCE the publication of Mr. Hunter's accurate
observations on the Venereal Disease, it has been
generally admitted that certain modifications of an-
imal matter, being applied to a susceptible surface
of the body, will in many instances excite an ulce.
rative disease, in which the diseased part secretes
matter precisely similar to that which had excited
it. These kinds of infectious matter Mr. Hunter
called morbid animal poisons, in order to distin-
guish them from those poisons with which some
animals are furnished for purposes connected with
their economy. Mr. Hunter further showed that
the animal matter of one person might induce dis-
ease in another, even though the person from whom
the matter was derived had no disease. * As Mr.
* See his cases of diseases induced by the transplantation of
teeth, and the sucking of children, in his work on the Venereal
Disease.

18:2
On Diseases
Hunter's opinions have been confirmed by the sub-
sequent experience of other practitioners, and ap-
pear to have obtained pretty general assent; and as
some of the cases which I mean to bring forward
seem still further to confirm and illustrate these
opinions, it does not appear necessary for me at pre-
sent to enlarge on these subjects.
Infectious matter may be the effect of disease in
one person, and the cause of it in another, and yet
it would appear a solecism were we to call the in-
fectious matter itself diseased or morbid. Besides,
as some kinds of animal matter, which are not the
products of disease, are nevertheless capable of ex-
citing it, I have, in the first edition of this book,
called all kinds of infectious animal matter, morbi.
fic animal poisons, which term there appears no
reason to change.
It cannot, I think, on due consideration of the
subject, be denied, that many sores are induced, on
the genitals, by sexual intercourse, which are not
the effects of the venereal poison, and that many of
them infect the constitution, and produce seconda-
ry symptoms resembling those of that disorder. It
may be asked, however, if these diseases be not ve-:
nereal, what are they? As they are all the conse-
quence of sexual intercourse, they may, in one sense
of the word, be said to be venereal. To avoid am-
biguity, therefore, I shall in these pages denomi-
nate that disease which broke out at the siege of
Naples, and which Mr. Hunter has described as the
venereal disease, by the name given to it by noso-
logical writers, that is, Syphilis; and I shall call
those diseases, which differ from it in their progress
and mode of becoming well, though they strikingly
resemble it in appearance, by a name importing
these circumstances, that is, Pseudo-Syphilitic Dis..
eases.
Resembling Syphilis.
183
To prepare the mind of the reader to take an im-
partial survey of these subjects, I think it will be
useful to make a few preliminary observations rela-
tive to the probable origin of pseudo-syphilitic dis-
cases.
Celsus describes eight species of sores with which
the genitals were affected in consequence of sexual
intercourse; and as this was long before Syphilis
was known, it follows that there must be other
causes producing them. Some of the sores describ-
ed by Celsus, are not unfrequently met with at pre-
sent, and they are not syphilitic. Sores also fre-
quently form upon the genitals of females in conse-
quence of that irritation which accompanies diseased
secretions from the vagina. Sores, for instance, very
frequently succeed to gonorrhæa in the lower class
of females, who pay little attention to cleanliness,
and do not abstain from sexual intercourse. Sores
frequently break out on the prepuce and glans of
the male, in consequence of the irritation which
gonorrhea or other diseases of the urethra produce
in these parts. These sores generally heal without
the use of mercury, frequently without inducing
any constitutional disease: and when they do infect
the constitution, the disease occasioned by them is
not syphilitic. I merely mention these circumstances
at present, to show that it is possible for ulcers to
form which may not be syphilitic, and yet the dis-
charges from them may prove morbific, and pro-
duce disease in others.
Even discharges from the genitals of one person,
where no ulcers exist, are capable of exciting ulcers
in another. "I am aware that no argument can be
grounded upon the observation of this fact in com-
mon cases, where the parties have been promiscu-
ous in their intercourse with others, and their vera-
city cannot be relied on. But I have known both


184
On Diseases
gonorrhæa and ulcers occasioned by connexion with
persons who had no syphilitic disease, where the
veracity of the parties might be relied on, and where
no promiscuous intercourse could be suspected.
The cases of supposed gonorhæa arising from sexual
intercourse with persons who apparently have no
disease are so very common as to need no exem-
plification. I think, however, it will be proper to
adduce some instances, in which ulcers have taken
place in consequence of the application of irritating
matter which was not of a syphilitic nature, because
cases which can be cited in proof of this fact must
be rare occurrences, and not likely to be met with,
except in the extensive practice of a large city.
CASE I.
A gentleman was connected with a female who
tvas kept by another gentleman, and derived from
such connexion several very irritable and foul sores,
which broke out on the prepuce, but which, howe.
ver, had not the syphilitic characters. As neither
the woman nor her keeper had any disease, he had
no wish to take mercury, nor had I, being consulted
on his case, any desire to recommend it to him.
The sores did not heal until between two and three
months, though a variety of local applications were
employed. He at length, however, became perfectly
well, and I cautioned him not to be again connected
with the same woman. But his inclination got the
better of his prudence, and another crop of sores,
equally irritable, foul, and tedious, took place in
consequence of a second connexion. These sores
were treated in the same manner as before, and
slowly healed. After some lapse of time, he again
erred in the same manner; and again received the
same punishment. He had no constituțional disease
from these sores.
resembling Syphilis.
185
CASE II.
A gentleman had been my patient with strictures
in the urethra, which were nearly, though not per-
fectly well. A large bougie could be passed with
facility, but it gave some pain on passing those
parts of the urethra where the strictures had been,
and there still existed a very trivial discharge from
that canal. Under these circumstances he connect.
ed himself with a female, who, there was good rea-
son to believe, had had no communication with any
other person. She, however, had in consequence
of this connexion, four sores which formed upon
the under surface of the labia pudendi, two on each
side. These sores'were very irritable, and became
larger than a sixpence, and of an oval form. They
threw forth exuberant flesh of a livid hue, were
very tender, and had a great deal of inflammation
surrounding them. Various dressings were em-
ployed without amending them, and after a month
had elapsed I was induced to recommend from 10
to 15 grains of the pil: hydrarg: to be taken daily.
After another fortnight, as no amendment was per-
ceived, and the mouth was not affected by the
medicine, the patient rubbed in 2 drachms by mea.
sure, of mercurial ointment every second night.
A second fortnight elapsed without any amend.
ment in the sores, though the mouth was slightly
affected. At this time, the uneasiness of the patient
and her friend induced me to desire they would
consult another surgeon, who thought the sores
syphilitic, and wished that the quantity of mercury
should be increased, so as more decidedly to affect
the mouth. In consequence of this consultation,
the patient rubbed in the same quantity of mercu.
rial ointment every night, and discontinued the
internal use of the medicine. At the conclusion of

2 A

186
On Diseases
another fortnight, the mercury suddenly affected
the gums, and produced a degree of ptyalism which
prevented its further use. Still the sores were not
amended, and on the abatement of the ptyalism,
I again had recourse to local means without re-
suming the use of mercury, the inefficacy of which
had been fully proved. The sores now healed
rapidly under the local use of a solution of cupr.
vitriolat. Wherever mercury has been used, it
must be difficult to decide whether cases are or are
not syphilitic. I think it very clear, however, that
the case just described was not of that nature; and
as to the sores healing suddenly, it is a very com-
mon occurrence when no mercury is used. For
sores which are not affected by a local application
in their incipient state, will sometimes heal rapidly
if the same application be made to them in an ad-
vanced state, when the activity of the disease is
abated or its nature changed by its continuance.
Though no constitutional affection succeeded to
the sores induced in the foregoing cases, yet that
the system is liable to be contaminated by absorp-
tion from ulcers of this description will clearly
appear from the cases related in the subsequent
part of this paper: and at present, to corroborate
this fact by the testimony of another, I shall relate
a case which was communicated to me by an emi-
nent and accurate surgeon in this town.
CASE III.
A gentleman lately married complained to his
surgeon of a running from the urethra, which so
strikingly resembled a venereal gonorrhea that the
latter could not but ascribe it to infection. He had
afterwards a swelling of the prepuce, and sores on
that part, which confirmed the surgeon in his opin-
resembling Syphilis.
187

ion, and produced a kind of dissension between his
patient and him, the one affirming that the disease
was venereal, the other that it could not possibly
be so, as his wife had no disease, and he had had
connexion with no other woman. The effect of this
litigation was, that the surgeon would not urge the
taking of mercury, nor would the patient require
the administration of that medicine, though a bubo,
sorethroat, and eruptions succeeded, which could
not be distinguished from similar complaints of a
syphilitic nature, but all of which spontaneously
got well.
The narrative of the following case was lately
sent to me by Mr. Watson of Stourport. It is an
instance of the nurse being infected from the child,
and similar instances in this respect are not unfre-
quently met with. Yet it contains some interesting
circumstances which are explanatory of my present
subject, and I therefore take the liberty of inser-
ting it in this place.
* CASE IV. -
Mrs. F., after suckling a nurse child about four
months, perceived a small ulcer on the breast near
the nipple, which she believed she caught from the
child, as it had a bad nose and sore lips. At this
time the ulcer was about the size of an almond,
and of the shape of one. As it did not heal from
simple dressings, the surface of the sore was rub.
bed with argent. nitrat. and a wash of calomel in
lime water was afterwards applied. Under this
treatment the ulcer healed, and a gland in the
axilla, which had enlarged, subsided. This hap-
pened about three weeks after the patient had first
consulted me. Two months afterwards the patient
had a severe febrile attack, accompanied with sore.
throat, of which she soon recovered. To this, suc-

188
On Diseases
ceeded a copper-coloured eruption which came out
on all parts of the body. No medicine was given at
first, but as the patient became uneasy, some com.
pound calomel pills, with small doses of nitric acid
were directed. She took about 12 pills and small
doses of the nitric acid for the same length of time,
when they were discontinued. In about two months
all the eruptions had disappeared, except some
white blisters, which had lately formed about the
labia pudendi, and which gave her pain, when she
walked. This complaint was removed in a few
days by a solution of sulphat of zinc. About a week
afterwards, her husband showed me a sore on the
penis, covered by a black scab. It was about the
size of a sixpence, the surrounding skin was much
inflamed, but the base of the sore was neither hard
nor thickened. In a few days a second sore ap-
peared in the course of the absorbents between the
first and the groin. The inguinal glands now be-
came enlarged, and one of them suppurated. In
about three weeks from the first appearance of the
sore on the penis, the patient was attacked with
feverish symptoms, which were followed by an
eruption, different from that which his wife had
been affected with, but very similar to the erythe-
ma papulatum syphiliticum, represented by Doctor
Willan. The sores on the penis spread rapidly for
some days, but did not penetrate deeper than the
skin, and after being twice touched with argent.
nitrat. they soon healed with the use of calomel in
lime water. The abscess in the groin was opened
by a lancet, and the wound ulcerated considerably,
but afterwards healed by the same means, that had
been serviceable to the other sores.
This patient never took any mercury, except
once, when some calomel was given with other
aperients, as a purge.

resembling Syphilis.
189
It may be rationally supposed that the discharges
from such sores as I have described, as well as the
discharges from secreting surfaces not in a state of
ulceration, may prove morbific and excite local
diseases, or if absorbed may contaminate the con-
stitution. Cases which render these opinions proba.
ble, are so frequent, that every surgeon must, I
think, have remarked them. In consequence, how.
ever, of his preconceived opinions, he might dis-
trust the veracity of his patients, and treat the
disease as if it were syphilitic, and the conse.
quences of such conduct will be displayed in the
subsequent part of this paper.in
After these preliminary observations, which are
designed to show how sores on the genitals may
arise from sexual intercourse at present, as they
did even in the time of Celsus; I may further
remark that from the time of the breaking out of
the lues venerea, it is probable such sores con-
tinued to occur, and were confounded with the
sores induced by that disease: thus we may account
for the opinions delivered by old authors, of even
syphilis getting well spontaneously, or by the ad-
ministration of medicines of acknowledged ineffi-
cacy. Every surgeon must have seen cases of
syphilis getting progressively worse, till corrected
by mercury, and regularly yielding to the effect of
that medicine, and being permanently cured by one
adequate mercurial course; so that his observations
will induce him to admit the accuracy and justness
of the description of that disease which Mr. Hunter
has given, in a great number of instances. Further,
when from the insensibility of the constitution to
the operation of mercury it has been difficult to ex.
cite its specific effect, how numerous are the cases
of chancres, ulcers in the throat, and nodes, that
have remained stationary and unvarying under a

190
On Diseases
long use of mercury, and yet have yielded and
become perfectly well, when by more energetic
: measures the constitution has at length been affec.
ted by this medicine. To identify what I consider
as true syphilis, and to excite the reader's attention
to that disease, so that he may contrast it with
those which make the subject of the present pub.
lication, I shall here insert a case which was related
in the first edition of my surgical and physiological
essays, to show the efficacy of mercurial fumiga-
tions in affecting the constitution, when other
modes of administering mercury had failed to
produce its specific effect. * des
CASE V.
A young man had a chancre by the side of the
frenum preputii, which had all the characters of
true syphilis. It was of a circular form, with a
thickened edge and base; there were no granula-
tions, and matter adhered to the surface. For this,
he took mercurial pills in large quantities, which,
never affected his mouth, though occasionally they
produced griping pains, and made him feel very
unwell. He was obliged at this time to travel pretty
constantly, so that he could not conveniently rub
* It is not my intention to republish the cases in proof of
this fact, because I think that the present one is sufficient to
evince its truth It seems, however, right to mention, that
my opinions on this subject are unaltered, and to repeat, that
recommended by the Chevalier Làlonette, a physician in
Paris in 1776, to be, in the majority of instances, a more
powerful and innocent means of producing a mercurial affec-
tion of the constitution than inunction or the internal use of
mercury, and equally certain of radically curing the disease
for which it has been thus administered. The fumigating
powder which I have used instead of Lalonette's is calomel
washed in water, containing a small quantity of ammonia:
resembling Syphilis.
191

in mercurial ointment. When the mercury was
taken in such quantities as to make him feel ill, and
to disorder his bowels, the sore looked red on the
surface, and seemed disposed to heal, but when he
diminished the quantity of the medicine the sore
assumed its former diseased characters. After the
chancre had continued for two months, a small
bubo formed, suppurated and burst. By perseve-
ring in the internal use of mercury to the greatest
extent that he could do, the chancre healed and the
bubo got well about the same time. This happened
four months after the occurrence of the chancre,
and six weeks after the breaking of the bubo. As
at last having got the chancre to heal by pushing
the use of mercury to an extent that made him feel
very uncomfortable, and much indisposed, he left
off the medicine sooner than he ought to have
done. In two months more, his former occupations
ceasing, he returned to London, where he after-
wards remained. Shortly after his return, which
was in September 1788, one of his tonsils seemed
a little enlarged, indurated, and tender, so as to
occasion a difficulty in deglutition. In the course of
a week it ulcerated, and the ulcer acquired by de-
grees all the characters of syphilis. It was of an oval
«form, excavated, without granulations, and with
matter adhering to its surface. The same circum-
stances took place in the opposite tonsil and an ex-
actly similar sore formed in it. As the history as
well as the appearances of the primary chancre left
no doubt of its nature, and as the secondary symp.
toms were equally unequivocal, he immediately
began a mercurial course: being healthy, and his
bowels not easily disturbed, he took, on an average
from two to three grains of calcined quicksilver,
or calomel joined with opium, every day for three
months; and also used mercurial ointment during

192
On Diseases
the same period, beginning with two drachms, and
gradually increasing it to an ounce daily: besides
which, he had for a short time taken a solution of
hydrargyrus muriatus. Yet all this scarcely pro-
duced any soreness of his gums, or caused any
visible amendment in the ulcers of his throat; the
only effect it had being that of preventing them
from becoming worse. His bowels indeed were
occasionally disturbed by the medicines, but were
easily quieted by opium. To rub in the quantity
of mercurial ointment used towards the latter part
of the course, the patient spent nearly an hour and
a half every night and morning; but as he became
weaker, he perspired considerably in consequence
of this exercise, which tended to frustrate his en-
deavours, by preventing, or at least greatly dimin-
ishing, the absorption of the medicine.
No ground being gained by pursuing this plan,
Sir Charles Blicke recommended mercurial fumi-
gation according to Lalonette's method, which he
had occasionally employed with success, and which
would not only relieve the patient from the fatigue
of rubbing in the ointment, but prevent any far-
ther irritation of his bowels, by superseding the
internal use of mercury. The patient was accor-
dingly exposed, for half an hour each night, to the
fumes produced from half an ounce of the powder;
by which means, in less than a fortnight, his con-
stitution and mouth became properly affected by
the mercury; the ulcers healed soon afterwards,
and in about a month he was permitted to discon-
tinue the remedy. -
In this case the disease in all its circumstances
precisely agreed with the description of syphilis
given by Mr. Hunter. It was unchangeable in its
characters; it regularly and progressively got
worse when no mercury was employed, it was sta-
resembling Syphilis.
193

tionary when opposed by that medicine, and it was
permanently cured by an adequate mercurial affec-
tion of the constitution.
Having been educated in the old school, under
professors who prided themselves in possessing the
Tactus and Visus eruditus, I was anxious to
obtain that happy discrimination of colour that
should enable me to pronounce from the copperish
tint of an eruption that it was undoubtedly vene-
real. But my endeavours were ineffectual; and
much was I gratified by the publication of Mr.
Hunter's book, which furnished me with a clue to
guide me through the labyrinth in which I had
been bewildered. All my observations, while a
student, corresponded with Mr. H.'s, and when I
experienced as well as witnessed the perplexities
of practice in these diseases, I saw nothing contrary
to his description. I saw cases of true syphilitic
disease, which had been regular in their progress
and increase, when no mercury was used, regularly
and permanently cured by that medicine. I also saw
diseases resembling the venereal, which were nei-
ther regular in their progress nor cure. Each year
additional facts presented themselves to establish
these opinions, and none appeared to contradict
them. The following case in particular, of a medi.
cal student of the hospital, made a strong impres-
sion upon my mind.
CASE VI.
This gentleman thought that he had infected a
slight cut on his hand (which was situated in front
and just below the little finger) with the discharge
from a bubo in the groin that he had opened. The
wound fretted out into a sore about the size of a
sixpence, which he showed me, and which I affirm-
ed had not the thickened edge and base, and other
2 B

194
On Diseases
characters of a venereal chancre. I therefore recom-
mended him to try the effect of local means, and
not to use mercury.
In about a month the sore, which had spread a
little, became again contracted in its dimensions,
and assumed a healing appearance. At this time
pain was felt extending up the arm, and suddenly a
considerable tumor arose over the absorbing ves.
sels, which proceed along the inner edge of the
biceps muscle. This tumor became nearly as big
as a small orange. As the original sore seemed now
disposed to heal, and as there was no surrounding
induration, I could not believe it syphilitic, and
therefore recommended him still to abstain from
mercury, and apply leeches, and linen moistened
in the aq: litharg: acet: comp: to the tumor formed
over the inflamed absorbents.
Under this treatment the tumor was discussed,
and the sore at the same time healed. About three
weeks afterwards the patient called on me, and said
that there were venereal ulcers in his throat; and in
cach tonsil there was an ulcer deeply excavated,
with irregular edges, and with a surface covered by
adhering matter; ulcers, in short, which every sur-
geon, who depends on his sight as his guide, would
have pronounced to be syphilitic. Shortly after
also, some copper-coloured eruptions appeared on
his face and breast. He showed his diseases to sev-
eral surgeons, on whose opinion he relied, who,
without hesitation, affirmed that they were syphili-
tic, and that the mercurial course had been impro-
perly delayed.
Whilst the patient was looking out for lodgings,
in order that he might go through the mercurial
process, a circumscribed thickening and elevation
of the pericranium covering the frontal bone ap-
peared; it was of the circumference of a half-crown
resembling Syphilis.
195

piece; and was, in short, what every surgeon, who
is guided only by his sight and touch, would, with-
out hesitation, have called a true corona veneris. I
now told the patient that I was still more inclined
to believe his disease was not syphilitic, from the
sudden and simultaneous occurrence of this node
with the sore throat, &c. Other surgeons thought
differently; and I believe this very sensible and
amiable young man imagined that his health would
become a sacrifice if he any longer attended to my
opinion. He was preparing to submit to a mercu-
rial course, when very important concerns called
him instantly into the country. He went with great
reluctance, taking with him mercurial ointment,
&c. and after a fortnight I received a letter from
him, saying that he found his complaints benefited
by his journey, that business had prevented him
from beginning the use of mercury for a few days,
that he now found it was unnecessary, for his symp.
toms had almost disappeared, and shortly after-
wards he became well.
At the time, and ever since, I considered this
case as meriting publication, as being a most un-
equivocal instance of a disease occurring, which
could not from appearance be distinguished by
surgeons of the greatest experience from syphilis,
and which, however, was undoubtedly of a differ.
ent nature; and I believe that there is no one, who
would not have decided on this case, as those did
who declared it to be syphilitic, unless they had had
an opportunity of watching its progress very atten-
tively. This case probably made me more scrupu.
lous than I should otherwise have been in admitting
diseases to be syphilitic, till their unabating pro.
gress established their nature beyond the possibility
of doubt; and from this hesitation in deciding I
have been enabled to prove, that a great number of



196
On Diseases
cases, in which mercury would have beenemployed,
have got well without the use of that medicine.
In the course of practice, I frequently met with
cases of a nature similar to the foregoing. In these,
I had opportunities of tracing constitutional symp-
toms from the primary sores which had caused
them, a circumstance which cannot frequently be
done in hospital practice. I saw that the primary
sores had not the character of syphilis, notwith-
standing the secondary symptoms often strongly
resembled those of that disease. As, however, I
did not meet with other surgeons who thought as
Mr. Hunter did on this subject, and as my ob-
servations so strictly coincided with his, I thought
it right in the first volume of my Surgical Obser-
vations, published 1804, to excite the public atten-
tion to these cases by laying before it the following
Essay, but previously I inquired of the best sur-
geons in London, whether constitutional symptoms
of syphilis do ever spontaneously amend? To this
inquiry no one decidedly replied in the affirmative,
whilst all without hesitation agreed that they were
generally, if not constantly, progressive, unless
checked by the operation of mercury. In con.
sequence of this opinion, so concurrent with Mr.
Hunter's description of the disease, I was induced
to publish the following cases and remarks.
resembling Syphilis.
197
SECTION II.
On Pseudo-syphilitic Diseases, becoming well spon.
taneously.
Mr. HUNTER, in his excellent Treatise on the
Venereal Disease, has related several cases sup-
posed to be syphilitic, and some of which were
certainly not so, as they got well without mercury;
but in the greater number the employment of this
medicine rendered their nature doubtful. Mr.
Hunter also, who was as cautious in drawing con-
clusions as he was accurate in making observations,
expresses himself in many instances so diffidently
on the subject, as, in my opinion, not sufficiently
to impress the minds of his readers with the cer.
tainty, importance, and frequency of such facts.
He concludes his observations by intimating “that
undescribed diseases, resembling the venereal, are
very numerous, and that what he has said is rather
to be considered as hints for others to prosecute
this inquiry further, than as a complete account
of the subject.” As it has occurred to me very
frequently to meet with such cases, and as the
necessity for discriminating them from syphilitic
diseases appears to me of the highest importance,
I shall prosecute the subject by relating some
unequivocal cases of diseases strikingly resembling
syphilis, but which, however, were disorders of a
different nature, provided it be admitted that sy-
philis does. not spontaneously get well without the
aid of medicine.
The necessity for discrimination between these
diseases will appear upon a slight consideration of
the subject. If a surgeon, who does not see that


198
On Diseases
extent of practice which occurs in a metropolis,
administers mercury in one of the diseases resem-
bling syphilis, he finds perhaps that the symptoms
yield slowly; and even after a considerable and
debilitating course of that medicine they may recur.
They are then counteracted by a still more severe
use of mercury, till they perhaps spontaneously
cease, which may not happen till the patient's con-
stitution is so enfeebled, that if it do not fall into
other states of disease it very slowly regains the
standard of health. Such cases would induce the
surgeon to consider the venereal disease as pecu-
liarly difficult of cure, and liable to recur on the
remission of even a severe course of mercury. The
consequence of this opinion is, that he employs
mercury to an unnecessary and injurious degree
in his general practice.
I do not mean, however, by these remarks to
imply, that, in my opinion, syphilitic diseases are
equally susceptible of cure in every instance by
mercury; nor am I an advocate for what has been
termed an alterative course of this medicine.
Cases which frequently occur have convinced me
that it requires a very considerable mercurial effect
to cure syphilis in some instances; and that this
effect must be continued for a considerable time
in order to insure a cure. Mr. Hunter probably
wished the subject of diseases resembling syphilis
to be prosecuted, in hopes that some distinctive
characters might be discovered as peculiar to them;
but the following cases show that these diseases
ensue from primary infected sores of very dissimi-
lar appearances, and sometimes arise without any
primary sore having been observed.
Whilst, then, the primary symptoms are thus
variable, and such as may perhaps in the greater
number of cases be distinguished from those of
resembling Syphilis. 199

syphilis, the secondary or constitutional symptoms
often so strikingly resemble those of that disease,
as not to be discriminated from them by sight,
though in general they may be by their progress.
I have kept no particular account of the nu.
merous cases which I have met with, but the five
following instances happened in my own private
practice within a few months, and the circum-
stances of them are still fresh in my memory. The
cases are drawn up from narratives which I re.
quested the patients themselves to make out of
their own diseases.
CASE VII.
A gentleman had a sore on the lower part of the
prepuce near the frænum, which was much irritated
by travelling from the country. When he came to
town there was a good deal of surrounding inflam-
mation, and a thickening adjoining the edges of
the sore which were irregular, and seemingly dis-
posed to spread. An appearance of granulations
had taken place on the surface of the ulcer, which
was at this time as large as a shilling. I gave him
the pilulæ hydrargyri, whilst I tried by local means
to quiet the irritation of the sore, and of the sur-
rounding parts. As the sore appeared to heal slow-
ly, and seemingly in proportion to the quantity of
mercury taken, the patient rubbed in at the same
time some mercurial ointment, and continued to do
so till after the sore was well, which was in about
a month. In three weeks after he had left off these
medicines, this patient applied to me on account of
an ulceration on the velum pendulum palati, and
on the surface of one tonsil; and soon afterwards
ulcers took place on the edges of the tongue, and
on the inside of the lips and cheeks. Copper-co-
loured spots also came out on his arms and legs,

