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Title: Dissertations on Inflammation, Vol. 2

Author: John Burns

Release date: May 22, 2019 [eBook #59578]

Language: English

Credits: Produced by Thiers Halliwell, and the Online
        Distributed Proofreading Team at http://www.pgdp.net (This
        file was produced from images generously made available
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*** START OF THE PROJECT GUTENBERG EBOOK DISSERTATIONS ON INFLAMMATION, VOL. 2 ***




Produced by Thiers Halliwell, and the Online
Distributed Proofreading Team at http://www.pgdp.net (This
file was produced from images generously made available
by The Internet Archive)





Transcriber’s notes:

Apart from correction of a few typographic errors (intentention →
intention, citrinc → citrine, scropulous → scrophulous), the text
of this e-book has been preserved in its original form including
archaic language and some inconsistent spelling (citrine/cintrine,
schirrous/schirrus, exsudation/exudation, eschoritics/escharotics).
Footnotes have been numbered and positioned below the relevant
paragraphs.




    DISSERTATIONS

    ON

    _INFLAMMATION_.

    VOLUME II.

    CONTAINING,

    DISSERT. II. continued.--ON THE CURE OF SIMPLE INFLAMMATION,
    AND ITS CONSEQUENCES.

    DISSERT. III.--ON THE PHAGEDENIC, AND SOME OTHER
    SPECIES OF INFLAMMATION.

    DISSERT. IV.--ON THE SPONGOID INFLAMMATION.

    DISSERT. V.--ON THE SCROPHULOUS INFLAMMATION.

    DISSERT. VI.--ON THE CANCEROUS INFLAMMATION.

    BY JOHN BURNS,

    _SURGEON IN GLASGOW_.

    GLASGOW:
    _Printed by James Mundell, Aytoun Court_,
    FOR JOHN MURDOCH, TRONGATE;
    MUNDELL AND SON, AND W. MUDIE, EDINBURGH;
    AND FOR LONGMAN AND REES, and J. JOHNSON, LONDON.

    1800.




DISSERTATIONS

ON

_INFLAMMATION_.




DISSERTATION II.

CONTINUED.

ON

SIMPLE INFLAMMATION,

_And its Consequences_.


_Of the Cure of Inflammation._

In attempting the cure of inflammation, or its consequences, we must
naturally be directed to the means of removal, by the nature of the
action itself, and the object which we have in view. The treatment
of the inflammatory action may be considered in two points of view;
first, as this action consists in peculiar changes of the natural
action, which changes we wish to remove; and, secondly, as this action
naturally tends to disappear, and produce other actions, which require
a peculiar treatment. The observations, therefore, which are to be
made upon the method of cure, may be arranged under the heads of the
different terminations of inflammation.


_Of the Treatment necessary to procure Resolution._

In the treatment of most wounds, our chief intention is to prevent
the accession of inflammation, and procure adhesion, which is, in one
respect, analogous to resolution. When inflammation has taken place,
either in wounds, or in other cases, our great object is, to remove or
lessen it as quickly as possible, which we effect, first, by removing
the exciting causes of inflammation, or such causes as tend to increase
the action; and, secondly, by applying such remedies as tend directly
to abate the inflammatory action.

Upon the propriety of removing the exciting causes, and the manner of
doing so, very little requires to be said. If any acrid, or stimulating
substance, has been applied to the skin, or any extraneous body been
forced into it, these must be removed before the inflammation can
be resolved; because, if they be allowed to remain, they will keep
up the action so long, and to such a degree, that suppuration will
be produced, or gangrene, if the part be very sensible, (as, for
instance, the cutis) or if the exciting cause be very irritating.
Acrid substances are to be removed by ablution with water, which is
in general much better than the solutions which are proposed upon
the principle of chemically combining with the acrid; because these
generally are likewise acrid, or stimulating, and increase still more
the inflammation which has taken place, before they can combine with
the substance which was formerly applied, and become neutralised. This
may be illustrated by the operations of acids and alkalis. If heat
have been applied, so as to induce inflammation, we must remove the
superabundant quantity of heat, but must not apply cold; because we
then do mischief, as will be afterwards mentioned.

When a substance is forced into the skin, so as to stimulate
mechanically, we must endeavour to lay hold of it, and pull it out;
but if it have penetrated so deep as to make this impracticable, we
must then enlarge the wound, and remove it; because we thus may enable
the wound to heal by the first intention. If, however, the injury done
be great, if the part be much bruised, or the extraneous substances
be numerous, we may be less anxious about the extraction of such as
require much trouble; because the irritation which is thus given will
tend to increase the degree of inflammation, and, very probably, its
extent, at the same time, that, from the original injury, there is
little prospect of adhesion being procured, or suppuration prevented.
We are then chiefly to search after, and extract foreign bodies, when
we apprehend that their removal may permit the inflammation to be
resolved, and adhesion to take place, and when we expect that their
presence will excite a greater action than our endeavours to extract
them will do. This is a rule which ought to be carefully remembered by
every surgeon, and especially by those whose situation makes them be
daily called to take the management of gun-shot wounds. They are not
brought to their patient to show how much they can do in the way of
cutting and probing; it is their duty to administer relief, and act so
as to prevent and abate the inflammatory action, which they will often
do most effectually by letting their patient alone, and throwing aside
their ball-screws and forceps.

The circumstance of being in an unusual situation, in which the natural
action cannot possibly be continued, is also a very frequent cause,
producing inflammation, and preventing its resolution. We ought, upon
this principle, which has been formerly mentioned, to endeavour, in
almost every instance, to bring the sides of the wound together, if
an wound has been the exciting cause of inflammation, by which we
shall much more readily prevent or overcome the inflammatory action;
because we thus bring the parts nearly to their natural situation,
with respect to interstice, and thus make the organic particles be
more readily thrown out[1]. This practice ought to be pushed farther
than is often done. Even in many contused wounds it will be useful;
because, although union may not be immediately produced, yet, when the
contused part is either recovered, or absorbed, the inflammatory action
may be prevented, or removed, by the restoration of the natural action,
if the part be in absolute contact. It must, however, be remembered,
that if much difficulty be experienced in bringing and retaining the
parts together, owing to the swelling, from the previous existence of
the diseased action, then our endeavour will be hurtful; because the
irritation which we thus give, has a greater power to increase the
action, than the circumstance of the parts being in contact, has to
diminish the inflammation, and restore the natural action.

[1] Bringing two surfaces in contact, although they naturally were not
so, will have the same effect. Thus, if the skin be taken off the edges
of our fingers, and the side of the one be applied to the side of the
other, adhesion will take place, and no inflammation will be produced.
When a part is inflamed, and one portion is brought in contact with
another, we uniformly find, that the inflammation is less where the
parts were in contact than elsewhere. Thus, when the intestines are
inflamed, the parts suffer least which touch other intestines, whilst
the angle betwixt the folds is most affected. This fact is observed by
Mr. Hunter, but explained upon the principle of contiguous sympathy;
or, “a mutual harmony being produced, which prevents their being
inflamed.”

By removing, then, the exciting causes of inflammation, before the
action be induced, we shall frequently prevent it altogether from
being formed; but, even although we should be disappointed, we, by
this removal, render the disease milder, less extensive, and much
more easily overcome; for, as long as the exciting causes continue to
operate, it is impossible to procure resolution; but the action will
be kept up until some other termination, or consequence, be induced.
But, although we thus prevent the action from being raised to so great
a degree as it otherwise would be, yet we do not immediately overcome
or destroy it; because the action, when once induced, has, like every
other action, a tendency to continue for some time after its cause is
withdrawn. This continuance may be longer or shorter, according to
circumstances, and its termination may be more or less unfavourable.
We are, therefore, under the necessity of employing such remedies as
have a power of directly diminishing or removing this action. It has,
however, been doubted, whether they ought, in every instance, to be
employed; or, in other words, whether resolution ought uniformly to
be desired. It has, for instance, been deemed unsafe to check those
inflammations which depended upon a general or constitutional specific
disease, or occurred during its existence. But this opinion, which
was evidently founded upon the supposition of the operation of morbid
humours, cannot be maintained, now that this is given up. Granting
inflammation, in every one of these cases, to be dependent upon the
general disease, and to exist as a symptom of it, no harm can accrue
from resolving it[2]; because, if the inflammation have once taken
place, the full effect of the general disease is produced, which,
therefore, cannot be affected by the peculiarity of the termination of
this inflammation, unless it be proved, that some humour be sent there
to be concocted and thrown out. In many instances, inflammation occurs
in a general disease, merely as an accidental circumstance; but, even
in those cases where the local inflammation is most decidedly dependent
on the general action, and is perhaps essential to it, we find, that no
bad effects follow from resolving the inflammation; and, if this be the
case with regard to specific inflammation, we may still more certainly
extend the principle to the treatment of the simple inflammatory
action, with which we have at present a more immediate connection.
There are, however, some inflammatory affections which we sometimes
cannot put back; such as those tumors which succeed the small-pox; but,
when we do succeed, no bad consequence follows; and the failure of some
of our attempts can be no argument against the general plan, more than
our failure in many other instances.

[2] If we attempt, without fear, to cure the general disease, why may
we not also endeavour to hasten the termination of the local disease?

Resolution is the quickest termination of inflammation, and, therefore,
ought, perhaps in every instance, to be attempted, unless in cases
where the injury is such that suppuration is unavoidable; as, for
instance, extensive bruises, &c. It is our great object, even in those
inflammations which we raise intentionally; as, for instance, in the
operation for hydrocele. At one time, however, this was not admitted
without limitation; and suppuration was, in many instances, anxiously
sought for, being considered by some as the only way of obtaining
a cure. “Union, (says Mr. O’Halloran) without suppuration, by an
immediate coalescence, or by the first intention, is merely chimerical,
and is opposite to the rules of nature. Inflammation (contrary to the
received canon) is not the time for a reunion of divided parts: This
happy minute follows, not precedes suppuration.” It was timidity, with
regard to the prevention of suppuration, and want of knowledge of the
powers of the animal frame, which so long retarded the progress of
surgery, and prevented the improvement of its operations.

The remedies which we employ, with the intention of abating and
removing the inflammatory action, are either general or topical.

General remedies are perhaps only useful, or have only a superiority
over topical ones, when a general disease, or fever, accompanies the
local inflammation. Topical ones are only to be trusted to alone, when
the disease is entirely local.

The general remedies, are naturally such as tend to abate action in
general, or to diminish the natural action; and, therefore, will
consist of bleeding, cold, purging, sweating, nauseating medicines, and
some of the agentes dissimiles.

Bleeding is justly considered as the most powerful, and the most useful
of all those remedies; and, in many cases, is the only one which can
accomplish a cure. The quantity of blood which it is necessary to
detract, will be regulated by the effect of the inflammation upon the
system, and by the previous condition of the person, with regard to
strength; for those who are weak bear bleeding worst; and in them we
cannot repeat it so frequently, as in the robust. Delay in them is,
however, more dangerous; because the inflammation makes a more rapid
progress, and, therefore, we ought sooner to push our remedies.

When the system is affected, in consequence of inflammation of vital
parts, the general action is greater than when other parts are
affected, and, therefore, bleeding must be used earlier, and with more
freedom. Mr. Hunter observes, that when these parts are inflamed, the
patient bears bleeding worse than when parts are affected which are
not vital; but this observation must not be admitted indefinitely.
When these parts are affected, the action is so violent, that the power
cannot long support it; and, therefore, we must have early recourse
to the lancet, and allow the blood to flow until the pain diminishes,
and ceases to abate any more, and until the pulse becomes softer,
and perhaps fuller. This is the time to stop; but, whenever the pain
returns, or the pulse becomes hard, the orifice should be again opened,
although we had bled only half an hour before. The system, in this way,
is not weakened, nor the action sunk so low as to injure the power of
recovery, which might be the case, were we to bleed too copiously at
once. This remark applies, in a particular degree, to inflammation of
the bowels; but it may also be extended to pulmonic inflammation; only,
in this case, we can detract more blood at a time than in the other
instance; because the system sympathises less strongly with the lungs,
and, therefore, general evacuation will be longer of operating on the
local disease. The same cause, however, makes the danger less; because
the general action is not raised so high, and the part itself not being
so delicate, can support the action longer, and, consequently, the
danger is less. It is an established point, that no action can subside,
or be destroyed suddenly, and the patient become free from disease.
All morbid actions must subside, more or less slowly, and, therefore,
bleeding ought not at once to be pushed so far as to produce fainting,
unless the patient be very liable to faint. This sudden cessation of
general action does not destroy the specific nature of the action
which is going on when it is induced, but rather leaves the parts
stationary, the tendency to morbid action still continuing, although
the capability to act be suspended for a moment[3]. In place, then,
of bleeding so as to exhaust the strength quickly, and endeavour, as
it were, by the quantity of the discharge, to destroy the disease by
one bleeding, it will be much better to bleed just until we produce
the feeling of weakness to a moderate extent, and abate, to a certain
degree, the pain and hardness of the pulse; stopping, whenever we
find that we are not abating it farther, distinguishing, however,
betwixt real abatement and syncope, or want of power to act and feel.
We then repeat the evacuation, whenever the hardness of the pulse and
pain return; and thus, perhaps in one day, and with infinitely more
benefit, bleed much more frequently, and, perhaps, to a greater extent
than is sometimes done in a week, by those who bleed more copiously at
once, and repeat it seldomer.

[3] When we are obliged to stop our bleeding, on account of fainting,
before we would otherwise do it, we will find it necessary to repeat
the venesection sooner than if this did not happen.

Concerning the exact quantity of blood, which ought, in the different
varieties of inflammation, to be detracted, I hold it, from the above
principle, to be ridiculous to give any direction; because no general
rule can be given, by which we may, a priori, determine the quantity.
We are to bleed until we procure an abatement of the action; and to
stop whenever this abatement ceases to be really progressive[4]. We are
to renew the bleeding, whenever the action again increases, and stop,
as before, whenever it is abated, remembering, that, after some time,
a more sparing detraction will produce a greater effect, than a more
copious one would do, in the commencement of the disease. It must also
be attended to, that, owing to the weakness induced by the disease, and
by the bleedings, we must, toward the end, bleed at longer intervals;
for, if we continue to bleed in the same way as formerly, we would
either kill the patient, or at least prevent the act of restoration
from taking place; because we would thus diminish the power, or vital
energy, which was to perform this act. Those, then, who order a certain
number of ounces to be taken away, must reason upon probability, and
prescribe less efficaciously, than those who direct no determinate
quantity, but regulate their practice by the effects. It is equally
foolish in those who order bleeding, pro viribus, and are satisfied
with this until their next stated visit; because bleeding until
fainting takes place, and not repeating it for some time afterwards,
may be doing a great deal too little.

[4] We must distinguish, as has been already mentioned, betwixt a real
abatement of the inflammatory action, and a mere temporary suspension
of action, or syncope.

As there is a proper time for stopping each individual evacuation, so
also is there a period at which we ought to stop the general plan of
cure by bleeding, or at least to intermit it. And to determine when
this period is come, is sometimes a pretty nice point, and one of much
importance; because, if we stop too soon, we allow the action still
to go on, and, perhaps, to terminate fatally. On the other hand, if
we bleed too long, we sink the parts below the state necessary for
recovery, and even accelerate the unfavourable termination. When, for
instance, from the state of the pulse, and other circumstances, we
apprehend the accession of gangrene, bleeding will not abate pain, but
will bring on the mortification sooner, and make it spread farther, as
will be afterwards mentioned.

As the accession of inflammation depends upon a change of the natural
action of the vital principle, so does its removal depend upon the
reconversion of this into the natural action, which implies activity,
or an active state. If, then, we bleed in the end of inflammation,
we lessen the powers of the part so much, as to prevent restoration;
gangrene, therefore, will take place: Or, if the part be less delicate,
and the progress of the action consequently slower, the inflammation
may continue stationary for a considerable time, and become chronic, or
habitual. This state is not to be cured by bleeding, but will rather be
made worse by it. Whenever, then, after inflammation has continued for
a length of time, we find, that venesection does not produce the usual
abatement; or, whenever, although there be a temporary abatement, the
pain increases afterwards to a greater degree, we may be certain our
treatment is improper. We likewise find, that the longer bleeding has
been delayed, in the beginning of the disease, the sooner must we stop,
and the less quantity must we take at a time; because, in this case,
the inflammatory action is nearer its termination, and is more ready
to produce gangrene, if the parts be delicate, or the action great,
or, if otherwise, the inflammatio assuefacta. We are also to refrain
from bleeding, when we find that the inflammatory action is about
to terminate in another action; as, for instance, the suppurative;
because, in the first place, bleeding, in this new action, can do
no good, but, by weakening, will do harm; and, secondly, if there be
only a tendency to this action, the action not being yet formed, or
beginning to form, we may, by bleeding, interrupt the progress of
the inflammation, and convert it into a more tedious disease, or the
inflammatio assuefacta.

Bleeding has been used, not only as a cure for inflammation, but also
as a preventative; but this must be considered as proper, only in
particular instances. When, for instance, an wound has been inflicted,
or an operation necessarily performed, on a robust person, bleeding
immediately, or very soon after it, may be useful; because it will
tend to lessen the chance of the natural action being carried so high
as to become changed. These people cannot have their action much
increased without disease; and, therefore, it is necessary to lessen
it, and bring it down to a more proper medium. But there are other
cases, where the action is naturally rather too low, and the patient
weakly. In these cases, bleeding can do no good, but much harm; because
it increases the previous weakness, and makes the inflammation, if it
does occur, more dangerous, on account of the little power which there
is to support the action. These people even bear bleeding worse than
others, when inflammation has actually taken place. It ought never to
be practised, in order to reduce the natural action, before disease has
taken place; and, after the inflammatory action is induced, it ought to
be used cautiously, and only to such an extent, as may be necessary for
removing the tendency to immediate bad consequences. It ought, however,
to be used very early in the disease; because, in weak people, the
action does more harm in a given time, than in the strong; but it
ought likewise to be sooner abandoned, otherwise we either hasten
mortification, or prevent the act of restoration from taking place.