200
On Diseasts
and all over his body. They were very numerous,
watching the progress of the disease, I found that
some of the ulcers amended spontaneously, and
to refrain from mercurial medicine, and he went
into the country. A medical gentleman, whom the
patient consulted, was very anxious to try some-
thing to cure this disease, when his patient was
seized with a severe febrile complaint, during the
continuance of which all these doubtful symptoms
disappeared, and there has not been any return of
disease since that time.
CASE VIII.
A gentleman had a small sore on the prepuce,
at a little distance behind the corona glandis, which
did not appear like a venereal chancre, and there-
fore no mercury was used. After about a fortnight,
during which time it could scarcely be said to be
better or worse, it suddenly became considerably
indurated in its circumference, and the surround-
ing parts became inflamed. The hardness was so
considerable that it resembled one of those indu-
rated chancres which so frequently occur; and in
consequence of this striking resemblance, another
surgeon, whom the patient consulted at this time,
insisted on his confining himself to his chamber,
and using mercury attentively.
The quietude of the patient, with some little at-
tention in regard to local applications, soon remov-
ed the inflammation and hardness, and the patient,
who was controlled by nothing but his fears, dis-
continued his medicine after thrice using some
mercurial ointment, and returned to his former
mode of life.
About a month afterwards, he called on me with
resembling Syphilis.
201

an uicer in each tonsil, one of which was deeply
excavated, with irregular edges, and covered by
adhering matter. Shortly afterwards, copper-co-
loured spots appeared on his body, but these dis-
eases all disappeared in about a month, without
using mercury.
CASE IX.
A gentleman applied to me with a very irritable
sore, or rather excoriation, extending itself over
the left half of the corona glandis. It was unlike a
syphilitic sore, as may be supposed from this de-
scription, yet, as the patient was young and healthy,
I advised him to take some of the pilulæ hydrar-
gyri to guard against the possible consequences of
absorption, and to bathe the parts affected with the
aq. litharg. acet. comp. c. opio, and to apply folded
linen moistened with the wash round the penis,
The prepuce soon became swollen and inflamed, so
that he was unable to retract it, and the attempt
gave him great pain. He was therefore directed to
cleanse the part by injecting frequently the decoc-
tion of white poppy heads of a lukewarm tempera.
ture. After a week he tried a very weak solution
of vitriolated zinc, and other metallic salts, but they
all increased his pain, and he was obliged to return
to the use of the anodyne wash. When he had per-
severed in this course three weeks without any evi-
dent amendment, he consulted another surgeon,
who recommended the discontinuance of the mer.
curial medicine, and in lieu of it, the free use of
the bark. This medicine he took for a week with-
out any amendment; he then tried the nitrous acid
for ten days, and afterwards took cicuta.
In about two months he was able to retract the
foreskin, and then the solution of vitriolated zinc
appeared to lesser the irritability, and contribute
2 C

202
On Diseases
to the skinning of the sore, which was merely on
the surface, not having been attended with any loss
of substance.
Afterwards the penis being subjected to some
accidental irritation, the same kind of soreness
spread over the other half of the corona glandis;
but this disease was not accompanied with so much
tenderness as the former one, and got well in less
than a month. As soon as it was well, the patient
had an ulceration of the velum pendulum palati,
round which the cuticle assumed a whitish colour;
the ulceration spread across the palate, but it was
evident that the part first affected got better, whilst
the ulcer became worse in the parts last affected.
Two or three ulcers took place upon each edge of
the tongue, and some on the inside of the lips. At
the same time many copper-coloured spots ap.
peared on the face, breast, arms, and lower extre.
mities; they came out in succession, were of an
oval shape, about the size of a sixpence, and had
a strikingly syphilitic aspect.
Believing that the primary symptoms of this dis-
ease were not syphilitic, and observing that some
part of the ulcer on the palate healed, and that some
of the sores on the tongue and lips got better, whilst
new ones broke out, I recommended the patient to
use no mercury. He went into the country, where
all these maladies gradually disappeared, and in
about a month he was perfectly well.
CASE X.
A person, whose irregular habits of life gave
reason to suspect the existence of syphilis in the
perficial, but deep. These were accompanied with
copper-coloured spots on the face and breast, and
eruptions on the head amidst the hair, accompanied

resembling Syphilis
203
with a great deal of scurf. These got well by anoint-
ing the head with ung hydrarg. nitrat. mixed with
simple ointment, which made me doubt whether
the other diseases were really syphilitic, and caused
me to delay the use of mercury. The complaints
did not amend, nor did they get materially worse.
There was attending these diseases a good deal of
general indisposition; the appetite failed, and no
sleep took place till the morning.
At this time a tenderness and thickening of the
periosteum of the tibia took place. Though other
medicines did not appear to be of any service I still
was averse to the use of mercury. Tired of delay,
the patient consulted another surgeon, who de-
clared the disease to be venereal, and desired that
mercurial ointment might be used. The patient
accordingly rubbed in two or three nights without
feeling any effect from the medicine, and then set
off on a party of pleasure to Brighton, where all the
diseases gradually disappeared without any further
use of mercury.
CASE XI. -
A gentleman had an enlargement of a gland in
the groin, probably from the absorption of some
infectious matter, though he was not conscious of
having had any sore. A second and a third gland
became enlarged, the integuments became thick-
ened and inflamed, and a very large bubo formed.
It suppurated and burst in three places. The gene-
ral tumefaction subsided, but by no means dis-
persed, and sinuses remained where the abscesses
had been. About this time I saw the patient, which
was two months after the first appearance of the
disease.
Shortly after this, he had an ulceration, which
spread over the velum pendulum palati, and ex-

204
On Diseases
cept that it was more superficial, much resembled
a syphilitic ulceration. It continued so long with-
out amendment, that I began to think it was syphi.
litic. Bark was now given plentifully, and the ulcer
evidently amended. The patient went afterwards
to the sea-side where the bubo gradually dispersed:
many months however elapsed before it entirely
disappeared. The ulcerations of the velum pendu-
lum palati also healed slowly; and ulcers, which af-
terwards appeared in the back part of the pharynx,
got well likewise without mercury.
rious, but because they all occurred to me within
the space of a few months, and because sufficient
time has elapsed since their occurrence to show
that there is no probability that there will be any
recurrence of these or similar symptoms. It must
be allowed that they are incontestable instances of
diseases getting well without mercury, which could
not be distinguished by mere inspection from sim-
ilar diseases truly syphilitic. For though mercury
was employed in some of the cases, it was used at
such a time, or in such quantity, that it cannot in
the least influence our decision as to this point.
For instance, in the first case though mercury was
employed for the cure of the primary ulcer, and did
apparently contribute to it; yet the secondary symp-
toms got well without mercury, which, according
to the opinions now prevailing among surgeons, is
a proof that neither was syphilitic. It may indeed
be supposed that the syphilitic poison may be mo-
dified by certain constitutions, and its effects spon-
taneously disappear; and some may question if the
secondary symptoms were the consequences of the
sores or absorption to which I attribute them.
What I have written is, I believe, in conformity to
resembling Syphilis.
205

prevailing opinions, and I forbear to enter into un-
certain discussions.
These instances, however, though not selected
for the purpose, show that the primary infected
sores which are capable of producing secondary
symptoms, strikingly resembling those of syphilis,
do not themselves possess any uniform characters.
In the first case the ulcer had no uncommon ap-
pearance; it was of the size of a shillling, with fret.
ful edges, and every where covered with granula-
tions. In the second there were no apparent granu-
lations, and a great degree of induration suddenly
surrounded it, giving it a striking resemblance
to the indurated venereal chancre. In the third,
the sore surface was extremely irritable; but
though the disease existed for a long time, the ul-
cerative process did not eat into the part; and at
the conclusion of the case there was no loss of sub.
stance. In the fourth and fifth cases, the absorp-
tion of the matter, which caused the secondary
symptoms, either took place without any breach
of surface, or the primary sores were too insignifi-
cant to excite attention. I lately attended a gentle.
man who had an ulcerated throat, and eruptions on
the head, which broke out between the second and
third month after the appearance of a sore on the
prepuce, which sore healed in a few days with no
other treatment than bathing it with a solution of
acetated lead, and applying to it a piece of lint
moistened with that liquor. This circumstance
made him disregard the primary sore, but he was
assured by a surgeon, whom he consulted, that
the secondary symptoms were syphilitic; they how-
ever got well without mercury.
It is probable, that the morbific poisons which
produce pseudo-syphilis may be absorbed without
any evident ulcer, or from a trivial ulcer, which

206
On Diseases
may heal spontaneously, much more frequently
than the syphilitic poison; and if the consequent
constitutional symptoms are considered as the ef-
fects of the latter disease and treated as such, I
need not say what confusion must be produced in
the mind of the surgeon who pursues this conduct,
and how bewildered his opinions must be respect.
ing venereal diseases. If, for instance, in the ele.
venth case, a surgeon had considered the second-
ary symptoms as syphilitic, and employed mercury
successfully for their cure, he would set this down
as a case of syphilitic bubo occurring without a
previous chancre, and be inclined in his general
practice to use mercury in all cases of buboes with-
out chancre, lest constitutional diseases should en.
sue. There, however, does not appear any thing
that should exempt the glands of the groin from
enlargement, and diseases to which other absorbent
glands are subject, whilst they are particularly lia-
ble to irritation and consequent disease from dis-
orders of the urethra and other parts, to which they
are connected by means of their vessels. The use
of mercury as a specific, therefore, in enlargements
of these glands, unless they have been preceded
by a chancre, must, I think, be considered as im-
proper.
I have met with many similar cases since those
five that have been related, and of which, from their
sudden and almost simultaneous occurrence, I was
induced to take a written account: within these two
months, I have seen two cases of eruptions and
three of sore throats. The eruptions took place par-
ticularly about the hands and feet: in one case, the
patient has been salivated for them; the disease,
however, recurred, and afterwards got well with-
out the use of mercury. In the other, there were
warts and sores on the prepuce, and buboes in the

resembling Syphilis. 207
groin, which suppurated and burst: the eruptions
so strikingly resembled those of syphilis, that all
the medical men, who accidentally saw the patient,
exclaimed that they were so, with a confidence
proportioned to their professional skill and accu-
racy of observation. Indeed in this case, and in
others, I have been almost impelled to use mer-
cury, in consequence of the opinion and wishes of
the patient and those of his friends. The history
however of this disease did not accord with that of
syphilis; the warts had preceded the sores; some
sores healed, and others broke out; and at last,
some of the eruptions began to get well, and the
rest gradually disappeared. The third patient had
a sore throat for which he had been salivated: it af-
terwards recurred, when it got well without mer-
cury. The fourth and fifth had ulcers in the throat
and on the lips and tongue: they all got well with-
out mercury. One of the patients who had the sore
throat had been salivated, but the disease recurred.
In the other two I forbore to use mercury, and I
have reason to say they will do well without it. In
one of the latter cases there were ulcers on the
tongue and the inside of the lips.
If, then, the occurrence of such cases be fre-
quent, and the necessity of discriminating them
from those of syphilis be of great importance, we
may solicitously inquire by what circumstances
we are to distinguish between diseases so similar
in appearance, but so different in their nature.
Mr. Hunter seemed to wish the prosecution of this
subject, probably from the expectation that some
characters appropriate to these diseases might be
detected: I have not, however, been able to dis-
cover any; the fictitious disease in appearance so
exactly resembles syphilis that no observation,
however acute, seems to be capable of deciding



208
On Diseases
upon its nature. Although the ulcers in these am-
biguous cases generally spread more extensively
along the surface of the part which they affect, yet
this does not constantly happen, as is shown in
the eighth case. In this case, however, the indura-
tion which surrounded the chancre occurred sud-
denly, and went away as rapidly. The progress,
therefore, of the two diseases was very dissimilar. **
It must also be remarked, that true syphilitic spots
and ulcers sometimes assume the appearance of
other diseases, and do not possess their ordinary
characteristics.
Since, then, our senses fail us in our endeavours
to discriminate between these two diseases, and
since the most important circumstance is to dis-
tinguish whether the disease be syphilis or not, we
may inquire whether there are any circumstances
in the progress of these different diseases which
will serve us in distinguishing one from the other.
It appears to me that there are; and these cases are
* On the subject of induration surrounding chancres I
think it may be useful to relate the following case, and to
mention that I have known similar ones in a less degree:
A student in surgery showed me an indurated chancre, for
the cure of which he had used a great quantity of mercury,
which had affected his mouth for a long time, though not
severely. The sore so exactly resembled a bad indurated ve-
nereal chancre that I did not hesitate to recommend him to
remain at home, and rub in so as to produce a slight saliva-
tion. But as no amendment was perceived after a fortnights
confinement, and under a considerable affection of the mouth,
I was induced to inquire more strictly into the local treat-
ment of the sore, which I found he was constantly irritating
by various stimulating applications. He also affirmed that the
hardness had several times gone away and returned again. By
bathing the part with milk and water, and dressing it only
night and morning with mild salve, the hardness quickly
abated, and though he desisted from the mercurial course it
soon became perfectly well,

resembling Syphilis.
209

published not merely to show the frequency of
such occurrences, and the necessity for discrimi.
nation, but to engage a more general attention to
the means by which such distinction may be made.
A very simple fact has enabled me in most cases to
distinguish between the two diseases; yet, simple as
it is, if it be generally true, it is very important; and
if it were universally true, it would be of the highest
consequence. The fact alluded to is, that the con-
stitutional symptoms of syphilis are generally pro-
gressive, and never disappear unless medicine be
employed. It may be added too, they are as gen-
erally relieved under an adequate effect of mercury
on the constitution. An attention to such plain and
simple circumstances has been of great use in
directing the medical treatment which I have pur-
sued, and I am induced to solicit the public atten-
tion to them, that others may determine the value
of such remarks.
I have asked the opinion of several surgeons of
great practice and abilities respecting this ques-
tion; Whether constitutional symptoms of syphilis
do ever spontaneously amend? and no one has de-
cidedly replied in the affirmative, whilst all, with-
out hesitation, agreed that they were generally pro-
gressive till checked by the effect of mercury. It
seemed useless to seek further information; for
what surgeon is there at present, if he sees dis-
eases that cannot be distinguished by the sight
from syphilis, and hears that they arose in conse-
quence of a chancre, that would suspend his judg-
ment, and forbear to administer mercury? If I have
lived in the habit of so frequently detecting the
imposing appearances of the secondary effects of
these diseases, it is because I have been upon the
watch, and because they have occurred in patients.
2D

210
On Diseases
in whom I have seen the primary sores, the appear-
ance and progress of which have excited my sus.
picion as to their nature. I have stated the rule as
general, but not universal; for I could myself relate
cases of diseases, in which, from the great abate-
ment, and even disappearance of symptoms, I have
concluded the disease was not syphilitic; yet, from
the duration of the disorder, or from the subsequent
aggravation of its symptoms, the patient has de.
sired, and I have recommended the use of mer-
cury, and the disease has been successfully treated
as syphilitic without its real nature being ascer-
tained.
The rule which has been mentioned relates to
the constitutional symptoms of the venereal dis-
ease, for the primary ones, chancres, do sometimes
heal spontaneously, generally however, though not
constantly, leaving a thickening or induration of
the affected part. They may also be induced to
heal by topical means, without mercury, with simi.
lar events. Some enlargements of glands in the
groin will also in like manner subside. -
It may be fairly supposed that if some chancres
heal spontaneously, constitutional diseases arising
from the same cause, may, in like manner, some-
times get well without mercury. The question
can only be solved by experience. Delay will I am
sure frequently enable a surgeon to decide, that
the disease is not syphilis; but there are cases in
which no amendment takes place, and the surgeon
is as it were forced, from the progress of the dis-
ease, to employ mercury, though doubtful of its
nature.
In recommending prudent delay and attentive
observation, I hope and believe that I am not re-
commending any thing likely to be of dangerous

resembling Syphilis.
211
-6
consequences. The venereal disease is generally
soon checked by the use of mercury; and in con-
stitutions where much medicine is required to
counteract its effects, that medicine may be given
with freedom. By delay and observation we per-
haps may perceive that eruptions and sore throats,
which could not from appearance be distinguished
from venereal, spontaneously amend: that some
eruptions scale and become well, and the proba.
bility will of course be that the rest will do so
likewise: or that an ulcer mends in one part though
it may spread in another, when the natural infer-
ence is, that the diseased actions in the sore will
gradually cease, and health return spontaneously;
and that what has occurred in one part of an ulcer
will successively take place in the others.
In recommending delay it cannot, I suppose, be
thought that I would advise any one to wait till an
ulcer destroyed the velum pendulum palati, or did
material injury to any important part. There are
cases where the progress of the disease obliges the
surgeon to use mercury, even though he may be
suspicious that it is not syphilitic. The effect of
exciting a mercurial affection of the constitution,
where we feel ourselves under the necessity of
employing that medicine, in diseases resembling
syphilis is, as far as my observation enables me to
determine, very various. It sometimes cures them
very suddenly, and very differently from the grad.
ual amendment which it produces in truly syphili-
tic diseases. Sometimes, however, these diseases
yield more slowly to its operation, and are cured
permanently. Sometimes the diseases recur in the
same parts after a severe course of mercury; some-
times mercury merely checks the disease, and can
scarcely be said to cure it; in which case it seems

212
On Diseases
important to support the strength of the constitu.
tion, and to keep up that mercurial effect which
controls the disease, and can be borne without
material derangement of the constitution for a
great length of time. Sometimes also the use of
mercury aggravates these diseases.
Again, in some constitutions, syphilitic disease
inay assume unusual characters, and be very diffi-
cult of cure. It must then be scarcely possible to
discriminate between these anomalous cases of sy.
philis and those of diseases resembling it, unless
some new distinctions are discovered.
But I suppress any further observation on the
subject, having accomplished the intention of this
paper, which was to depict a kind of cases which
very frequently occurs in this metropolis, and
which is, I believe, too commonly treated as sy.
philitic, but which may be distinguished not to be
so by a little prudent delay and attentive observa.
tion. The frequent cases of such disorders which
I have recently met with, has suggested the idea
that they are increasing of late; nor is it improba-
ble, since they are like syphilis, propagated by pro-
miscuous intercourse from secretions, or sores not
so readily curable by mercury as those that are sy-
philitic, and some of which are not from their na-
ture so prohibitory of that intercourse.
It is now years since this paper was drawn out
as a subject for discussion at a medical society;
and, after such an interval, the chance of any of
the disorders which are described in it returning
is diminished almost to nothing. I have since met
with considerable numbers of similar diseases,
which give confirmation to the opinion that they
are frequent occurrences. In some later cases,
when the disease has been long protracted, and the
patient very anxious to get rid of it, I have given a
resembling Syphilis. 213

little calomel for that purpose, but not so as to in-
validate the opinion that the disease was not syphi-
litic. Having waited, for instance, four months from
the occurrence of a sore throat with eruptions, and
being assured by the progress of the disorders that
they were not syphilitic, I have directed that the
compound calomel pills* should be taken in such
doses as to control the disease without weakening
the constitution, which generally disposes the sores
in the throat to heal, but I have taken care to remit
the use of even this small quantity of mercury if it
seemed to heal the sores too speedily; for it seems
to me better to let the disease exhaust itself, than
suddenly to cure it, as in the latter case it is very
likely to return. In confirmation of this opinion I
may mention, that, about five years ago, a gentle.
man applied to me to undergo a salivation for the
cure of a sore throat, for which he had been sali-
vated three times, once in each succeeding year,
I need scarcely say that it was one of those ul.
cerated throats which have been described. All
medicine was abstained from; and in between three
and four months the sores spontaneously became
well, and have never since recurred. The whole of
this paper has been written upon the presumption
that diseases which spontaneously get well are not
syphilitic, which is, I believe, the general opinion.
It may, perhaps, be questioned by some, whether
the diseases here recorded may not be modifica-
tions of the venereal disease. The practical rules
of conduct will not, however, be altered even if such
a supposition were verified, so that it does not seem
necessary to discuss this point: it may however be
* The pill, as prescribed in the pharmacopeia of St. Bar.
tholomew's Hospital, contains 1 grain of calomel, 1 grain of
the precipitated sulphur of antimony, and 2 grains of pow.
dered gum guaiacum.
214
· On Diseases

right to remark, that there are cases which would
induce the belief that ulcerated sore throats, erup-
tions, and nodes on the bones, similar to those de-
scribed in this paper, may occur from a general
disturbance of the constitution, without the absorp-
tion of any infectious matter.
The object of this paper being simply to excite
attention to such cases as are recorded in it, I did
not think it necessary to enlarge much upon a cir-
cumstance which, however, is a strong evidence of
the necessity of discriminating between such dis-
eases and true syphilis. The circumstance to which
I allude is, that though a course of mercury may
at the time remove all the symptoms for which it
has been employed, yet it will not cure the consti-
tutional disease; for the symptoms will recur when
the medicine has been discontinued after repeated
and severe courses of mercury, as will be fully
shown, by cases which I shall afterwards relate.
Having written the foregoing account, I intend-
ed here to conclude, having, in my own opinion,
accomplished my purpose, which was to prosecute
in some degree the subject which Mr. Hunter
deemed worthy of investigation, and to depict the
circumstances of diseases which I believe very fre-
quently occur, and which are often confounded
with cases of syphilis, to the detriment of patients,
and the discredit of our profession. But having re-
quested the opinions of two of my medical friends
on the foregoing paper, one of them said, that he
thought the publication of it would be injurious,
as it might induce the younger surgeons to abstain
from the use of mercury, to the prejudice of their
patients; the other gentleman said, that he thought
more explicit descriptions should be given of the
cases in which mercury should be withheld or em-
ploved. In consequence of these opinions, I am

resembling Syphilis. 215
induced to take a closer comparative view of the dis-
eases that are, and of those that are not syphilitic.
I undertake the task reluctantly, because the
brevity with which I must speak of these subjects
may render my opinions liable to misapprehension,
and because I do not feel competent to its proper
performance. Yet, by this means, I think I shall
do away the objection of one of my medical friends;
for I believe that I am myself more likely to errin
recommending the too free than the too sparing
administration of mercury in diseases of this na.
ture. Any surgeon who has observed the ruinous
consequences of repeated mercurial courses in
some constitutions would probably err in the same
manner; and his dislike to disorder the constitu-
tion by mercury would probably lead him even to
use it more freely than might be absolutely neces-
sary: this he would do in cases clearly syphilitic, in
order to prevent the possibility of the recurrence
of disease, and a repetition of a mercurial course.
In doubtful cases, which are cured by exciting the
mercurial action in the constitution, he would
adopt a similar mode of treatment, in order to sup-
press the disease for so long a time as to make it
less likely to recur; or if any subsequent disease
should take place, to render it highly probable that
this was not syphilitic, since it had broken out af-
ter such a course of mercury as must be consider-
ed to be adequate to the cure of almost any disease
of that nature. By undertaking this task I shall per-
haps comply with the wishes of my other friends,
in stating more explicitly the circumstances which
should induce a surgeon immediately to use or ab.
stain from the administration of mercury, and, at
the same time, contribute my mite of observation
to those already offered on this still obscure sub-
ject of venereal diseases. ,