Bleeding is rarely necessary in inflammation of the cellular substance
alone, unless the action be extensive; in which case, the system is so
affected, as to require our interference. When the cutis is inflamed,
producing erysipelas, the system suffers considerably; but, as this
frequently ends in mortification, bleeding has been neglected by many;
but it is evident, that, if the disease be simple, and not dependent
upon any specific agens dissimilis, or epidemic contagion, venesection
is the proper cure, provided it be early employed, as we thus diminish
the action more certainly than by any other means. If, however, the
disease have been neglected, and the action be nearer a termination,
then we must either do nothing in the way of general treatment, or
must give opposite remedies from bleeding, according to circumstances.
When muscles are inflamed, bleeding is often necessary to a very great
extent, as we observe in rheumatism; and, in the beginning, we must
take a greater quantity at a time, in order to procure an abatement,
than in many other cases. When the viscera are inflamed, bleeding is
uniformly necessary, and generally requires to be frequently repeated.

It is a common opinion, that the blood ought to be taken, if possible,
from a vein which arises from, or near the affected part; that, for
instance, in phrenites, we should bleed in the jugular vein; in
inflammation of the feet, we should bleed in the leg, &c.: And, when
this can conveniently be done, it may be preferred; because, it not
only possesses all the advantages of general bleeding from any other
vein, but also may be supposed to produce, in a slight degree, a
topical evacuation. If, however, the veins be so small, that we cannot
detract enough of blood, and sufficiently quickly; or if, from any
other cause, we cannot do so, then, if the general action be violent,
we must have recourse to another vein, as the loss to be sustained, by
confining ourselves to this vein, is infinitely greater, than any good
which can be derived from it, as a local evacuation. Indeed, when we
consider the laws of the circulation, we must allow, that very little
good can be done in this way, as a local detraction; because one vein
does not lose more blood than another, except during the moment of the
flow.

The blood, when drawn during inflammation, has always a buffy coat,
which is, in general, thicker, and more concave, in proportion to
the violence of the inflammatory action; and the continuance of this
condition, is one circumstance which points out the necessity of
continuing our evacuation: But the mere existence of a buffy crust, is
not, without these circumstances, any infallible sign of the necessity
of bleeding; because this crust is to be found on the blood, after
the inflammation has begun to become passive; and it is to be found
also, when mortification is approaching; we observe it likewise very
frequently upon the last cup of blood which we find it necessary
to take away. In these cases, however, the crust is much softer,
generally thinner, always flat, instead of concave, and looser in
the texture; it is also more of a greenish hue. These circumstances,
conjoined with the state of the pulse, will enable us to judge, whether
we should totally desist from, or continue our evacuations with
caution. Most frequently they forbid farther bleeding.

Cold, or the subduction of heat, is chiefly useful as a topical
application; but it is also proper to be applied, in moderation, for
the abatement of the general fever, unless we be desirous of procuring
perspiration. The quantity of bed-clothes ought to be lessened, cold
drink should be allowed, and a free circulation of cool air into the
room. The application of cold, however, ought, in general, only to be
carried to such an extent as shall be sufficient for diminishing the
morbid degree of heat, and not so far as to produce sensible cold,
or the sensation of cold; because this, in many instances, will be
pernicious, upon the principle of the sympathy of equilibrium, the
action of the internal parts being increased by the speedy application
of cold to the surface; and, therefore, if the internal parts be
inflamed, their morbid action must be still farther increased. If the
cold be long applied, to any considerable degree, it will likewise,
by the sympathy of association, weaken the whole system too much, and
injure the act of restoration. As bleeding is to be used only until
it restores a natural state, and abates pain, so also is cold only
to be applied in such a degree as may be necessary for diminishing
the preternatural heat, and sensation of the surface; which it does,
by lessening the morbidly increased action, and reducing it to the
natural state. The degree must therefore gradually be diminished,
in proportion as the general disease subsides, otherwise we injure
the system, and prevent recovery. There is, however, this difference
betwixt bleeding and the application of cold, that the first may be
used suddenly, and to a considerable extent at once, whereas, the
second ought, especially in all cases of internal inflammation, to be
employed more slowly, and its degree regulated by the degree of the
general heat of the surface.

Nauseating medicines are also very useful, independently of the
sweating which they frequently induce; and are a very powerful mean of
abating action in general[5]. Employed, after bleeding has been used
once or twice, they are productive of considerable benefit; but there
are some affections, in which they cannot be used, such as inflammation
of the stomach and intestines; but in inflammation of the lungs, of the
throat, muscles, or surface, they may often be prescribed with benefit.
The remedies usually employed for this purpose, are, small doses of
emetics, given without drink. It must, however, be remembered, that
these frequently produce considerable evacuations, either from the skin
or bowels, and, therefore, may occasion a permanent weakness. We must
likewise avoid raising the sickness to a great degree, and keeping
it long up; because the same objection applies nearly to this as to
bleeding ad deliquium.

[5] Nausea has often been employed with success, in checking active
hemorrhage.

Purging is frequently employed in the cure of inflammation, especially
such purgatives as are called cooling, which, in this case, is an
imaginary quality; but, unless in so far as they tend to abate the
irritation of costiveness, they can do no more than bleeding can, and
are, in many respects, inferior to it. They are, in one view, to be
compared with the application of cold, which is only indicated when
there is much heat; both are intended to diminish action, chiefly by
removing stimuli from the part to which they are applied. Purging is
very uncertain in the effects which it produces on the system, and in
the degree of weakness which it causes; and, therefore, never can be
put in competition with bleeding, as a general remedy; and, wherever
bleeding is improper, or its propriety doubtful, purgatives are still
more injurious. They operate likewise so slowly, at least comparatively
speaking, that they do not influence the local action so much, as the
loss of such a quantity of blood, as would produce an equal effect on
the body, will do, unless in particular cases, when they act upon the
principle of the sympathy of equilibrium; as, for instance, in pulmonic
inflammation, when they sometimes are of service, by increasing the
action of the intestines, and diminishing that of the lungs[6]. In the
same way, emetics sometimes cure slight inflammation of the tonsils.
One of the best and pleasantest saline purgatives, is the phosphate of
soda, which may be given to an adult in the dose of an ounce, in order
to obviate the effects of costiveness. If we wish to use it, upon the
principle of the sympathy of equilibrium, we must give two ounces, or
more. The same cautions which were given, with regard to bleeding,
apply also to purging.

[6] This action is, in this respect, similar to that of blisters.

Sweating, considered as a mean of abating general action, is, in
most cases, inferior to bleeding; and can never, when the general
inflammatory action is considerable, be trusted to alone; but, after
the use of the lancet, it is generally serviceable. It is useful, in
particular, when the local disease is not confined to a small spot, but
affects a considerable surface, or different parts of the body; as, for
instance, in the rheumatism; but it acts, in these cases, rather by the
sympathy of equilibrium, than by any other mode. At the same time, the
induction of a sweat, preceded by bleeding, (which tends to abate the
local action as well as the general one) will sometimes be useful, by
giving a secretory termination to the general disease, and hastening
its conclusion. In the first point of view, sweating may be used early
in the disease, especially if preceded by bleeding. In the second, it
will be chiefly useful toward the end, as it will then accelerate the
termination, and thus influence the local action; for the abatement
of the general action must also produce an abatement of the action of
a particular part. Sweating, as well as purging, must be used with
caution in weakly people, or in those who are reduced by disease;
because, although the action of particular parts may be increased by
it, yet, partly in consequence of this temporary increase, and partly
on account of the fluid which is discharged, general weakness is
induced. One of the best sudorifics is the pulvis ipecacuanhæ comp.; of
which we may give ten grains every hour, until sweating be produced,
giving warm lemonade alongst with it. The tartar emetic is also a very
useful sudorific; the sixth part of a grain may be given every half
hour, until the proper effect be produced[7].

[7] One grain of emetic tartar may be dissolved in five ounces of
saline julep, and a table spoonful given every half hour, as long as
may be necessary.

Some of the agentes dissimiles may be considered as proper remedies
in this complaint; such as, digitalis, laurel water, lead, &c.; But
they are certainly inferior to blood-letting; and have been so little
employed in this way, that their effects are not ascertained[8].

[8] Some of these agents might perhaps only change the nature of the
inflammation, and render it specific.

Bleeding, of all the general remedies, is the best; and, next to
that, cold, and nausea, which may be considered as useful adjuvants.
Sweating and purging are mostly to be used when particular indications
present themselves, as may be understood from what has been already
said. The first of these remedies, act chiefly by producing an
universal abatement of action; and, of these, bleeding produces the
most permanent effect on the body, and the most certain effect on
the local disease. The two last are perhaps more useful, upon the
principle of the sympathy of equilibrium, than that of abating action
in general, which is only a secondary operation; and, therefore, they
may be considered as remedies, acting rather topically than generally;
for, according to this view, they act chiefly on the affected part.
These two kinds of remedies may, in many cases, be usefully conjoined,
producing thus a greater effect than either would do singly.

Before quitting this subject, it may not be improper to attend to the
proposal which has been made, of exhibiting anodynes immediately after
bleeding, in order to remove the pain. “The most effectual remedy for
this purpose, (says Mr. Bell) is opium, which, when pain and irritation
are considerable, as in extensive inflammations very frequently
happens, should never be omitted. In large wounds, especially after
amputations, and other capital operations, in punctures of all kinds
too, large doses of opium are always attended with remarkably good
effects. In all such cases, however, opium, in order to have a proper
influence, should, as we have observed, be administered in full doses,
otherwise, instead of proving serviceable, it seems rather to have the
contrary effect; a circumstance which is perhaps the chief reason why
opiates in general have been very unjustly condemned, in every case
of inflammation.” That, in every case of inflammation, opiates are
hurtful, is what no one can assert; and their utility will afterwards
be fully manifested. But, that opium is useful, or even harmless, in
the inflammatio valida, which we are at present considering, cannot
be admitted; because daily experience, independent of every theory,
proves, that, by their use, the general fever is increased, and the
local action aggravated. Even given as a preventative of inflammation,
after operations, anodynes are almost uniformly hurtful[9], producing
restlessness, heat, and thirst, and afterwards head-ache, sickness,
and frequently troublesome vomiting. I have therefore now, after almost
every operation, laid aside their use, and find, that the diseased
action[10], subsequent to the local irritation, runs its progress
with much less disturbance, and is much milder, and shorter, than
where anodynes have been administered; and, in general, the sleep is
much more composed, and always more refreshing. I have therefore,
after lithotomy, amputation, the extirpation of the mammæ, and after
labours, in almost every instance, omitted them.

[9] Opiates may indeed abate the smarting, or soreness, which is
consequent to the immediate mechanical injury of wounds, or operations;
but this relief is commonly only temporary; for the general action
is very apt to be afterwards increased, and, consequently, union by
adhesion is less likely to take place.

[10] There are two general diseases which are connected with local
actions, and which opium is supposed to cure, or prevent from taking
place; the inflammatory fever, dependent on an wound, and the febrile
state, consequent to a temporary increased action, or exertion of a
particular part, or the whole of the system; as, for instance, the
effect of parturition. The first of these is always aggravated by
opium; the second, if it be not increased, cannot possibly be cured by
it.

The local applications are such as tend either simply to abate action
in the part, or such as tend to change its nature, by exciting a
specific change, or such as act in both ways. The first comprehends
cold, the second the agentes dissimiles, and the third topical bleeding.

Cold, applied directly to the inflamed part, is a most useful remedy,
diminishing the action to a natural state; but, for this purpose, it
must not be applied in too great a degree, otherwise we diminish the
action so much, and so suddenly, (and, consequently, the power of the
part) that recovery cannot take place. If we apply much cold to a
healthy part, we sink its action so far, that it is irrecoverable;
if we apply cold to an inflamed part, so as to diminish its action
equally suddenly, and in the same proportion, we produce the same
effect. Poultices of ice, or snow, are therefore highly dangerous; and
even water, although it cannot be made nearly so cold as these. The
same direction which has been given, with regard to the application of
cold as a general remedy, ought also to be remembered, when we use it
as a local application, namely, it ought to be carried just to such
a degree, as shall diminish the morbid sensation, and ought to be so
adjusted, as to keep the part nearly in its natural degree, or at least
very little lower. For this purpose, it must be applied in moderation,
repeatedly, and with assiduity; and not, as is commonly done, in a
considerable degree at once, and renewed only at long intervals. Cold
has been supposed to be useful as an active astringent, producing
a contraction in the vessels; but it does not seem to possess any
active power in producing such a state in the vessels to which it is
applied. Where injury is taking place, from excessive action, cold,
by abating it, may strengthen, and produce more natural contractions;
but, when applied to a healthy part, it diminishes the action of that
part, the blood is less forcibly circulated, and the part shrinks; it
therefore stops active hemorrhage in the part on which it acts. When
cold is applied suddenly, or to delicate parts, it excites an universal
action, or contraction, or shrinking, from weakness; and, therefore,
may likewise stop hemorrhage from distant parts. In many cases, when
this shrinking, or temporary contraction, is suddenly induced by cold,
it becomes converted into the natural muscular contraction of the part;
thus, for instance, if cold be applied to the uterus itself[11],
when torpid, after delivery, we find, that, after the first effect,
or shrinking of the vessels, a more natural contraction takes place.
If, however, cold be long applied, we find, that the contraction thus
induced ceases, owing to the diminution of action which is occasioned
by its continuance, and the original state of collapse, or shrinking,
alone remains.

[11] When applied to the skin of the abdomen, it acts chiefly by
exciting action, on the principle of the sympathy of equilibrium.

Blisters likewise act by simply abating the action of the part; but
differ from cold, in requiring to be applied, not to the part which is
affected, but to some other, with which it exhibits the sympathy of
equilibrium; as, for instance, to the integuments of the thorax, in
pulmonic inflammation; to the skin of the knee, in affections of the
joint, &c. It is, however, necessary, when a general disease, or fever,
is induced, that bleeding be fully employed, before we have recourse
to blistering; because, if it be not, the inflammation, excited by the
blister, co-operates to increase the fever, alongst with the original
disease, which it has not had time to overcome, or lessen. Blistering
likewise acts more effectually, when the local action has been already
diminished, by previous bleeding. The size of the blister should be
proportioned to the probable extent of the diseased action; at the same
time, we must set bounds to this magnitude; because, if too large,
they may not only produce, or keep up a general disease, but also, by
lessening the action of the internal parts too much, and too quickly,
they may prevent recovery[12]. It is therefore better to apply them of
a moderate size, and renew them frequently, than to apply one too large
at once. It must, however, be remembered, that inflammations of every
part are not equally readily overcome in this way; and, therefore, one
will require a larger blister than another; thus, the same quantity of
inflammatory action in the brain, will be more difficultly subdued,
than in the breast; and, therefore, we must apply, in that case, a
larger blister. As it is the inflammatory action, induced by the
blister, and not the discharge, as was once supposed, which is useful,
it follows, that the same blistered place should not be kept too long
from healing, or in the state of an issue, but that we ought rather to
apply a succession of blisters; and this succession should be pretty
rapid. There is indeed one case, in which issues are admissible,
namely, where, from the nature of the inflamed part, or the peculiarity
of the inflammation, if it be specific, or scrophulous, the progress
of the action is very slow. In these cases, a rapid, and continued
succession of blister would, doubtless, be most useful, but, from the
duration of the treatment, would scarcely be submitted to: Issues,
which are less painful, and less troublesome, are, therefore, generally
preferred. We have an instance of this in many diseased joints.

[12] Were this not the case, we should cure pulmonic inflammation, with
the greatest certainty, by covering the whole thorax with a blister.

The remedies which tend to diminish the inflammatory action, by
producing a peculiar, or specific change, are, the agentes dissimiles,
of which, for this purpose, lead is the best, and the one which is
most frequently employed. Lead, in the state of an oxyde, was long ago
used; but it does not appear, in this condition, to have much activity;
and, therefore, the saline preparations are now introduced into use.
The acetite of lead, on account of the supposed power of vegetable
acids in abating inflammation, has been considered as possessing a
great superiority over other forms; but its chief recommendation over
other soluble preparations, is its cheapness; for the nitrate of lead
seems to be equally powerful. The acetite of lead may be employed,
either before or after crystallisation; but, if we use the crystals,
they must be redissolved; for which purpose, soft, or distilled water,
must be employed, otherwise a decomposition takes place. The strength
of the solution which we apply, must be determined by the natural
delicacy of the part, and its morbid sensibility, in consequence of
inflammation. In the inflammatio valida, in which alone it is proper,
the solution never ought to be so strong as to produce pain. When the
eye, urethra, and other delicate parts, are inflamed, the application
ought to be just so strong as to produce sensation, and should be very
frequently repeated. When the cellular substance is inflamed, and we
begin the application before the cutis be much affected, the solution
will not require to be so strong as to produce sensation; because,
were it to be so, the action excited might, from the quantity required
to produce the effect, be so great, and so suddenly induced, that
the powers of recovery would be lost, or a specific inflammation be
occasioned, as we observe, when the solution is very much concentrated,
in which case, even sloughs are sometimes produced. On the same
account, we must renew the application frequently, at least if we
use pledgets, otherwise the evaporation of the solvent increases the
strength more than we desire. For incipient phlegmon, we may employ a
solution consisting of three pounds of rain or river water, and five
drachms of sugar of lead; or the following, which is more elegant:

    R. Cerussa Acetatæ dr. iii ss.
       Aceti Vini unc. iii. Solve super focum dein adde.
       Aq. Distill. Frigid, lb. i ss.
       Aq. Rosar. unc. iv.

This may be applied by means of pledgets of linen; or part of it may be
made into a poultice, with crum of stale bread.

Saturnine poultices ought always to be applied cold; because we thus
receive both the benefit of the cold, and of the lead. The directions
which have already been given, with regard to the application of cold,
are to be attended to here.

Lead has been supposed to act as an astringent; but, if astringents
were useful, alum would be more effectual than any of the preparations
of lead.

The vegetable acids have been considered as sedatives, and are
generally employed in the cure of inflammation; but it would rather
seem, as if they belonged to the class of agentes similes; for, in
moderate quantities, they increase the appetite, &c. which no sedative,
or agens dissimilis, ever does[13]: They also excite a general action,
which is different from that induced by sedatives, and which is useful
in curing many of the actions induced by these agents. We likewise
find, that they are not serviceable, as local applications, in the
cure of inflammation, unless in so far as they become the vehicle for
applying cold. The surface is not very susceptible of their action;
and, therefore, those who are inclined to continue their use, may do so
without injury, and even with benefit, if they be cold; but then the
same benefit will be derived from cold water.

[13] Like other agents of this kind, they may kill speedily, if drunk
in too great quantities; and, after death, the vitality, from the
previous great action, is found completely destroyed.

Alcohol is likewise considered by some as a sedative, and introduced
as a remedy, in the enumeration of those which are applicable in
inflammation[14]; but, whatever its use may be in the inflammatio
debilis, it must be allowed to be evidently hurtful in the inflammatio
valida.

[14] Hunter on Inflammation, p. 350.

The last division of local application, contains those which tend,
both simply to abate action in general, and also to excite, to a
certain degree, a specific change of the action. Topical bleeding is
the chief remedy belonging to this division. Bleeding with leeches, or
the scarificator, is employed in two different circumstances: First,
when we detract directly from the inflamed part; as, for instance,
from the surface of a phlegmon: Secondly, when we detract only from
the neighbourhood of the inflamed part; for instance, from the skin
which covers an inflamed joint. When we employ topical bleeding, in
the first case, we may suppose, that the aperture, and effusion from
the extremities of the inflamed vessels, produces, to a certain degree,
a change of action. Every action of the vessels is performed at their
extremities, and the trunks and branches may be considered as canals
subservient to the extremities, and which contract and dilate, in a
degree proportioned to the general and local action. If, during health,
we open a number of the extremities of these vessels, we induce the
hemorrhagic action, which continues longer or shorter, according to
circumstances, and which gradually terminates in a serous discharge, or
secretion. If, during inflammation, we open a number of the extremities
of vessels, either in the inflamed part, or immediately contiguous to
it, we induce a similar hemorrhagic action, which is different from the
inflammatory one, and, therefore, tends to diminish that action in the
part. We likewise, by inducing the serous secretion, tend to produce a
termination to the inflammatory action.

Topical bleeding will also, in part, operate, by simply abating the
action, in consequence of the mere loss of blood; for, as the blood
is withdrawn immediately, by different orifices, from the vessels of
one part, that part, and those near it, may be supposed to suffer
sooner, and to a greater degree, than the rest of the system. The
branches which yield the blood, will even suffer considerably, for
a time, although the loss of blood be very trifling, and produce no
effect on the system. Thus, if one small artery be divided, we find,
that, although the quantity of blood which flows from it be very
inconsiderable, yet it is sufficient to produce evident changes in
that vessel, making it contract, and become smaller, although the
vessels in other parts be not at all affected. This depends upon the
peculiar[15] action of the individual artery being affected[16], and
the contracting state of the orifice, spreading along the branch and
trunk by degrees[17], by which less blood is made to circulate through
it. Bleeding from a vein, however, has not the same effect; because the
quantity of blood in a part, is not so immediately dependent upon the
state of the veins; and because veins are not the seat of much action.
When we divide a small vein, we find, that it, by degrees, contracts,
and transmits less blood, or closes completely; but the blood from
the part does not circulate faster, nor is less blood sent to that
part than formerly; therefore, topical bleeding from veins near the
affected part, can have no great superiority over general bleeding.

[15] By peculiar action, I do not here mean what is commonly understood
by the term specific, but the action which is proper to the artery,
considered as an individual, in opposition to the action of the heart
and arteries, considered in general as an entire circulating system;
for one part of this system may act less powerfully than another, and
may be more dilated, &c.

[16] The distance to which this will extend, depends chiefly upon the
quantity of blood which is lost, and the size of the vessel which is
affected.

[17] This depends upon the operation of the sympathy of association.
Sympathy was, in the preliminary dissertation, divided into that of
association, and that of equilibrium; and it was mentioned, that the
same parts might be made to exhibit either of these, but that naturally
the sympathy of association is chiefly, and most easily exhibited by
those parts which are similar in structure, and contiguous to each
other; and, in them, the action spreads fastest. At the same time, if
the action continues long, or be very strong, it may be propagated to
dissimilar parts, and produce either a very extensive, or an universal
action, which is just a greater degree of the sympathy of association.
In this case, it has, however, been called universal sympathy.

The division, then, of a number of small arteries, may cure
inflammation in two ways; first, by inducing a different action;
secondly, by possessing the general properties of bleeding, namely,
a simple diminution of action. The first will operate chiefly, when
we apply the leeches on part of the inflamed portion. The second will
operate, when we detract only from the immediate vicinity; and, in
this case, the quantity of blood which is taken away, must be greater;
because the effect has to be extended some way, the vessels not being
in the inflamed part. The quantity must likewise be greater, because
the effect depends entirely upon this; whereas, in the other case,
it depended, in part, upon the peculiarity of the action which was
produced.

The number of leeches which it is necessary to apply, will depend upon
the violence of the action, and the place on which they are set; for,
the greater the distance from the inflamed part, the more numerous
ought they to be. It is therefore impossible to give any particular
rule for the extent of topical bleeding. It may, however, be proper
to observe, that we ought not to be satisfied with one application,
more than with one venesection, for a general disease, but ought to
repeat the local bleeding, whenever it may be necessary, although it
may be twice or thrice in a day, founding our indications upon the same
principle on which we use general bleeding. It is by a too sparing
application of leeches, and their not being repeated sufficiently
frequently, that we so often fail in removing inflammations, which,
by a more active treatment, we might resolve. In general, the leeches
ought to be applied as near the affected part as possible, or upon it.
If, however, the seat of the inflammation be chiefly in the cutis,
as in erysipelas, it will perhaps be more prudent not to apply them
upon the spot; because the subsequent irritation is apt to increase
the action afterwards, on account of the great delicacy of the part.
There may even be some doubt as to the propriety of applying leeches to
the vicinity of the inflammation; for the irritation of the bites may
produce erysipelas in the part, or cause the original disease to spread.

The scarificator may be used where leeches cannot be obtained; but it
is not so useful, when applied to the inflamed part, on account of the
irritation which attends its application, and the cupping; but it is
equally proper, where we detract not from the part itself, but from its
vicinity.

Of the topical remedies, bleeding is the most powerful; and, next to
that, cold solutions of lead. Where these cannot be employed, owing to
the internal situation of the inflamed part, blisters must be used in
their place.

Many other remedies used to be recommended, under the name of
discutients, repellants, &c.; some of which have been formerly
mentioned, when considering the ancient theories of inflammation;
these, however, are now laid aside. But many practitioners still have
an idea, that benefit will be derived from mechanically softening the
parts by means of oils, or what they call emollients; and seem to
consider, that poultices are chiefly useful for the same purpose; at
least they only direct, that they shall be removed before they turn
“stiff or hard.” But inflammation must be attributed to a different
cause than increased attrition, and its cure must be effected by
different agents from those which we employ for softening a piece of
dead skin. Oils and liniments, in so far as they form a basis for
other applications, or are used alongst with gentle friction, may
be occasionally proper in the inflammatio assuefacta; but, in the
inflammatio valida, they must be considered as absolutely useless.

There are also some remedies, recommended with the intention of
absorbing acrimonious excretions; such as, flour or magnesia, in
erysipelas. But these seem to act entirely by allowing the action
to run its course, without interruption, affording a softer defence
than could otherwise be obtained. From the quick progress of violent
cuticular inflammation, the applications which are usually made
in other inflammations have been forbid here, and are said to be
pernicious; but this rather appears to arise from the application not
being properly timed, than from any peculiarity in the disease. It is
not easy to give any good reason why cold saturnine solution, of a
proper weakness[18], and sufficiently early applied, should not be
useful; nor do we find, that they are in reality hurtful in simple
erythema. Where this, however, attends wounds, or is not an original
disease, these are improper; because it is in general, in these cases,
an attendant upon the inflammatio debilis, or a symptom of it, and
requires either to be let alone, or to have stimulating applications
made to it, at the same time that we give bark internally[19].

[18] The solution must, upon the principles already laid down, be both
weak, and only so cold as to reduce the sensation of the part to its
natural condition, that is to say, so as to abate the morbid feeling
of heat; because, if we make it otherwise, we may injure the powers
of recovery, and perhaps induce gangrene. The application ought not
to be so cold as to excite the sensation of coldness, at least in any
considerable degree.

[19] Bark is useful and necessary in every case of erysipelas, after
the inflammatio valida has abated. Local applications, of a stimulating
nature, are also useful at this period, as will afterwards be
mentioned, when the inflammatio debilis comes to be considered.

These remarks upon the resolution of the inflammatio valida, may be
concluded, by observing, that the diet ought to be low and sparing,
in a degree proportioned to the violence of the action. Such motion
as affects the local action, must at all times be prevented; but when
a general action likewise exists, then general quietude must also be
insisted on.


_Of the Remedies which are necessary for inducing Suppuration._

Suppuration is a new action, the exciting cause of which is
inflammation; but, that it may take place, it is requisite, that the
inflammatory action be prevented from subsiding too soon, or too
suddenly; in which case, either resolution, or inflammatio assuefacta,
takes place: Whilst, on the other hand, we must prevent the action
from rising too high, and proceeding too rapidly; in which case,
mortification is caused.

In these cases, in which resolution cannot be obtained, suppuration
will generally take place, without any interference on our part,
provided we prevent the action from terminating in gangrene. This
we observe in many internal inflammations. At the same time, we may
sometimes accelerate this process, by a proper regulation of the
original action.

The remedies proper for moderating and removing the inflammatory
action, have been already mentioned; but these sometimes fail
to produce resolution; in which case, either suppuration, or
mortification, take place. When the symptoms of suppuration take place
(which have been already noticed), all that is perhaps essentially
necessary, is, to give up the resolving plan, and not interrupt the
natural progress of the action. If, however, the inflammatory action
continue longer stationary, and seem neither to be resolving, nor
decidedly inducing the suppurative action, then such remedies as
increase the action, and accelerate its progress, are essentially
requisite. These remedies, however, are, in general, indiscriminately
applied in both cases.

For the purpose of inducing, or accelerating the suppurative action,
it was formerly the practice to apply liniments, cataplasms, and
fomentations, composed of stimulating substances, such as garlic,
turpentine, galbanum, &c.; but of late these have been almost entirely
abandoned. Heat and electricity have the property of increasing the
performance of every action which is existing at the time of their
application, and, therefore, are the remedies chiefly to be employed in
the present instance.

Heat may be applied in two ways, with or without moisture. In the
first, it increases action more suddenly, and perhaps more simply. In
the second, its effects are more gradual, and are likewise complicated
with those of moisture, which certainly is an agent capable of
operating on the living system, and generally tends to excite a
secretory action, or to give a secretory termination to those increased
actions, which are induced by agents operating alongst with it. Dry
heat is therefore evidently improper in the inflammatio valida, because
it will tend to produce mortification; but, if moisture be conjoined,
then the suppurative action is excited. When, however, the action
has made an approach to the inflammatio assuefacta, then it may be
useful to raise the action simply by dry heat, for a little, before we
apply heat and moisture; because, if we apply moisture at first, the
progress is more tedious, and the action is less certainly excited[20].
Electricity is similar in its operation to heat and dryness, and may
be usefully employed in similar cases; but we must, if we expect any
benefit, repeat its operation frequently, and continue each application
for a considerable time[21].

[20] From what has been said in the preliminary dissertation, we may
understand how moisture should tend to induce a secretion. Agents
frequently excite conditions somewhat similar to their general
properties: Thus, putrid matter tends to induce the action of descent,
and consequent putrefaction. We likewise experimentally find, that,
if moisture be applied during a general increased action, it induces
perspiration, unless it be conjoined with cold, which lessens the
action.

[21] The proper way to use electricity, in this case, is to draw
scintillæ from the part, the patient being insulated.

There are two forms in which we employ heat and moisture, namely,
fomentations and poultices. Fomentations[22] have this superiority
over poultices, that the same degree of heat is always kept up during
their application; whereas, when we use poultices, the heat subsides,
as they are renewed only at considerable intervals; but fomentations
require longer attendance, and more trouble; and, therefore, are only
employed for a short time, and commonly betwixt the intervals at
renewing the poultices.

[22] Fomentations are made, by applying a soft cloth, dipped in any
warm fluid, (commonly water) to the part. Sometimes the cloth is wrung
hard, in which case it is chiefly steam which is applied.

Poultices are generally made of bread and milk boiled together, so as
to form a thick kind of paste, to which is added, so much olive oil
as will preserve it from hardening quickly[23]. These ought to be
applied, either of the same temperature with the inflamed part, or
hotter, according to circumstances. When the inflammation seems to be
naturally and quickly tending toward suppuration, it is, as has been
already mentioned, by no means essential, that any application be made
externally, in order to induce the suppurative action[24]; but still
poultices are used, and, in many cases, accelerate the progress. In
this case, the poultices should only be applied so hot as not to give
any considerable sensation of heat, otherwise we increase the action
too much, and too rapidly, and, if early employed, may even interrupt,
or stop the incipient purulent action, renewing the inflammation, and
perhaps making it terminate in partial gangrene. Poultices, then,
should not be applied very hot at first, especially when the action
seems to be such as to make us expect that it shall run its course
without any assistance. But when the inflammatory action has been more
tedious, and does not terminate in the suppurative one so soon, and
so decidedly as we would wish, then poultices must be applied, with a
different intention, being meant, not solely to prevent the action
from sinking, as in the first case, but also to raise it, and make it
brisker. The heat must therefore be greater, and such as to give a
considerable sensation; and the poultices, instead of being changed
only when they begin to grow hard[25], which is perhaps all that is
necessary in the first case, must be renewed very frequently, in order
to keep up the increased degree of heat, or the agent which supports
the action, and accelerates its progress. They ought, in this case, to
be taken off and warmed, or renewed almost every hour, at least when
the action is tedious, that is to say, when they are most required. We
are then not to lay down any certain degree of heat which is to be
employed, nor fix any particular number of times at which the poultices
must, in every instance, be changed, but regulate our practice entirely
by the nature of each particular instance, taking the progress and
degree of the action as our guide, in this respect, and interfering
exactly in proportion to the necessity for interference. It may not,
however, be improper to remark, that, cæteris paribus, the heat must
be greater in proportion to the depth of the inflamed part below the
skin; or, in other words, we must apply more heat, when we are obliged
to act on a part not yet inflamed, than when we act directly on the
inflamed part itself. When an abscess forms at a distance from the
surface, the parts betwixt it and the surface gradually come, as was
formerly mentioned, to assume the purulent action; and the sympathy of
equilibrium, which naturally exists betwixt the surface and the parts
below, gives way to the sympathy of association[26], the parts coming,
by degrees, to perform one uniform action together, which spreads from
within to without. When we apply heat to the surface, at this place,
we, by continuance, likewise induce the sympathy of association, and
the increased action spreads and operates on the disease; but there is
this difference, that the action of the heat spreads from without to
within, and thus accelerates the progress of the suppurative action.

[23] Poultices may also be made, by boiling pounded linseed-cake, or
from potatoes, or mashed vegetable leaves (which are the cheapest for
hospitals), such as tussilago, &c.

[24] The inflammatory action, when moderately strong, acts naturally
as an exciting cause, inducing the purulent action, which is
therefore said to be a termination of inflammation. It is therefore
as unnecessary to interfere in the production of this secretion,
when the action is of proper strength, &c. as it would be to attempt
to increase, by local means, the vesication which is produced by a
blister. Poultices are, in this condition, perhaps chiefly useful, by
removing the causes which tend to abate the action at an improper time,
such as those which produce resolution, as cold, &c.

[25] They keep up the heat of the part, and keep it moist until this
happens, and prevent the action from flagging suddenly, which is all
that is required of them, when the action is going on of itself in a
proper degree.

[26] When two parts are affected at the same time, in consequence of
an agent operating quickly on one of them, they commonly exhibit the
sympathy of association, which takes place suddenly, but generally
at first lasts only for a short time, if the parts be distant; but,
if the original disease still continue, it may spread, inch by inch,
until it arrives at the part which was formerly affected, and which
is again affected more permanently, by the same kind of sympathy
taking place, but in a different way. In the first case, we have the
sympathia consociationis interrupta; in the second, the sympathia
consociationis serpens. It is this last which is the cause of the
extension of all action in a part, and which, when strongly excited,
overcomes the natural tendency to the exhibition of the sympathy of
equilibrium. It is, however, more difficult for local action to spread
by degrees to parts which evince the sympathy of equilibrium than other
parts; and these, in general, are longer of being affected. Thus, when
inflammation begins in the skin, it can much more easily spread along
the skin than dip down to the muscles.

When the suppurative action has existed a certain time, we find, that
it gradually extends itself to the skin, purulent matter being formed,
instead of organic particles; on which account, the cavity enlarges,
and the covering becomes daily thinner. At last, the action reaches
even to the cutis, which becomes white and flaccid, first at a point,
and then to a greater extent[27]. When this happens, the thin covering
is either torn by the pressure of the contained fluid, acted on by
the surrounding parts, or acting by its own weight; or, if this does
not take place, the suppurative action still proceeds going through
the cutis, the organisation of which, like that of the parts below,
is lost: The thin cuticle now rises up into a little blister, and
then gives way. The matter runs gradually out, the sides collapse,
and come nearer by degrees to each other, at the same time that the
ulcerative action succeeds to the suppurative. The quantity of the
discharge, therefore, daily lessens; the internal surface, or sides of
the abscess, come in contact; and the granulations at the margin or
circumference unite; those belonging to one side uniting with those
of the other, and thus producing recovery by successive circles of
reunion, which form rapidly, or more slowly, according to circumstances.

[27] In proportion as the action extends outward, it also becomes more
concentrated. An abscess is therefore somewhat conical, or at least
hemispherical, the base being turned inward, and the apex outward. When
the action reaches the surface, it is first at a single point; but, by
degrees, it becomes extended, and the apex becomes broader.