216
On Diseases
The most clearly marked syphilitic chancre has
been excellently described by Mr. Hunter. The
striking characters of the disease are, an ulcerating
inflammation without any reparation, attended with
induration of the surrounding parts. The descrip.
tion is, a sore of a somewhat circular form, excav.
ated, without granulations, with matter adhering to
the surface, and with a thickened base and edge.
There is another species of chancre in which the
disposition to ulcerate is less than usual, and the
disposition to indurate is greater; so that the ulce.
rated surface may heal, and leave an indurated knob
or tubercle in the affected part.
There are besides some chancres in which the
diseased action seems to be very inert; in these the
ulcer is superficial, the thickening of the surround-
ing parts slight, and, after some time, the ulcerated
surface acquires a state of health, and cicatrizes,
without producing any perceptible granulations. I
conclude that the truly syphilitic chancre some.
times assumes the appearances just described, be-
cause I have repeatedly considered the constitu-
tional symptoms which succeeded to such sores as
truly syphilitic, yet I may have been deceived, for
reasons which I shall afterwards explain.
But it is impossible to depict by words the vari-
ous sores, some of which are of a very irritable
nature, that are produced by sexual intercourse,
and through the medium of which the constitution
becomes contaminated; neither is it possible to
know from local circumstances whether they be
syphilitic or otherwise. It is from their effects
upon the constitution alone, that we can judge
whether they were syphilitic or not. Many we
know are not so, since they do not produce the
constitutional effects of syphilis. The subject can
alone be decided by future experience derived

resembling Syphilis. 217
from watchful observation made by unbiassed men.
Mr. Hunter thought that syphilitic poison might
produce a sore which might be modified by the
diseased propensities of the constitution and the
part, and thus lose its distinctive characters.
Influenced by this belief, he speaks but briefly
on the subject of chancres. I have also seen cases
of constitutional disease, which I considered as sy.
philis originating from primary sores which had
not the usual character of syphilis: the more, how-
ever, that I see of the subject, the more I am in.
clined to doubt the correctness of my opinions on
this point, and of this I am certain, that the greater
number of the constitutional diseases originating
from sores, which have not the syphilitic character,
differ materially in their progress and mode of get-
ting well from those which are the consequences
of true syphilis, and that they require a propor-
tionate peculiarity of treatment.
However, if, according to the opinion of Mr.
Hunter, the action of a syphilitic chancre may be
sometimes so modified by the diseased propensi-
ties of the constitution, or part, as to form an ulcer
scarcely cognisable as a syphilitic one, it follows,
as a general rule of conduct in practice, that sur-
geons are not to confide in their powers of discri.
mination, but in all cases of ulcers arising from im.
pure intercourse, to act as if the sore was syphili-
tic, to give sufficient mercury slightly to affect the
constitution, in order to guard against the conse.
quences of absorption, and, by local and other gen-
eral means, to cure as quickly as possible the local
disease, and thus remove the source of contamina-
tion, and the necessity for the continuance of me-
dicine. The quantity of mercury necessary for the
cure of a syphilitic chancré will never, I believe,
be found to be so considerable as materially to dis,
2 E
218
On Diseases

turb the constitution. We may therefore, without
hesitation, employ it in almost all cases of primary
ulcers, and be guided as to its continuance or ces-
sation, its increase or diminution, by the effects
which it produces in the sore or constitution. Mer-
cury in small doses inclines other sores to heal, as
well as those which are syphilitic; it may therefore
act beneficially when the disease is not syphilis,
and by contributing to the healing of the sore, re-
move the source of contamination and the neces-
sity for the continuance of medicine. It is surely
an object of importance to get the local disease
well as soon as possible, and topical applications
often greatly contribute to this desirable event;
yet they should not be of a very irritating nature;
for such means frequently aggravate the disease,
as may be seen in some of the cases which are re-
lated; nor should our applications be of an astrin-
gent nature, since by checking discharge, they ill-
cline the disease to become indurated, and it re-
quires a longer continuance of mercury to remove
a small induration than to heal a large sore. This
observation applies equally to sores of a syphilitic
nature and to others. Whilst there remains an in-
duration, we can never be sure that it may not ul-
cerate again, upon leaving off the use of mercury,
nor can we be assured that it may not contaminate
the constitution. Indeed, in the syphilitic chancre, it
seems best to use none but the simplest dressings;
for when it heals by the effect of mercury on the
constitution, we are assured of the adequateness
of the quantity which is employed to the intended
purpose, and we have reason to believe that the
constitutional mercurial affection which has sub-
verted the local actions of the disease, will have
prevented its contamination by any matter that
may have been imbibed from it. If then we may,


resembling Syphilis. 219
for the reasons above stated, employ mercury with
out hesitation in primary infected sores, being gov.
erned with respect to the degree and duration of
its use by its effects, we ought, as has been shown
in the preceding part of this chapter, to pursue the
reverse conduct with respect to constitutional
symptoms. Here we are required to hesitate, that
we may learn the nature of the disease previous to
attempting its cure. It has appeared to me, that a
longer and more active operation of mercury on
the system is necessary for the permanent cure of
constitutional symptoms in true syphilis, than for
that of the primary chancre. Here, if we use mer-
cury unhesitatingly, we may employ it to an inju-
rious degree, where it is not wanted, and we gene-
rally fail in preventing a recurrence of symptoms.
These are, I believe, the general rules of practice
adopted by the best surgeons, and they appear to
me, in the present state of our knowledge of these
diseases, to be judicious. One advantage results
from this plan of conduct, which is, that if consti-
rutional symptoms follow from a sore treated in a
manner that ought to have prevented contamina-
tion of the habit had the sore been syphilitic, our
suspicions are excited, and by attentive observa.
tion we may perhaps discover that the symptoms
are of another nature.
In cases of anomalous sores it may be inquired,
if in those where the event renders it probable that
they were of a syphilitic nature, the disease devi.
ates materially from its common characters, that of
an ulcerative process without reparation, and ex-
tending in every direction. Do these sores enlarge
by sloughing, or produce granulation or fungus?
do they spread otherwise than nearly equally in
their whole circumference? does the ulceration ex.
tend in them only in particular directions? do they


220
On Diseases

heal in one part and spread in another? or do they
suddenly amend and become worse without an
adequate mercurial iufluence to produce such
changes. Those infected sores which are not sy-
philitic have such peculiarities, as have been shown
in the first part of this paper, and as they are so
very various, it becomes necessary to distinguish
them from those which are syphilitic, by accurately
noting the progress of anomalous cases of the lat-
ter disease. It is extremely difficult to form any
correct opinions on this subject on account of its
intricacy, and the almost impossibility of abstain-
ing from the use of mercury; but it is a subject
highly deserving inquiry, and which never can be
fairly investigated till it be known that the second-
ary symptoms arising from sores may not be syphi-
litic, though their appearances cannot be distin-
guished from such diseases by sight alone.
With respect to sores that are not syphilitic the
difficulties of investigation are greatly multiplied.
If a description cannot be given of syphilitic sores,
it seems almost absurd to say any thing of those
multiform sores produced by infectious matter,
the qualities of which, it is probable, may be vari-
ously modified, and the effects of which appear
equally liable to modification from peculiarities of
constitution. Yet in this intricate subject there are
certain facts which can be distinctly observed, and
deserve attention. Some of these sores spread by
ulceration, and some by sloughing, of which in-
stances are related in the first section of this paper.
Even Celsus has described several species of sores
which, as Dr. Adams has observed, we are ac-
quainted with in the present day. I have never seen
that phagedenic ulcer, which suddenly sloughs,
affect the constitution; neither do I believe that sur-
geons in general have remarked it; those who re-


resembling Syphilis. 221
gard all these sores as syphilitic attribute the ab-
sence of secondary symptoms to the chancre having
been removed by the sloughing of the surrounding
parts. Yet in the case related by Mr. French in
Mr. Hunter's Treatise on the Venereal Disease,
secondary symptoms did occur from a sore of this
kind, and got well without mercury. It may there-
fore, perhaps, be doubted whether this disease be
not an aggravated form of the sore which sloughs
more slowly, and from which the constitution is
much more frequently affected. Though Dr.
Adams has restricted the term Phagedæna to one
kind of destructive sore, yet I feel more inclined
to leave it as a generic term for all these destruc-
tive sores, and to divide them into species accor-
ding to their peculiar characters. Then we may
describe them as ulcerating phagedenic sores, and
sores which spread by sloughing. Again, the ul-
cerating or sloughing process may extend not in
all but in particular directions, and the sloughs
may take place from the edges or from the whole
surface. As Dr. Adams has treated these subjects
at large, I refer the reader to his book; but I will
take upon me to describe some species of sores
which frequently occur, and are treated generally
as syphilitic, but which I am convinced are not so.
. The sores, in one species alluded to, generally
break out in succession, and sometimes after con-
siderable intervals of time; which circumstance, if
remarked, would render it improbable that they
arose from infection of the ulcerated part, since
such sores would probably be contemporary. The
ulcer is at first inflamed, and spreads ordinarily to
the size of the finger nail: its circumference is
thickened; it throws out new flesh, which rises
above the surrounding skin; sometimes there is an
appearance of several little cells or spaces in the


222
On Diseases
interstices of the granulations, if they may be called
so, owing to the whole ulcer not producing new
flesh in an equal degree. The edges of the sore
generally retain their diseased state after the mid-
dle has become healthy; from this cause, the heal.
ing of the sore is retarded. These sores are slow in
healing under any mode of treatment, and they
generally get well in the same succession as they
broke out. They sometimes form in a circle round
the orifice of the prepuce, and cause a contraction
in that part after they have healed. I do not mean
to say that all sores occupying this situation are
not syphilitic, but merely to state, that sometimes
after a gonorrhea of the prepuce, either originally
occurring there, or having happened by a metas-
tasis of disease from the urethra, sores do break
out in this situation at a remote period from the
reception of the infection, which are not syphilitic.
The sores which I am endeavouring to describe,
seem to be the consequence of an irritated state of
the prepuce, from which there is sometimes a slight
general discharge, like that which takes place
when the gonorrhæa shifts its situation from the
mouth of the urethra, and becomes the gonorrhæa
of the prepuce. The glands in the groin sometimes
swell from irritation in these cases, and generally
subside again, though I have known them sup-
purate: but I never saw any secondary symptoms
succeed to this species of ulcer.
In the earlier part of my practice, in conformity
to general rules, I used to give mercury in these
ulcers to secure the constitution against infection,
whilst I tried to heal the sores as speedily as I
could by topical applications. Slightly destroying
the surface with the argentum nitratum every
second day, and dressing with the solution of zin-
'cum vitriolatum, were the local means which


resembling Syphilis.
223
seemed to be most successful. An attention to the
history of the disease, and frequent applications for
advice from persons who had been severely and
unavailingly salivated for the cure of this species
of sore, soon emboldened me to abstain from the
use of mercury, and I have never found, though I
have met with a considerable number of instances,
that I have in this respect acted wrong.
I shall mention the circumstances of a case
which occurred to me no long time ago. A gen.
tleman had a slight irritation in the urethra, and
after a few days, found the prepuce a little swollen,
with a small discharge from beneath it. This was
checked by a weak solution of zincum vitriolatum;
and afterwards three sores, such as I have descri.
bed, broke out in succession, for which he used
mercury so as to affect his mouth. The sores slowly
healed, but two new ones made their appearance,
and the mercurial course was persevered in. These
sores also healed slowly, and a running came on
from the urethra, no new'sores having appeared. The
mercury was left off, the gentleman came to town,
and was much distressed to find that three other
sores, exactly like the former ones, now broke out,
but the discharge from the urethra had ceased. At
this period he applied to me, and gave me the fore-
going narrative of his disorder, with an assurance
that he had exposed himself to no new risk of in.
fection. I employed only local means for their cure,
being satisfied by the history as well as the appear.
ance of the sores that they were not syphilitic.
Near a month elapsed before any considerable
amendment took place, when a swelling appeared
in the groin, and the sores healed suddenly in a
few days. Leeches and Goulard's wash were em-
ployed to disperse the bubo, but in vain: it suppu-
rated, and formed a very unhealthy abscess. There
224
On Diseases

was a great deal of surrounding erysipelatous in-
flammation, the cuticle separated from the surface
of the bubo, the skin became livid, and gave dis-
charge to the matter by a partly sloughing and
partly ulcerating process. This, however, proved
the crisis of the complaint: the abscess having thus
broken filled up, and healed in the course of about
three weeks, since which the patient has had no
return of disease. This gentleman was liable to
have sores break out spontaneously on the pre-
puce: they got well readily by bathing them with
a weak solution of zincum vitriolatum; and I be.
lieve that persons who have naturally an irritable
state of the prepuce are most obnoxious to such
affections. We must not, however, impute the oc.
currence of these peculiar sores to mere irritability,
but to some specific contagion.
The discharge from the urethra in such cases is
not considerable, nor attended with much inflam-
mation or chordee, nor does it increase in violence;
it may therefore be easily distinguished from com-
mon gonorrhæa and its varieties..
Sometimes in a common gonorrhæa, the disease
shifts its ground and attacks the foreskin, and sores
form about the orifice of this part. These are of a
different nature from the sores which I have been
describing: their surface is generally glossy, not
producing exuberant new"flesh, and their colour is
unhealthy. They generally get well as the disease
returns to its original situation in the urethra. I
merely mention these circumstances to induce at-
tention, and to prevent surgeons from confounding
the sores which I have been describing with any
others similarly situated, but different in their na-
ture.
I wish also to excite attention to another species
of sores which I have frequently met with, and


| resembling Syphilis.
225
which differ considerably in their progress from
those truly syphilitic. The first appearances of the
sores are various, but in their progress a thicken-
ing in the surrounding parts takes place, whilst the
centre is soft and less diseased than the circum-
ference. I have seen the surrounding parts much
elevated, and an opening leading into a cavity in
the middle. I have seen them, on the contrary,
heal with a flat surface and acquire a circular hard-
ness, the middle being quite soft, and the area of
the circle gradually increase. I have known sores
heal apparently well and smoothly, and afterwards
the edge has acquired a circular hardness like a
ring of some firm substance.
In all these sores I have given mercury in doses
short of producing a tenderness of the gums, and
the disease has gradually but slowly got well. In
the greater number of cases no constitutional affec-
tion has ensued. In some, however, it has, but it
has got well without mercury, or with such small
doses as would certainly not have cured syphilis.
So that these observations concur with the history
of the disease, in inducing me to believe that sores
of this description are not syphilitic.
Under this head of sores which occur on the
genitals, and which are not syphilitic, I may men-
tion one species that I have several times seen on
the side of the penis, which is herpetic, affecting
new parts whilst those first affected get well; so that
the sore may exist a long time, and be very trouble-
some, though its situations may have varied con.
siderably.
I have also seen a circle of small sores, like what
takes place in tinea, occur on the outside of the
prepuce in consequence of some acrimonious se-
cretions being applied to it in sexual intercourse.
Some diseases, whatever may be their primary
2F

226
On Diseases
nature, do, after a time, extend themselves between
the integuments and the subjacent parts. I have
known many diseases which burrow in this man-
ner treated as syphilitic, and, as the event of the
cases has proved, improperly. Indeed, the progress
of such diseases is so different from that of syphi-
lis, that it is natural to discredit their being so.
Diseases which proceed in this manner seem to be
of an irritable nature, and to affect most those parts
which have least powers of life, which appears to
be the cause of their peculiar mode of extending
themselves.
To corroborate this remark, that sores which
burrow are not likely to be syphilitic, I may men-
tion the case of a gentleman of the medical profes-
sion, who had a sore of this description, which be-
gan on the dorsum penis, near to the pubes, for
which he rubbed in two months, and had his con-
stitution considerably affected; nevertheless, the
sore spread and burrowed under the integuments
of the pubes, and the mercury was left off. The
disease became communicated to a considerable
district of the integuments of the bottom of the
belly, and to those of the scrotum. The affected
parts sometimes ulcerated and sometimes healed.
A great variety of local and general remedies were
tried without benefit. No mercury was used except
in very trivial quantity. The cavities beneath the
skin were in some parts laid open, at different peri-
ods of the disease; but without much advantage.
After two years and a half the disease became well,
when nothing but simple dressings were applied,
and when he took nothing but decoction of sarsa-
parilla and small doses of rhubarb.
I have in the foregoing pages endeavoured to
represent briefly the circumstances of the primary
ulcers of diseases which are, and of those which


rese
resembling Syphilis. 227
are not, syphilitic, and to state the general rules
for the administration of mercury; and, at the same
time, I have described some sores which have not,
as far as I know, been distinguished, and which, in
my opinion, are not syphilitic, though they are ge-
nerally treated as such. To take a similar compa-
rative view of constitutional diseases arising from
these various sores would render this paper too
prolix. I hope it will be seen that I do not presume,
nor do I see cause, to deviate from the established
rules of practice founded on the general experi-
ence of surgeons. It would indeed, in my opinion,
be presumptuous in an individual to form general
rules drawn from his scanty experience; I may be
allowed, however, to remark, that individuals of
the profession are likely to err by inferences drawn
from their own practice; and it appears to me that
some professional men at present are inclined to
believe all sores arising from impure connexion to
be syphilitic, whilst others may be too scrupulous
in expecting all syphilitic sores to possess their
common characters. The truth probably in this,
as in other cases, lies between the extremes. Much,
however, it must be acknowledged, remains to be
ascertained, and I think that those surgeons would
do 'essential service to science, who would give an
accurate account of the irregularities of the vene-
real disease. But such an account never can be
given by one, who esteems all diseases syphilitic
which resemble them in appearance. The fore-
going cases will, I think, at least prove this to be
fact; and it was a principal incitement to their pub-
lication, that if this fact were generally admitted,
it might excite that scrupulous attention and im-
partial observation of syphilitic diseases, which
would probably lead to accurate distinctions, and
the removal of that obscurity with which they have

228
On Diseases
hitherto been surrounded. I have suppressed many
observations of my own on this subject, from a be-
lief that it is better to say nothing than to offer opi-
nions not fully confirmed by facts. The idea that
syphilis is a most variable and Proteus-like disease,
has probably arisen from those irregular diseases
which I have described in the first section of this
paper having been confounded with it. The opinion
is however prejudicial, as it checks attentive obser-
vation by declaring its inutility. If it should be in
our power, as I should hope it may, by directing
our attention to the history rather than to the ap-
pearances of these diseases, to distinguish syphilis
from other complaints, then we may also be able to
describe the irregularities of this disease, and to
inform others when it assumes deceptive charac-
ters, and pursues an unusual track, what disguise
it puts on, and what courses it follows.


resembling Syphilis.
229
SECTION III.
On the constitutional Origin of Pseudo- Syphilitic
Diseases.
IN order further to elucidate the nature of pseu-
do-syphilitic diseases, I published some cases in
which they originated spontaneously, or without
there being any reasonable ground for supposing
that morbific animal matter had been imbibed to
contaminate the constitution. The cases included
in this section were first published, amongst others
which were designed to show the importance of
correcting disorders of the digestive organs in at-
tempting to cure local diseases. A disorder of those
organs constantly exists in these cases; and pro-
duces, or at least aggravates and protracts a state
of weakness and irritability of constitution; to
which the origin of the disease must undoubtedly.
be referred.
CASE XII.
A gentleman residing in the country, who had
been many years married, and whose moral char.
acter prevented any suspicion of his having ex-
posed himself to venereal infection, had an ulcer
in the right tonsil, possessing every character of a
truly syphilitic sore. The figure of the ulceration
was oval; it had extended itself deeply, and pre-
sented a surface covered with adhering matter, and
without the least appearance of granulations. It had
continued three months without amendment, al-
though various medicines had been employed dur-
ing that period. These circumstances impressed.
the minds of the medical attendants with an opin-

230
On Diseases
ion, that the disease was syphilitic. On me they
had a contrary effect. I thought that a syphilitic
ulcer would have become materially worse in that
time, as mercury had not been used to arrest its
progress. Finding that the patient had a furred
tongue, and disorder of the digestive organs, I re-
commended, as the first object of attention, the
correction of that derangement of the stomach,
from which the sore throat had probably origi-
nated. The patient went to the sea-side, where his
throat was alternately better and worse; but the
dimensions of the ulcer were not enlarged. Three
months elapsed before I saw the patient a second
time; when I told him that my argument against
the complaint being syphilitic was greatly strength.
ened. It was manifest that the disorder, to which
I had imputed the sore, still existed. Being un-
willing however that the responsibility should rest
entirely upon myself, I advised him to consult an-
other surgeon, who, judging of the nature of the
sore from its appearance, (which indeed was strik-
ingly characteristical of syphilitic disease,) recom-
mended a course of mercury. The patient under-
went, in consequence of this advice, a regular mer-
curial course; during which the sore got well. Be.
tween two and three months afterwards another
sore formed in the palate, which had the characters
of a syphilitic ulcer, in a still more striking degree,
if possible, than the former. It was situated just
where the soft palate proceeds from the bone. It
was of a circular figure, and so deep as to expose
the bone. The circumference of the ulcer was tu-
mid and inflamed; its edges were not smooth, but
had a tendency to ulcerate. There was no appear-
ance of granulations, and the discharge adher-
ed to the surface of the ulcer. The patient now
applied to me again; when I repeated my original

resembling Syphilis.
231
opinion, that these sores depended on the state of
the health in general. He consulted another sur-
geon, who recommended the use of the Lisbon
Diet-Drink, with the application of the oxymel
æruginis to the part; under which treatment the
ulcer healed; and no other complaint has since oc-
curred, though two years have elapsed.
CASE XIII.
A gentleman, who was habitually subject in a
great degree to disorder of the digestive organs,
had an excoriation of the prepuce, which had con-
tinued about three weeks, when copper-coloured
eruptions came out all over his body, so strikingly
similar to those which are venereal, that some of
his medical attendants recommended the immedi-
ate use of mercury. It was however agreed to de-
lay the mercurial course for a little time; and to
give the patient half a grain of calomel, with three
grains of hemlock night and morning, and a solu.
tion of magnesia vitriolata in mint-water, so as to
keep the bowels freely open. The spots began to
die away almost immediately, and soon disappear-
ed altogether. The patient then mentioned that he
had several times had the same kind of eruption,
which had disappeared in like manner upon taking
some opening medicines.
In calling the reader's attention to those diseases
of the bones which resemble syphilitic affections,
I shall not pretend to relate any case in detail; for
surgeons can seldom trace the progress of these,
diseases for themselves, but are obliged to rely on
the doubtful history given by their patients. I shall
endeavour to sketch the principal parts of the sub-
ject, referring to particular cases, merely to show
that the picture is not drawn from fancy, but is co-
pied from nature.

232
* On Diseases
I have been frequently consulted on account of
supposed venereal affections of the bones; where
the periosteum has been thickened and tender, and
the bone enlarged, and the concomitant pains have
been so much aggravated at night as to deprive the
patient of rest. The history of the case has remov.
ed all suspicion of a venereal origin; while general
indisposition, a furred tongue, loss of appetite, and
other attendant symptoms, have clearly indicated
great disorder of the chylopoietic viscera. By at-
tending to the state of the digestive organs in these
cases, the patient's health is amended; the general
rheumatic pains are diminished; sleep is procured;
and the disease has receded almost entirely. After
some time has elapsed, the bone may again swell,
the swelling may again be checked, and return no
more. Perhaps similar diseases may take place in
other bones, at times very remote from the first oc-
currence of the disorder. If mercury be not em-
ployed, there are decisive circumstances in the his.
tory of the case, which proves that it is not syphi-
litic. Sometimes suppuration takes place, and ex-
poses the bone: this occasionally proves a kind of
crisis to the disease at that part. But the circum-
stances of these affections are so variable as to pre-
clude a complete enumeration of their symptoms.
I shall briefly mention the cases of two patients,
by whom I was consulted about the same time, in
order to identify the diseases to which I allude.
Both these gentlemen had been married for many
years; and there was not the least reason to suppose
that any morbific poison had been imbibed. They
became generally indisposed, had restless nights,
pain in the head, and about the shoulders; and a
painful thickening of the periosteum of the tibia,
with enlargement of the bone, took place. The chy-
lopoietic viscera were disordered in both these

resembling Syphilis. 233
cases. One gentleman had used mercury repeatedly
to a considerable extent, which produced a tempora-
ry alleviation of his disease; but his sufferings seem-
ed to be augmented upon the cessation of the mer.
curial excitement. The other patient never used
any mercury. They both experienced a considera-
ble mitigation of pain from those medicines, which
corrected the state of the chylopoietic organs.
Their diseases were checked, and never became
again so bad as before attention had been paid
to the state of the viscera. Both these patients
were better or worse as the state of the bowels
varied; and they both gradually, but slowly, recov.
ered.
Similar diseases are so common, that I believe
every surgeon of experience will admit that affec-
tions of the bones, with wandering pains, often oca
cur from general disorder of the health. I have
never seen these cases unaccompanied by disorder
of the chylopoietic organs; and I have always found
them most benefited by whatever has tended to
rectify the functions of these organs.
There was no reason, in any of the cases alluded
to, to suspect the absorption of poison. I will add
another, to corroborate this statement. A gentle-
man, who had been married about eight years, and
who had no venereal disease during that period,
was seized with a violent fever, Shortly after his
recovery, a thickening of the periosteum on the
parietal bone took place. The scalp was also much
swollen, so as to threaten suppuration. He was at
this time in ill health, and had great derangement
of the digestive organs. By attention to this latter
disorder, the swelling subsided, and no trace of it
remained. The patient afterwards went into the
country, where his health was still more amended.
In about twelve months he had several tumors of
2 G

234
On Diseases
the same kind in different parts of the cranium; one
alone threatened to suppurate: for these he under-
went a mercurial course, which relieved them, so
as to induce him to persevere in it to an extent,
which almost constantly cures venereal disease.
His health, during the latter part of the mercurial
course, being much disordered by the medicine,
his diseases became proportionally aggravated; he
therefore desisted from the use of mercury; at
which time his complaints were but little better
than at their commencement. These diseases,
however, gradually got well in the space of little
more than a year; still the patient continued in a
bad state of health, the symptoms of which were a
furred tongue, indigestion, and faulty biliary se-
cretion..
I add another case, which came under the obser-
vation of Dr. Baillie. A student of medicine, who
attended the lectures in Windmill-street, was ob-
served to look very much out of health; and, on
inquiry, it was found that he had nodes upon his
shins, which so exactly resembled those that are
venereal, that no doubt was entertained of their
being of that nature. It was therefore earnestly re-
commended to him not to delay the mercurial
course, which seemned requisite for the cure. He
was very reluctant to comply with this advice, and
declared upon his honour that he had similar swel.
lings before he had had any sexual connexion. This
declaration made this proposal to be laid aside; and
the nodes got well by a strong decoction of sarsa-
parilla: without a single grain of mercury being
employed. Now, if this account be accurate, it
shows that diseases like syphilis can arise from dis-
order of the health, even without any sexual in-
tercourse.

resembling Syphilis. 235
All surgeons of experience will, I believe, admit
that diseases resembling syphilis occur from dis-
order of the health in general. In all the cases
which I have instanced, there was not the least
reason to suppose that any morbific poison had
been imbibed to produce the diseases which ex.
isted. I wish much to have this point ascertained
or refuted by the general experience of surgeons.
The cases, which would tend to establish it, must
be of rare occurrence. Most of the instances, to
which I have alluded, occurred in men who had
been long married, and on whose veracity I could
rely. There is also, in my opinion, sufficient in-
trinsic evidence in each case to prove that the
disease was not venereal. It was this kind of cases
which I had in view in my last publication, in dis-
cussing the question whether those diseases, which
may be denominated pseudo-syphilitic, arise from
some modification of the venereal poison, or from
a peculiarity of constitution in the patients, who
are exposed to the action of truly syphilitic virus.
I have there said, that "it deserves to be observed
that diseases resembling syphilis do occur, with-
out any reason to suppose that any morbific poison
has been admitted into the system.” I have been
induced to dwell upon this subject, which may
perhaps be considered more speculative than use-
ful, because if the opinion were verified, it would
explain the occurrence of pseudo-syphilitic dis-
cases in a very striking and satisfactory manner. If
local diseases resembling syphilis may take place
in the throat, skin, and bones, from a certain state
of weakness, and irritability of constitution, then
various modifications of animal matter being ab.
sorbed may so disorder the general health as to
induce such a state of weakness and irritation, as is
likely to produce those symptoms, and such symp-
236
On Diseases

toms are rather to be regarded as arising from the
propensities of the constitution, than from the pe-
culiar properties of the matter which has been im.
bibed. It is shown in my former publication, that
the poison which produces pseudo-syphilitic symp-
toms, is sometimes absorbed without an evident
breach of surface in the skin; sometimes from a
trivial sore which soon heals; whilst, in other cases,
it produces local sores of various and dissimilar
characters.

resembling Syphilis.
237
SECTION IV.
On the Effects of Mercury in Pseudo- Syphilitic
Diseases.
HAVING thus by the publication of the cases
related in the two preceding sections, endeavoured
to excite a general investigation of a subject which
I think every one will admit to be highly impor.
tant, I proceed to relate some additional cases of
diseases which I consider as pseudo-syphilitic, and
in which mercury was employed for their cure, in
order to show the effects resulting from its use.
I was necessarily precluded from bringing forward
such cases in my first attempt to elucidate this
subject, because my object at that time was merely
to show, that diseases, which could not by sight
be distinguished from syphilis, yet differed from it
in the primary sores from which they originated,
and also in their progress; for they got well with-
out the administration of mercury, and generally
recurred after the severest course of that medi-
cine. The latter fact will, indeed, be more strik.
ingly manifested by the succeeding cases. I was
also prevented from relating cases of this descrip-
tion, because the administration of mercury may
be supposed to render the nature of the subsequent
symptoms ambiguous; since they may be consid-
ered as the effect of that disorder of the constitution,
which the poison and the antidote have conjointly
produced.
As the tide of public opinion seemed at that
time to run strongly against me, I mentioned, that
any experienced surgeon, who regarded the cases

238
On Diseases
in question as anomalous cases of syphilis, would
do a most essential service to society, if he would
lay down practical rules for the treatment of such
diseases. As no one has undertaken this task, I
shall endeavour to accomplish it; for I think, that
the cases which I shall relate will at least show
what mercury will do, and what it will not do, in
these diseases. An attempt to establish rules for
the treatment of these diseases appears to me of
great importance; because discordance of opinion
is both discreditable to the profession, and injurious
to patients.
Before, however, I relate the facts from which I
mean to deduce the practical rules of treating these
diseases, I wish briefly to recapitulate the reasons
which induce me to think that they are not syphili-
tic; and also to advert to the arguments which I
have heard brought forward, by those who enter.
tain a contrary opinion. I wish, also, to consider
the effects likely to be produced on the constitution
at large, by the absorption of morbific animal poi.
sons; and to discuss the probable effects of mer-
cury, administered in different degrees; because I
think it necessary, that all these circumstances
should be borne in mind, whilst the reader peruses
the cases, in order that he may form a proper judg-
ment of the nature and treatment of these perplex-
ing diseases.
I concur, then, with Mr. Hunter in opinion, that
these diseases are the effects of kinds of animal
poison different from that which produces syphilis,
first, because they may be contracted from parties
who have no syphilitic disease; and that I perceive
how they may be contracted at present, as they
were in Rome, during the time of Celsus. * Se.
* See the cases related in the preliminary remarks.

resembling Syphilis. 239
condly, because I see such diseases occurring in
persons whose constitution is disordered, but
where there is no reason to suppose that any poi-
son has been imbibed. * Thirdly, because these
diseases differ from syphilis, in often getting well
without mercury, and in recurring after the sever.
est courses of that medicine.t Yet I wish, as a
comment on the latter clause, to observe, that
though it may be regarded as a general rule, it is
not absolutely without exceptions. We have some.
times recourse to the use of mercury, on account
of the destructive progress of diseases, which we
have the strongest reasons to believe, are not sy-
philitic; and mercury sometimes cures these dis-
eases, without relapse. It is indeed not improba-
ble, that the alteration which mercury produces in
the state of the constitution, may occasionally cure
a disorder which is not syphilitic. Formerly, when
I met with a case in which the constitutional symp-
toms were regularly progressive till mercury was
employed; if they yielded, and were cured by an
adequate course of this medicine, I concluded that
the disease was syphilitic, and I regarded, there-
fore, any deviations which I might have observed
in the progress of the primary sore, as the effect of
some peculiarity in the patient's constitution. Of
late, however, I have thought this inference to be
erroneous.'
I shall next advert to the arguments of those
who think differently. First, it is said, that the
spontaneous cure of these diseases is no proof that
they are not syphilitic. Secondly, the peculiarity
of the disease is accounted for by peculiarity of the
patient's constitution, which may not only contri.
See the cases related in the 3d section.
† See the cases related in the 2d section.

240
On Diseases
bute to modify the disease, but also to prevent its
ordinary cure by mercury; because the constitu-
tion may be incapable of bearing at once so much
mercury, as is necessary for its cure. Cases, how-
ever, stand in direct opposition to these opinions.
For these diseases may be contracted by persons
of very healthy constitutions; and I have known pa-
tients who have contracted pseudo-syphilitic dis-
cases, contract also real syphilis, both a short time
before and after the pseudo-syphilitic affection.
Further, in many persons, who are the subjects of
pseudo-syphilitic diseases, the disease recurs, with-
out the intervention of any new exciting cause,
even though a mercurial course has been submit-
ted to, greater in degree and longer in duration
than is necessary for the cure of true syphilis, even
though the mercury has also acted on the patient's
constitution, in the most regular and complete man-
ner. It is indeed, highly probable, and accordant to
general observation, that these diseases will be
greater and more obstinate in weak and irritable
constitutions, than in those that are healthy, and
this circumstance has probably given rise to the
preceding suppositions. Y-
I wish also to consider the probable effects which
would be produced on the constitution from the
admission of morbific animal matter into the circu.
lation. Such infectious matter is likely to produce
irritability or weakness of the nervous system, and
consequent general disorder. The nervous disor-
der is likely, more especially, to disturb the func-
tions of the digestive organs, and by their reaction
to become prolonged and aggravated. In almost
every case of pseudo-syphilis a disorder of the di-
gestive organs is manifest, and in many, most evi-
dent benefit is derived from correcting this, as far ·
as we are able.

resembling Syphilis. 241
It is probable, that the disorder of the nervous
system and constitution in general, will be more
transient in some constitutions than in others; and
is likely to be prolonged by every thing that in.
duces debility and irritability. Indeed, if we have
no specific remedy, or means of counteracting the
effects which the poison has produced; the rational
indications of treatment would be to tranquillize and
strengthen the system, in the expectation, that the
effects resulting from the action of the poison, will
gradually subside. Analogy would lead us to ex-
pect, that the disorder of the nervous system, in-
duced by the operation of the poison, would, as it
declined, become intermittent, and recur in par.
oxysms. I have premised these observations, that
the reader may bear them in his mind, during the
perusal of the cases, assuring him at the same time,
that they are the result of practical remarks.
I wish, also, to explain my ideas respecting the
operation of mercury. First, small doses of that
medicine do not seem to affect the constitution in
general, but merely to act upon the digestive or-
gans; yet, by this operation they are often produc-
tive of the most important benefit, as has been
shown by cases recorded in the first volume of
these observations. As in diseases produced by
the absorption of morbific poisons, the digestive
organs are disordered, in consequence of nervous
irritation, and in some patients, in a most remarka-
ble degree, owing probably to a predisposition to
disorder in them, so an attention to keep these or-
gans in as correctly natural a state as possible, is an
object of primary importance. Secondly, mercury
exhibited in larger doses, exerts an influence on
the constitution in general, though scarcely per-
ceptible by its effect upon the pulse or secretions;
but by affecting the nervous system, in a peculiar

242
On Diseases
manner, and by inducing a specific state of consti.
tution, it counteracts that morbid irritation which
has before prevailed, and is the effect of the poison. I
Thus mercury relieves many other disorders, as
well as those which are syphilitic. The dose which
is necessary to produce such effects, must vary in
different persons. Such a state of mercurial excite-
ment, or action, as is necessary to produce these ef-
fects, may also be kept up without inducing debi-
lity;--on the contrary, patients frequently become
stronger and more healthy under its influence, be-
cause it controls the irritation attendant on dis-
ease. Thirdly, a greater mercurial effect upon the
constitution produces an acceleration of the pulse,
renders the constitution in general irritable and
weak, and produces a more evident and conside-
rable disorder of particular organs. Such an affec-
tion cures completely and radically syphilitic dis-
eases; whilst others, which had been checked and
cured by a slight mercurial affection, often increase
and break out again, under that which is greater in
degree. This violent action of mercury never fails
to weaken and disorder the constitution in general;
and thus, with its powers impaired, and its func-
tions deranged, it has still to endure the continu-
ance of the disease.
· The cases, which I shall now bring forward, are
selected, because I think they show as great a va-
riety of circumstances incidental to these diseases,
as could be displayed in an equal number of ex-
amples. I could have crowded the book with in-
stances, tending more directly to illustrate and
confirm the opinions delivered in it. My object,
has, however, been, not to represent the subject as
more clear than it will appear in practice.

resembling Syphilis.
243
CASE XIV.
A medical student had, without any previous
chancre, an indolent bubo, which had increased in
the course of two months, to the size of a small
egg, at which time I first saw him. After about
three weeks, it inflamed and suppurated. The in-
flammation was of an unhealthy nature, and the
bubo ulcerated, forming a foul ulcer, about three
inches and a half in length, and two and a half in
breadth. During this process, he was much disor-
dered in his health, and he confined himself to his
bed. Lint, moistened with a watery solution of
opium, was applied to the sore; it was covered by
a dressing of spermaceti cerate, and linen moist.
ened in some wash was applied over all, to regu.
late the temperature of the part. Under this treat-
ment the sore granulated, cicatrized, and had con-
tracted into a small compass, when the patient's
health again became disordered, and an ulcer form-
ed on the upper surface of the velum pendulum
palati. He snuffled in speaking, and blew from one
nostril thick mucus, some matter, and occasionally
blood. Pain extended in the course of the eusta-
chian trumpet towards the ear.
His disorder was so troublesome at night as to
preclude sleep, and his situation was altogether so
uncomfortable as to induce him to have recourse to
mercury. He accordingly rubbed in two drachms
of mercurial ointment, for ten successive nights.
In this time the mercury produced a slight effect
upon the gums, and relieved him so much, that he
determined, notwithstanding my remonstrances, to
discontinue it, feeling himself perfectly well. In
about six weeks subsequent to this, he had a pain-
ful affection of the upper part of the tibia, attended
with a collection of fluid under the fascia. He was
244
On Diseases

feverish at night, and had but little sleep; his sto.
mach and bowels were, during the whole of the
disorder, affected in the manner I have described
in the first paper; he had no appetite, and when he
was most indisposed, his tongue was extremely
furred. He again used mercury, but after having
rubbed in about six times he discontinued it, as
he found himself worse, which he attributed to the
use of the mercury. The disorder of his leg did
not increase, but after some little time diminished;
still, however, it prevented him from walking about,
and he had occasionally fits of pain in it, which, af-
ter continuing for a few days, abated, so as to leave
him comparatively easy. Thus his leg continued,
from about February to June, when he took lodg-
ings in the country. He had, about a month after
the affection of his leg, a similar attack in the el.
bow, the progress of which was also similar. His
health was improved by his residence in the coun.
try, and he was soon able to walk about, which
contributed to his recovery. He for a few days,
took a little hydrarg: muriat: in decoct: sarsæ, but
left it off by my desire, as I was convinced that his
disease was not syphilis; and as the symptoms were
declining spontaneously. He was once or twice
induced to besmear the skin with mercurial oint-
ment; but excepting this, he used no mercury,
and by the autumn of the year, all local disease had
left him. His health, however, was not correctly
right, his tongue remaining furred, and his bowels
irregular. He passed through the winter without
any relapse. In about a year afterwards he had
some rheumatic complaints, from which he soon
recovered, and has continued well since, except
that he has been subject to occasional returns of
rheumatism. *
* The chief circumstances, which seem to me to deserve
attention in this case, are, that probably infectious matter was

resembling Syphilis.
245
CASE XV.
A gentleman about thirty years of age, of a heal-
thy, robust habit, had a sore behind the corona
glandis, which I saw on the third or fourth day af.
ter its appearance. It was then nearly as large as
the nail of the finger, and so deep as to descend to
the ligamentous substance of the corpus caverno.
sum penis. It was indurated in its circumference,
and there was no appearance of any new growth
from its surface. This ulcer appeared to me to
have been too rapid in its progress to be syphilitic;
however, as it had most of the characters of sores
of that nature, I recommended the patient to take
fifteen grains of pilul: hydrarg: daily, to bathe with
milk and water, and to be very gentle in the appli-
cation of mild dressings, and to keep the penis sur-
rounded by some linen, moistened with a cooling
lotion. After a fortnight had elapsed, an enlarge.
ment of the glands in the right groin took place;
and as the sore had not spread, I recommended
him to rub two drachms, by measure, of mercu-
rial ointment, into the right thigh every night, wish-
ing to produce an evident mercurial affection of the
constitution, with a view to discover what effect it
would have on the sore. In about a week, the con-
stitution was affected by the mercury, and the gums
were slightly tender and swollen; the sore waș, how.
ever, rendered worse; it became enlarged, and in-
flammation took place round it. The inunction was
absorbed, without any evident breach of surface or primary
sore; that the constitutional symptoms were at first suddenly
cured by a small quantity of mercury; that afterwards the use
of mercury rather aggravated them, in consequence of which
it was discontinued; that the disorder of the constitution after-
wards gradually subsided; and that the whole of the mercury
employed seems quite insufficient for the cure of syphilis.
246
On Diseases

therefore omitted, but the pills were continued. As
the mercurial irritation subsided, the sore became
tranquil, and the bubo stationary. In about five or
six weeks from the beginning, granulations ap-
peared, and the sore began to heal, so that by the
seventh week it was quite well. In healing, that
edge which was next the body got well first, while
the other rather spread, so as to encroach a little
on the back edge of the corona glandis. The bubo
gradually subsided. When the sore was healed,
(the patient still continuing the mercurial pills,) he
was seized with difficulty of swallowing, and un-
easy sensations on the upper part of the soft palate,
causing him to snuffle in speaking, and to blow his
nose frequently. I advised him to desist wholly from
the use of mercury, that these constitutional symp.
toms might go on unchecked by that medicine,
observing at the same time, that if they were sy.
philitic, and required the use of mercury, it might
be used with more freedom, and perhaps effect, in
consequence of this suspension. The disorder ra-
pidly increased, and it was much worse in the night,
when the sensations were so disturbing, that the
patient could obtain no rest, The pain extended to
the ear, and matter and blood were sometimes
blown from the nose. -
The health of the patient was much disordered;
and, as he said that no course of mercury could
harass and weaken him so much as the continu-
ance of this disease, it was agreed in consultation,
that he should begin a mercurial course, and that
the disease should be treated as syphilitic. The
patient confined himself to his chamber, and rub-
bed in two drachms, by measure, of mercurial oint-
ment every night. In the course of a week the dis-
ease was much mitigated; in a fortnight, at which
time the gums were swollen and tender, it was

"resembling Syphilis.
247
well. The mercury was continued (so as to keep
the gums as sore as they could be, without pro-
ducing that state of disease which would have
obliged us to desist from the use of it) for three
weeks more, when a new occurrence took place.
The left tonsil became somewhat enlarged, and an
ulcer was formed upon its surface. This, another
surgeon who was consulted, attributed to mercu.
rial irritation, whilst I on the contrary, felt assured
that it was the effect of the disease breaking out
anew under the full effect of mercury. As the
course of mercury was deemed perfectly adequate
to the cure of syphilis, it was now discontinued.
The ulcer however continued to spread, nor did it
cease till it had entirely destroyed the tonsil, when
it healed. About three weeks afterwards, and six
weeks after the disuse of mercury, a similar ulcer
formed on the opposite tonsil, which pursued ex-
actly the same course, and ended in the same man-
ner. After about three weeks more, an ulcer appear.
ed to have formed upon the upper surface of the ve.
lum pendulum palati, in a situation corresponding
to the first, but on the opposite side. It was attend.
ed with the same difficulty of deglutition, altera-
tion in the voice, occasional discharge of pus and
blood from the nose, and tormenting pain, extend.
ing to the eustachian trumpet. It seemed in vain
to use mercury, and I felt great apprehension that
this ulcer might destroy the soft palate. It fortu-
nately happened otherwise; for (after continuing
for about a fortnight to spread, so that its edge
could be distinctly seen on the margin of the ve-
lum palati, and left side of the uvula), it healed,
leaving no greater imperfection than what was pro-
duced by an adhesion of the left side of the uvula
to the soft palate, which took place during the heal.
ing of the ulcer. After this complaint was well,
248
On Diseases

various eruptions appeared on different parts of the
body, many took place on the head, forming sores
which were slow in healing, and many sores which
were formed in like manner on the trunk of the
body, became herpetic, healing in one part and
spreading in another. An inflammation and indu.
ration of the coverings of the lower part of the
right tibia also took place, which subsided, so as
to leave but little appearance of any disorder hav-
ing existed. During these occurrences the patient
took the decoct. sarsæ. and Lisbon diet-drink, ni-
tric acid, cicuta and bitters, and was as attentive
as possible to keep his bowels regular, which was
difficult, as his digestive organs were throughout
the whole of the complaint disordered. He had also
lived a good deal in the country, and made occa.
sional excursions to the sea-side, and used the te-
pid salt-water bath. Upon his return from one of
these, about six months after the discontinuance of
mercury, he felt himself so perfectly well, that he
indulged himself in dining with his friends, and
undertook a journey into the country on business.
The exertion attending this undertaking seemed
to have operated in reinducing disease, for he was
soon laid up with a rheumatic affection of the right
foot, and one of the testes became enlarged to a
considerable degree, but it was indolent. Nodes
also appeared on the middle of either tibia, which
regularly increased. The enlargement of the testis
subsided, when the other became affected in the
same manner. For between two and three months
after the patient's return to town he consulted va-
rious surgeons, who knew nothing of the history
of his case, and they so uniformly concurred in af-
firming it to be syphilitic, that the patient was even
anxious to use mercury again. As the nodes did
not abate as the other symptoms had, and as they

resembling Syphilis. 249
did not yield to the application of leeches, evapo.
rating lotions, or bandages, I thought an alterative
course of mercury at this period even advisable, to
see if it would control this local affection. The
nodes were not like venereal nodes. They were
elevated and bony, and there was a small quantity
of fluid beneath the periosteum. I would have di-
vided the periosteum at first, but I was restrained
by the apprehension of the wounds becoming sores,
and of exfoliation taking place and augmenting the
patient's already distressful situation. He now rub.
bed in small quantities of mercurial ointment, with-
out confining himself. This course was attended
with manifest benefit; insomuch as to impress his
mind with an opinion that a more liberal use of
mercury would now cure him. In this opinion he
was confirmed by some surgeons whom he had
consulted, and he therefore resolved to stay at
home, and rub in every night till his constitution
was affected by mercury. By the accomplishment
of this object, however, he was made materially
worse. His pains were tormenting, the nodes in-
flamed, and threatened to ulcerate. The mercury
was left off, and I divided the periosteum to the ex-
tent of an inch and a half on the surface of one node,
and let out some serum mixed with pus. The knife
in passing down grated against different portions of
bone, which were heaped up to a considerable
height above the level of the tibia. The node was
no longer painful. The wound healed, and pain
occurred again in a slight degree and gradually in-
creased. The same treatment was pursued with
respect to the node on the other shin, and the con-
sequences were the same. After the wounds had
healed the pain gradually returned, and in about a
month he found himself nearly in the same state as
before his confinement. Under these circumstances
2 I
250
On Diseases

he again began to take diet-drink, with some mild
mercurial pills, which never perceptibly affected
his constitution, and under the use of which he
became muscular and fat, and by this treatment
the pains left him, and in the course of three months
he was well. *
CASE XVI.
A gentleman between twenty and thirty years of
age, residing in the country, had an ulcer in the
prepuce, which, to use the words of his surgeon,
had more the appearance of excoriation than chan-
cre; it was succeeded by a bubo and ulcerated
throat. For each of these diseases he used mercu-
ry so freely as to convince some of his medical
attendants that the disease could not be syphilitic;
his surgeon said enough to cure twenty syphilitic
patients. The ulcers in his throat were sometimes
better and sometimes worse, both during the con-
tinuance and after the cessation of the mercurial
* The principal circumstances worthy of remark in this
case are, that the primary sore though resembling syphilis in
many respects differed in others. It was aggravated by the
free use of mercury, and it healed on one side whilst it spread
on the other. The constitutional symptoms were speedily
cured by a slight mercurial affection, but they broke out
again under a severe course of mercury. Many constitutional
symptoms got well without the use of mercury, and when at
last it was employed again on account of the stubborn nature
of the nodes, these diseases yielded to a slight, and were ag-
gravated by a severe course of mercury. The disease lastly
yielded to an alterative course of mercury, so slight as not
manifestly to affect the constitution, and during which, the
patient got muscular, fat, and healthy. The subject of this
case was a remarkably healthy man, and had before con-
tracted syphilitic diseases, which were regular in their pro-
gress and cure. Mercury also affected his constitution in the
mode which is considered most desirable for the cure of
syphilis.

resembling Syphilis.
251
course. After about a year and a half from the
commencement of the disease I first saw the pa-
tient, and informed his surgeon, that in my opinion
pseudo-syphilitic diseases generally gave way to
an alterative course of medicine, conjoined to de-
coction of sarsaparilla.
About nine months afterwards the patient came
again to town; his throat was not ulcerated, but
his nose was greatly diseased. Some affection of
that part had taken place when I first saw him,
which had increased to such a degree, that he was
almost constantly blowing from his nose tough
mucus and pus, mixed with blood. The skin cov.
ering the ossa nasi was also very red, so as to
threaten the giving way of the arch of the nose.
He was much emaciated and feeble, and had a
chlorotic appearance.
Under these circumstances, I desired him to
drink a pint of decoction of sarsaparilla daily, to
keep his bowels strictly regular, and to take five
grains of the pilul: hydrarg: every night, desiring
to see him at the expiration of a week. After that
time, when he called on me, he said he could per-
ceive no difference whatever in his disease. Think-
ing that perhaps in another week the mercurial
effect would be increased, so as to affect the con-
stitution and control the disease, I made no altera.
tion in the quantity of the medicine; but when at
the expiration of that time, I found the disease un.
diminished, I recommended him to take five grains
of the pilul: hydrarg: night and morning. After
the expiration of another week, when he called
upon me, he said that the disease of his nose
seemed gone, though when he blew it some puru.
lent discharge still took place. The mercury had
no effect upon his gums, and he looked more
healthy and felt stronger than he had done before
252
On Diseases

he began the mercurial course. Finding the dis-
order so completely subdued by this quantity of
mercury, and wishing above all other considera-
tions, that the patient should acquire some mus.
cular strength and vigour of constitution, I advised
him to take but one pill daily for the future, and
to observe whether the symptoms subsided or in-
creased under its use. In one week more there was
no discharge from his nose, even when the air was
forcibly driven through it. And after three weeks
had elapsed, or at the end of six weeks, he had be.
come so muscular, fat, and healthy looking, as to
produce the greatest astonishment in all who had
seen him before, and saw him after that short in.
terval of time..
This surprising recovery must be ascribed to
the youth and strength of his constitution relieved
from disorder. I mention it particularly, to show
that the quantity of mercury that controlled the
disease did not weaken the constitution. When
the patient returned into the country, I recommen-
ded the continuance of the pills every other night
for some time, to prevent any relapse; but I was
informed that he soon left them off, and has since
had no disorder. *
* When a disease resembling syphilis attacks the nostrils,
we are almost compelled to use mercury, since we cannot
see the character, extent, and progress of the ulcer; yet ex-
tensive experience demonstrates in a manner horrible to
observe, how many such diseases pursue a most destructive
course uncontrolled, nay, often aggravated by the most pow-
erful effects of mercury. The cases above recited, I therefore
deem worthy attention, as they show that diseases resembling
syphilis may occur in the nose as well as elsewhere, and that
our practice should be regulated by the same principles in
reating these, as in other symptoms of venereal diseases.