Such is the natural progress of an abscess; but it has been proposed,
that it ought not to be allowed to follow this, but ought to be
opened before it bursts spontaneously; and this opening has generally
been desired to be pretty large, chiefly perhaps on the principle of
allowing a free evacuation of the matter. Where abscesses are seated
over cavities into which they may burst[28], instead of opening
externally, there can be no doubt of the necessity of making an early
evacuation; and, in these cases, we ought to open them before the
skin becomes white; or, in other words, before the action reaches
the surface; because, if the abscess be seated equally betwixt the
skin and the cavity below, we may suppose, that, if it be extending
itself in all directions, or toward the cavity[29], in the same
proportion as outwardly, that the parts below will become almost
irreparably diseased before it can reach the surface, and will give
way afterwards[30], even although an opening be made externally.
Where, from the confinement of the matter, it seems to be spreading,
or diffusing itself, by its gravity, through the cellular substance,
or among the muscles, it will likewise be necessary to open the
abscess early; but, in this case, the abscess is unhealthy; for, were
it otherwise, the matter would be confined by the circle of diseased
organic matter thrown out during the inflammatory action, and which
is only removed gradually. In this case, the suppurative action has
extended itself laterally, and perhaps downward, more quickly than
in health, and has not observed the same ratio, with regard to the
extension toward the surface; the action, therefore, reaches parts
which were not formerly inflamed (by the sympathia consociationis
serpens), before the surface gives way; and, therefore, the matter
spreads or diffuses itself; for, by the spreading of the action, the
confining barrier is removed, and the matter mechanically extends
itself. This is an unhealthy abscess, and the action is of the
phagedenic nature. Opening the abscess will not always stop this morbid
action; but, by removing the matter, it will lessen the chance of
diffusion. We must, however, continue the free evacuation, and place
the member in a proper posture; because, if the action continue, the
matter which still is formed will lodge, and form sinuses.

[28] Such as the thorax, trachea, &c. Instances have happened of
suffocation being thus produced.

[29] Although, in general, an abscess has little tendency to extend
itself deep down, but rather moves toward the surface, although so far
from it originally, that, had the action extended equally in all other
directions, the size of the abscess must have been immense; yet, when
it is situated over a cavity, it may proceed toward that as if to an
external surface. Even, however, in this case, the general law, of
all actions tending to the skin, obtains; for the progress outward is
much quicker than that inward; but, if the action commenced near the
surface of the cavity, as is commonly the case, the difference of the
distance will compensate for the superior tendency to extend outward;
and, therefore, the abscess may burst at the internal surface into the
cavity.

[30] In abscesses seated on the thorax, I have known the intercostal
muscles and pleura continue the suppurative action, after the external
surface had opened, and thus an opening came to be formed into the
thorax.

In healthy abscesses, where we do not apprehend any detriment to the
neighbouring parts, the question comes to be, whether opening them
will accelerate the cure? Perhaps much of the diversity of opinion on
this subject, has arisen from not attending to the condition of the
abscess which we have been managing, and thus we apply the prognosis
and treatment of one kind of abscess to different ones. When an abscess
has been formed slowly, and runs its course rather tediously, we may
suppose, that the action shall continue for a considerable time without
being converted into the ulcerative one; and, therefore, the abscess
shall remain long without healing. In this case, a free incision, or
the irritation of a foreign body, may excite the ulcerative action, and
thus accelerate the cure; for these abscesses have come to approach
toward the nature of common encysted tumors, and require the same
treatment. But, where abscesses are running their progress with due
celerity, and the action is proceeding through its proper course,
there is not the same cause for interference. If, in this case, we
open them before the action has gained the surface, we derive no
benefit; because the action still proceeds, and the same events and
circumstances take place as if we had allowed it to burst. If we make
a large aperture, when the abscess is ready to burst, we, by the
irritation, interfere with the process which was going on, and delay
the cure. The admission of the air to the abscess, owing to the free
exposure, is one cause of this delay; for it changes the nature of the
purulent action, and, if the ulcerative action takes place, frequently
renders it unhealthy; the consequence of which, if the abscess be
large, or situated in vital parts, is hectic. We likewise, in large
abscesses, by the sudden evacuation of the matter, and removal of
the distension, sink the action of the parts, and make covery more
tedious[31]. When the abscess, then, is healthy, and the action strong,
it will be more proper to allow it to follow its natural course, and
burst spontaneously, than open it, by a large incision, or by the
introduction of a seton: If we do open it, the orifice should not at
first be large, but should just comprehend the diseased or whitened
surface.

[31] This likewise affects the system, and produces syncope, if the
mechanical support be withdrawn suddenly from the parts.

Sometimes, after an abscess has burst, or been opened, it continues
in a progressive state of amendment for some time, and then becomes
stationary, continuing to discharge matter without healing. This
either takes place from the whole surface, or from a particular part
of it, forming a sinus, the treatment of which will afterwards be
mentioned, being the same with those which succeed abscesses which are
originally unhealthy.

After an abscess bursts, the proper application is a warm poultice[32],
which should be continued in general as long as there is any stool,
or hard margin; that is to say, until the increased quantity of
diseased organic particles, which were formed during the inflammation,
be absorbed, and the vessels at that part have either assumed the
suppurative or natural action. After this, the orifice ought to be
covered with a slip of lint, and moderate pressure applied over the
surface of the abscess[33], by which the sides are kept in constant
contact, and reunion is accelerated. Good diet is also necessary,
for we thus increase the powers of recovery, or keep up a proper
action, and renew the vital principle, the quantity of which has been
lessened during the inflammation, both by the continuance of a state
of overaction, and by the remedies which are employed to diminish the
action; for a state of real and permanent weakness is thus induced.

[32] This poultice does not require to be so hot, nor changed so
frequently, as before the full formation of matter.

[33] If this produces pain, we may in general conclude that it has been
used too soon.

It sometimes happens, that suppuration takes place very slowly, and
the action seems to be performed with little vigour. In this case,
if the abscess be allowed to burst of itself, we both lose time, and
are often, in the end, disappointed in a cure, the healing process
not taking place. It is therefore useful, in these cases, to have
recourse to other agents besides heat. If the pain be trifling, and
the suppuration be what may be called chronic, or approaching to it,
we will perhaps succeed, by applying gentle pressure on the abscess,
by means of a thin roller, and laying a warm poultice over this. But,
when this fails to increase the action, we ought to pass a seton, by
which we evacuate the matter, and keep up the subsequent action to a
degree sufficient for producing recovery. In doing this, however, it is
necessary to attend to the state of the tumor; because, if, in every
instance, we pass it from the highest to the lowest part, we shall
sometimes make the part give way in a third place. If, for instance,
the abscess be much thinner at the apex than elsewhere, or, if the
action have made considerable progress toward the surface, then the
stimulus of the action increases the performance of the natural process
which was going on, and the action continues to extend itself until
the part gives way. In these cases, then, we ought to pass the seton
from the thin part to the lowest part; and this, in general, will, from
the sympathy of association, be sufficient to excite the action of the
whole internal surface.

When we resolve to use the seton, the following is the easiest method
of introducing it: Make a puncture with a lancet either into the upper,
or the thinnest, and most prominent part of the tumor, according to
circumstances; and, into this puncture, introduce, using the lancet as
a directer, a probe, having a piece of tape passed through its eye.
The lancet is then to be withdrawn, and the probe pushed down to the
under part of the abscess, where its point will be felt under the skin.
A small incision is here to be made upon the knob of the probe, which
is next to be passed through, and the tape drawn after it. The matter
is then to be slowly pressed out; the tape is to be folded; and the
abscess bound up with a compress and roller, so as to make moderate
pressure upon it. Next day, the dressings are to be removed, and a
clean piece of the tape drawn through, after which, pressure is again
to be applied.

The size of the tape, the time which the seton ought to be employed,
and the degree of pressure to be used, must be regulated by
backwardness of the action, and the imperfection of the healing
process.

If, either from improper management, or the morbid condition of the
action, the abscess, after it bursts spontaneously, or is opened by
art, continue to suppurate, without undergoing the ulcerative action
preparatory to healing, then we find, that either the sides remain
quite separate, producing a cavity, extended more or less, or one
particular portion remains open, forming a sinus. Both of these cases
require a treatment, which, in its principle, is the same, namely, the
indication of the ulcerative action.

In the first case[34], we shall frequently succeed by means of the
seton, especially if we use pressure alongst with it; for, by keeping
the internal surface in close contact, we tend to check the purulent,
or suppurative action, and produce organic particles[35]. We may also
succeed, by using stimulating injections, of such a strength as to
produce a moderate degree of smarting. Of this kind are, wine and
water, solutions of white vitriol, corrosive sublimate, &c. These ought
to be used frequently in the course of the day, and pressure employed
during the intervals. Incision, or laying the part open, is, being the
most severe, the last remedy which is to be had recourse to. Small
chronic abscesses may be laid open during their whole diameter; but
larger ones require only to be cut up for a certain length.

[34] This is exactly similar to an encysted tumor which has been
opened, and requires the same treatment. The internal surface becomes
thick and somewhat hard, like that of a cyst. It differs from an
encysted tumor only in its cause and origin.

[35] If pressure be employed early, to a considerable degree, the
irritation of the means employed produces pain, and a morbid increase
of action, unless we keep down the action by cold, as will be explained
when considering the treatment of ulcers.

The second case, has generally been considered as a species of ulcer,
and has been named the sinus ulcer; but, although the orifice may
sometimes possess the diseased ulcerative action, yet the sinus itself
still continues in the suppurative state, and, therefore, cannot heal.
These sinuses depend, in different instances, upon very different
causes, and, therefore, require a variation in the treatment. The most
simple species of sinus may be called mechanical, and is produced
by matter flowing from a neighbouring cavity, and which cannot be
freely discharged: Thus, for instance, if a deep abscess open at the
highest part, or at a point above the level of its bottom, the matter
constantly oozes out, and keeps the canal open. This is most apt to
occur, when abscesses are formed deep amongst muscular parts; in which
case, although the matter point at the centre, yet an accumulation
must take place below, and the matter must continue to be discharged by
the aperture, when it becomes so abundant as to be raised to the level
of the opening; or, being once raised, it continues to flow out. The
cure of this may at first be attempted mechanically, by tight bandages,
which press out the matter, and keep the sides in contact; but, if the
disease have been of long duration, then, whatever may have been its
nature at first, we find, that the suppurative action extends along the
mechanical sinus, which then becomes affected with a chronic action;
in which case, it becomes similar to the second species of sinus. We
must, in this species, make an opening at the most dependent part, and
employ the means which will be now mentioned in considering the second
species, or that produced in consequence of the suppurative action
becoming chronic or habitual, independent of any mechanical cause.
This may take place, although the aperture have been originally in a
proper place, and the matter, instead of being retained and keeping up
the disease, shall have been regularly discharged. The case in which
this is most likely to happen, is that in which the abscess has been
very tedious in its progress, and the action has been, from the first,
slow. The distinction betwixt this species, and those which remain
to be mentioned, is founded upon the absence of the symptoms which
they possess, and by our examination with the probe, which points
out the cause and extent, and informs us whether we be near a bone.
The orifice is flabby, and has the appearance of the indolent ulcer.
The cure of these sinuses is to be attempted, by pressing out the
matter by means of proper bandages, or by making a dependent opening,
which is generally necessary, at the same time that we raise the
action of the part to a proper degree, and render the suppurative
action acute and vigorous; in which case, it naturally terminates in
the ulcerative, and thus the part has its structure restored. This
is most easily effected, by passing a seton, and applying a proper
degree of pressure, diminishing the size of the seton gradually, and
in proportion to the vigour of the action and the approximation toward
health. When, from the situation of the sinus, we cannot pass a seton
(which rarely happens in this species of sinus), injections of wine
may be used frequently, and pressure applied during the intervals.
When these means fail, which is seldom the case, the part should, if
its structure permit, be laid open. If this sinus have remained long
open, its surface, like that of the chronic abscess, becomes changed,
and a coat is formed, like the cyst of a tumour. When this is thick
and hard, the sinus has been called a fistula, and it has been deemed
necessary to dissect out the tube; but it is in general sufficient to
use the remedies which increase the vigour of the action, and make it
run its natural progress; such as the seton, or a free incision, if the
parts be superficial, or no considerable vessel or nerve runs the risk
of being wounded.

The third species of sinus is that in which the suppurative action is
kept up by the operation of some adventitious cause; such as a caries
bone, diseased cartilage, or the lodgement of a foreign body; as, for
instance, a ball, a splinter of wood, bit of cloth, &c. This species
is distinguished by our feeling the extraneous body, or diseased bone,
with the probe, and by the fungous protuberance, or papilla, which
shoots out from the orifice. In addition to the method of curing other
sinuses, we must here endeavour to remove the adventitious cause, which
is generally very difficult to be done. If the foreign body be deep,
or if the diseased bone lie deep, and the sinus be narrow, we can do
little in this way; sometimes, indeed, by enlarging the external part,
we can come at the foreign body with a pair of small forceps, and may
extract it, or may accelerate the exfoliation of the diseased bone;
but we can have no certainty of success. If, however, the sinus be
superficial, which sometimes happens in caries of the tibia, &c. it
ought, in every instance, to be fully laid open, and the bone exposed,
and treated in the way immediately to be mentioned. When this cannot
be done, we may sometimes, by conveying the proper remedies through
a tube down to the bone, procure exfoliation; or may, by setons,
injections, and pressure, procure a temporary cure; but, as long as
the adventitious cause remains, we cannot expect a permanent recovery.
It is observed, that sinuses, when they can be healed in these
circumstances, break out again upon very trifling exertions, and very
frequently are renewed, after a short interval, in spite of all our
precautions; such as rest, warmth, &c.

A caries[36] of the bone is at all times a disease which is difficult
to manage, both on account of the mechanical obstacles which we have
to overcome, and the slowness with which the affected parts perform
their actions either of disease or recovery. The divisions of this
disease have generally been taken from the appearance of the caries,
and its extent. We have the dry caries, the worm-eaten caries, the
spongy, or carnous caries, &c. and we have the deep and superficial.
But, as the cure of these is to be conducted on the same principles in
all of them, and as they are most probably different degrees of the
same complaint, it will be more useful to divide them into those which
affect bones lying deeply, and those which affect the more superficial
bones; because these different cases are attended with very different
circumstances and symptoms. The first is preceded by an abscess, which
forms generally with much pain, runs its course slowly, and does not
burst for a considerable time. When it does open, its sides do not
ulcerate, at least universally, but a sinus remains, the mouth, or
exposed part of which only, assumes the ulcerative action. The second
is more rarely preceded by any abscess, but is either coeval with the
ulcer of soft parts, (both being produced by mechanical violence) or
it succeeds the ulcer, and is caused by it. This ulcer belongs to the
third genus, and will be afterwards described.

[36] When a bone becomes carious, the periosteum is completely
detached, and, therefore, it is felt to be rough by the probe. Its
colour becomes first of a dull white, or dirty yellow, which it either
preserves, or changes for the intermediate hues betwixt these and
black. It is generally more porous than formerly, and lighter; but
these qualities vary, from very slight degrees, to the appearance of a
light coralline.

In treating of the cure of caries, the first thing is, to determine
by what means the disease of the bone may be removed; and, secondly,
what modification our treatment must undergo, in consequence of
the caries belonging to the first or second species. From the very
earliest periods, we find the application of stimulating and corrosive
remedies recommended in this disease. The actual cautery, euphorbium,
mineral acids, scalding oil, the essential oils, and warm balsams,
have been universally employed, and frequently alternated with rasping
and perforating the bone. This proceeded from observing, that, on
the one hand, mild applications had no effect, and, on the other,
that the natural slowness of exfoliation was overcome by the use of
these more powerful remedies. A caries of a bone is correspondent to
a mortification of a soft part; and, therefore, it is impossible to
restore the diseased part to health, or life. Our chief object, then,
must be to prevent the disease from spreading, and to procure a speedy
separation of the dead portion. The first is much less under our power
than the second; for, it is most probable, that, in the majority of
instances, at least of those of a simple nature, the disease, from the
first, extends a certain length, affecting a portion of the bone, and
that it afterwards makes very little progress. There is, however, a
specific disease which affects the bone in common with the soft parts.
The bone becomes rough, and suppurates; and the soft parts have a
fiery appearance: This has been called the phagedenic caries. Cancer,
scrophula, lues, and other specific actions, also spread after they
are once induced. The second object is to be effected by such means
as operate upon the vitality and action of the part, and those which
act mechanically. Those which tend mechanically to remove the dead
portion, are perforations down to the sound part, which we know has
happened, by the bleeding which ensues; or, we may saw down this length
with a trephine. We thus, by cutting off the communication of part
of the diseased surface with the adjacent parts, kill it completely,
sooner than could otherwise happen, and likewise stimulate the parts
below to assume the ulcerative action, and throw it off. We may also
sometimes be able to turn out these portions with a levator. Those
which act more exclusively, by affecting the action of the part, are
stimulating applications; such as heat, acids, &c. The actual cautery
is so terrifying to the patient, that it is now laid aside; and it
is likewise liable to this objection, that it may, by its operation
on the neighbouring parts of the bone, produce disease in them. The
potential cautery is more useful, and may frequently be employed with
advantage, either in a solid form, as to callus, &c. or dissolved
in water, and applied with a pencil[37]. M. Sue, in his notes to
Ravaton’s Practique, &c. recommends l’eau mercurielle, or solution of
mercury, in nitrous acid. By these means, the sound part below assumes
the ulcerative action, its connection with the diseased portion is then
destroyed, and reparation takes place. The ulcer of the bone is red,
and its surface covered with innumerable granulations, which rise up to
the level of the surrounding parts, after which a cicatrice is formed.
These granulations in the bone are absorbed, and others more perfect
are deposited in their place, until at last they become completely
osseous[38].

[37] If we use the solution, we must, if the bone be very porous, or
spongy, apply only a little at once, otherwise it may sink down, and
injure a part which we do not wish to act on.

[38] There is a curious case of caries, which is frequently met with:
The diseased part, instead of being cast off, is surrounded by a
covering of new bone, (except at one portion, where a sinus and ulcer
is formed in the soft parts) and may be felt rattling within it. In
this case, there is necessarily a permanent enlargement of the part,
from the additional bony matter; and this, together with the sinous
openings, and the internal caries, being felt with the probe, form the
character of the disease, which has been called necrosis, a term which
formerly implied merely mortification. The cure of this complaint is to
be accomplished by extracting the diseased part, when it becomes loose,
if the opening in the case be sufficiently large; if not, it is to be
enlarged with the trephine, &c. See the works of Ruysch, Default, &c.;
and, more lately, the publication of Mr. Russel.