resembling Syphilis.
253
CASE XVII.
A gentleman had a trivial sore upon the pre-
puce, and being engaged to marry in the course of
a few months, he underwent what was considered
as a more than adequate course of mercury, for
the cure of the disease. After he had married,
however, his throat ulcerated. His surgeon hesi-
tated in pronouncing it to be syphilitic, and its
progress contra-indicated that supposition, for one
sore healed and another broke out, or ulceration
again ensued in the same place. One of the testes
afterwards became considerably enlarged without
pain, and sores broke out upon the scrotum, which
was much thickened, and in the perinæum. Six
or more months passed during the progress of the
disease to this state, when I was first consulted on
the case. It was in the spring of the year, and we
agreed that he should spend the summer at the
seaside. During this summer the sores on the
scrotum healed, and it regained its natural state.
The swelling of the testis subsided. His throat
occasionally ulcerated and healed; but a kind of
disease seemed to spread along the alveolary pro-
cess from behind, for the teeth loosened and came
out, and in some parts the gums ulcerated. This
happened on the left side of the mouth, and it ad.
vanced as far forwards as the first small grinder,
which still remained firm. In November he re-
marked, that whenever his stomach and bowels
were disordered, his complaints were aggravated;
and by the means which were suggested for regu.
lating those organs, he passed through the winter
without any increase of disorder. In the succeeding
summer sores broke out again on the perinæum,
and by the side of the rectum, which healed under
254
On Diseases

dressings of red precipitate ointment. He had also
a slight enlargement of the testis, which soon got
well. In the succeeding autumn the disease in the
alveolary processes seemed to trouble him, and
there was a slight discharge from the nose. I had
recommended him to abstain from the use of mer-
cury, while his disorders were stationary; but fear-
ing that there might be an increase of disease in
this part, I advised him to take the compound de-
coction of sarsaparilla and one of Plummer's pills
night and morning. Under this treatment he soon
recovered, without any perceptible effect of mercu-
ry on his constitution, and has remained well since.
Though I feel pretty confident, for the reasons
stated in the preliminary observations, as well as
those contained in the third section, that many dis-
eases which resemble syphilis, do not originate
from that poison, I am by no means equally cer-
tain, that none of the cases which I am now pro-
miscuously relating, might not have arisen from
that source. Such an assertion would be to deny
the possibility of the effects of syphilitic poison be-
ing modified by the diseased propensities of the
constitution. It would be also to affirm that there
is only one kind of syphilitic chancre, and one kind
of constitutional syphilitic disease, which is far
from being my intention. I merely state, that when
the primary sores differ materially from the ordi-
nary characters and progress of syphilitic chancres,
that they may fairly be suspected to be of a differ-
ent nature; and that in general the constitutional
symptoms will be found equally to deviate from
the progress of syphilis, and consequently to re-
quire a different mode of treatment.
I proceed to relate some cases of this descrip-
tion, and to give an account of the constitutional
symptoms subsequent to these kinds of sores, in a

resembling Syphilis.
255
few cases, that the reader may judge of them for
himself.
CASE XVIII.
On burrowing Sores.
A gentleman forty years of age, who had lived
very freely, in the month of July 1806, contracted
a sore between the prepuce and glans penis, near
the frænum, which he believed to have originated
from some acrimony in the secretions. This pro-
bably was the opinion of his surgeon, as he merely
recommended cleanliness, and a poultice, until the
spreading of the sore induced him to use mercury.
A considerable swelling of the prepuce was occa.
sioned by the irritability of the sore, which continu-
ed to spread by ulceration forwards, so as to extend
over the whole of the lower half of the glans, to
within theeighth of an inch of the urethra, and back-
wards between the integuments and lower half of the
body of the penis for more than half way to the scro-
tum. It did not prevent him from denuding the glans,
and cleansing away the discharge in some degree,
but the extent of the sore backwards could not be
seen. It had continued to spread gradually for more
than two months, although the mouth was affected
by the use of a great deal of mercury. His consti-
tution was much enfeebled, in a great measure ow-
ing to the mercury he had used. In this state he
came to London, and consulted me. Fearing that
the sore might continue to spread if the mercury
was laid aside, I desired him to rub in every se.
cond night, so as still to keep his constitution un.
der the influence of that medicine, while I endea-
voured to correct the sore by local means. Vari.
ous washes were tried, for instance, weak solutions
of sulphate of zinc, and nitrate of silver, calomel, and
256
On Diseases

muriate of mercury in lime water. In less than a
month, the sore was nearly healed, except in that
part which covered the urethra about half way be.
low the penis; and here the ulceration seemed kept
up by the escape of some urine from the canal, and
he had at this time a frequent propensity to void
his urine. It appeared probable, that the urethra
had not been in a sound state prior to his contract-
ing this complaint, and that it had derived addi.
tional irritation from the proximity of the sore to
the mouth of the canal, as well as from that part
where its ulceration had occasioned an opening.
At this time an indolent enlargement of the right
testis took place, and so large a hydrocele was
formed, that I was much inclined to puncture it,
to relieve him from the inconvenience occasioned
by its weight. The patient, however, was anxious
to return into the country, where he was directed
to continue the same mild mercurial course. In
January, 1807, he returned to town, and during
the interval, the hydrocele disappeared, though
some enlargement of the testis still continued. The
aperture of the urethra had inflamed and ulcerated,
leaving an external sore. The other part of the pe-
nis which had been ulcerated, continued firmly
healed. His health, however, was much disordered.
He had a rheumatic swelling of the finger, and a
node upon one shin, with rheumatic pains in vari-
ous parts of his body. Finding constitutional symp-
toms apparently originating from a sore, for which
from its commencement mercury had been used
unremittingly, I advised him to discontinue rub-
bing in, and he went to Bath in pursuance of the
recommendation of some of his friends. I previ-
ously, however, introduced a bougie, and found
several strictures in the urethra, which had proba-
bly existed before he had contracted the other com-



resembling Syphilis. 257
plaint. As a bougie of a moderate size passed
through the urethra, I merely advised local warm
bathing. During a month's residence at Bath, he
suffered much from pains in the tibia, but the nodes
had not increased during that period. An ulcer
larger than the surface of a shilling, with thicken-
ed inflamed and spreading edges, deep in the mid-
dle and without granulations, had formed near the
outer angle of the orbit of the eye. Some sores of
the same nature, but less in degree, took place also
on the arms. Wishing to know if these symptoms
were truly syphilitic, I determined to try if they
would get well without mercury. A poultice of
bread and water was applied to the sore on the face
at night, and a dressing of simple cerate in the day.
The edges of it were occasionally touched with ar-
gent. nitrat. to control their fretful disposition, and
under this treatment the ulcer healed. The patient
was anxious to return into the country; and as I
thought his health might be better than in town,
he returned to his own house with an injunction
not to use mercury if it could be avoided, and there
his pains in a measure subsided. After some time,
however, the nodes on the shin became more pro.
minent, though less painful. The nostrils also be-
came very much affected by the disease. He blew
from them pus in a fluid form, and concrete lumps
resembling (to use his own words) “the internal
parts of the nostrils, but this” he continues, “gradu.
ally went off, leaving the nostrils as clear as before.
Mygeneral health now improved, andencouraged by
this circumstance, I was induced to make a jour-
ney to London in the month of June, where I lived
more freely than before and took fresh cold. Upon
my return home, I had a recurrence of the pain
and swelling in my shin bones, and the pain of the
legs to so great a degree, that it was esteemed pru-
2 K

258
On Diseases
dent to consult a physician, who recommended ni-
trous acid, two mercurial pills and an opiate pill at
night. Milk diet was also recommended, which
constituted my principal food. The acid was con-
tinued a fortnight, the pills about a month, but lit-
tle relief from pain was experienced. The nodes
gradually lessened, but the pains were unabated,
and occupied my knees and ankles as well as shins;
they continued during the night, and remitted in
the morning.” On the weather becoming very
cold, he was recommended to pass the winter in
some warmer place than the situation in which he
resided. He came to town and consulted Dr. Bail-
lie as well as me. He was advised to take the de-
coction of sarsaparilla, with a small quantity of hy-
drarg: muriat: and to control the night pains with
extract of henbane. This plan answered very well,
and he returned into the country, where he said his
stomach was so much nauseated by the medicine,
that he was obliged to leave it off. He came to town
again in the beginning of January, 1808, in a very
emaciated and crippled state, owing to rheumatism.
His nights were passed in great pain, and this ter-
minated in profuse perspiration in the morning, so
that he seldom rose till past noon on the following
day. He was scarcely able to walk, and dreaded
the least exposure to air, which considerably ag-
gravated his pains. Some sores had again broken
out upon his face, and one of the largest was situ-
ated on the front of the ear, extending over the
tragus, the discharge from which generally filled
the concha, and this obstruction together with the
irritation, made him very deaf. I had often express-
ed to the patient my conviction that an alterative
and undebilitating mercurial course would tempo-
rarily cure his disease, but wished to see him when
that medicine was employed, that I might observe



rese
resembling Syphilis.
259
its effects. He now took a pint of decoction of sar-
sap: daily, and five grains of the pil: hydrarg: every
night, and in about a fortnight he was so much re-
covered that he was able to ride out, which he did
as often as the weather permitted. At the end of
the third week, he went into the country, a short
distance from town, to spend a week, from whence
he rode at the expiration of that time, eighteen
miles without stopping. His rheumatic pains had
nearly left him, and the sores on his face were heal-
ed. In short the cessation of the disease was as strik-
ing and as rapid as in almost any case, that I had
seen, but he was not restored to perfect health.
Though comparatively muscular and strong, he
did not acquire that strength which he had pos-
sessed prior to the occurrence of the disease, nor
did he look healthy. He continued in town, taking
the same medicine a fortnight longer, during which
time he committed, in consequence of the liberty
he had acquired, some little irregularities, such as
sitting up late, and eating and drinking too much.
The effect of this alterative course of mercury,
which did not produce any evident mercurial ac.
tion in the constitution, and under which the pa-
tient acquired a surprising degree of strength and
apparent health, fully equalled and even surpassed
my expectation. Inferring the probability of a re-
lapse, and that half the dose of the medicine was
not likely to be in any degree prejudicial to the con-
stitution, I recommended him to return into the
country, and to continue the same medicines,
taking the mercurial pill every second night only.
The patient, however, did not prosecute the plan
laid down, and his health has continued greatly dis-
ordered ever since this period. He has been sub-
ject to various local diseases, but their nature was
such, that I believe no unprejudiced person could
260
On Diseases

consider them as syphilitic. He has had severe
rheumatism, but it never produced a local attack
on a bone, so as to resemble a syphilitic node. He
has had gout to which he had formerly been sub-
ject.
He had a great degree of inflammation and indu-
ration of both his legs. He had violent pain about
the first joint of the great toe, and matter seemed
to have formed beneath the periosteum, for, upon
the abscess breaking, the bone was denuded. He
has a redness, thickening, and tendency to ulcera-
tion, of the integuments of the alæ nasi.
The patient had formerly lived very freely, and
the alteration in his ordinary modes of life, with
the effect of mercury on his constitution when em-
ployed freely, at first, for the cure of the primary
sore, seem conjointly to have produced this deplo-
rable derangement of his constitution.
Under these circumstances, he sometimes took
the compound calomel pill in the dose of one grain
of calomel each night, and it generally appeared to
be of service to him. Sometimes he took no mer-
cury. His local diseases did not seem to be much
affected either by the use of mercury in this degree,
or by its discontinuance.
When once, without my knowledge, he took
the compound calomel pill more freeely, it evi-
dently was injurious both to his health in general,
and to his local diseases.
CASE XIX.
A gentleman had a sore between the prepuce
and corona glandis, which was treated as a syphi-
litic chancre. After a time it began to spread in
the cellular substance, between the integuments
and body of the penis towards the pubes. In pro-
portion as the sore became worse, the quantity of

resembling Syphilis.
261
the mercury administered for its cure was increas-
ed; so that he had gone through a very considera-
ble course of mercury, which had made his mouth
very sore, and had greatly impaired his strength.
The sore, however, was not amended, but when I
first saw him was extending itself still nearer to the
pubes and more round the penis. I directed him
to clean away the discharge by frequently injecting
a warm decoction of poppy heads, and to keep a
bread and water poultice round the penis. After
some time the skin of the dorsum penis ulcerated,
and gave an outlet to the discharge in this direction.
The degree of disease which took place seemed to
have been prejudicial to the front of the prepuce,
for it became very ædematous, and the ulceration
spread rapidly forwards so as to divide it, leaving
the glans and body of the penis projecting above
the separated and tumid sides of the prepuce. The
sore gradually got well without any other medical
treatment than what appeared necessary to regu.
late the actions of the bowels. He took indeed oc-
casionally some decoction of sarsaparilla and some
nitric acid. The patient had no subsequent consti-
tutional disease.
Respecting these sores, which I have called bur-
rowing sores, I may observe, that only a few of
them begin to burrow in the first instance. It is
generally an after process, and may be considered
in the greater number of cases as the effect of a new
action taking place in the sore. It is, however, so
discordant to the progress of true syphilis, that I
cannot believe it to be an effect of that disease. If
we have any doubt we must look to the constitu-
tional symptoms which succeed to them, and these
we find to partake more of the nature of pseudo-
syphilis than of true syphilis. Some burrowing
sores do not so affect the constitution as to produce

262
On Diseases
secondary diseases, whilst others do. I have re-
corded a specimen of each, and think it unneces-
sary to cite more; though I could bring forward a
considerable number. The secondary symptoms
in the first case were very obstinate, and those sur-
geons, who are inclined to believe all these diseases
syphilitic, may probably think the symptoms in
this instance were so. To me, however, it appears
that the most potent mercurial course was inade.
quate to the cure of the primary symptoms, and
would have been so to those of a secondary nature,
while the latter were readily controllable by an al-
terative course, and in some instances got well
spontaneously. It is also my opinion, that their
continuance depended much upon the disordered
state of the constitution produced by former irre-
gularities of living, by the irritation of disease, and
the debilitating effects of the too free use of mer-
eury for the cure of the primary sore. I could pro-
duce many instances in which the secondary symp-
toms were more slight and more clearly pseudo-
syphilitic, than in the one which has been related.
The present case I brought forward, because it
made a stronger impression on my mind, than those
which were less vexatious, and because I do not
wish to represent the subject of the secondary
diseases in pseudo-syphilis, as less obstinate and
severe than they will often be found to be.



CASE XX.
On sloughing Sores.
A gentleman about thirty years of age applied
to me on account of a sloughing sore about the size
of a shilling on the dorsum penis. I desired him to
dress it with a watery solution of opium, covered
with spermaceti cerate spread on linen, and to sur-

resembling Syphilis.
263
round the penis with linen kept constantly wet with
water. His bowels were obstinately costive, his
tongue much furred, and he had so much fever and
headache, that the use of mercury seemed to be
prohibited by the disordered state of his constitu-
tion. The sore spread so as nearly to encircle the
penis, and to occupy its whole length. Various
dressings were employed until the surface of the
sore was no longer sloughy, but the edges were
every day with argent: nitrat: which seemed to
counteract their fretful state: they afterwards be-
came healthy, and the sore healed in the space of
two months from its commencement. Before the
appeared. The throat became sore, but did not
ulcerate in any material degree. Spots came out
on the skin and breast. He had afterwards a rheu-
matic affection of the knee and foot. All these
symptoms disappeared successively without the
use of mercury, to which medicine he had so strong
an aversion, that it would have been difficult to
persuade him to take it: he soon recovered from
the effect of his disorder, and felt as well as before
he had contracted it. The medicines which were
taken in this case, were sarsaparilla, nitric acid,
bark, and aperients. Secondary symptoms do not
succeed to every sloughing sore, and these symp-
toms occasionally approach more to the nature of
syphilis than in the preceding case; yet I have
known no instance in which, either from the irre-
gularity of the progress of the symptoms, and their
insusceptibility of cure by the powerful action of
mercury, they could not be distinctly recognised
as pseudo-syphilitic.
264
On Diseases
CASE XXI.
A gentleman had a sloughing sore, which spread
round the prepuce, without extending backwards
to the integuments covering the body of the penis,
yet its breadth was so considerable as to involve
the whole of the prepuce, which it eventually de.
stroyed. The surgeon who first saw the patient had
given him mercury, but doubting the propriety of
its continuance, I was consulted, and immediately
opposed its further use. Fumigations with cinna-
bar were found to be more efficacious than any
other applications which were tried to this sore;
these quickly arrested the sloughing process, but
an ulcerative one continued till the prepuce was
eaten away. After two months from the commence-
ment of the sore, when it was nearly healed, the
constitution of the patient became much disturbed,
and secondary symptoms appeared. These were
spots and blotches of rather a livid aspect, the lat-
ter of which in many parts of the body spread out
into extensive sores which had a sloughing appear.
ance. One on the outside of one foot and ancle was
as large as the palm of the hand. The original sore
was also irritated by the disturbance of the consti-
tution, and began to ulcerate again very rapidly,
insomuch that the glans penis, and a considerable
part of the corpora cavernosa, were destroyed. Nei.
ther fumigations nor any other of a great variety of
applications appeared to retard the destructive pro-
gress of this sore, and mercury was employed.
The patient was ordered to rub in two drachms by
measure of mercurial ointment every night, for five
weeks, when his gums became tender and swollen,
and his constitution considerably influenced by the
mercury, yet no material alteration took place in
the disease. The unavailing effect of mercury be-


resembling Syphilis. 265
ing proved, the patient went into the country,
where all these complaints gradually disappeared.
His health, however, was still disordered, and new
symptoms came on. His nose became slightly af.
fected, and he had pains in his bones. He now re.
moved to the sea-side, and after continuing there
for a considerable time, he wrote to me, saying,
that ulceration had taken place in his nose, which
had destroyed the septum narium, and that the in-
teguments, covering a kind of node on one shin,
had formed into a foul and fretful sore. I now re-
commended an alterative mercurial course. He
took five grains of pil: hydrarg: at night, and a pint
of the decoct: sarsæ daily, and in the course of four
or five weeks he was apparently well, having ac.
quired health and strength at the same time. In a
second letter he expressed his great surprise at his
amendment, and wished for my further directions.
I then desired he would take the pil: hydrarg: every
second night, if the state of the biliary secretion re.
quired it; but as that was not the case, he took no
more of that medicine, and has since remained per.
fectly well.
CASE XXII.
A gentleman had a very irritable sore on the
prepuce, just behind the corona glandis, which
was covered with slough; this having been thrown
off was succeeded by another slough, and the sore
spread laterally to the right and left; but it neither
extended backwards so as to affect the skin cover-
ing the body of the penis, nor forwards so as to
touch the glans; neither did it eat deeply into the
part so as to affect the corpus cavernosum. I tried
various dressings, but none seemed to do much
good. I touched the surface of the sore with ar-
gentum nitratum, but that did harm. I therefore
2 L

266
On Diseases
was obliged to soothe this sore, since I could not
correct it. A salve made of spermaceti cerate, with
as much aq: litharg: acet: and tinct: opii as could
be incorporated with it, seemed to answer best;
and the parts were kept cool by enveloping them
in linen moistened with the decoction of poppies.
The most perfect quietude was enjoined, and the
part laid upon a pillow with the extremity rather
raised above a horizontal line. I had given the pa-
tient some pilulæ hydrargyri in the first instance,
but his constitution was so deranged by the irrita-
tion of the sore that it would have been absurd to
persevere in the use of mercury. The sore conti-
nued to slough, and to extend in a circular direc-
tion nearly all round the prepuce, the lower part of
which became extremely swollen. This took up
nearly two months: about five weeks after the com-
mencement of the disease, a spot appeared more
than an inch from the corner of the mouth. It was
soon covered over with a scab, which rose far above
the surface. It had increased to the size of a six-
pence, when I thought right to dress it, that I might
distinguish the surface of the sore. I found that the
ulcer was very deep, but I could not see the sur-
face for a very viscid discharge, which adhered to
it like mucus. Poultices and various dressings
were employed, but the appearance of the sore was
unchanged, and it gradually became of the size of
a shilling. At length a kind of fungus shot from
that edge of the sore farthest from the mouth. A
similar spot had made its appearance on the ear,
and was also increasing. The activity in the dis-
ease of the prepuce had gradually declined, and I
began again to try some medical applications:--
the sore seemed much benefited by touching it
daily with argentum nitratum; but when this was
omitted the sloughy appearance of the sore again

resembling Syphilis. 267
took place, and it increased in dimensions. It was
now agreed at a consultation that this patient
should use mercury, and he rubbed in two
drachms by measure, every night for six weeks. As
the mercury took effect it seemed to operate be.
neficially on the spot on the ear, which gradually
died away; and on the sore of the penis, which also
gradually acquired a healthy appearance, and the
parts became sound, except at one part where the
prepuce was not quite destroyed, and which still
retained an unhealthy appearance. The mercury,
however, did not affect the sore on the cheek; the
fungus which I mentioned seemed to increase,
and, after a time, skin formed over it so that the
farthest from the mouth. But it still spread in the
other direction till it reached the angle of the mouth,
and it afterwards extended itself along each lip. On
the upper lip it had spread to the extent of one
third of an inch, and still retained the same dis.
eased appearance which characterized it at the be-
ginning. It was deep, and its surface could not
well be seen on account of a viscid matter which
adhered to it. It was now agreed in consultation
to leave off mercury, lest the irritated state of the
mouth should increase the destruction which the
ulcer was committing on the lips. The sore now
no longer spread; it very slowly lost its diseased
state, and healed. This also happened in the re-
maining diseased part of the sore on the pre-
puce.
268
On Diseases

CASE XXIII.
Of Sores which become indurated in their Circum-
ference.
A medical man contracted a sore on the prepuce,
which, while it was healing, became indurated in
its circumference, and when healed, it became soft
and apparently healthy in the middle. The patient
had taken and rubbed in mercury from the com-
mencement of the complaint; in short he treated it
strictly as syphilitic. When it assumed the appear-
ance and character which I have described, he
showed it to me. I advised him to continue the
mercury, in such small quantity as not to affect his
health, until the induration subsided, lest from
want of this precaution it should fret into a sore.
Under this plan of treatment, however, constitu.
tional symptoms occurred. The throat became ul.
cerated, and numerous small spots came out all
over the body. His health was also much disor.
dered, and he could only take such small quanti.
ties of mercury, as could have no influence on true
syphilis. He took at the same time the decoct: sar-
sæ. All the symptoms gradually disappeared, and
he got perfectly well in the course of a few months.
CASE XXIV.
A gentleman who had just left London on a visit
to some friends in the country, perceived a sore on
the prepuce, which he undertook to manage for
himself. He dressed it simply, and took from ten
to fifteen grains of the pil: hydrarg: daily. After a
month he came to town with the sore much en-
larged, having diseased indurated edges, but with
a healthy surface. As his mouth was affected I de-
sired him to continue the mercury in less quantity,

resembling Syphilis. 269
so as not materially to disturb his constitution.
The sore healed under this treatment, in the course
of another month, but it exhibited the appearances
which characterize those ulcers of which I am now
speaking. It was soft in the middle, but had a cir-
cular hard rim, of the extent of a shilling. At this
time his health was much disordered, and his
throat ulcerated. Deep and foul ulcers also took
place in his cheeks opposite to the grinding teeth,
and some sores appeared on his tongue. His gums
were spongy, and loosened from his teeth, like
those of a person having scurvy. I now recom-
mended him entirely to discontinue the mercury,
and to take the nitric acid, which he did, in the
dose of from 60 to 90 drops daily. Under this treat.
ment, both the constitutional symptoms, and the
remaining induration of the primary sore got well
in the course of six weeks. Nearly a year after-
wards he had a severe and intractable ophthalmy,
attended with nervous symptoms, and disorder of
his constitution. After a time, spots again appeared
on his skin, and he then applied again to me. By
taking decoction of sarsaparilla daily, and five
grains of pil: hydrarg: every second night, at the
same time paying attention to keeping his bowels
regular, his health was restored, and all these com.
plaints totally disappeared in about five weeks. -
These circumstances occurred in the spring of
the year, and in the autumn the pituitary mem-
brane of his nose began to ulcerate, and it conti.
nued to do so more or less during the whole win.
ter, and even soine discharge continued for the
space of a year. The ulceration destroyed a great
part of the cartilaginous part of the septum nari.
um, so that the alæ nasi being less supported sunk
a little, and made the termination of the bones ap-
parent beneath the skin. The deformity was, how.

270
On Diseases
ever, too trivial to attract the notice of an indiffer-
ent or inattentive spectator. For this disease the
alterative plan of treatment which had been so suc-
cessful on the former occasion was again instituted,
though with little advantage. At first, when the
patient's apprehensions were considerable, as the
alterative course of mercury failed to do good, the
dose was increased even so as to affect the mouth,
but the disease was so evidently aggravated by it,
that the medicine was for a time left off and with
manifest advantage. In the autumn of the succeed.
ing year a new disease occurred. A large deep ul-
cer formed in the throat, which had all the charac-
ters of syphilis. It, however, very suddenly ac-
quired its largest dimensions, being about an inch
in length, and half an inch in breadth. It was situ.
ated obliquely between the top of the tonsil and
the front of the velum palati. It was very deep. As
so little success had attended the alterative course
of mercury in the ulcerative disease of the nose,
and as the progress of the present ulcer could be
noted, no mercury was employed, and in about a
month this ulcer was well, and the patient has not
which has since elapsed, it is highly probable that
he never will have any.
I have already said, that sores which indurate in
their circumference do not in every instance pro.
duce constitutional symptoms. Apprised of their
nature I generally order for the patients that dose
of mercury, which may be taken without affecting
the constitution, as a discutient of the hardness,
and I have known nearly six months elapse before
it has been completely dispersed. This kind of par-
tial induration is so different from the progress of
true syphilis, that I think it must be readily granted
not to be of that nature. It must however be also

resembling Syphilis.
271
remembered, that sores which indurate in all parts
are not always syphilitic. As I have already related
two instances I think it unnecessary to add more.
Having thus endeavoured to represent the con-
stitutional effects resulting from sores, which dif-
fer materially in their characters and progress from
syphilitic chancres, I wish to subjoin another case,
though I am doubtful whether the disease origi-
nated from infection, or was the product of consti-
tutional disorder. I think it deserves to be recorded
on account of its duration.
In the year 1793, a gentleman aged twenty-six,
who had been married two years, had a paralytic
affection of the whole of the left side, from which
he gradually but not completely recovered in about
nine months, the latter of which he spent in the
country, and he attributed much benefit to the
country air. About four months from the com-
mencement of the paralysis, he had an indolent
enlargement of the testis as big as a large fist,
which did not subside, but in 1796 suppurated,
broke, and very slowly got well. In 1797, he had
an ulcerated sore throat, for which he went through
a very regular and severe course of mercury. He
was confined from July to November, and the
mouth was in a greater or less degree affected dur.
ing the greater part of that time. The throat soon
got well. The year 1798 he spent in the country,
and regained his health and strength in a very con-
siderable degree. In 1802, a node appeared about
the middle of the right shin, which was removed
by a blister kept open for some time. He had at
the same time a pimple on the nose which formed
a scabby ulcer, but slowly got well from the ap-
plication of the solution of the hydrarg: muriat:.
He had subsequently several eruptions, forming
scabs upon the trunk of the body and arms which
272
On Diseases

did not ulcerate, and got well without medicine. In
1804, there was a thickening about the os calçis
and tendo achillis, which threatened to suppurate.
In 1805, I first saw the patient; his tongue was fur.
red, secretion of bile irregular, with a great degree
of nervous irritation. He was also subject to rheu.
matic pains which particularly affected his knee.
I recommended a strict attention to the state of the
bowels, and soothing applications, with pressure
to the heel. Under this treatment the heel gradu.
ally got well, and the spots disappeared. In the
spring of 1806 some nodes appeared on different
parts of the skull, when I told the patient to prose-
cute the same plan of treatment, and if they got
better to disregard them, but if worse, to let me
see them. In the autumn of this year he called
upon me with the nodes on his head considerably
augmented; one on the right side of the forehead
break, and two on the left parietal bone, but of less
size, had broken and healed. There was also a very
considerable node near the top of the left tibia,
which had been opened by caustic, and had left a
foul ulcer. I then recommended the decoct: sarsæ
with a compound calomel pill, night and morning.
This plan was continued from November to the
end of May, when the decoction was left off,
though the pill was continued in a smaller dose
for some time longer. Under this course, which
never produced the slightest mercurial effect on
the constitution, all these complaints got well, and
the patient became healthy and fat, and, as he says,
better than he has been from the commencement
of his disorders which is fourteen years ago.
This case appears to me to be very similar to
that related at page 233. In neither do I believe
that the symptoms were the effects of poison imbi-

resembling Syphilis. 273
bed, but on the contrary, of a disordered state of
health.
Whilst I was attending this patient, his wife's
throat ulcerated to a considerable degree. Both
tonsils were ulcerated, and the ulcer continued
from one along the edge of the velum palati to
the extremity of the uvula. The ulcers were hol-
lowed, covered by viscid matter, and surround-
ed by inflammation. I should without hesitation
have pronounced these sores syphilitic had they
succeeded to a chancre. Another surgeon had no
doubt of their nature. The patient's bowels were
disordered, and she felt generally unwell. I direct-
ed her to take some decoction of sarsaparilla, and
small doses of rhubarb, whilst I attentively watch-
ed the progress of the ulcer. In the course of a
week it was so decidedly amended, that I had no
doubt of its not being syphilitic. Where it ran
down the side of the uvula, it had granulated, and
was in a great measure healed. As the discharges
from the bowels were blackish, I directed five
grains of the pilul: hydrarg: to be taken every
night for a fortnight, which gradually corrected the
biliary secretion, and in that time the ulcers were
perfectly healed. The patient took the pills every
second night for another fortnight, when the bow.
els being in all respects right, and the constitution
in general relieved from all disorder, they were
discontinued.
About six months afterwards, this patient being
in the country, thought she had caught a cold in
her head, as she had frequent occasion to blow her
nose, and as she snuffled in speaking; this com-
plaint gradually increased, and after a fortnight
had elapsed, she perceived a difficulty of degluti-
tion, which alarmed her, because it reminded her
of her former indisposition. She was at this time
2 M
274
On Diseases

also very unwell, and felt in the same manner as
when her throat had ulcerated. These symptoms
gradually increasing, after another fortnight she
came to town. There was no doubt but in this se.
cond attack ulceration had taken place in the up-
per surface of the velum palati, for the ulcer had
eaten through the soft palate át a small distance
from the termination of the bone, there presenting
a circular aperture, about as large in circumference
as a pea. This complaint was made perfectly well
in three weeks, by the same treatment as was in.
stituted in the former. The health in general, and
the digestive organs particularly, were disordered
in the second attack as they were in the former
one, and both were set right by the measures that
were pursued.
I have known many ulcerated throats, which
could not, by inspection, be distinguished from
syphilitic diseases, and which were even supposed
to be so on account of the difficulty of curing them,
arise from an irritable state of the stomach, and
they have readily got well by the treatment above
described.
The foregoing case might have been one of this
description. Might it not, however, have arisen
from contagion, and have been caught from her
husband? I have recorded it chiefly on this account;
for I am desirous of mentioning, that I have seen
several instances of pseudo-syphilitic diseases
communicated from husbands to wives, where
there were no sores, nor apparently any morbid
discharges from the genitals. If this supposition
be true, it would probably be considered as a very
curious fact, and I mention it to excite general ob.
servation, by which alone it can be confirmed or
confuted. I shall briefly relate another case, sug-
gesting the same opinion.


resembling Syphilis. 275
A gentleman had been my patient on account of
a chancre, for which he regularly took mercury so
as slightly to affect his mouth. He had afterwards
an ulcerated throat, which got well without the use
of any medicine. Shortly afterwards he married a
very healthy woman, who in about three months
became very unwell, and had pseudo-syphilitic
diseases, for which a mercurial course was insti-
tuted without benefit. As I had attended the hus-
band, I was once consulted on her case. She had
then a deep and foul ulcer between the ala nasi and
upper lip. Her diseases afterwards got slowly well
under a plan of treatment calculated to restore her
general health.
I am aware that the cases which I have related
by no means represent all that deserves to be dis-
played, in order to convey to the reader that ex-
tensive knowledge of the subject which a surgeon
living in this metropolis may and ought to possess.
For example, I have not related any case to show
that the primary sores, in many instances, are sub-
ject to paroxysms of disorder; that they will amend
and seem inclined to heal, and when, from their ap.
pearance, the greatest hopes are entertained, on a
sudden, a renovation of disorder takes place and
more parts become diseased or destroyed. This
circumstance happens whether mercury be em-
ployed or not, and under an equal operation of
mercury on the patient's constitution. Also in sy-
philitic and pseudo-syphilitic affections, sometimes
diseases occur which are the effect of derangement
of the constitution at large, such as unhealthy ab-
scesses and sores; and whilst mercury, if employ-
ed, acts beneficially on the symptoms for which it
was administered, it often has a prejudicial effect
on these accessory diseases.
I have now lying before me the written records
276
On Diseases

of many cases similar to the foregoing, each of
which exhibits some interesting variety observa-
ble in these diseases. I forbear, however, to adduce
more instances, from a conviction that recorded
cases will never make a forcible impression on the
minds of practitioners, and that they merely serve
to induce attention to the occurrences which are
met with in practice, so as to lead each person by
observing circumstances to which he had perhaps
before been too little attentive to acquire practical
information and knowledge from his own experi.
ence.

resembling Syphilis.
277
SECTION V.
On the Treatment of Pseudo-Syphilitic Diseases.
THE impropriety of putting patients under a
full mercurial course, such as is necessary for the
cure of syphilis, without taking into consideration
the nature of the primary sore, or watching, even
for a short time, the progress of the constitutional
symptoms, must I think, be to every one sufficient-
ly evident. If the constitutional symptoms proceed
in the manner detailed in the second section, and
get well spontaneously, it would be absurd to use
mercury; but if they are progressive, and threaten
to destroy parts of importance, even though we
may have great reason to believe that they are not
truly syphilitic, an alterative course of mercury,
with the addition of decoction of sarsaparilla, seems
to be, in general, the most efficacious means of ef-
fecting a temporary cure.
In the second section, I stated, that after having
waited till I was assured that the constitutional
symptoms were not truly syphilitic, and conse-
quently, did not require for their cure a strong mer.
curial course, I generally gave the compound ca,
lomel pill with a view to shorten the duration of
those symptoms. This practice has been said to
be ridiculous. I only wish to show that in general,
it is the most successful that can be pursued. The
cases which have been related attest, that an alte.
rative course of mercury will cure diseases which
a potent one will aggravate; and that neither course
can be considered only as producing the temporary

278
On Diseases
effect of curing the present symptoms without era-
dicating the constitutional disease. In proof of this
point, I could adduce the most abundant and clear-
est evidence. I take the liberty to mention, that
some eminent surgeons of this metropolis, who
concur with me in opinion respecting the nature
of these diseases, are averse to employing mercury
for their cure; and as such sentiments and practice
may become very general amongst those who
clearly perceive that the most powerful mercurial
courses will not radically cure these diseases, and
that they will get well without that medicine, I feel
it necessary to discuss the subject a little more at
large.
I have found a compound calomel pill, or five
grains of the pilul: hydrarg: taken every second
night, sufficient in many cases to heal sores more
rapidly than I wished, while in others, the same
pill taken every night has been insufficient, and the
disease has been controlled and cured when the
pill was taken night and morning. The dose which
has been most successful, has been one that has
not perceptibly affected the mouth nor weakened
the constitution; during its use, on the contrary,
patients have acquired muscular strength and in-
crease of bulk.
The constitutional symptoms in these cases fre-
quently occur when the patient's health is much
disordered, and it may be feared that any course of
mercury, however trivial, may increase the weak-
ness and irritability of the constitution. However,
it will be found, on the contrary, that an alterative
course of mercury, by controlling the disease, will
produce a diminution of irritability, and increase
the strength of the patient. All persons who are
not familiarly acquainted with the fact are extreme-
ly surprised at the wonderful acquisition of bodily

resembling Syphilis.
279
strength and vigour obtained by the patient during
the use of a medicine which they have always con-
sidered as likely to debilitate. The difficulty is to
ascertain the precise dose that shall cure the local
diseases, without apparently producing any mer-
curial effect on the constitution in general. This
dose must necessarily be various, as the suscepti-
bility of being acted on by mercury varies greatly
in different persons.
Respecting doubtful cases, and of this descrip-
tion must many be, which are presented to the no-
tice of a surgeon who has had no opportunity of
observing the characters of the primary sore, &c.
I wish to ask the following question. If a disease
that may be suspected to be syphilitic gets well,
when the patient takes only five grains of the pilul:
hydrarg: each night, (taking also the decoction of
sarsaparilla in the day) without the mercury appa-
rently disturbing his constitution, but, on the con-
trary, contributing to the increase of his strength,
ought such a disease to be regarded as syphilitic,
and requiring a persevering course of mercury for
its cure? Were I to answer this question agreea-
bly to the dictates of my own experience, I should
reply in the negative, because I have seen many
such instances, wherein it was evident that the dis-
ease was of the kind which I have termed pseudo-
syphilitic. Within these few months three cases
have come under my observation, in which the
throat was deeply and very badly ulcerated, and
the general health greatly impaired; and yet all the
patients got well in about a month by such a course
of medicine as I have described, increasing in health
as the local disease amended, and without any mer.
curial effect on their constitution being manifest.
This is a point of practical conduct, much de-
serving of consideration, and requiring to be esta-

280
On Diseases
blished. It would appear wrong to use more force
for effecting a purpose than is requisite. In syphi.
lis the cure of the diseases for which mercury is
administered, is a proof of the sufficiency of the
mercurial course. "Syphilitic symptoms will not,
however, as far as my experience enables me to
determine, give way to so trivial a quantity of mer-
cury. Therefore the mode of cure of these diseases
may serve as a test of their nature, and as a guide
for our conduct on a recurrence of symptoms, in
cases where no other evidence can be obtained.
Were this question determined, were it decided,
that truly syphilitic symptoms would not yield to
an alterative course of mercury, which produced
no apparently mercurial effect on the patient's con-
stitution, but under which it acquired a natural de-
gree both of tranquillity and strength, another in-
quiry would yet remain. Are we warranted in con-
tinuing or augmenting the mercurial course, in or-
der to prevent a return of the same or similar symp-
toms? Were my own experience to direct me in
my reply to this question also, I should again an.
swer in the negative; because I have frequently, in
such dubious cases, put patients under a full mer-
curial course, in order to prove, that if any relapse
should occur, the disease could not be syphilitic,
or curable by such a course of mercury. The cases
to which I allude were those of officers and persons
of strong constitutions, in which it seemed neces-
sary to establish this fact, with a view to the sub-
sequent treatment of any symptoms that might oC-
cur. Yet in these cases new symptoms were mani-
fested. I have also been frequently consulted with
respect to the degree to which a mercurial course
should be carried, and the time it should be con-
tinued, that had been instituted for the cure of pseu-
do-syphilitic symptoms, which had been mistaken

resembling Syphilis. 281
for those of true syphilis; and I have recommend-
ed that it should be continued to that degree and
for that duration, that should render a repetition of
it unnecessary, by proving it to be unavailing,
should a recurrence of symptoms ensue. Yet in
these cases also, either the same symptoms return.
ed, or similar diseases took place, and in most in-
stances these returning symptoms have got well
without the use of mercury. The cases also, which
I have detailed, show how unavailing the most po-
tent courses of mercury are, in effecting the radi.
cal cure of these disorders. It seems therefore bet-
ter to desist from the use of medicine, when the
local diseases are well; and, should they recur, to
cure them again by an alterative course of mercu-
ry, which appears, from its effects, to be not only
innocent, but even salutary. In some cases which
I have attended, after having cured the local symp.
toms by an alterative course of mercury, with the
addition of the decoction of sarsaparilla, without
producing the slightest apparent mercurial effect
on the patient's constitution, I have recommended
the continuance of half this innocent quantity of
mercury for a considerable time, in order to pre-
vent a relapse, and in many instances, this plan of
treatment has seemed to succeed, whilst in others
it has failed.
In some cases of pseudo-syphilis, one set of
symptoms will disappear without the use of mer-
cury, yet new symptoms occurring, they will be
progressive and destructive so as to require mer.
cury for their cure. The reverse of this also hap-
pens: one set of symptoms seemed to require, and
to have been cured by an alterative course of mer-
cury; yet others, subsequently arising, may disap-
pear without its administration. Even an innocent
and alterative course of mercury should not, in my
2N
282
On Diseases

opinion, be hastily resorted to. The object which
we are to keep in view, throughout the whole treat-
ment of the disease, is to tranquillize and invigo-
rate the constitution, and only to check or cure
destructive or very distressing symptoms by an
adequate quantity of mercury. Though an altera-
tive course of mercury is sp generally beneficial,
yet in some instances it aggravates these diseases.
There are persons of so peculiar a constitution,
that the smallest doses of mercury cannot be given
without producing irritation and disorder. Mer-
cury also may fail to be beneficial, when adminis-
tered at one period of these diseases, and yet have
the most desirable effect at another. It may for in-
stance fail to do good at an early period of the dis-
ease, when it is in a state of considerable activity,
and yet may counteract and subdue it, when its
vigour is on the decline. The cases furnish exam.
ples of these facts.
Though in general the decoction of sarsaparilla
appears to be the best medicine that can be given
in addition to alterative doses of mercury; yet,
when the constitution of the patient is weak, it is
useful to give medicines of a tonic and cordial kind.
This practice is peculiarly proper, when it requires
a more powerful operation of mercury than I have
in general described, to control and cure urgent
symptoms. *
* It may be thought by some, that I have relied too much in
the treatment of the foregoing diseases, upon the internal ad-
ministration of mercury, and have not sufficiently tried its ef-
fects by inunction. I therefore think it right to explain, that it
seems to me immaterial, whether a mild oxyd of mercury,
such as should be contained in mercurial ointment, and quick-
silver pills, is absorbed from the skin or the alimentary canal.
I generally find that as much of the quicksilver pill can be ta-
ken internally as is necessary to produce the degree of mer-

resembling Syphilis.
283
Such is the result of the observations I have
made on the treatment of these most vexatious
diseases; -diseases which must, I believe, per-
plex all surgeons, whatever opinions they may en-
tertain respecting them, and whatever conduct
they may pursue with a view to their cure. They,
who believe them all to be syphilitic, and regard
mercury as the only remedy, must be perplexed by
discerning its inefficacy. They who abstain from it
must be perplexed by observing the pertinacious
nature of the disease, and the frequent recurrence
of new and distressing symptoms. They who steer
a middle course, as I have done, will not avoid dif-
ficulties. Without any particular investigation of
the nature of venereal diseases, two different
modes of treatment seem to have been adopted
by the profession. One party has used mercury
liberally for evident reasons. It seemed necessary
for the cure of syphilis, and it has been successful
in cases of that disease. Believing all venereal dis.
eases to be of that nature, and further incited by
frequent recurrence of symptoms, one party of pro-
fessional men has used mercury, as I believe, in
a most injurious degree: whilst others, from wit-
nessing the beneficial effects of an alterative course
of mercury in pseudo-syphilitic diseases, have con-
sidered such a course to be all that was necessary
in every instance.
curial affection of the system, which is requisite for the cure
of pseudo-syphilitic symptoms, without in the least disorder-
ing the functions of the digestive organs; but on the contrary,
with evident benefit by exciting and maintaining the natural
and healthy actions of those organs.
It is right, however, to add, that the pilul: hydrarg! which
I have always employed, has been procured from the Apothe-
caries' Hall; and that when it has been obtained from other
places, its effects have by no ineans corresponded to what I
have represented of then, either in this, or the preceding vo-
lume.
284
On Diseases

No improvement in practice could possibly take
place, whilst former opinions prevailed; whilst sur-
geons regarded every constitutional disease that
had the appearance of syphilis to be really of that
nature, and treated it accordingly. This was done,
whatever might have been the characters and pro.
gress of the primary sore from which it originated;
and even when it was preceded by no sore, it was
considered as an instance of syphilis long lurking
in the constitution. Even Mr. Hunter, who so ac-
curately observed diseases, and so clearly distin-
guished, that there were many diseases resembling
syphilis which were not of that nature, must have
been exceedingly perplexed in his opinions and
practice. As he believed chancres might be modi-
fied by the diseased propensities of the constitu-
tion, when he met with ulcers in the throat, erup-
tions, and nodes consequent to such chancres,
which, not even his accurate observation could, I
will venture to affirm, in many cases distinguish,
from those of syphilis, he must, I think, have deem-
ed it right to treat them as if they were syphilitic.
The cases, to which I now allude, are recorded in
the second section.
But in these cases, the symptoms will recur in
general after the severest course of mercury. That
he met with such cases, and was perplexed by
them may be inferred from his opinions, he hav.
ing accounted for such failures by saying, that mer.
cury will cure the disease, when in an active state,
but will not cure the disposition to diseased actions,
which certain parts may have assumed. I believe,
however, it will be found that mercury cures both
the actions and dispositions to act in true syphilis,
and that the perplexing cases were of a different
nature to that disease. How far the diseased ac-
tions incited by syphilitic poison admit of conside.



resembling Syphilis. 285
rable modifications from peculiarity of constitution
in the primary sores or chancres, we have, I be.
lieve, yet to learn. There are, however, good rea-
sons for supposing that when a poison is absorbed
without inducing a sore, and when that sore is of a
nature very discordant to those of syphilis, that the
constitutional symptoms will be found equally to
differ from those of syphilis in their nature, and re-
quire a different mode of treatment.
Having been instructed by Mr. Hunter to be.
lieve, that there were diseases resembling the ve
nereal disease, which were different in their origin
and progress, having perceived nothing to contra-
dict, but on the contrary, every thing to confirm
that proposition, I have in this publication, avowed
my opinion of their existence to a far greater ex.
tent than Mr. Hunter supposed. Knowing how
much opinions influence our judgment and con-
duct respecting facts which come under our ob-
servation, I have even wished that these opinions,
if they be correct, might become general and con-
firmed. Being conscious that they have not been
hastily adopted; and that in surveying the facts
upon which they are founded, I have endeavoured
to keep my mind as unprejudiced as possible, I
should think myself guilty of a culpable timidity,
were I not to avow them. If the opinions be cor-
rect, it must indeed be acknowledged, that cases
of true syphilis are much less frequent now than
formerly, and for this I have endeavoured to assign
a reason in the second section. Well aware how
liable an individual is to err, in forming general
conclusions from his own limited experience, and
conscious that the opinions which I entertained re.
specting these diseases were different from those of
a great number of eminent surgeons, I at first pub-
lished my observations on the subject in portioris;
286
On Diseases, &C.

and the same apprehension as to the possibility of
error has now induced me to republish them in a
less methodical manner than I could have wished.
I thought this mode would show better the rise
and progress of those opinions which I cannot but
entertain; inasmuch, as they appear legitimately to
be deduced from facts. Had I published all I knew
and thought, relative to these subjects under ano.
ther title, had I called the book additional observa.
tions on venereal diseases, or on progressive and
remittent syphilis, it might have been better re-
ceived, because it might have been more accord-
ant to the notions of others. Yet in whatever way
I might have represented the subject the difference
would only have been in the manner of displaying
it; there would have been none in the matter to
which it related, as that consists of actual occur-
rences in practice.


DISEASES OF THE URETHRA;
PARTICULARLY OF THAT PART, WHICH IS SURROUNDED BY
THE PROSTATE GLAND.
SECTION I.
EVERY surgeon will, I believe, acknowledge
that an obscurity hangs over the subject of stric-
tures of the urethra, which prevents us from per-
ceiving the cause of many circumstances, which
occur in daily practice. Contractions of this ca.
nal are sometimes readily enlarged to their natural
diameter by the introduction of common bougies,
and the cure thus effected is permanent. In other
cases it is difficult to procure even a temporary
enlargement of the contracted part; and the stric-
ture returns, when the means by which it was re-
lieved are discontinued. This variety in the event
of different cases may, in some instances, depend
on the kind and duration of the disease in the
strictures themselves; yet, in many others, I am
convinced that it is owing to other circumstances,
which it is my design to consider in the present
paper. Before my observation had been directed
to these circumstances, I was much puzzled to
account for the discordance in the result of cases
apparently similar. I was equally unable to under-
stand some occurrences, like those which are re-
presented in the following case.
288
On Diseases of the Urethra.
CASE I.
A gentleman, whose life was made uncomforta-
ble by a very frequent and very urgent propensity
to void his urine, applied to me for advice. Two
strictures were discovered in the further part of
the urethra, which did not oppose the passage of a
bougie as large as a goose-quill. Some difficulty
was experienced when the bougie entered that part
of the urethra, which passes through the prostate
gland; and the patient complained of pain, which
was considerably increased at the orifice of the
bladder. The instrument, however, entered the
bladder, though with difficulty; and it seemed to be
grasped by the sphincter. The prostate was enlar-
ged to twice its natural size; which circumstance
seemed to me, to explain the cause of the slight
impediment which occurred to the passage of the
instrument through it. The urethra was unusually
long in this patient; and though bougies had been
frequently introduced, I suspect that they had



was of this opinion, from the peculiar sensations
which he experienced, and which he had never felt
before. He called upon me four days afterwards,
said that he was much relieved, and requested to
have the operation repeated. The same bougie
which had been used before now passed with much
greater facility. The patient still felt peculiar sen-
sations, though much diminished in degree, as the
instrument went through the prostate. It entered
the bladder without difficulty, and without appear-
ing to be grasped. I now introduced a larger bou.
gie, which went through the strictures with less
difficulty than the smaller one had done on its first
introduction. This produced the same uneasy
sensation on entering the prostate; it was retarded
for a moment at the orifice of the bladder, and was

On Diseases of the Urethra. 289.
slightly grasped at its entrance. All the symptoms
were still more relieved by this second introduce
tion. The same operation was repeated a few
times; at first every fourth day, and afterwards
once a week, till a bougie of the largest size could
be passed without occasioning any uneasiness. The
patient, during the latter part of the time, did not
require to void his urine more frequently than is
common. He was relieved from a great trouble;
and though many years have elapsed, he has not
experienced similar inconvenience.
Such cases as the preceding induced me to sus.
pect that a stricture might exist in the orifice of
the bladder. The following case gave me new, and,
as I think, just ideas relative to this subject.
Whether the opinions be correct or not, the cases,
it must be admitted, deserve attention.
CASE II.
A gentleman, more than seventy years of age,
had experienced for about six years a difficulty in
voiding his urine, which gradually increased, till
the stream became very small. This was attended
with a frequent propensity to discharge the urine,
which disturbed him every second or third hour
during the night. At last a complete retention took
place when he was in the country; and a surgeon
attempted to introduce a small catheter, which
however was prevented, by a stricture, from pass-
ing farther than six inches. The patient immedi-
ately came to London, when I directed him to
take some castor oil, and to bathe the perinæum
and adjacent parts frequently with warm water.
After some time the urine flowed again, and he
was relieved from the present urgent symptoms.
In two days I examined the urethra, and found a
stricture at six inches, through which I could not
20
290 On Diseases of the Urethra.