The next point which merits our attention, is the situation of the
bone, and the circumstances which attend the caries. When superficial,
a fungous ulcer is produced, and the modification which this situation
requires in the application of the general plan will come afterwards
to be attended to; the modification in the treatment which is required
in sinuses has been mentioned above. It may here only be remarked,
that, where the sinuses are superficial, they may be laid open, which
will induce the ulcerative action in their course, and allow us to
apply the proper remedies to the bone; but where they run deep, we
must either allow the disease to run its natural progress, and treat
the constitution according to the effects produced, or, by means of a
canula, convey a piece of caustic to the diseased part, in the same way
as we treat obstinate strictures of the urethra, &c. When, with the
probe, we feel the bone loose, we may assist its exit with the forceps,
or by enlarging part of the sinus, according to circumstances.

When these sinuses communicate with joints, and depend upon diseased
cartilages, tendons, or articulating surfaces of the bones, we can
do very little in the way of curing them by injections or incisions;
because we cannot thus remove the disease of the joint, but may
increase it. Issues placed over the joint, with rest, cleanliness, and
good diet, country air, &c. are the remedies chiefly to be employed
in these cases; or, if hectic be induced, and these remedies fail, we
must remove the diseased part, if this, on account of its situation, be
practicable. When, however, these sinuses are superficial, and depend
upon tendons not immediately connected with the articulation, it may
be useful to lay them open, and treat the disease of the tendons with
caustic, like a caries of a bone, or with escharotics, and stimulating
applications.

The fourth species of sinuses, are those where a specific action
exists[39], and prevents the healthy ulcerative action from forming. Of
this kind is the scrophulous sinus, which is generally accompanied with
a caries bone, or diseased cartilage, and, therefore, is a complicated
sinus[40]. This is distinguished, where the bone is diseased, by a
shining or polished red skin, like a cicatrix, surrounding the fungus
papilla at the orifice of the sinus, or the scrophulous-looking sore
which exists there. When no caries bone exists, we have no papilla,
but only the diseased ulcer at the orifice. In both cases, there are
generally the marks of a scrophulous habit. In the first case, we are
to treat the sinus as if it were of the third species. In the second
case, we are to treat it as if of the second, conjoining the proper
remedies internally, as will be mentioned in considering the cure of
scrophulous action. These sinuses, although healed, have a tendency to
break out again, especially in the spring or summer.

[39] These sinuses cannot be considered in this dissertation.

[40] This may sometimes be produced by the formation of an abscess,
without any evident cause; but at other times it is produced by wounds,
&c. in scrophulous habits.

The effects of the suppurative action upon the constitution, may be
divided into those which are dependent upon the formation of the
action, such as coldness, listlessness, &c. which are common to all
new actions; and those which are peculiar to the action when fully
formed. The first set requires no particular treatment, with an
immediate reference to their removal; but their presence indicates the
necessity of changing our method of cure, if we have not already done
so. In conjunction with proper local applications, we must give light
nourishing diet, with or without wine, according to the extent of the
action and the weakness of the patient. Rest, and general warmth, are
also necessary; but the heat ought not to be carried so far as to
produce any considerable sensation, or sweating. Diaphoretics have been
recommended[41]; but there does not appear to be any necessity for
their exhibition; because the cold, and other symptoms which we intend
to relieve, depend upon the state of the local action, and are only
to be removed by fully forming this action. Heat will not cure this
coldness, or shivering, when the action which causes it is extensive;
but, on the contrary, will frequently increase it, by accelerating the
formative process. The immediate effects, then, or the primary symptoms
of suppuration, require no particular treatment, with a view to their
own removal, but are to be attended to as marks which point out the
necessity of a change of treatment, with a view to keep up the action
which induces them, and to prevent it from producing bad consequences
afterwards to the constitution. Sometimes, indeed, in delicate people,
suppuration at this period produces hysterical symptoms, such as
languor, flatulence, or sometimes starting, tremors, and hysteric
paroxysms, more or less distinct. The slighter affections of this kind
may be frequently removed by a little warm wine and water; the more
severe, by anodynes, conjoined with aromatic waters.

[41] Mr. Hunter supposes that these are useful, “because they endeavour
to keep up an universal harmony, by putting the skin in good humour,
which quiets every sympathising part, and by counteracting the effects
of irritability.” P. 381.

The second set of symptoms, or effects, are those which have been
already described under the name of hectic, the production of which
has formerly been explained. This action, when slight, has been called
weakness, and has been considered as dependent upon the quantity of
the discharge; but, for the reasons formerly mentioned, this cannot be
admitted. The cure of this state is to be attempted, by lessening the
local action, at the same time that we give soups, and other articles
of nourishing diet, with a moderate proportion of wine, if this do
not quicken the pulse, and produce heat of the skin. Anodynes in the
evening, by procuring rest, will also be useful; but none of these
remedies will produce their proper effect, unless the patient respire
a pure air. Bark is considered as useful in these cases; but, unless
good diet be conjoined, it is not of much benefit. If, however, we give
the means of increasing the quantity of vital power, bark, by inducing
an action more nearly resembling the natural one, will be serviceable;
but, for this purpose, it must be exhibited in full doses. It is from
giving this medicine too sparingly, and in cases where other causes,
tending to counteract its effects, such as poor diet, bad air, &c.
are allowed to remain and operate, that bark has been brought into
disrepute.

When the general action is very considerable, then the exquisite
hectic is induced, and the situation of the patient becomes alarming.
When the local action is simply the suppurative or ulcerative action,
we may consider that the general disease is also simple, and are to
attempt the cure by the remedies which have been just now mentioned.
In conjunction with such local applications as tend to check the
local action, we must have recourse to all those means which tend
to strengthen or renew the natural action of the system in general;
for which purpose, we must attend, in the first place, to all the
particular functions, or individual parts; and, in the second, to
the whole in the aggregate. Under the second head are included bark
and wine, with moderate exercise[42], and proper diet; in the choice
of which, we must be directed by the nourishment which is yielded,
and by the capability of digesting the articles which we employ. In
general, milk, soups, and jellies, answer best. Under the first head
are included such remedies as tend to promote digestion, such as steel,
bitters, mineral acids, &c. although in general the bark will supersede
their use. The state of the bowels must also be attended to, avoiding
costiveness on the one hand, and diarrhœa on the other. The secretion
of the skin must also be regulated, stopping the colliquative sweating,
if possible, by getting up for some time when it commences[43].
Lessening the quantity of bed-clothes, for a few minutes, will also
sometimes interrupt it; but when it has continued long, it can only be
checked by removing the diseased action[44]. A full dose of the bark
given before the accession of the sweat, may sometimes, by influencing
the morbid action, prevent the discharge. The respiration must in
particular be attended to; for, by breathing country and pure air,
the action of respiration is more fully performed, and, consequently,
the source of vitality is increased, and the effects of our other
remedies are increased. The importance of a change of air can only
be known by those who have observed how fast patients have recovered
from operations when removed to the country, and clean lodgings, with
well-aired beds, although before this they were daily sinking. Indeed
no capital operation, which is likely to induce the suppurative action,
ought to be performed, where cleanliness, and a free circulation of
air, free from fœtor, cannot be procured.

[42] Exercise may be used either on foot, or on horseback, or in a
carriage; and its degree must be regulated by the strength. There are
few patients who cannot bear moderate exercise (were it no more than
walking half a minute in a garden), and who will not be the better of
this.

[43] Acids are supposed to check it; but they can only act by
increasing the strength in a secondary way.

[44] Sweating is perhaps to the general hectic action what the
suppuration is to the local one; and, therefore, can only be stopped by
influencing this action.

It is not yet discovered that any remedy has a specific power of
removing the hectic, or diseased formative action, more than the local
purulent one[45]; and, therefore, we are obliged solely to trust to
these already mentioned, which have a natural tendency to increase the
healthy action, or induce one nearly similar to it, and especially to a
proper local treatment, by which we remove the exciting cause.

[45] A diet solely animal has been proposed in that peculiar species
of hectic which accompanies diabetes; but whether it would be equally
useful in other species remains to be determined.

When these remedies fail, and the disease seems to continue, or
increase, in spite both of general and local remedies, then we must,
if it be practicable, remove the diseased part by an operation; and,
in doing so, we must remember, that delay beyond a certain period
is dangerous; because the general action becomes so rooted, and the
strength so reduced, that recovery cannot take place. Operating in
these circumstances, therefore, can only hasten death. The wound will
not unite nor heal, and the general action will continue unabated.

When the local action is specific, the general one is also different
from the simple hectic; and, therefore the remedies which are useful
in simple hectic will not be of equal advantage in these cases, unless
a specific remedy be conjoined, as, for instance, mercury prudently
exhibited in the venereal hectic, dependent upon a neglected local
complaint. The most frequent instance of specific hectic is the
scrophulous; for the cure of which we possess no remedy which acts
with certainty. Whenever, therefore, the local complaint cannot be
cured, and the hectic increases, we must, if possible, remove the
diseased part[46]; after which, the general action, notwithstanding
its specific nature, most commonly declines; but the constitution still
remains, as formerly, scrophulous, or even more so than before. That
this is the case, would appear from the following fact: If a person
slightly scrophulous, although originally sprung from a scrophulous
stock, or in whom the constitutional disease seems to be disappearing,
in consequence of intermarriages, &c. has, by means of a local injury
done to a joint, &c. the scrophulous action excited, and consequent
hectic, that person will, after cure, have the tendency to scrophula
stronger in him than formerly; and the disease will even frequently be
communicated to his children with its original violence.

[46] When this disease attacks the lungs, as it too frequently does,
then, until a specific remedy for scrophula be discovered, no cure can
be obtained. Simple ulceration, or suppuration of the lungs, however,
and consequent hectic, may be cured, though not in every instance.


_Of the Treatment of the Ulcerative Action._

Suppuration is a natural termination of inflammation; and the
ulcerative action is invariably induced by the suppurative, unless
this remain chronic. The ulcerative action is to be considered as in
part a restoration of the natural one; for we find, that it produces a
restoration of the structure, granulations being formed by the vessels
which formerly supplied the organic particles, whilst the interstitial
vessels still yield a morbid fluid, called pus; but this they cease
to do, whenever they again are placed in the natural situation; that
is to say, whenever they become covered with the granulations, or are
rendered interstitial. In proportion, then, as granulations are formed,
a certain number of vessels are rendered interstitial, so that the
discharge gradually diminishes, until at last it ceases; for, when
we come to the formation of a cuticle, we have very few interstitial
vessels left, the skin having naturally few. At this time, the one set
of vessels having completed their action, and the part being restored,
the other also resume their action, and a thin exhalent fluid is thrown
out by the new cuticle, which keeps it soft and moist, and which is the
natural insensible perspiration. The action of the two sets of vessels,
then, is dependent on each other; and, whenever one is diseased, the
other becomes also more or less so.


GENUS I.

_Of the Healthy Ulcer._

From these remarks, as well as from those which were formerly made, it
will appear, that a healthy ulcer has a natural tendency to heal, and
that we ought only to be careful not to interrupt the natural progress,
nor allow the action to flag.

In this genus of ulcers, the bottom of the sore seems to be paved
with a number of small fleshy points, with minute interstices betwixt
them, or surrounding their bases. These are of a red colour, with
a slight shade of the purple, and are wet with a yellowish fluid,
which is called pus; but which must of necessity differ from the
fluid yielded by suppuration. This separates freely from the surface,
when it is wiped or touched with a sponge, and then the granulations
may be distinctly observed[47]. The margins are smooth, thin, and
a very little rounded, that is to say, are almost imperceptibly
raised above the granulations, a circumstance which is essential
to this ulcer, because, were they both on the same level, it would
show, that the cicatrizing process did not go on properly; for,
whenever the granulations rise to the level of the surface, they
ought instantly to form skin. This cicatrix, which extends gradually
from the circumference to the centre, is of a pale red colour; but
the integuments immediately beyond it are white, and of the natural
appearance. Sometimes, from a slight deviation or imperfection, one
spot of the disk rises to the level sooner than the rest; but, in this
case, it immediately skins, and the cicatrix extends from this in the
same way as from the circumference, until they both meet. The sore is
free from pain, the only sensation being a slight degree of smarting,
or itchiness.

[47] Whenever the discharge does not separate completely from the
surface, when it is wiped, but part of it remains, like a film, or
jelly, betwixt the granulations, or on particular spots, we may be sure
that the action is not healthy.

The treatment of this ulcer is very simple; for, in most cases, it is
only essentially necessary that we prevent the operation of hurtful
causes. We defend the part, by covering it with a soft pledget of
lint, and keep it warm. When the cicatrization has commenced, it may
be assisted by using an ointment containing any harmless powder, in
such a proportion as to form a paste or scab upon the part[48], by
which we afford an artificial covering, which remains in close contact
with the granulations; and, by thus bringing them nearly into the
same circumstances as when skin is formed, the cicatrizing action is
accelerated. The same effect is sometimes produced, by allowing the pus
to form a scab over superficial sores, by exposing them to the air,
without any covering.

[48] Simple ointment, rubbed up with a fourth part of its weight
of finely levigated calamine, or flowers of zinc, makes a useful
application. Mr. Bell recommends, amongst other remedies, a saturnine
ointment; but, if this produces any specific operation, it must be a
hurtful one, injuring the action.

Dry lint is a very useful application; but, as it is apt to stick to
the granulations, and tear them, when tender, it ought always to be
well moistened before removal, which should be attempted slowly.

Mild ointments, such as the simple cerate, are frequently employed; but
they must be free from all rancidity, otherwise they fret the skin, or
injure the sore. In general, they are less useful than dry lint. When
we do employ them, they ought to be applied only to the granulations
and cicatrix, and not to the sound skin. More frequently we use these
ointments spread on a pledget of linen, to keep the dry lint on the
sore.

Poultices are also recommended in these cases; but they possess no
peculiar advantage, and are apt to make the part feeble, and more
likely to break out again.

Moderate pressure, by keeping up the action, is generally of service;
but it is still more necessary when the action begins to flag, or
becomes stationary. In this case, a compress ought to be placed
over the sore, and the whole member rolled firmly round with a
cotton bandage or, what will be still more useful, the part should
be encircled with strips, spread with adhesive plaster, in the way
which will afterwards be mentioned. Pressure acts by taking away the
condition of vacuity; it forms an artificial covering and interstices
for the superficial granulations, by which the natural process of
forming granulation and skin is greatly assisted. The parts are, in
this way, not only more quickly formed, but also in greater perfection;
and their powers of action are greater. The cure is therefore more
permanent, and the part is not so apt to die, or ulcerate again, as
when healed with simple dressings.

This practice, which is useful in ulcers which from the first are
healthy, is still more necessary in curing those which were formerly
diseased, but have now become healthy; because, in them, the action is
still more apt to flag.

The healing of large healthy ulcers which succeed to wounds, &c.
will also be much hastened, if we artificially diminish the size of
the cavity, and procure contact. Whenever one part can be brought in
contact with another, it ought to be done, if the figure and functions
of the part be not thereby injured, or if pain be not produced by doing
so.

The older authors, from a mistaken theory, never allowed the action
to proceed uninterrupted, or never co-operated with it in a rational
manner. In every ulcer, it was necessary, first, to digest, or
suppurate it, which was done with turpentine, or basilicon; next it was
to be deterged with turpentine, mixed with yolk of eggs, or by the red
precipitate; then it was to be incarned by sarcotics, such as tincture
of myrrh and aloes, balsam of Peru, frankincense, &c.; lastly, the
surface was to be dried into a callus, with dragon’s blood, white-lead,
chalk, &c. These plans have, however, been long laid aside; but some
practitioners still advise the use of styptics and spirit of wine to
produce a cicatrix; they forget, however, that skin is formed by a
different process than corrugation.

The diet ought to be good, in all cases of ulcers; but spiritous
liquors, and the irregularities of life, must be avoided.

In ulcers of the legs, if pressure be employed, rest is not absolutely
requisite; but, if this be not used, no cure can be obtained, if the
patient walk about. Even if the adhesive plaster be applied, we ought
not to allow of so much motion as to produce fatigue, or any uneasiness
in the sore.

The treatment, then, of this genus of ulcers, may be comprised in two
aphorisms.

First, When the action is, from the first, healthy and vigorous, and
is continuing so, all which is essentially necessary, is to defend the
part, and prevent the operation of any cause which might injure the
action, such as cold, too much heat, mechanical irritation, &c. This
may be done, by applying a bit of dry lint, or a rag spread with simple
ointment, and wrapping the limb round with a flannel roller. But, if
the action begins to flag, as it often does in large ulcers, or if the
process become stationary, we must then indispensibly have recourse to
gentle pressure.

Second, When the action has, at any one period, been diseased, or too
low, but has been restored to a proper state, we must of necessity
continue gentle pressure, and treat the sore as if the action were
stationary, although it may not be so.


GENUS II.

_Of the Indolent Ulcer._

In this genus, the action is diminished, and, consequently, rendered
imperfect and diseased.

Indolent ulcers, like those of the next genus, are divisible into two
species: First, that in which both parts of the ulcerative action,
namely, the granulating and purulent, are equally diseased, and equally
imperfectly performed: Second, that in which one part is more affected
than another[49].

[49] The circumstance of one part of an ulcer being more affected than
another, will be more fully noticed in considering the next genus, in
which it is of more practical consequence. Ulcers generally belong to
this species, before they assume the characters of the second (for they
frequently change from one species, or genus, to another; in which
case, the treatment must also be changed).

The first species is distinguished by the following symptoms, which
appear in greater or less degrees, according to the diminution and
imperfection of the action.

The granulations are pale, and imperfectly formed, partaking less
of the firmness and organisation of the healthy fleshy granulations
in proportion to the affection of the action. They are obtuse, and
scarcely at all elevated; and, therefore, the surface loses its doted,
or red pointed appearance. The discharge is thin, and of a whitish
colour, at the same time that we frequently observe isolated spots
of lymph interwoven here and there with the imperfect granulations.
Although these granulations are said not to be elevated, yet the
surface often exhibits a species of fungus; but the individual
granulations are not elevated, or pointed. This fungus never rises
higher than the twentieth part of an inch above the level of the
surrounding skin[50], and often appears only at particular parts of the
surface. It is pale, and somewhat of a gelatinous appearance. The pain
is trifling.