pass even a very small bougie. I touched this with
the argentum nitratum; but the application did not
produce any alteration in the circumstances of the
disease. On the third day the bougie passed on to
a stricture, at seven inches, which was also touch-
ed with caustic: and the same treatment was re-
peated with another stricture, at the distance of
half an inch from this. The bougie now passed
through all the strictures, and entered the prostate,
when I was obliged to withdraw it immediately,
from a sudden attack of pain and faintness. No
enlargement of the prostate was discovered by an
examination per anum; nor was it tender when
compressed. I told the patient that I considered
it very desirable to introduce a tubular instrument
into the bladder, but that the minuteness of the
stream of urine rendered it doubtful whether this
could be accomplished. I requested him to call in
another surgeon, that the attempt might be made
by us conjointly. A flexible varnished catheter,
containing a strong wire, was readily passed into
the prostate, but could not be made to enter the
from an apprehension of doing injury, if the instru-
ment were not guided in the right track. No blood
flowed upon withdrawing the catheter. A slight re-
tention of urine followed this attempt, but, after a
few days, the patient was in the same state as be-
fore. On examining the urethra four days after-
wards, I found that the smallest bougie would not
pass farther than six inches; so that the contrac-
tion of the first stricture had been reexcited by
the irritation occasioned by our late attempt. As
the application of the argentum nitratum had so
suddenly and completely relieved this stricture in
the first instance, I now repeated this application,
although I knew that the stricture was merely

On Diseases of the Urethra. 291
spasmodic. In the course of a few days a small
bougie was introduced into the prostate, and after.
wards a larger one. I now wished to ascertain
whether I could pass the bougie into the bladder,
or learn, by means of that instrument, the cause of
the obstruction. As the patient found that he could
void his urine most easily when lying on the left
side, it seemed probable that the orifice of the ure.
thra might be found in that direction. I therefore
depressed the point of the instrument, and carried
most unexpectedly it went forwards into the blad-
der. When the bougie was withdrawn, a conside,
rable quantity of clotted blood and mucus, with
some matter, oozed out of the urethra; and the
patient afterwards voided in a large stream about
eight ounces of turbid and fetid urinę mixed with
mucus; after which he felt as if his bladder was
completely emptied. From this time he had no
occasion to void his urine more frequently than is
natural, and he expelled it in as large a stream,
and with as much facility, as he had ever done at
any period of his life. The bougie was for some
time introduced every third day, and afterwards
once a week. It passed easily not only through the
urethra, but into the bladder, when guided in the
direction which has been mentioned. At first the
point was soiled with blood and inatter, but after-
wards these appearances were no longer observa-
ble, which led me to conclude that the circumfe.
rence of the ulcerated orifice of the bladder had
completely healed. Two years afterwards this gen-
tleman experienced a recurrence of his former
complaints; a small bougie only could now be in-
troduced into the bladder. A larger bougie was
passed through the urethra on the next attempt;
but was not carried forwards into the bladder,
292 On Diseases of the Urethra.

from an apprehension of irritating the prostate.
After a few days the larger bougie was introduced
into the bladder, and met with a little resistance at
its orifice. From this time it passed with the same
facility as when I discontinued my former attend-
ance, and the patient found himself equally well.
Two years have now elapsed, without any necessi-
ty for repeating these operations.
In this case a disease took place in the prostate
gland, without producing any evident enlargement
or tenderness of its substance, though it had pro-
ceeded to a state of ulceration. The disease seems
to have operated on the continuous parts in two
directions; backwards upon the bladder, rendering
that organ irritable; and forwards upon the ure-
thra, causing strictures, which were in some de-
gree organic, though chiefly of a spasmodic nature.
It must be allowed. however, that the obstruction
of the aperture into the bladder by the discharges
from the ulcerated surface contributed in a great
degree to maintain the irritability of the organ, by
impeding the discharge of the urine. This disease
was also of a nature that admitted of relief, and
the passage of a bougie seemed to effect its cure.
It had, however, a tendency to recur, and the use
of the bougie lessened the irritability of the part,
and arrested the progress of the disease.
The circumstances of this case do not indeed
unfold the cause and precise nature of the disor-
der, which, however, will in my opinion be eluci-
dated by those which follow. They induced me to
suppose that those instances, which I had former-
ly met with, and which appeared so unintelligible,
were of a similar nature; and they made me parti-
cularly attentive to the state of the urethra, where
it passes through the prostate gland, as I saw the
possibility of this canal being diseased, without the

On Diseases of the Urethra. . 293
prostate being materially implicated in the disor.
der. The following case occurred soon afterwards.
CASE III.
A gentleman, between fifty and sixty years of
age, had for twenty years been subject to occasion-
al fits of dysury. I was desired to see him in one
of these, which had been very severe and long con-
tinued. He was obliged to void the urine at least
every hour. The calls were sudden and urgent,
and the pain continued for a considerable time
after the urine had been discharged. He had some
fever, which such irritation would naturally pro-
duce. A moderate-sized bougie stopped at two
strictures, but passed through them without much
difficulty; when it entered the prostate, the patient
complained of burning pain; of a strong irritation
to make water; and grew so faint that I had merely
time, by a gentle pressure, to ascertain that the
bougie would pass into the bladder: when I with.
drew it, the point was covered with blood. The
patient was directed to bathe the perinæum with
warm water frequently, if the dysury was urgent.
He was much relieved by the introduction of the
bougie, and did not want afterwards to void his
urine oftener than every second or third hour.
The calls were less urgent, and the subsequent
uneasiness less in severity and duration. After two
days, a bougie of the same size was introduced to
the extent of eight inches, and withdrawn; no
blood adhered to its surface. A smaller bougie,
much curved, was now passed into the bladder;
the patient complained of the same uneasy sensa-
tion as before, when it entered the prostate; but he
did not grow faint. The point was bloody for
three quarters of an inch, but less so than on its
first introduction. More relief was experienced
294 On Diseases of the Urethra.

this time. The urine was now voided only every
fourth hour. Two days afterwards the bougie was
again introduced into the bladder, considerably
curved, and with the point carried along the upper
surface of the urethra, where it passes through the
prostate gland. The point was soiled with a yel-
lowish fluid, slightly tinged with blood. As the
patient was getting much better, the operation was
not repeated till after four days, and then after the
interval of a week; at which time the blood and the
yellow fluid had entirely disappeared. The urine
was not voided more frequently than natural, nor
was its expulsion attended or succeeded by any
painful sensation. The strictures in this case felt
firm, and not easily dilatable: I thought it necessa-
ry to relieve them, lest they should contribute to
reinduce the irritation in the prostate; but the
patient felt himself so well, that he was averse to
any thing which might renew his former suffer-
ings, and he has had no symptoms of dysury since
that period. The prostate in this patient was not
enlarged nor tender. Conclusions similar to those,
which were deduced from the former case, may
be more fairly drawn from this; viz. that a disease
may occur in the membrane of the urethra where
it passes through the prostate, and that it may ren-
der the bladder irritable, and produce strictures
in the urethra; for in this case there was no me-
chanical obstruction to the expulsion of the urine
to produce irritation in the bladder. It also ap-
pears, that the disease admitted of relief by the
introduction of a bougie.
I have lately met with another case in a younger
man, who is between twenty and thirty years
of age, and who was afflicted with similar fits of
dysury, the cause of which could not be ascertain-
ed. I passed a bougie for him a few times, but

On Diseases of the Urethra.
295
found no stricture in the urethra. The same pain-
ful sensations were produced in the prostate, as in
the preceding cases. The bougie did not appear at
the time to relieve the dysury; but the complaint
gradually ceased, and the patient left town. He has
been much better since this time, and attributes
his relief to the passage of the bougie.
CASE IV.
A gentleman, about sixty years of age, was af-
fected with dysury, which increased with violence,
though various means were employed during two
years for his relief. He voided his urine every se.
cond hour, or oftener, with great pain and severe
irritation, which continued for some time after its
expulsion. He had such a sensation of heat and
uneasiness in the perinæum, that he could not bear
to bring his thighs together; and he was obliged to
use a cushion, with a vacancy in the middle, when
he sat down. He could not ride in a carriage, or
even walk out, although his general health was
good. A moderate-sized bougie halted a little at
two strictures, and when it arrived at the prostate
produced a violent burning sensation, a vehement
propensity to void the urine, and extreme pain at
about two inches from the orifice of the urethra;
which part was always particularly painful during
the time of voiding the urine, and after its expul-
sion. On withdrawing the bougie, which had en-
tered the bladder, its point was found to be covered
with blood. The prostate being examined, felt ra-
ther broader than usual, but was not tender. The
patient was relieved by the introduction of the bou-
gie, which was repeated on the third day: it went
more freely through the strictures, and the sensa.
tions, caused by its passage through the prostate,
were diminished. The point of the bougie was
296 On Diseases of the Urethra.

bloody. I ascertained that the blood came from
that part of the urethra which is situated in the
prostate, by introducing a large bougie to the dis-
tance of eight inches, and then withdrawing it: the
point was not in the least soiled with blood. The
second introduction of the bougie produced con-
siderable relief. The urine was retained longer,
the uneasy sensation in the perinæum was dimi.
nished, and the patient could walk or sit down
more comfortably. The bougie was used every
third or fourth day for three weeks; and then once
a week for a month longer, its size being gradually
increased. The appearance of blood on the point
gradually ceased: it was afterwards soiled with a
purulent and then with a mucous fluid, which ap.
pearances also gradually ceased. The water was
now voided only at intervals of four hours, the sub-
sequent pain being either trivial or entirely want-
ing; the uneasiness in the perinæum was so incon-
siderable, that the patient could walk for several
hours, and sit down without pain. The seminal
discharges had been attended with extreme pain,
so great as almost to produce fainting, before the
state of the prostate had been relieved: they after-
wards took place without any unusual sensation.
These cases show that the urethra may become
irritable and diseased, where it passes through the
prostate gland, without any material disorder of the
contiguous parts. They induced me to pay parti-
cular attention to the state of that part of the ure-
thra; which attention will, in my opinion, be found
of great consequence in directing our treatment of
these disorders. As it would render this paper ex-
tremely voluminous to detail the particular cases
which I have met with, I shall merely relate the
observations which I have made, and the inferences
which I have drawn from them; that the profession

On Diseases of the Urethra.
297
in general may investigate the subject, and deter-
mine how far these observations and opinions are
correct.
First, then, it has appeared to me that a state of
inflammation and irritation may take place in the
remote part of the urethra to a greater or less ex.
tent. It may produce in the prostate that peculiar
sensibility of the part which I have described;
and in the perinæum it may cause contractions of
different parts of the canal. Either of these affec.
tions may be more permanent than the other, even
where each part has been equally affected in the
beginning. This state of inflammation and irrita-
tion is frequently produced by gonorrhæa, though
it may occur from other causes. If a bougie be in-
troduced injudiciously, when this disorder first oc-
curs in a gonorrhæa, numerous spasmodic stric-
tures* are met with; the patient becomes alarmed
by the difficulty of passing the instrument, and by
the name of strictures, and consults a more expe-
rienced surgeon, who directs local warm bathing,
and the application of leeches to the perinæum. -
The disorder is cured; the patient expects that
strictures remain; a full-sized bougie is introduced
to satisfy him, which passes without the least dif.
ficulty. I am unable to determine, whether in such
cases the urethra is affected in the first instance in
that part which passes through the prostate, as I
never made any examination under these circum-
stances, though I think it very probable that it is
so. When a gleet becomes unusually protracted,
it is frequently owing to the effects of this disorder
* I have used the term spasmodic strictures in the indis-
criminate manner in which it is generally employed, though
I am aware that it is objectionable: a stricture from spasm is
not a stricture; and a stricture may be irritable or spasmodi-
cal, or otherwise.
2 P
298 On Diseases of the Urethra.

in the remote part of the urethra, maintaining a de-
gree of irritation in the front. Under these circum.
stances it is allowable to introduce a bougie, when
strictures will frequently be found in the perinæum;
and in many cases, the patients whom I have at-
tended, have experienced those sensations, which
are characteristic of tenderness in the membrane of
the urethra, where it passes through the prostate.
If, therefore, we look to the origin of those cases,
which we are called upon to attend in their ad-
vanced stages, we might expect to find the disor-
der of the urethra various with respect to the kind
and extent of the disease. That it will be found so
in practice I do not hesitate to affirm, from the ob-
servations which I have already made relative to
this subject. In some cases, strictures in that part
of the canal, which is subject to such contractions,
will be the sole disease. In others, an uneasiness,
and such sensations as I have described, will be
complained of as the bougie passes through the
last inch of the urethra, which is contained in the
prostate gland. In some cases also, the strictures
will be the less degree of the disease, and the irri.
tation in the prostate the greater; and in some cases
it will be found that nothing is discoverable which
can fairly be denominated a stricture, and yet the
tenderness which I have described exists in a most
painful degree.
A student of the hospital who had a slight gleet,
but of long continuance, having also some pain and
irritation after voiding his urine, though without
any frequent desire to void it, passed a bougie,
which arrived at the prostatic part of the urethra
without impediment, or causing him to feel any
particular uneasiness; but when it glided on
through the prostate, it occasioned, he said, a
burning pain and irritation, so peculiar, as not to

On Diseases of the Urethra.
299
admit of description, and so severe, that he could
not have believed it, but on the evidence of his own
senses.
My observations have also led me to believe,
that the inflammation of the testis, which is so fre-
quent an attendant on gonorrhæa, is excited by in-
flammation of this part of the urethra, and not by
a sympathy between that gland and the urethra in
general.
In deducing these diseases from the inflamma.
tion which gonorrhæa excites, I mean only to trace
them from a very common origin. The same dis-
orders frequently take place without having been
preceded by that complaint. An attention to the
circumstances, which have been mentioned, seems
to me to explain the contradictory events which
happen, when a similar plan of treatment is pur.
sued for the cure of diseases of the urethra. When
strictures are the sole disease, they are often read-
ily, and generally permanently cured. When an ir-
ritation, such as I have described, exists in the
prostate, it is difficult to enlarge the contracted
portions of the canal; and, when that is accomplish-
ed, the strictures recur, as a cause of irritation to
the urethra still continues. In some cases, the en-
largement of the strictures fails to mitigate the dy.
sury, and in others it is augmented by the mea-
sures which have been employed to cure the stric-
tures, when the state of irritation at the neck of the
bladder has been unadverted to. Many patients
have applied to me under these circumstances, af-
ter having been under the care of other surgeons.
They have stated, that small bougies only could be
passed in the first instance, and that though the
largest could now be introduced, the complaint
was no better; nay, some have thought themselves
materially worse. A bougie has passed in these
300 On Diseases of the Urethra.

cases eight inches, without meeting any conside-
rable obstruction, or exciting much sensation; but,
after this point, it caused a most acute and burning
pain, with vehement desire to make water. Some
have inquired if I was withdrawing the bougie,
whilst it was slowly proceeding, and some have
complained of great pain in the front of the ure-
thra. Similar cases have occurred in my own prac-
tice. I have relieved strictures, without materially
benefiting my patients; of late years, I may ven-
ture to say, without making them worse; because
I have been cautious not to hurt the canal, where
it passes through the prostate.
Some cases of disorders of the urinary organs
are made worse by the attempt to cure strictures:
and I think I deliver an important admonition, to
the younger part of the profession, when I caution
them to beware, in their attempts to cure strictures,
that they do not irritate nor injure the last inch of
that canal, where there are no strictures, but in
which considerable disorder may nevertheless ex-
ist.
In some cases of diseased urethra, which I have
not unfrequently met with, strictures are found,
through which a small bougie passes with difficulty;
and it produces those sensations, in passing through
the prostate, which I have described, as peculiar to
that part of the canal when in a diseased state. The
patient, however, experiences relief from the intro-
duction of the bougie; and if it be passed again on
the third day, it will meet with no obstruction from
the strictures, and cause less uneasiness in passing
through the prostate. I have then taken a bougie
of a larger size, such as it would have been impos-
sible to introduce in the first instance, and this has
passed through the strictures to the distance of
eight inches; but I have forborne to carry it any.

On Diseases of the Urethra. 301
farther, lest I should irritate the urethra near the
neck of the bladder. It appears therefore to me,
that you may relieve or aggravate strictures in such
cases in proportion as you diminish or augment the
morbid sensibility of the remote part of the ure.
thra; and an attention to the state of this part is on
this account of the greatest importance.
Having thus adverted to the probable origin of
the disease, which I am endeavouring to describe,
and its connexion with strictures, I proceed to ob.
serve, that such a state of morbid sensibility in that
portion of the urethra, which passes through the
prostate, may perhaps exist as a symptom of an
irritable bladder. If the lining of the bladder be in-
flamed and irritable, it is probable that the disorder
will extend into the urethra for some small distance.
In the fourth case, I believe that the disease in ques.
tion was complicated with an irritable state of the
bladder; but whether it was to be considered as an
adjunct circumstance, or in the relation of cause or
effect, cannot be determined. The irritability of the
bladder was diminished, but not cured, by the treat-
ment which lessened this disease. In one gentle-
man, who apparently died of an irritable bladder,
and who complained of the sensations, which I
have described, in an acute degree, on the bougie
passing through the prostate, the diseased parts
were examined, but very trivial morbid appear.
ances were discovered. The lining of the bladder
was not perfectly natural, and was inflamed; yet the
diseased appearances were not striking; and in the
urethra the deviation from the healthy structure
was still less observable.
It is not improbable, however, that such a mor-
bid sensibility of the prostatic urethra may arise
from an irritable bladder. Perhaps, also, it may oc.
casionally arise from the irritation of the last stric-
302 On Diseases of the Urethra.

ture. Many patients with strictures who complain.
ed much of the sensations at the neck of the blad-
der, at the commencement of the treatment of their
complaint, have asserted, that they felt no unusual
sensations when the bougie passed through the
prostate, after the strictures had been cured. Yet,
though I would admit that a tenderness of the ca-
nal of the urethra in the prostate may sometimes
arise from its proximity and continuity with the
lining of the bladder, or with the last stricture, I
think it more frequently exists as an original and
independent disease. It has been shown, that it
may render the bladder irritable, and excite con-
tractions in the urethra. Some cases have been ad-
duced, which show that this state may exist, and
yet the bladder may not be constantly irritable, but
that it may be affected by fits. I have also met with
a case where this sensibility existed in an extreme
degree, and yet it seemed to have very little influ-
ence on the bladder. I have likewise known this
irritable state of the urethra complicated with en-
largement of the prostate.
- I proceed, in the next place, to relate what I
have observed respecting the treatment of the dis-
ease, which I have been describing. The three first
cases show, in a striking manner, the advantage
derived from the introduction of bougies; and I
have seen many similar ones, though I scarcely
think so demonstrative of the utility of this mode
of treatment. I know some patients with occasional
attacks of dysury, and who have this tenderness of
the remote part of the urethra, in whom the pas-
sage of a bougie, together with warm bathing of
the perinæum and adjacent parts, very speedily re-
lieves a disease, which had proved very tedious
and distressing, before these measures were adopt-
ed. If a bougie be introduced, for the first time, in

On Diseases of the Urethra. 303
a case of this description, severe pain is felt, and
faintness is occasioned: if this operation be repeat-
ed three days afterwards, the pain perhaps is much
less severe, and it may diminish at each succeed-
ing introduction of the instrument. Should this be
found to be the case, surely nothing need be far.
ther said in commendation of this mode of treat-
ment. The morbid sensibility of parts is diminish-
ed by it. This happened in the three first cases in
a remarkable degree, and I have known it take
place in many others. Nor is there any thing in this
event that should excite surprise: every surgeon
is familiar with the same circumstance, with rela-
tion to strictures in the urethra. The first introduc-
tions of a bougie are very painful; the subsequent
ones become to be even disregarded. Still, howe-
ver, I think it may be useful to dwell a little on
this subject, and to consider the probable causes
of these effects, as it may tend to establish rules
for our conduct in practice. It appears to me, that
we diminish the morbid as well as the natural sen-
sibility of parts by doing them a degree of violence,
short of that which produces a kind of reaction in
them, by which their sensibility is heightened. This
is, indeed, the consideration which guides my prac-
tice in these and many other cases. If, even in stric-
tures of the urethra, the sensibility of the canal be-
comes increased by the introduction of bougies,
or, in other words, if inflammation is excited, sure-
ly it is wrong to prosecute such measures at this
juncture. If the morbid sensibility be diminished,
we may use more freedom in the prosecution of
our measures. In passing the bougie, in the cases
now under consideration, it ought at first, I think,
to be so small as not at all to distend the irritable
urethra. I have always curved it considerably, and
kept the point in contact with the upper surface of

304 On Diseases of the Urethra.
the urethra, as it passes through the gland. I re-
commend warm bathing to the perinæum, with a
view to obviate or diminish irritation. If I find, on
the second introduction of the bougie, the sensibi-
lity of the parts diminished, it induces me after-
wards to proceed more freely; but at all times with
a caution excited and regulated by the considera-
tion which I have mentioned. Now, though such
conduct has been successful in many instances, I
am concerned to state, that it has failed in some
others; and, when I clearly ascertain that I am not
likely to succeed, I cease to make farther attempts
by the introduction of bougies, and pursue only
general methods, such as warm bathing, bleeding
by leeches, &c. When there are strictures, which
it is right to enlarge, and when the irritation of the
prostatic part of the urethra is not relieved by the
measures which have been suggested, I pass the
bougie through the last stricture, without carrying
it on, so as to irritate the tender part of the ure-
thra, which lies behind it. A knowledge of the na-
ture of diseases cannot but be desirable, even
though it does not enable us to cure them all. If
strictures are removed, and dysury remains, I be-
lieve it is common to consider it as arising from an
irritable bladder: now, though this may be gene-
rally true, there are many exceptions. I do not find
that attention is paid to that description of cases,
which makes the subject of the present paper: I
was unacquainted with them till I met with the
cases which I first mentioned: the knowledge
which I have thus obtained, has enabled me to af-
ford relief in many cases, and has prevented me
from error in others.

On Diseases of the Urethra.
30%
E
SECTION II.
On the constitutional Origin and Treatment of
Diseases of the Urethra.
HAVING in the preceding section, pointed out
one cause which renders strictures and other dis-
eases of the urethra difficult of cure, in this I shall
advert to another; I mean a state of irritability and
disorder of that canal, produced or maintained by
constitutional causes. To explain my ideas on this
subject, I wish, in the first place, to excite the at
tention of the profession to the constitutional ori.
gin of disorders of the urinary organs. That they
are very liable to be disordered by the state of the
health in general, is very apparent. Indigestion
becomes a cause of foul and unhealthy urine, in
consequence of much unassimilated matter being
conveyed into the blood with the chyle. Nervous
irritation affects the kidney and impairs its func-
tions, so that, whilst under its influence, scarcely
any thing but water is separated by that organ
from the blood. The nervous irritation at the same
timé operates on the bladder, and creates a fre-
quent and sometimes urgent desire to void this
unstimulated urine. Many persons during the day,
or until they have dined, are greatly incommoded
by this circumstance; whilst on the contrary, after
dinner, nervous irritation ceasing, and the urine
becoming in consequence loaded with salts and
animal matter, the bladder will retain the acrid
urine, even in a large quantity, for a great number
of hours.
2Q
806 On Diseases of the Urethra.

In other cases, nervous irritation takes place,
and limpid urine is frequently voided after dinner;
which Ì merely mention, because it may tend to
throw light on the cause and nature of the nervous
irritation.* If the kidneys and bladder can thus
be operated upon by nervous irritation, it is rea-
sonable to suppose, that the urethra will partici-
pate in the affection; and I am convinced by nu-
merous observations, that many diseases of the
urethra, in both sexes, originate from a continu-
ance of this kind of constitutional dysury. The
cases of such diseases occurring in females who
have passed the middle period of life, will proba-
bly be considered as affording the most unequivo-
cal proofs of the correctness of these opinions.
Under such circumstances, I have known in dif.
ferent instances, strictures in the urethra, indura-
tion and tenderness of the whole tube, and even
ulceration of its orifice to ensue. Though I have
seen relief obtained in cases of this description by
bougies and local remedies, yet I believe the treat-
ment of such diseases ought to be constitutional,
and that such treatment will succeed in curing the
disease without local remedies. I know one in.
stance in which the dysury had been very severe,
and two considerable strictures had formed in the
urethra; there was also a thickening accompanied
with whiteness and hardness of the membrane of
the vagina, causing a contraction in the orifice of
that canal; yet all dysury ceased, and no inconve-
nience was experienced upon the patient's acquir-
* The qualities of the urine are sometimes the only cir-
cuinstances by which we can discover that there is general
irritation of the nervous system; they also denote imperfect
digestion; they may further indicate the state of the blood;
and for all these reasons they deserve particular attention and
investigation.
On Diseases of the Urethra. 307

ing better health; which change was effected part-
ly by medicine, and partly by removal into the
country. Women will suffer a great deal from
these disorders before they reveal their distress;
and when from the urgency of the symptoms, and
the belief that they have a stone in the bladder,
they are willing to submit to examination, the dis-
order may be speedily and completely relieved and
cured by means which have the effect of tranquil-
lizing nervous irritation. It may be useful to relate
a case in proof of this assertion.
CASE V.
A lady, between thirty and forty years of age,
who had long suffered very considerably from dy-
sury, agreed to permit an examination to be made
of the nature of a disease, which, from the severity
of its effects, she could not but believe to be of a
very serious and alarming nature...
. On inquiry, I found, that though she voided her
urine frequently, and with great pain, yet it flow-
ed freely, and that she did not suffer that extreme
and continued pain afterwards, which is generally
the consequence of the stone.
I found also, by inquiry, that her bowels were
not in a proper state, and her tongue was much
furred. Supposing that a state of nervous irritation
might be caused or aggravated by disorder of the
digestive organs, I objected to making any exami-
nation of the state of the urethra, &c. till the func-
tions of those organs were put right by medicine,
because I was aware that nothing but a convic.
tion of the indispensable necessity of examination
would have induced her to submit to it. In a very
short time, the state of the primæ viæ being cor-
rected, and her health in general amended, all dy-
sury completely ceased.
308 On Diseases of the Urethra.