[50] The cause why these granulations rise, even this trifling height,
above the level of the skin, is the indolence of the action, which
prevents a cuticle from being formed in due time.

In more advanced cases, the whole disk is covered with a thin layer of
lymphatic substance, which adheres firmly, and gives the idea of a thin
pellicle being thrown over the granulations, which are seen imperfectly
and irregularly through it. The discharge is generally thin, like
serum, and considerable[51]. The edges are hard and tumefied, sometimes
of a light purple colour, at other times white[52]. The surrounding
integuments are also hard and thickened, at least in old ulcers, and
the veins are generally more or less varicose.

[51] Indolence of the action does not imply that the quantity of a
discharge should be lessened, but only that its nature should be
changed. In this species, the discharge is much the same in quantity as
in a healthy ulcer of the same size, but its perfection is greatly less.

[52] Sometimes the granulating action and the cicatrizing one seems to
be confounded, the surface exhibiting a fibrous fleshy appearance. This
I have seen most frequently in the calf of the leg; but it may occur in
other parts.

These appearances vary in degree from the soft pale surface, and thin
whitish purulent discharge, with slightly thickened edges, to the state
now described. The pain, when compared to the size of the ulcer, is not
considerable.

This genus may occur, in a slight degree, in recent sores, from
neglect, &c.; but it is chiefly after ulcers have been of long
standing, that they assume these appearances in the greatest degree.
They may then be said to have become chronic, or habitual; and, in many
instances, it is absolutely impossible to restore the action to its
natural state, and produce recovery[53].

[53] These ulcers, after long continuance, frequently induce a disease
in the bones or muscles seated below them, as will afterwards be
mentioned.

The second species is distinguished by the paleness and imperfection of
the granulations, whilst the discharge is tolerably good; but it never
can be equal to that of the healthy ulcer; because, when one part of
the action is affected, the other is also more or less affected. This
species does not require any more particular observation or remark,
because it is to be treated exactly as the first, of which it is often
just a slighter degree, or a forerunner; for it is frequently the first
change which takes place in a healthy ulcer. When it becomes diseased,
it does not continue long; for both parts soon come to suffer in the
same proportion; in which case, the ulcer belongs to the first species.
For this reason, we never find old ulcers belonging to this species.

Chronic ulcers sometimes induce a disease of the bones, &c. below; but,
in this case, they generally are converted into a different genus.
They also come naturally, in consequence of the great imperfection of
their action, and the consequent want of power, to act beyond the due
proportion betwixt action and power; and, therefore, most ulcers of
this genus come at last, if neglected, to belong to the next.

The most effectual remedy for these ulcers is pressure. This has been
long employed, by means of tight rollers wound round the limb, or by
the laced stocking. But, of late, a more effectual method has been
proposed, namely, a bandage of adhesive plaster, which applies itself
closely to the surface, and produces a state of artificial contact and
covering. This has been recommended by Dr. Darwin in the form of a
many-tailed bandage, and by Mr. Baynton in the form of strips, wrapped
round the limb. The following is the method of applying them: A strip
of adhesive plaster, about an inch broad, and so long as to encircle
the limb and cross at each end, is to be warmed, and the middle of
it applied to that part of the limb which is exactly opposite to the
sore; both ends are now to be brought forward, and one of them laid
tightly over the under part of the sore (if it be so large as not to
be covered with one strip), whilst the other is brought firmly over
this from the opposite side, and doubled down upon it. The ends of
the strip thus fold over each other at the ulcer. Another strip is
then to be applied to the part of the sore contiguous to this which is
not yet covered, and so on in succession, until the whole be covered.
This is the best way of applying the strips, if the integuments be
firm; but, if they be loose and yielding, it will be useful to push
forward the loose skin from behind, with the strips, as we bring them
forward; and, instead of laying down first one end, and then the other
over it, make the two ends cross each other at the same time, and lay
them down upon the skin, and not on each other, the under end covering
the lower part of the sore, and the upper the part next it. The same
strip, therefore, covers two portions of the surface, whereas, in the
first way, it covered only one; but, in this case, the strip must be
longer, as it must fairly cross the ulcer on each side, and be retained
by sticking to the adjacent skin. When the ulcer is deep, the strip
will press only on the margins; and, therefore, it will be useful to
fill up the surface with a fold of soft lint. A thin cotton roller is
now to be wound firmly round the limb, beginning at the extremity, and
continuing the bandage to the next joint above the sore.

By this contrivance, we obtain a firm covering to the granulations, and
bring a substance in contact with each individual. We then restore,
as it were, the natural state of the parts, each granulation having a
substance in contact with it; and a slight interstice is left between
each, owing to their pointed structure. They become, therefore,
similar, in this respect, to the organic particles of internal parts;
on which account, healing goes on more quickly, and the organic
particles, or granulations, are deposited in greater perfection, and
with greater powers of action; for the unusual and morbid condition of
exposure and want of contact is now removed. The same circumstances
promote cicatrization, when the granulations have risen to a proper
height. This is more evidently seen in the cure which is effected of
the smaller ulcers, by dusting them with chalk, &c. or dressing them
with an ointment made thick with some mild powder, by which a scab, or
covering, is formed, which operates clearly independently of pressure.
Pressure, applied with this view, ought to be moderate and permanent,
and may be used with utility in almost every case of solution of
continuity, however healthy the action may be. But, besides being
of use in this way, pressure also produces a second set of effects,
by mechanically exciting action in the part to which it is applied.
Applied to the skin, it increases the cuticular action, and the skin is
formed thicker. Applied to a weakened part, it increases the natural
action of that part, and strengthens it: This is seen in the instance
of debilitated muscles, &c. But, if the pressure be too great, then a
morbid increase of action takes place, which even goes the length of
inflammation, if the pressure be considerable; and this inflammation
is either strong or weak, according as the pressure has operated;
for, if many vessels be obstructed, as is commonly the case, then the
power of the part is injured, and the action is weak; or, the same
happens if pressure be applied in any manner to a weak part, or if the
constitution be weak; as, for instance, from previous disease.

Pressure, applied to a part, increases in particular the functions of
absorption and deposition. If moderate, these functions are moderately
increased, and the structure of the part continues either the same, or
it augments in size, as we observe, in the effects of walking, on the
skin of the feet; but, if the pressure be greater, then these functions
are morbidly increased, the particles are deposited imperfectly
formed, and are as quickly taken up. The structure is therefore
destroyed, and a vacuity formed. These effects are produced more easily
upon diseased than healthy structures; because their powers of acting,
and sustaining action, are less. Friction is in this respect similar to
pressure.

From these remarks, we may understand the mechanical utility of
pressure in the cure of ulcers; for, when in a proper degree, it causes
the absorption and destruction of the callous edges, or diseased
substance, and likewise makes, if moderate, the diseased granulations
be taken up, and more healthy ones be formed. We may likewise
perceive, that, if the degree be too great, the action will become of
an inflammatory nature, and injury will be done. We are therefore
frequently under the necessity of counteracting this hurtful effect;
for, the degree of pressure which is requisite for answering the
first intention in old sores, or inducing action, in consequence of
bringing the granulations or particles into the natural state of being
in contact with some body, or covered by it[54], is often attended
with such mechanical irritation, that the one effect would destroy
the other, unless we kept the action within due bounds, by applying
cold to the part. In healthy ulcers, the pressure necessary to produce
its first set of effects, or to accelerate healing, by producing
contact, is so trifling, that no counteracting effect takes place
by the production of the second set of effects; and, therefore, no
cold requires to be applied: But, in old ulcers, the pressure must be
greater; and, therefore, cold water must be constantly applied to the
bandage over the sore, by means of a sponge. We thus indeed lessen the
effects of pressure on the absorbing system, and, therefore, the callus
will be longer of being destroyed; but we, on the other hand, prevent
the action of the granulations from being rendered morbid.

[54] The degree of pressure necessary for producing this effect is
proportioned to the susceptibility of the granulations, or organic
particles, for receiving the impression of being in contact. When a
part is healthy, the mere circumstance of juxtaposition is sufficient
for this purpose; and, in a healthy ulcer, the weight of the body
applied, such as powdered chalk, or plaster of Paris, or at least
the gentle pressure of a stocking, or easy bandage, is all that is
necessary. But, when the action is too low, and the granulations are
consequently imperfect, both in their structure, power of acting, and
capability of receiving impressions, the contact, in order to operate,
must be nearer, and more complete; or, in other words, the pressure
must be greater. In these cases, bandages not only act on the surface,
but also on the parts below, and, therefore, increase the degree of
contact of the newly-formed organic particles, and thus strengthen the
part.

The good effects of pressure, applied in a degree proportioned to the
effect which we wish to produce, and to the state of the sore, are so
universal, that it is unnecessary to give any examples of its success
and utility. But, at the same time, it must be observed, that in old
ulcers, and even in many of a more recent date, which have been much
neglected, no application whatever will produce an uninterrupted
cure; for, after some time, it ceases to produce the same effect upon
the action. The part seems, by continuance, to be less acted on by
the agent; the action is less affected, and slowly returns to its
former state of imperfection. It is therefore necessary, either that
we from time to time increase the power of our application, or vary
our remedies, whenever the process becomes stationary. The latter is
generally the most effectual way; and the remedies which we alternate
with the effects of pressure, are those of what have been called the
stimulating kind; but which of the individuals of this division ought
to be employed, cannot always be determined, because one succeeds
better in a particular instance than in another. It would, however,
be of much importance, to ascertain which in general operated most
effectually; because, if we employ one which does no positive good,
we sustain positive harm; for the action is allowed to persevere in
a retrograde process. I, therefore, paid particular attention to the
operation of these applications, in the patients who were under my care
in the Glasgow Infirmary.

Heat is found to increase almost every action; and, therefore, in
indolent ulcers, it is sometimes of use, especially for a few days
after we begin the management of the sore, as it paves the way for the
action of other agents, by beginning a change of the action. Poultices
are the vehicle by which it is most frequently applied, and answers, in
general, better than other forms. Fomentations are much used by many
practitioners, who employ decoctions of different kinds of vegetables;
but they have no superiority over poultices. Dry heat was used by M.
Hevin, who held ignited charcoal near the sore; and it is sometimes of
use to repeat this practice betwixt each dressing.

Electricity is of little service; because it cannot be constantly
employed; and, therefore, its operation is only temporary.

It is worthy of observation, that although this kind of ulcer may be
sometimes completely cured by the use of heat, that yet the action is
not so perfect, and consequently the structure and power of the part is
weaker, than when stimulating dressings are employed. Exercise, or any
other cause, is therefore more apt to injure the part afterwards, and
make it again break out into an ulcer.

The red precipitate, mixed with resinous ointment, in the proportion
of a drachm of the former to an ounce of the latter, is a very useful
dressing; but the ung. hyd. nit. mixed with four times its weight of
hog’s lard, forms an ointment which is still more generally useful.

Ten grains of the cuprum ammoniatum, rubbed up with an ounce of
basilicon, or simple ointment, is sometimes useful, but cannot be
depended on. The same may be said of an ointment composed of an ounce
of ung. simplex, and ten drops of the oil of cloves, or of savin.

Cloths dipped in the aqua zinci vitriolati, or the solution of cuprum
vitriolatum, diluted with water, so as only to smart moderately, are
likewise of service, but not so frequently as weak solutions of the
nitrates of silver, zinc, copper, bismuth, and many other metallic
salts, such as muriate of mercury, &c.

Solution of common salt, or of nitre, of such a strength as to produce
a moderate smarting, are of temporary advantage, but will not continue
their effect long. Indeed all solutions of saline substances, whether
alkaline or metallic, are most useful when applied only for half an
hour at a time, when the sore is dressing.

Mixtures of Thus, elemi, turpentine, canadine balsam, &c. with wax, or
oil, have no advantage over the common ung. resinosum[55].

[55] An ointment composed of these resinous substances is much
recommended in the Acta Med. Berolin. Tom. VII. p. 58.

The bile, either by itself, or diluted, or mixed with yolk of eggs,
does not seem to be of much service.

Lemon juice, or the mineral acids, particularly the nitrous, diluted
so as to be of equal strength with the juice, are frequently of
service[56]. Port wine is also an useful lotion.

[56] These acids coagulate the pus, and thus afford an artificial
covering, or film, which remains in close contact with the
granulations, and thus, by producing the natural circumstance of
contact and covering, the effects of which have been already mentioned,
as well as by creating a more vigorous action by their specific action,
they frequently bring those sores into a healthy state.

Infusion of Cayenne pepper, in vinegar, added to water, in such a
quantity as to smart, forms also a very useful application.

Of all these remedies, the ointments composed of the nitro-metallic
salts, particularly the mercurial, are most generally useful: And
the cure seems to be accelerated, by applying cloths dipped in weak
solution of metallic salts, or weak acids, during the intervals of
dressing. Whenever these applications fail, they must be dropped: And
those which fail first, and soonest, seem to be the watery, or fluid
applications; and, next to these, the simple resinous ointments.

These remedies generally produce their effect first at the margins.
When this takes place, we must diminish the strength of the application
at that part, in proportion to the activity of the action, which is
marked by the redness and pointedness of the granulation, and the
cicatrizing state. The circumference, and the rest of the surface,
must, in this case, be dressed with different strips of linen, spread
with different ointments. Soft linen, spread with simple cerate, or
dry lint, which is preferable, should be applied to the cicatrix, and
cicatrizing granulations, whilst a stimulating substance is applying
to the rest of the surface.

When the surface is obstinately diseased, or the action very torpid
and imperfect, caustic has been applied; but, although I have often
used it, and even applied cloths dipped in solutions of metallic salts,
so strong as to form an universal eschar, or slough, yet no benefit
whatever was derived; for we do not thus change the nature of the
action, but only remove a layer of the surface, and leave that below
in possession of the same mode of action with the former. Caustic is
more useful, when applied to callus edges; but even these are more
effectually removed, by remedies which act more permanently, and
gradually, particularly by pressure. The ancients used to extirpate
these with the knife, but few will consent to its use. It is indeed
more speedy and effectual than the caustic; but, unless the action be
afterwards properly supported, it will be of no permanent service.

The hard and thickened state of the surrounding integuments, in old
ulcers, is best moderated by pressure; but this must be long continued.

Varicose veins, were, by the ancients, considered as canals running
into the sore, and furnishing the discharge; but, when we consider that
these varices frequently occur without any ulceration, or discharge,
the opinion must be abandoned. In such cases as occur alongst with
ulceration, it will be more natural to consider the affection of the
vein as a disease dependent originally on the ulcer, and induced by it,
in the same way as the structure and functions of other neighbouring
parts are changed and impaired by the continuance of a tedious and
diseased ulcerative action. This state of the vein being once induced
in any part of it, and even in a slight degree, two consequences
follow: First, from the power or property of the vein being impaired,
the blood is not duly propelled, but circulates slowly, and cannot
overcome readily the weight of the blood above, which presses more
powerfully, in consequence of the valves being rendered imperfect
by the distension of the vessel. The disease, therefore, gradually
increases; for, every day, the power of acting properly diminishes,
at the same time that the mechanical necessity for acting, or the
resistance of the column of blood increases. On account of the
dilatation of the vessels, and the morbid or abortive effect to propel
what they are unable to do, pain is produced, in the course of the
varix, whenever the legs are kept in a dependent posture, or exercise
is used. This pain is confounded with the uneasiness arising from the
ulcer; and, therefore, these ulcers are said to be painful, and to be
attended with pain in the course of the veins.

The second consequence is, that, as the veins which are more
immediately connected with the ulcerated part, are diseased, and do
not perform their part in the circulation properly, the functions of
the part must be still more injured, and the varix, which originally
perhaps was produced by the ulcer, comes in its turn to act on the
sore, and prevent its healing; for the vein not acting properly, and
conveying the blood fully, the action at the capillaries must be
injured, and the artery and vein cannot act healthily. If this be the
case, the power of forming granulations must be impeded, and these
never can be deposited in the necessary degree of perfection.

Two modes of cure have been proposed, the one palliative, and the other
radical. The first is effected by means of rollers, or bandages, which
prevent the vein from being distended, and, therefore, enable it the
better to carry on its circulatory function. In this way, we prevent,
to a certain degree, the hurtful operation of the vein upon the ulcer,
and are often enabled to heal it up. But, as we do not thus restore the
vein to its natural powers, unless in young people, who continue the
support or pressure for years, we can obtain no permanent cure of the
varix; and very frequently the parts again ulcerate; because, whenever
the pressure or support is withdrawn, and the patient walks about, then
the function of the part becomes affected, the organic particles are
not deposited in the same state of perfection, and the action which
is induced by exercise causes the destruction of these granulations;
or even the very circumstance of their being formed imperfectly is
sufficient to produce their destruction, and the opening of the part;
for all parts which have been formerly ulcerated are most ready to
assume this action again, and the organic particles of that part are
less perfect, and less able to bear action.

The second is obtained, by obliterating the diseased vein, or
interrupting its communication with the trunk above, by which we make
the blood take a different course, and be transmitted by healthy veins.
If we now cure the sore, we find, that the same effects are produced as
if we used permanent pressure; and, therefore, the functions of the
part are more properly performed, and the organic particles possess
greater power of acting, and sustaining action. The older surgeons
proposed to effect the radical cure, by tying the vein at the two
extremities of the diseased part, and cutting out the intercepted
portion, or by laying it open, and digesting it, as they said. This,
however, was, as they confess themselves, very seldom submitted to
in ulcers of the legs; and was rather inserted to complete their
treatises, than from a belief that the operation ought to be insisted
on. Of late, it has been proposed by Mr. Home, to tie only the upper
extremity of the diseased portion[57], by which adhesion takes place
at that spot, and the circulation is there stopped. The pressure of the
blood above is thus taken off, and the blood from below must circulate,
in a greater degree, through vessels which are better able to perform
their functions; and, therefore, the actions of the capillary vessels,
whether nutrition, absorption, or conversion of the blood from arterial
into veinous, must be more naturally performed. After the veins are
tied, they gradually become smaller; for the pressure being permanently
removed, the diseased veins can more fully propel their blood by
lateral branches, at the same time that they receive less blood, more
going by other vessels.

[57] This operation is performed by making an incision through the skin
which covers the vena saphena below the knee; a ligature is then passed
under the vessel, by means of a blunt needle, and the vessel is tied.
In two or three days the ligature may be removed, its circle being
previously divided with a pair of scissars.

It is a curious circumstance, that although ulcers may have remained
in an indolent state for many years, and have become almost habitual,
that yet, the cause of the indolence being removed, they recover their
powers rapidly, and with very little assistance. Thus, when a varix,
which originally was produced by the ulcer, reacts on the sore, and
prevents it from healing, we find, that if this cause be removed,
the ulcer frequently heals quickly, owing to the sudden removal of
a principal cause of indolence, although a similar ulcer, without
varices, would not be cured by the same application in the same time;
because then all the usual causes of indolence would still remain to
be removed, or their effects counteracted; but, in this case, having
suddenly removed one great cause, the action rises so much, that it can
overcome the rest, although, without this alleviation, the healing
process would not be commenced, nor continued. It may be useful to
attend to this circumstance in every case of indolent ulcers, whether
attended by varices or not; because, if we can remove any particular
cause, we do much toward producing a cure. Thus, callus edges, and
diseased, or thickened integuments, &c. although originally dependent
on the ulcer, yet react on it, and prevent it from healing. If, then,
by pressure, or otherwise, we remove these causes, we accelerate the
cure.

As an instance of the good effects of tying varices, I shall transcribe
the following case from Mr. Home’s Observations: “A man, sixty years of
age, had, for many years, gained his livelihood by going on messages,
having been rendered unfit for any more laborious employment by a large
ulcer on the left leg, just above the inner ankle. The complaint was
of twelve years standing: It had been sometimes much better than at
others, but had never been well during the whole of that period. In
the year 1792, it became so bad as to confine him entirely. It was at
this time I first saw him. Upon examining the limb, the veins were
extremely large, and varicose; and the trunk of the vena saphena, at
the knee, appeared almost the size of the little finger. The size of
this vein led me to the idea of taking it up at that part, with a view
of relieving the lower branches from the pressure of the blood, which
I believed to be the cause why the parts remained weak, and the ulcer
could not be healed. I explained my opinions upon this subject to the
patient, and told him, that, if he thought it worth while to try it, I
was very ready to do it for him. The man’s desire to get well was such
as to induce him to embrace the offer of any mode of treatment which
afforded the smallest chance of it. The vein was taken up in the way
that I have mentioned: He complained of very little pain, no improper
degree of inflammation was brought on by this operation, the ligature
came away in nine days, and in fourteen the wound was healed.

“The ulcer upon the leg was dressed with dry lint; it put on a better
appearance on the second day after the operation; on the fourteenth
it had diminished in size one half; and in twenty-eight days was
completely healed. He was also freed from a pain in the course of
the veins of that leg, to which he had been subject for many years,
whenever he used any exercise.

“He returned to his business of carrying messages, and called upon me
a year after, perfectly well; his leg having continued sound.”

Issues have been proposed for the cure of this genus of ulcers; but,
upon the principles which have been already mentioned, it must be
evident, that they can be of little or no service; and, I am sure,
that I never saw the smallest influence exerted by them over an ulcer.
They are useful, however, after the ulcer is healed, by keeping up a
secreting action, diminishing the risk of apoplexy, &c.; but then they
ought never to be introduced until the sore be nearly healed, or until
we have reason to suppose that the sore will heal, and that they will
be required.

The treatment of this genus of ulcers may be comprised in the
following aphorisms:

First, When the action of an ulcer becomes too low and imperfect,
pressure is the best remedy for restoring it to its proper state, and
for accelerating the cure.

Second, Whenever this ceases to produce any farther effect, or the
action relapses, and begins to go backward, we must lay aside the
pressure for a time, and dress the sore with some of the stimulating
applications above mentioned, particularly the nitro-mercurial salts;
and these, in their turn, must be laid aside, when they cease to
produce a good effect, and the pressure be again had recourse to.

Third, When we use stimulating dressings, we must attend to the
effects which they produce on different parts of the sore, and dress
these differently, according to their condition. We must likewise
proportion the strength of application to the state of the general
action. Our remedies ought to smart most when the action is most
torpid, and the smarting ought to continue longest; but, when the
action has begun to be more perfect and vigorous, the same application
will often be too strong.

Fourth, We must, in conjunction with this general plan, attend to
particular morbid structures, which may be produced by the particular
state of the ulcer, and which may react on it. The chronic thickness
and hardness of the integuments, are best removed by pressure, and
gentle frictions; but the restoration of the natural structure is very
tedious. Callous edges are likewise best removed by pressure. When
this fails, caustic must be repeatedly applied. Varicose veins may
be palliated by firm bandages, but are, in general, after they have
continued long, only to be cured by an operation.

Fifth, When chronic ulcers can be healed, it is useful to form an
issue, in order to keep up the accustomed secretory action; but these
issues have little effect in advancing the cure.


GENUS III.

_Of the overacting Ulcer._

This genus comprehends two species: First, that in which the
granulating, or purulent process is morbidly increased, or the two
parts of the ulcerative action, the granulating and the purulent, do
not correspond, or bear the same proportion to each other that they
do in a healthy ulcer: Second, that in which a state of general acute
overaction takes place, both parts of the ulcerative action being
equally affected, and rendered diseased.

For the illustration of the first species, I may remark, that there
are some actions performed by particular parts of the body which are
apparently simple; but there are others which are complicated, and
consist evidently of different parts, which, in the aggregate, form
a peculiar action, but which action may be modified according to the
degree in which these different parts exist. Thus, there are various
parts which, when taken together, form the inflammatory action, heat,
redness, swelling, &c.; but these may, in certain cases, exist in
different proportions. The ulcerative action is a complicated one, and
consists of the secretory and organising action, or the purulent and
granulating. These, in a healthy ulcer, bear a certain relation to
each other, and are at all times so connected, that, when one part is
injured, the other is also affected; but the one part may be affected
more than the other. In the indolent ulcer, or that in which the action
is too low, both parts are most commonly (at least after some time)
equally affected, and a state of universal diminution, and consequent
imperfection, takes place; but, in the beginning of this state, that
is to say, when the healthy ulcer is first becoming diseased, and when
the unhealthy condition has made little progress, it is not uncommon to
observe an inequality in the action, or the granulations more affected
than the discharge. In this genus of ulcers, however, the inequality is
more striking, and frequently more permanent.

It is worthy of remark, that though the granulating action may be
increased beyond the purulent one, that yet the purulent one never
exists in a state of overaction without a correspondent affection of
the granulating action; in which case, very different effects and
symptoms are occasioned, and the second species of overacting ulcers is
produced.

The first species has generally been described under the name of the
fungous ulcer, or ulcer with hypersarcosis. The granulations are soft
and indistinct. They are imperfectly formed, and, therefore, do not
possess the pointed appearance which they exhibit in health; nor have
they equal powers of action, nor longevity. They are formed quickly,
and rise to a greater or less height above the level of the surrounding
skin. The margins are generally soft, tumid, and of a dull red colour.
The discharge, if there be no carious bone, is tolerably thick, and of
a white colour, and not in greater quantity than would be yielded by a
healthy ulcer of the same size: The quantity is even sometimes less.
The pain, unless when a bone is diseased, is seldom considerable. This
species admits of two varieties. In the first, the granulating process
is increased, in consequence of some affection of the action, which
is independent of any mechanical cause. In this case, the fungus is
generally pretty firm, but commonly pale, and the discharge tolerably
good. In the second variety, the granulating process is increased,
in consequence of some mechanical irritation underneath, such as a
piece of carious bone; and, in this case, the fungus is softer, and
less firm; it is of a redder and more lively or fiery colour, and is
sometimes covered, in particular parts, with spots of lymph; it bleeds
upon the slightest touch. The sore is generally painful, and the
discharge thin, serous, and of a fœtid smell, whilst we can frequently
perceive at least one small foramen on the surface which leads down to
the bone, and through which it may be felt to be rough. Out of this is
discharged a thin matter from the bone, of a brownish colour, somewhat
like soup, and more or less different from the discharge from the
rest of the surface. These luxuriant granulations, however, must not
be confounded with those which, at a later period, come from the bone
itself, after it has begun to ulcerate. These are generally of a more
florid red colour, though sometimes pale, and rise up either through
chinks of the bare caries, or from such portions as are denuded by a
previous exfoliation. They have, in general, a more pointed appearance
than those which arise from the soft parts, so that, in many cases,
the fungus resembles the surface of a strawberry, being rough. This
variety may be induced quickly, the bone being injured, at the same
time that the soft parts are affected; but, at other times, and perhaps
more frequently, the bone becomes diseased, in consequence of the
continuance of a simple ulcer immediately over it; as, for instance,
on the tibia. In this case, the ulcer, which perhaps was formerly
indolent, now changes its nature.

The second species exists in various degrees, and its symptoms admit
of modification from the previous state of the ulcer. Sometimes an
ulcer, although previously healthy, has its surface excited into a
state of overaction, by exercise, or other causes. In this case,
the sore becomes painful, and the granulations assume first a kind
of light crimson colour, and then a brownish hue, from a species of
mortification. They do not indeed become gangrenous, and slough, but
they approach to a state nearly resembling death, and are absorbed.
The edges are slightly erysipelatous, and the discharge watery. This
may be called the first degree or stage of the disease; and the
ulcer frequently recovers soon from this, and reassumes its healthy
condition. But if it be neglected, or the injuring causes still
continue, the state of overaction is increased, and becomes more
perfect[58]; that is to say, the action which was injured in its
different parts, and rendered unconnected by the incipient or new
condition, becomes more completely and connectedly performed in its
different parts, in an increased degree. The overacting state, which,
in the first stage, took place, perhaps only for a few hours, or at
least if it continued, did not rise to any great degree, or receive
an augmentation in this stage, continues with violence, and generally
with exacerbation. The granulations are absorbed almost as soon as
they are deposited; because, owing to the overaction of the part, they
are very imperfectly organised, and possess very little life and power
of supporting action[59]. They evidently appear to be in a state of
overaction; for they are fiery, and their colour, whether it be red or
brownish, is bright or clear, and quite opposite to the dull hue which
even the same colour may have in a different kind of sore. These bleed
upon the slightest touch; on which account, the discharge is generally
bloody. The margins are red and ragged, as if they were bitten by a
mouse; and they are evidently in an ulcerating state. The surrounding
skin is hot and erysipelatous, the discharge is thin and serous, and
the pain great, generally somewhat of the burning kind. This sore,
from the destruction of the granulations, and the propagation of a
morbid degree of action, spreads as long as this condition continues;
but the progress, as long as the ulcer belongs to this genus, or as
granulations are formed, is not very rapid.

[58] By this I mean more perfect in its state of overaction.

[59] In highly overacting ulcers, the granulations seem to possess
a middle state, betwixt proper organic particles and the morbid
substance, called pus.

It not unfrequently happens, that, after a sore which has been indolent
has begun to heal, it, from fatigue, or some less evident cause, has a
state of overaction induced, in which case, different appearances are
exhibited, according to the previous state of the sore. If it has begun
to form a natural cicatrix, this gives way, the surface becomes livid,
the discharge thin, and the pain considerable. A thin slough of the
granulations is then generally formed, and comes off in portions mixed
with the discharge. If this state be not checked, it frequently comes
to exhibit the acute symptoms of the overacting ulcer which was last
described. More frequently, however, it occurs when the sore is still
indolent, and not in the healing state, and when the edges still remain
callous, and the granulations foul and unhealthy. If, at this time, a
disproportionate, or overaction be induced, by exercise or otherwise,
we find, that the surface becomes dark and sloughy, the granulations
flat and indistinct, the discharge is increased, and the margins become
tumid, and of a modena colour, whilst the surrounding integuments are
of a dull red mottled colour, or erythematous; and the foot, if it take
place in the leg, is frequently cold, and the pain darts down to the
toe.

This state is not unfrequently produced in old ulcers, by a disease of
the parts below[60], which has been induced by the long continuance
of the ulcer, which renders the bone carious, if it lie immediately
under it (in which case, the first species of overacting ulcers is
produced); but, at other times, by the sympathy of association, a
diseased formative action (owing to the diseased formative action in
the ulcer, or the imperfect granulations which are formed) is induced
in the neighbouring parts, the muscles become pale, and have less of
their fibrous texture, or the bone becomes rough, or pointed, like
shagreen, and also becomes thickened, but without any appearance of
caries. This diseased condition of the parts reacts on the ulcer, and
induces overaction.

[60] This affection of the ulcer, produced by a disease of the parts
below, is induced with a frequency nearly proportioned to the aptitude
of the part below for becoming diseased, by the continuance of an ulcer
over them. Tendons and bones are particularly apt to be injured in
this way; and, therefore, ulcers seated over tendinous parts, or bones
thinly covered, are more apt to affect these, and to be reacted on
themselves, than when seated over fleshy parts. On the same account,
ulcers on the foot, or ankle joint, are worse to heal than those a
little farther up the leg; and the difference is greater than can be
explained wholly, by the circumstance of distance from the heart, and
possessing less power of performing action properly. Recent ulcers
likewise heal easily on the feet, by proper treatment. It is old ulcers
alone which are difficult to manage, and the cause is obvious.

This state of overacting may also be induced in old ulcers, without
any malformation of the parts below, but merely in consequence of
continuance; for, after an ulcer has remained long indolent, it comes
to act so imperfectly, that it naturally goes beyond its power. This
may be said to be a spontaneous change, or conversion of one genus into
another.

We have then two varieties of this species: First, the state of
overaction induced in an ulcer which was previously healthy; and
this admits of two stages, the incipient and confirmed: The first
sometimes consists only of one short paroxysm: The second continues for
a longer time, and generally depends upon the neglect of the first
attack. Second, the state of overaction induced in an ulcer which has
previously been indolent; and this admits of two subdivisions, which
arise from the condition of the ulcer at the time of its overacting,
namely, whether it have been healing and cicatrizing, or the edges have
been callus, and the action imperfect and morbid.

The observations on the cure of this genus of ulcers must naturally be
arranged under the different species and varieties of these ulcers.

In the first variety of the first species, our object is to remove
the supernumerary, or fungous granulations, and to replace them with
others, which are formed more slowly, and in greater perfection.

Pressure, applied in the manner already explained, is one of the most
useful remedies in this variety, and ought always to be tried first.
The luxuriant granulations are quickly absorbed, and the succeeding
ones are rendered more compact and healthy, and the cicatrix begins
to be formed. If, however, we apply pressure in this, or indeed in
any sore, to such a degree as to produce its specific effect, we
must counteract its irritation by cold. If we do not, this sore is
frequently converted into the second variety of the second species of
this genus.

Caustic, and escharotics, have been sometimes applied to these sores;
but they only remove a layer of granulations, without affecting the
formation of the succeeding ones so much as some other remedies.

Stimulating applications are more useful; for, as they act more slowly,
they produce a greater influence on the action.

The cuprum vitriolatum, mixed with simple ointment, in the proportion
of a drachm to the ounce, is frequently serviceable; but the ung. hyd.
nit. is still more useful. One drachm of this may be mixed with an
ounce of hog’s lard and a scruple of camphor. Red precipitate, mixed
with resinous ointment, is also often of service.

The application of powdered rheubarb is recommended by Mr. Home, and is
frequently of service.

Lotions of port wine, solutions of white vitriol, or rose water,
containing as many drops of l’eau mercurielle[61] as will make it
moderately pungent, may be usefully applied before the dressing.

[61] L’eau mercurielle is a solution of mercury in nitrous acid.

Poultices seem to increase the diseased state; and mild dressings do
not counteract it, but allow it to go on.

The second variety is only to be cured by removing the caries bone;
but the same remedies which are used in the first variety may be
employed here, as palliatives, or the means of preventing the ulcer
from becoming worse. By a continuance of these applications, in cases
of slight caries, a cure may, after some time, be obtained; for the
thin layer of diseased bone, either comes away in fragments through
an opening in the ulcer[62], or it is sometimes absorbed. This last
event, the absorption of the bone, is particularly induced by pressure,
applied by means of the adhesive plaster; and, therefore, where the
disease is not extensive, it is always proper to have recourse to this;
but if, upon trial, we find it to fail, or to convert the sore into the
second species of this genus, which it sometimes does, we must omit it.

[62] In the description of this variety, it was mentioned, that there
frequently was a small opening in the surface, which communicated
with the bone; but, even where this is not the case, the layer of
dead bone, when it exfoliates, comes through the granulations; for
the granulations of the sound bone below raise it up, in consequence
of which, pressure is made from within outward upon the ulcer, by
which absorption is produced at that part, in a greater degree than
deposition; and, therefore, a vacuity is produced.

As it is only in slight cases of caries that absorption of the bone
is to be expected, we may consider it as necessary, in general, as a
preparatory step toward healing, that the diseased portion of the bone
be separated, and come away externally. It is therefore of advantage to
endeavour to accelerate this; because, whatever does so, hastens the
cure. Our attempts, with this view, are made at two different stages,
and with different intentions. First, when the bone has separated,
or exfoliated from the part below, by making an incision through the
ulcerated surface, we remove the dead part, and allow the sore to
heal. This stage may be discovered, by pushing a probe through the
opening, if there be one, or through the granulations, down to the
layer of bone, which we find to be elastic when we press on it. But,
even although the incision be made before this stage has taken place,
no harm is done, because it is of use in the first stage. Second, when
the carious bone has not yet exfoliated, but remains in contact with
the rest of the bone, ulceration of the sound part not having yet taken
place, it will be useful to make an incision down to the bone, and, as
soon as the bleeding stops, or lessens, to apply caustic freely, in the
whole course of the incision, so as to act upon the caries, or rough
portion; or we may use the trephine, or other remedies, which have been
formerly mentioned. It sometimes happens, that the soft parts are, at
particular portions, and often to a considerable extent, removed by
absorption, and the bone, at these parts, is left bare. In this case,
no incision is necessary, except occasionally through some bands of
granulations which extend across the bare bone; and, therefore, we can
at once apply our remedies to the bone, or make perforation with the
trephine.

The second species requires to be treated differently, according to its
varieties.

As the incipient stage of the first variety frequently consists of only
one short paroxysm, it would often be unnecessary to have recourse to
any peculiar treatment; but, as it is impossible, a priori, to say
whether the state of evacuation is to continue, it is requisite, in
every instance, to vary our treatment, and apply the proper remedies
for the disease.