· Dysury of this description is liable to occur in
paroxysms. I have known it alternate with disor-
ders of the bowels, and with rheumatic affection,
which I think, shows that there is a common con-
stitutional origin, producing such various com-
plaints; and I repeat, that I have known such dy-
sury lead to actual disease of the affected organs.
It is very common for men, who have been marri-
ed many years, and who perhaps never had gonor-
rhæa; (or if they had in their youth, it is probable
that it had left no disorder in the canal of the ure-
thra,) to gradually acquire, as they advance in life,
diseases of the urinary organs. Surely, then, the
origin of such diseases must be regarded as spon-
taneous, and likely to be induced and maintained
by whatever occasions irritation in the affected
organs.
There is, however, no period of life exempt
from this kind of dysury. Children are frequent-
ly much affected by it, and at that age when the
bodily powers are generally in the greatest vigour,
if they become disordered, dysury occurs in com-
mon with other diseases. I have mentioned in the
first part of these observations, in speaking of the
constitutional origin of local diseases, that I have
known dysury of this description.
I subjoin another striking case of constitutional
dysury occurring in a child.
CASE VI.
A child, about two years of age, became affect. :
ed with dysury, for the relief of which, various
means were tried without benefit: on the contrary,
the symptoms increased, and strikingly resembled
those occasioned by a stone in the bladder. The
calls to void the urine were frequent and urgent,
and the pain afterwards very severe. There was
On Diseases of the Urethra. .. 309

an elongation and stricture of the orifice of the
prepuce, which induced a surgeon who attended
the child, to divide that part, as he thought it
might contribute to the difficulty experienced in
expelling the urine. Under these circumstances,
the child was examined by a surgeon of great pro.
fessional eminence, who had no doubt that the
symptoms were caused by a stone, which he
thought he felt; yet recommended that no opera-
tion should be attempted till it had increased in
size. The child continued to suffer in the same
manner for two years, when I was desired to exa-
mine him. I could not, however, discover any
stone, and upon inquiry, I found that the child
complained of considerable pains in his loins, and
that his digestive organs were greatly disordered
in the manner that I have described in the first vo-
lume of these observations. Unirritating and un-
debilitating doses of pilul: hydrarg: were given
every second night, and strict attention was paid
to keep the bowels clear, without inducing what
is ordinarily called purging. The effect of this
treatment was surprising, all the symptoms were
immediately relieved, and they completely ceased
in a month, at which time the functions and
secretions of the digestive organs appeared to be
so correctly healthy, that all medicine was dis-
continued. After some months, a slight relapse of
dysury took place, which immediately ceased,
upon resuming for a short time the same plan of
treatment; and the boy has since remained perfect-
ly well, though several years have elapsed.
If, then, irritation of the urinary organs, even to
a degree productive of local diseases in them may
occur from constitutional causes, and more appar-
ently from a disorder of the digestive organs, I
need not then urge the propriety of our endeavour- /
310
On Diseases of the Urethra.

ing to keep the latter organs, as nearly as possible,
in a state of health, whilst we are endeavouring to
relieve the diseases of the former by local mea-
sures. Of the beneficial effects of such conduct, I
could relate many instances, but it does not seem
necessary to detail cases in proof of so self-evident
a proposition. I have explained in the first vo.
lume, my ideas of the mode by which relieving
disorders of the digestive organs, relieves and
cures local diseases; and in local diseases of the
pelvic viscera another reason may be suggested
for the benefit which is obtained. It has been ob.
served, that in disorders of the digestive organs,
the lower part of the intestinal canal is frequently
most affected. Irritation in the rectum must affect
the plexus of nerves, from which not only that in-
testine, but the pelvic viscera in common derive
their energies; and thus it may lead to a similar
participation of disease.
On Diseases of the Urethra.

SECTION III.
On some effects of Diseases of the Urethra.
I SHALL take the present opportunity of ex.
citing the attention of the profession to some
effects of disorders of the urethra, which have not
hitherto received in my opinion a sufficient share
of attention. If a violent affection of this canal can
produce a corresponding degree of inflammation of
the testis, as it frequently does in gonorrhæa, it may
reasonably be expected, that a less degree of dis-
order in the urethra may produce a milder irrita-
tion of the testis, which may terminate in a slow
disease of that gland. Indeed it has appeared to
me that there are two circumstances causing irri.
tation and consequent disease of the testis: one is,
disorder of the urethra; and the other, that de-
rangement of the constitution at large, which I
have described in the first part of these observa.
tions. I need not point out how inefficacious any
local treatment of an irritated or diseased gland
must be, whilst we leave the causes which pro.
duced it still to operate in full force for its conti.
nuance. I proceed to relate a few cases, in which
irritation originating in the urethra first caused,
and subsequently maintained, disease of the testis.
CASE.
A gentleman who had been confined with a
chronic disease of the left testis, which had proved
very refractory and irreducible by various means
employed for its cure, applied to me when the
gland was four times its natural size, and very

312 On Diseases of the Urethra.
hard. I recommended the application of three or
four leeches once a week, a bread and water poul-
tice at night, and aq: ammon: acetat: during the
day.
This treatment was pursued for six weeks with
very little benefit. I then changed the poultice to
one made of linseed, over which mercurial oint-
ment was spread. The ointment was also rubbed
upon the scrotum in the morning, and a soft rag
applied over it. The patient likewise took a com-
pound calomel pill every night.
This treatment was also persevered in for about
six weeks, but with no manifest advantage. I then
put two setons* through the scrotum, and conti-
nued the poultice at night and a dressing of sperma-
ceti-cerate during the day. Under this treatment
the testis diminished very considerably in size, but
at the end of two months, the setons had gradually
come out, in consequence of the ulceration which
they occasioned. Shortly afterwards, the testis
became painful, and it enlarged to its former di-
mensions, so that no advantage was obtained from
all these endeavours to reduce the disease. I had
frequently inquired of this patient respecting the
state of his urethra, and been as often told that he
was not conscious of any disorder existing in that
canal. Now, however, on repeating my inquiries,
he said, that he had remarked the stream of urine
to be small, and that the calls to void it were more
urgent than formerly. On passing a bougie, I
* Setons may be conveniently made and worn in the scro-
tum. I first employed them in conformity to those general
principles which regulate our conduct in the treatment of
local diseases; and I have known several instances of diseas-
ed testis, which resisted various local modes of cure, and
éven considerable courses of mercury, yield and get well
when setons were employed.
On Diseases of the Urethra. 313

found two strictures considerably contracted and
a tender state of the urethra where it passes through
the prostate. These diseases being relieved, all ir -
ritation in the testis ceased, and the enlargement
rapidly subsided; so that in two months it was
scarcely larger than the other, and all disease had
ceased. This happened without any other local ap-
plication than a poultice at night, and support by
a bandage. Even the poultice at night was saon
discontinued. This patient has had no return of
disease of the testis, and many years have elapsed
since the occurrences which I have been relating.
The following case was drawn up by a medical
man, of considerable information and talents, who
was himself the subject of it, and who was con-
vinced with respect to his own case, of the truth
of those opinions which I am now offering to the
public.
CASE.
- ætat, thirty, about four
years since had an uneasy sensation in both testi-
cles, which, however, occurred so seldom, and was
so trifling, that he paid little attention to it; about
a twelvemonth after, he found the left testicle
harder than natural, but not enlarged; for some
time previous to this, he had been obliged to void
his urine very early in the morning from great ir-
ritation to do so; but not too frequently during the
day; and occasionally had a tightness and sense of
constriction in the perinæum, with frequent aching
pain in the glans penis. The testicle remained in
the above mentioned state (without pain or in-
crease) till March 1806, when he received a blow
from an accident on horseback; no violent pain was
immediately felt, nor did any apparent alteration
take place till about a fortnight after, when he per-
2R
114 On Diseases of the Urethra.

ceived the testicle larger and much harder than it
had hitherto been; and it gradually though slowly
increased till the end of August, when he saw Mr.
Abernethy. The testis was at this time of twice its
natural size, hard and painful to the touch. Leeches
were applied once a week, and the testicle was kept
suspended, and wrapped during the day in a cloth
dipped in tinct: opii and water, and an evaporat-
ing poultice was applied at night. By this treat-
ment it gradually became less, but the hardness
still continued. He saw Mr. A. again in Septem-
ber, and was then desired to rub camphorated mer-
curial ointment upon the testicle, and cover it with
a soap plaster. The testicle still kept decreasing,
but remained equally indurated till the twentieth
of November, when it swelled with considerable
pain and irritation, and began to adhere to the
scrotum.* He again saw Mr. Abernethy, who in-
troduced a small bougie, and found a stricture
about six inches from the orifice of the urethra,
and a second the eighth of an inch from the for.
mer. The bougie passed without much pain or
difficulty through the strictures, till it came to the
prostate when much pain and sensation of heat, ir-
ritation, and strong inclination to make water were
felt; the bougie, however, passed into the bladder,
and was closely held by the sphincter. The peri-
næum was then ordered to be bathed night and
morning with warm water, and a bread and water
poultice to be applied to the testicle, which were
done, and at the end of the week, the pain and irri-
tation in the testicle were greatly relieved; the same
bougie was then passed, but with greater ease, and
* The testis was now about three times its natural size,
and at the upper part of the epidydimis, the scrotum had ad-
hered to the subjacent part, and was so inflamed as to indicate
the probability of the formation of an abscess,
On Diseases of the Urethra.. 315

the painful sensations which had before been felt
on its entering the prostate were much diminished.
The warm bathing and poultices were continued,
and the same bougie passed at the end of the fol-
lowing week with still greater ease and slighter
sensations. At the end of the third week the stric-
tures were touched with kali pur: which produced
little irritation; and on the week following a much
larger bougie passed with ease; the warm bathing
and poultices being continued in the interval. Dur-
ing the three following weeks the large bougie
passed with great ease; no irritation was felt after
it, and the sensations, whilst it was going through
the prostate, were slighter each successive time.
The testicle at the end of this time, (seven weeks)
was reduced to its natural size, and was become
nearly undistinguishable from one that had never
been diseased.
Shortly after the first introduction of the bougie,
all the shooting pains and occasional uneasiness of
the testis ceased, and it so rapidly and regularly
declined as the state of the urethra amended, as to
leave no doubt but that the amendment of the tes-
tis is to be ascribed to the relief of disorder in the
urinary canal.
CASE.
A gentleman between twenty and thirty years
of age, consulted me on account of an hydrocele,
from which I discharged about six ounces of fluid.
The testicle did not appear enlarged, but both it
and the bag of the tunica vaginalis seemed very
tender to the touch. I recommended that the parts
should be supported, and that Goulard's wash,
should be applied. In about six months the tunica
vaginalis was more distended than at first, and as the
part was troublesome from its size and sensations,
316 On Diseases of the Urethra.

it was again punctured; and the same circumstances
were noted upon the evacuation of the water. The
hydrocele again collected, and when it was full,
which happened in about six months, the patient
was desirous of having the tunica vaginalis inject-
ed, in order that he might be made radically well.
As there was nothing prohibitory except the ten-
derness, I consented to his desire; but when the
fuid was discharged this time, he complained of
greater pain than formerly, and could scarcely bear
ine to touch the testicle, which made me dislike to
perform the operation, and it was therefore post-
poned till the next time that the hydrocele should
become full. I thought it right, however, to direct
the application of leeches, once a week, and of linen
kept damp with Goulard's wash. * Under this treat-
ment the hydrocele filled very slowly. After four
months had elapsed, the patient consulted me rela-
tive to sores which frequently broke out upon
the prepuce; some of which were very tardy in
healing. He also was subject to a considerable col-
lection of that substance which is secreted to moist-
en and lubricate the prepuce. I told him that these
symptoms were the effects of irritation of the pre-
puce, and was led to inquire more particularly into
the state of the urethra than I had done before, be-
cause I thought both the disorder of the testis and
* I have known many cases of hydrocele, the consequence
of irritation and inflammation, cured by evaporating washes:
and it would be right to distinguish the kind of hydrocele,
upon which such treatment may be expected to have benefi-
cial effects. Without such discrimination, a surgeon, seeing a
hydrocele cured by these means, would prosecute the same
measures in an indolent, and, as I may call it, dropsical hy.
drocele; or finding the means fail in many cases from their in-
discriminate use, he may be induced to consider the treat-
ment under the whole as inefficacious, and thus neglect it in
cases, in which it is likely to be beneficial.
On Diseases of the Urethra. 317

the prepuce might originate in the same cause, that
is, disease in the urethra. On examining that canal
with a bougie, I found strictures, and a tender state
of it where it passes through the prostate. By local
warm bathing, and the occasional and gentle use of
bougies, the morbid sensibility of the canal was di.
minished. The strictures were touched with kali
purum, and in conclusion, I could pass a large-sized
bougie without occasioning any particular uneasi-
ness in one part more than in another.
The effect of this treatment was, that the remain-
ing fluid of the hydrocele was soon dispersed, and
the testis was no longer irritable or painful when
compressed, so that even the suspensory bandage
was laid aside, nor has any inconvenience been ex-
perienced since that time, which is more than four
years ago.
The sores also on the prepuce healed, and that
part was much less irritable, but it still remains so
in some degree; indeed, sores have been since con-
tracted from sexual intercourse, which circum-
stance may perhaps have contributed to prolong
the disorders of that part. I also suspect that the
urethra may again have become in some degree ir.
ritable.
In the foregoing case, it is said, that the habitual
occurrence of sores on the prepuce, led me to sus.
pect disorders of the urethra; and this is an effect
of such disorders, which I think has been but lit.
tle adverted to, and which is nevertheless desery-
ing of particular attention. That disorders of the
urethra do, in many cases, cause temporary or con.
tinual irritation in the external parts which are
continued from its orifices, I shall prove by the res
cital of a few cases.

318
On Diseases of the Urethra.
CASE.
.. A gentleman between forty and fifty years of age,
had for fifteen years been subject to sores about
the prepuce and glans, so as to oblige him to pay
constant attention to prevent and control them. He
had consulted many eminent surgeons, who recom-
mended various washes and modes of treatment.
A new application had generally the effect of heal-
ing the sores, but when persisted in for some time,
gradually lost its effect. When the patient consult-
ed me, the whole of the skin covering the glans,
and lining the prepuce, was thickened and white,
and the prepuce was so thickened, that though it
was naturally large and loose, it was difficult to un-
fold it. There were numerous sores of an oblong
form in the transverse direction, appearing like
chops covered by adhering pus. I told the patient
that it was necessary to inquire whether there were
any cause maintaining this irritable state of the pre-
puce, and mentioned that I had observed it very
frequently to depend upon strictures of the urethra.
The patient had no suspicion that he had such
disorder, for he voided his urine readily, and not
much more frequently than is common. Upon ex-
amining with a bougie, however, several much
contracted and very firm strictures were discover-
ed; and these being relieved, the sores on the pre-
puce healed without any further attention, than
what cleanliness required. The foreskin became
soft and pliant, as did also the skin which lined it,
and is extended over the glans. This case occurred
many years ago; and as I have not seen the patient
since, I conclude that the relief which he thus ob-
tained was permanent.
To show that strictures may exist in the urethra,
and may perhaps prove the cause of more vexa-
On Diseases of the Urethra.. 319

tious disorders, though the original exciting cause
escapes observation, I may mention an instance
which occurred to a medical man.
CASE.
This gentleman had been subject to sores which
frequently broke out on the prepuce without any
evident cause. There was not, however, any strik-
ing evidence of general irritation in that part, as in
the former instance. Sometimes the sores which
occurred, put on the appearance of chancres; and
in consequence of the advice of his friends, he un-
derwent a salivation. The sores for which mercu-
ry was employed, healed under the use of that me-
dicine, but broke out upon its discontinuance. He
then consulted me, and upon my mentioning my
suspicions of strictures existing in the urethra, he
smiled at the opinion, and said that it might be
given to patients in general, but not to those of the
medical profession. I told him that nothing would
convince me that I was in error, but his permit-
ting me to examine by means of a bougie. Two
considerable strictures were found, and these be-
ing relieved, the sores healed under simple dress-
ings. The gentleman, however, did not reside in
London, and I know not the further history of the
case, which I mention merely for the purposes that
have been stated in the beginning.
I have also seen a very troublesome phymosis,
in which the prepuce could not be retracted with.
out great difficulty and pain, depending upon the
same cause, in a case in which the patient had been
long accustomed to the daily use of bougies;* but
* As strictures of the urethra depend on a disordered state
of parts of the canal, so when the introduction of simple bou-
gies fails to cure them, the too frequent use of those instru-

320 On Diseases of the Urethra.
after the strictures had been touched with kali, and
the constant use of bougies desisted from, the phy-
mosis relaxed, and the prepuce could be retracted,
without the least difficulty or uneasiness.
These cases are related to show, that irritation
and diseases may be induced in parts, which have
a sympathetic connexion with the urethra, even
where the original affection may have been too tri-
vial to attract attention. It appears to me to be of
the utmost importance to investigate, as far as pos.
ments sometimes keeps up and aggravates an irritation, which
might otherwise, perhaps, subside. This is a subject foreign
to my present purpose; but I mention it to introduce the fol-
lowing case, which deserves publication.
A gentleman more than fifty years of age, had for more than
twenty years been in the habit of introducing bougies for him-
self, which he generally kept in for an hour daily.
At length his urethra became so irritable, that he could
scarcely void his urine, which he was frequently called upon
to attempt. Apprehensive of caustic bougies being employed,
he consulted me, and I found I could introduce a small bou.
gie without much difficulty; it halted at several strictures,
but with very gentle pressure it passed through them. I re-
commended him to bathe the perinæum and contiguous parts
with warm water, by means of a sponge, night and morning,
and told him, I wished to introduce the bougie again after
three days had elapsed. He was extremely apprehensive that
the passage would completely close during the interval, and
strongly remonstrated against such inefficient practice. On
the third day he acknowledged that he passed his urine more
freely, and the bougie which I had first introduced went
through the urethra without impediment. I took one of a lit-
tle larger size, and passed it with the same sort of resistance
which the first had met with. The warm bathing was continu-
ed, and by pursuing these measures for three weeks, I passed
a bougie one third larger than he had been able at the best of
times to do for many years.
The patient now voided his urine in a large stream, and not
more frequently than is common; in short he felt himself per-
fectly well. Since that time, no bougie has been introduced,
except once, annually by myself, that he might be assured
that the strictures had in no degree contracted.
On Diseases of the Urethra. 321

sible, the causes of diseases; for how can we ex-
pect to cure the effect, while the producing cause
continues to operate? The secondary disease may
also become even of an established or malignant
nature, if there be diseased propensities in the con-
stitution or affected part.
- Diseases in the canal of the urethra may not only
cause such effects as I have represented, by pro.
ducing a state of irritation on the continued surface
of the glans and prepuce, but they may also cause
sores contracted from sexual intercourse to be very
irritable, peculiar, and slow in getting well. I have
seen many such instances, but none in which the
fact was more strikingly apparent than in the fol-
lowing case.
CASE.
A gentleman who had just arrived in this coun-
try, had connexion with a female, which was fol.
lowed by general irritation of the prepuce, and
surface of the glans. Shortly afterwards six sores
formed, three of which became of considerable size.
I desired him to wash the parts three times a day
with the poppy-fomentation, and to incircle the
penis by linen kept damp with it, in order to lessen
the heat of the part. He at the same time took five
grains of the quicksilver pill night and morning.
After some days, he could no longer retract the
prepuce, so that he was obliged to cleanse the part
by means of a syringe. After a little time, a weak
solution of zincum vitriolatum was tried, but the
pain it occasioned was too severe to permit its con.
tinuance. It was therefore left off, but after four
days tried a second time, when the pain which it
occasioned was very tolerable, and as it diminish-
ed daily, it allowed us to increase the strength of
the wash.
2S

322 On Diseases of the Urethra.
After a few days he was able to retract the fore.
skin, when the smaller sores were healed and the
principal ones had granulated, so that a fungus
bulged forth above their surface; they appeared of
a tawny colour, and their edges were slightly
thickened. I slightly touched these sores every
third day with argentum nitratum, which appear-
ed to do them much good. The vitriolic wash was
continued. In about five weeks from the com-
mencement of the disorder, the patient was quite
well. The mercury had occasionally affected the
bowels, which obliged the patient frequently to
omit his pill in the morning. It never affected the
gums, nor did I urge the continuance of it, after
his sores were healed, because I did not believe
them to be syphilitic. .
About three weeks afterwards, being in compa-
ny with some dissolute females, he had his pas-
sions much excited, and one of them forcibly com-
pressed the penis with her hand. The irritable state
of the foreskin again took place, and a great num-
ber of sores broke out, particularly behind the
glans, which appeared like chops, being long and
not wide, and the matter, which they discharged,
adhered to the surface.
After a few days he could not retract the pre-
puce, so that I can give no distinct account of
these numerous sores. It appeared that they were
very fretful, for the external skin became inflamed
opposite to them; and they gave much pain when
pressure was made on the inflamed part.
- The external inflammation and tenderness on
pressure changed their situation, showing, that a
sore which was most fretful at one time, became
less so at another.
The sores were, however, so painful as to pre-
On Diseases of the Urethra.
3223

vent the patient from sleeping; and as no amend-
ment of the complaint took place in three weeks,
though various local measures were employed dur.
ing that period, the patient wished to use mercury,
and I acquiesced in his desire. As this medicine
formerly affected the bowels, I desired him to rubin
two drachms by measure every night, which was
done for one week, without any amendment in the
sores, or indeed any perceptible effect on the consti.
tution. The patient now complained of a pain in the
perinæum, when he voided his urine; and I direct.
ed him to bathe that and the contiguous parts for
seven or eight minutes, with comfortably warm
water by means of a large sponge, three times a
day. This produced a most evident diminution in
the irritability of the sores, and convinced me that
there was a stricture; I therefore introduced a
bougie, and found two strictures, the front one of
which was so tight and tough, as to admit but a
small bougie to pass through it, which it grasped
and indented. The warm bathing was continued.
I touched the stricture with kali, as Mr. Whately
has recommended. From the time that the stric-
ture became an object of attention, the sores had
so rapidly amended, that in a few days the patient
was enabled to retract the prepuce; when it was
found, that though the sores had been numerous
and extensive, they had been merely superficial,
and had not destroyed any part. From the time
that I first passed the bougie and ascertained a
stricture, the mercury was discontinued, neverthe-
less the sores healed so rapidly, that in ten days
they were perfectly well.
After the sensibility of the stricture had been
heightened by the touch of the kali, the patient
complained of acute pain in the sores when he
made water; and once, when I touched some of
324 On Diseases of the Urethra o

the sores with argentum nitratum, he complained
of equally sharp pain in the perinæum.
I lately attended a married man, who had been
for many years tormented by occasional sores
forming about the prepuce, which were so irrita.
ble, as to be prohibitory of sexual intercourse. In
the last attack they were considered by several
surgeons as syphilitic, but as they had not the
characters of that disease, I dissuaded the patient
from the use of mercury otherwise than as an alte-
rative. This patient upon taking food had the pain
and inflammation of his sores so aggravated, that
he was obliged to rise from table, and bathe the
affected parts with warm water. These sores imme-
diately lost their irritability, and even rapidly got
well, upon a stricture in the urethra being relieved
by local warm bathing and the use of bougies.
I have still further to observe, with respect to
the occasional consequences of diseases of the ure-
thra, that many diseases of the glands in the groin
originate from them. I shall not, however, detail
any cases in evidence of this fact. It will be suffi-
larged inguinal glands dispersed by relieving dis-
orders in the urethra; and I have seen instances of
foul and irritable sores, losing their diseased cha-
racters, and healing from the same cause. The lat-
ter event is not, indeed, likely to be a frequent oc-
currence.
In a gonorrhea, the glands in the groin are com-
monly irritated, and sometimes slightly swollen;
the swelling rarely increases and suppurates, ex-
cept in cases where there is a predisposition to dis-
ease in those glands. If then, irritation in the ure-
thra, occurring from gonorrhea, can thus affect
the inguinal glands, it may be rationally inferred,
that other causes of irritation of the urethra may
On Diseases of the Urethra. 325
produce similar consequences. Nocturnal emis.
sions are also commonly the effect of morbid irri.
tability or disease of the urethra; and it seems
therefore irrational to attempt to cure them by
tonic medicines or sedatives, without adverting to
the state of the urethra. Indeed in many of the per-
sons who are subject to these discharges, the mor-
bid sensibility of the urethra is connected with
a disordered condition of the digestive organs;
which is of itself a sufficient cause of great weak-
ness and hypochondriac feelings. After thus advert-
ing to such causes, we cannot wonder at the ter-
rors felt and described in cases of tabes dorsalis.
That diseases of the urethra may exist without
producing the consequent diseases which I have
been describing is very manifest; that such diseas-
es may arise, independently of the causes to which
I have attributed them, is also evident. My object
therefore is merely to announce, that I have very
frequently observed the diseases, which make the
subject of this section, to arise from a disordered
state of the urethra, leaving it to the experience of
the public to determine, how far such cases may
be regarded as frequent occurrences in general
practice.

THE END.


Gec
S
EN