Poultices are frequently useful in this kind of ulcer, when the
surface is dark coloured, and the integuments are not yet affected.
They have sometimes an effect of checking the morbid state, if this
be not already done; but they more generally promote the absorption
of the morbid granulations, after which the surface becomes healthy.
If, however, the action be still greater, and more permanent, then the
ulcer is tending toward the confirmed, or perfect state of overaction,
and poultices are not of equal service; they are even sometimes hurtful.

Gentle pressure, accompanied with the use of cold water, is of service
in the same cases in which poultices are employed; that is to say, when
the action has not become perfect, but has rather begun to subside, and
the granulations remain dark coloured, and in a dying state. They are
absorbed, and replaced with more perfect and healthy granulations.

When, however, the action still continues in the same state of
overacting, or seems to be increasing, these remedies are rather
hurtful; and we will derive more benefit from using applications
of a gentle stimulating nature, which restore the action to a more
perfect and natural state, in the same way as they cure the inflammatio
debilis. For this purpose, one of the best applications is the
following:

    R. Opii drachmas duas.
       Camphoræ scrupulum.
       Vini Albi uncias quatuor. Macera per triduum, dein cola.

This may be applied by means or a bit of lint to the sore. It generally
produces considerable smarting for a few minute, after which the pain
abates. The application is to be repeated every hour, or every two
hours, until the sore begins to look healthy, and the pain abates. The
adhesive plaster ought then to be substituted in its place.

Laudanum may also be employed with the same intention, but it is
inferior to the other.

Lemon juice is also sometimes useful, and may be employed where the
opiated wine fails, or is not at hand.

When the state of overaction becomes confirmed, and progressive, the
sore spreads, becomes very painful, and assumes the appearances which
have been already described. In this case, the application of carrot,
or turnip poultices, is frequently useful. These vegetables are
sometimes made into a poultice by boiling them, and, at other times, by
rasping them down raw.

Camomile flowers, boiled in milk, and then expressed, yield a
decoction, which, when made into a poultice with crumb of bread,
frequently abates the pain. Sometimes the application of cloths, dipped
in fine oil, give relief.

These sores are also frequently reduced to a more healthy state, by
applying cloths dipped in the following mixture:

    R. Ammon. Hepatizatæ[63] guttas decem.
       Aq. Font. uncias octo.

[63] The ammonia hepatizata is prepared by passing a stream of hepatic
gas through the aqua ammoniæ.

This produces a moderate degree of smarting for a little time, during
which the former painful sensation arising from the sore lessens, and
does not return for some time. When the peculiar pain of the ulcer
again manifests itself, the solution is again to be applied.

An ointment, consisting of two drachms of powdered opium, and one ounce
of simple cerate, is also a very useful application.

Sprinkling the sore with red precipitate, or touching the surface with
caustic, frequently stops the disease.

The kind of erythematous affection, which frequently affects the
surrounding skin, is best removed by stimulating applications, which
abate the pain or hot sensation, and make it less apt to ulcerate. The
following is a very useful application for this purpose. The affected
part is to be lightly dusted with it occasionally:

    R. Hyd. Precip. Rub. unc. i.
       Pulv. Opii semiunc.
       Cretæ Ppt. unc. ii. Tere simul ut fiat pulvis subtiliss.

When, by any of these applications, the state of overaction is
overcome, pressure is the best remedy for preserving our ground, and
producing a cure; for, remedies which may be useful in the diseased
state, will be hurtful when this state is removed.

In this sore, anodynes are to be freely employed internally; for, given
sparingly, they do no good[64].

All the applications ought to be made gently, and lightly; because any
mechanical irritation increases the disease.

[64] No external application whatever will produce the same good
effect, if used by itself, as when such a general action is induced as
shall co-operate with the local remedies. In slight cases, thirty drops
of laudanum may be given twice a-day; but, when the overaction is more
violent, the dose must be more frequently repeated.

The second variety of this species is a very troublesome ulcer, and
admits, as has been already observed, of two divisions: First, it
not unfrequently happens, that, after an indolent ulcer has been in
a healing state for some time, a state of overaction is induced, by
fatigue, or other causes, particularly by the natural inability of
the newly formed, and not completely perfect granulations, to sustain
the action which is necessarily induced in them by their connection
with other parts (upon the principle of the communication of action).
In this case, the sore becomes foul, dark coloured, and painful,
whilst the cicatrix ulcerates, and the new granulations die, so
that, in a short time, the ulcer regains its original size, and even
spreads slowly to a greater extent. Second, an old ulcer may, without
having been previously in a healing state, become converted into the
overacting ulcer; because the surface has its power so weakened, that
common agents, which naturally excite action in the part, excite a
disproportioned and morbid action in the ulcer; but this action is
of the low kind, and bears somewhat the same relation to the first
species, (or overacting ulcerative action, in ulcers previously
healthy,) that the inflammatio debilis does to the inflammatio valida.
In this case, the surface is bloody, and the half-formed granulations
are of a livid colour; the callus edges are of a dusky red, or modena
colour; the integuments are generally mottled; the inferior part of the
limb is cold and painful.

In the cure of the first division, we must enjoin rest, as in the
second variety of the first species, and apply cloths, dipped in a
mixture of two parts of laudanum and one of camphorated spirit of
wine, which produces at first considerable smarting; but the sensation
is different from the former pain; and, although uneasy, is yet more
tolerable than the peculiar pain of the ulcer. This application ought
to be renewed two or three times in the course of the day, until the
surface becomes of a better appearance, and the pain abates.

The application of the powder of bark to these sores is sometimes, but
very seldom, of service[65].

[65] This was probably recommended on account of the sphacelated
appearance which these sores sometimes have.

A poultice, formed of decoction of camomile flowers, opium, and
charcoal[66], is frequently of use, and should be employed when the
laudanum and camphorated spirit fail. This should be applied cold.

[66] Let two ounces of camomile flowers be boiled in three pounds of
water down to two. When this is cold, it ought to be strained, and
half a drachm of opium diffused in a pound of the decoction. Of this,
a sufficient quantity is to be added to powdered charcoal, in order to
form a poultice.

In the second division, the fermenting poultice[67] is often of
service; but it must, like all other applications, be continued no
longer than the state which it was intended to remove remains. If
we continue it too long, we do hurt; for, if it be kept on when it
produces continued pain, it induces a state of overaction, similar to
that which it was intended to destroy. Whenever the surface becomes
redder, and the pain less, it may be useful to employ some other
application, such as laudanum, &c.

[67] The fermenting poultice is made by adding a spoonful of yest to
an oatmeal poultice, and placing it before the fire until it begins to
emit air, or rise up in a bubbling way. It is then fit for applying to
the sore.

The same observations apply to the use of the gastric juice. Cloths
dipped in this sometimes make the overacting surface slough off,
and leave the parts below more healthy. The same may be said of the
expressed juice of sorrel.

Lime water sometimes operates in the same way.

Red precipitate, mixed with its weight of powdered opium, and half its
weight of camphor, may be usefully sprinkled over the surface.

A pound of the recent leaves of hemlock, boiled for half an hour in
two pounds of milk, and then expressed, forms an application which
sometimes abates the pain, and renders the action more healthy. The
juice is to be made into a poultice with crumb of bread.

Decoction of the walnut tree leaves, applied by means of pledgets of
linen, or made into a poultice with bran, is occasionally of service.

When, by any of these applications, the morbid state of the ulcer is
removed, it is to be dressed according to the genus into which it is
then converted.

After these remarks, the treatment of this genus of ulcers may be
comprised in the following observations:

First, In the first variety of the first species, or the simple
fungous ulcer, the cure is to be attempted by pressure, and gentle
stimulants, which render the action more natural, and the granulations,
in consequence, more perfect and compact.

Second, In the second variety of this species, we are to employ the
same remedies, as palliatives, or as means which may promote the
exfoliation of the bone. But, if the disease in the bone be more
extensive and tedious, we must cut down through the ulcer, and apply
caustic, or mechanical cures, such as perforation, to the caries.

Third, In the incipient stage of the first variety of the second
species, we must avoid motion, and all other such causes as tend
simply to increase action. When the disease has consisted of one
short paroxysm, which has terminated, we must promote the absorption
of the diseased granulations, and the process of replacing them with
others which are more perfect, which is effected by such remedies as
render the action which forms them more natural. This is best done
by gentle pressure, and sometimes by poultices. If, however, the
paroxysm continue longer, but in a moderate degree, we must use such
applications as tend more directly to change the action, and diminish
the morbid condition; such as camphorated and opiated preparations, and
sometimes the vegetable acids.

Fourth, When this state becomes confirmed and progressive, the action
being violent, we must use remedies nearly similar to those which are
employed in the last case, and which are useful in the cure of the
inflammatio debilis, at the same time that we enjoin rest, and keep
the part as easy as possible. In some instances, the action cannot
be overcome directly by any application, but is rather increased by
them. In this case, we must lay these aside, and use mild and light
applications; such as fine oil, fresh cream, &c.; at the same time that
we avoid the general causes tending to increase action; such as motion,
heat, spirits, &c.

Fifth, When this state occurs in chronic ulcers, we must use such
remedies as tend to remove the dead or dying granulations which
frequently cover the surface, and such as at the same time produce a
more natural action, and restore to the succeeding granulations greater
powers and perfection, and a more healthy mode of acting. Stimulating
applications frequently have this effect; such as the fermenting
poultice, precipitate ointment, &c.; at other times, narcotic
applications; such as cicuta, &c. are useful.

Sixth, In these ulcers, the redness and pain of the skin which
surrounds the ulcer, is to be treated as the inflammatio assuefacta, by
being dusted with the powder which has been already mentioned, or by
similar remedies.

Seventh, In all of these ulcers, where the action is violent, much
benefit will be derived from inducing the general narcotic action to a
considerable extent. Anodynes are therefore to be freely administered,
at the same time that we employ the proper local remedies.

Eighth, Whenever the ulcer becomes more healthy, and the action less
morbid, the strength of the application is to be diminished; and,
when the state of overaction is destroyed, it must be treated as the
indolent ulcer, because the granulations are still feeble. Pressure is
most useful in this case.


GENUS IV.

_Of the Inflammatory Ulcer._

It sometimes happens, that the ulcerative action becomes converted
into the inflammatory; the discharge diminishes, and sometimes ceases;
the surface is red; and the edges and surrounding skin are elevated
and inflamed. This, which has been called the phlogosis ulceris[68],
strictly speaking, does not belong to the division of ulcers, because
the ulcerative action is destroyed; but, as it is preceded, and very
quickly followed by this action, and as the solution of continuity, and
other external appearances continue, this affection may be allowed to
rank as a genus amongst ulcers, in conformity to common language.

[68] “Siccitas rubido et phlogosis ulceris facile cognoscuntur; dolore,
pruritu, calore stipantur; ca impediunt carnis excrescentiam, adeoque
indicant remedia emollientia,” &c. Sauvage Nosol. Meth. Tom. II. p. 613.

When the pain and inflammation are considerable, leeches are frequently
applied with utility in the vicinity of the sore; but it is more
generally useful to apply warm poultices, which restore the secretory
state, and the ulcerative action.


GENUS V.

_Of the Suppurating Ulcer._

This genus, like the last, accurately speaking, does not belong to the
class of ulcers; but, as it is so intimately connected with it, both
in its causes, and treatment, and appearances, it is of some practical
utility to admit the arrangement.

When an abscess is opened before the ulcerative action is induced, we
have an open suppurating sore; but this is not the sore which is meant
to be described here.

The suppurating ulcer is, when simple, and independent of any specific
action, most frequently only a high degree of the overacting ulcer;
but, as its symptoms are somewhat different, and as it nearly resembles
some specific sores, differing from these only in the absence of the
peculiar action, resulting from the application of a poison, it may be
proper to consider this as a separate genus.

When the ulcerative action is very imperfectly carried on, which often
arises from overaction, we find, that the organic particles are thrown
out, not in the form of granulations, but in a more inorganic state,
and lie upon the surface, mixed with the discharge from the other set
of vessels. This has the appearance of very thick tough pus, and the
sore which yields it may properly be considered to be in a suppurating
state. This ulcer is distinguished by the pain which attends it, by a
redness which surrounds the margin, and a hardened base, whilst the
cavity of the ulcer is filled up with a thick straw-coloured substance,
somewhat like lymph, which adheres firmly to the surface. This is
improperly called a slough.

This appearance and condition may be excited in a simple ulcer, without
any apparent application of contagion; but it is still more frequently
the consequence of some morbid matter acting on the part, and producing
specific ulceration, which will be afterwards considered. I may only
here observe, that it has, in some of these cases, been considered as
a species of gangrene, as, for instance, in the cynanche maligna; but,
whatever may take place in the advanced stages of this disease, there
is at first no gangrene, but a suppurating ulcer, which throws out
imperfect granulations, or rather a morbid purulent discharge (for the
one runs naturally into the other), which forms what is called a slough.

The treatment of this ulcer consists first in procuring a separation
of the tenacious covering, by such remedies as shall, at the same time
that they do this, make the action more healthy.

A pretty strong solution of the argentum nitratum, or l’eau
mercurielle, diluted with equal parts of distilled water, applied by
means of a brush, frequently produce the desired effect.

The acetous infusion of Cayenne pepper, applied in the same way, is
likewise useful.

Poultices made of decoction of camomile flowers, and equal parts of
charcoal and barley meal, are sometimes of service in removing the
matter, and rendering the action more truly ulcerative.

Opiates ought to be freely administered.

When this state of the sore is removed, the ulcer must be treated
according to the condition of the ulcerative action. Most frequently
it belongs first to the overacting genus, and must be treated
accordingly, and then to the genus of indolent ulcers, in which case,
pressure is to be employed as a termination to the cure.

When an overacting ulcer has, without the assistance of local
applications, ceased to overact, it not unfrequently suppurates; that
is to say, no granulations are formed, but the two sets of vessels
throw out an inorganic matter, and the surface of the sore has a
lymphatic appearance.

The best dressing for this state is dry lint, with a pledget spread
with cerate laid over it.


_Of the Effects of the Ulcerative Action on the Constitution._

The condition and qualities of an ulcer, do not, in every instance,
depend upon causes which are entirely local, but frequently are
connected with some general state, or mode of action, of the system.
General weakness must, for example, influence the performance of any
action in a particular part; and, therefore, an ulcer in those who are
infirm, and exhausted, cannot readily perform the necessary healthy
action, or proceed quickly toward a cure; nor is it easy, in these
circumstances, by any local applications, to communicate the necessary
action, and the correspondent power, which shall enable the part to
heal. In the same way, there are some people so irritable, that an
ulcer shall very readily assume the overacting state, which can only
be removed by such remedies as act on the general system. Besides those
which may be considered as simple conditions, there are many other
actions, which are peculiar and unnatural, which influence the ulcer,
or in which ulcers often appear as symptoms. These ulcers are specific,
and must be afterwards considered.

As the state of the system has a considerable influence on the
condition of an ulcer, so also has the state of the ulcerative action
an effect on the constitution. A healthy ulcer, unless very extensive,
has little effect on the system; but, unhealthy ulcers, or those which
are very large, although the action may be sufficiently perfect,
produce a greater or less degree of the general diseased formative
action, or what is called hectic.

From the principles which have already been laid down, it may easily
be understood how an unhealthy ulcer should induce hectic. When
considering the doctrine of suppuration, the effects of this on the
constitution, or the production of a general diseased formative action
were attended to. It was also mentioned, when considering ulceration,
that the ulcerative action had a tendency to produce similar effects;
and this it does, with a certainty proportioned, cæteris paribus, to
the unhealthy condition of the action, or its approximation to the
suppurative action; for the less perfect that the ulcerative action is,
the more nearly does it resemble the suppurative one.

Healthy ulcers, if very extensive, produce likewise considerable
effects on the constitution. This is chiefly perhaps owing to the
purulent action, which makes a part of the ulcerative one; for this
morbid local secretory action induces a general change, in the same
way as other acute changes, of either the formative action itself,
or any other intimately connected with it, such as the interstitial.
But, besides this cause, the granulating action, although healthy,
co-operates with the diseased interstitial action, or the purulent
part of the ulcerative action; because, although the granulations, or
organic particles, be healthy, yet they are formed in an unnatural
situation, and with greater rapidity, and in greater numbers, in a
given time, than naturally they ought to be; and, therefore, the
action of the part requires greater power for its continuance than is
possessed. There is consequently, then, weakness produced, which, by
association, affects the system, and co-operates with the diseased
formative action, increasing the general disease. The consequence of
this state, likewise, is, that the ulcer comes, after some time, to
be rendered unhealthy, owing to the deficiency of power to support
the necessary action; in which case, the granulating action comes to
be also diseased, and co-operates still more with the former morbid
condition of the interstitial vessels, or the purulent action, which,
although a part of a healthy ulcerative action, is yet itself a morbid
secretion, and an unnatural action.

The effects of the ulcerative action on the constitution, are to be
alleviated by good diet, free air, and the other remedies which have
been pointed out when formerly considering hectic, to which I now
refer. I shall only observe, that some of these remedies are employed
occasionally with little judgment, and when they are not indicated. It
is, for instance, a common practice with some, to prescribe the bark
for the cure of every ulcer, whether the constitution be affected or
not. But, from many trials, I am confident that it is of very little
service, unless when a general disease, whether it be called weakness
or hectic, exists.

When the proper remedies for the cure of hectic, conjoined with
necessary local applications, fail, the diseased part must be removed;
but, before doing so, it is, in every instance, proper to form a pea
issue, in order still to keep up a secretory action, the good effects
of which have been already noticed.

The restlessness, and febrile symptoms, which are sometimes produced by
painful sores, are best relieved by anodynes.


_Of the Cure of the Inflammatio Debilis, and the Treatment of
Mortification._

The causes and nature of mortification having been already explained,
I shall now consider the means of prevention, and the method of cure.
The remedies necessary for procuring the resolution, or suppuration of
the inflammatio valida, having been formerly enumerated, it will be
unnecessary here to make any repetition, or to say more than that we
are to prevent mortification by endeavouring to induce one or other of
the other terminations, and that the remedies which do so are to be
employed with a promptitude and assiduity proportioned to the greatness
of the action compared to the powers of the part; and, therefore, that
in the intestines, &c. we must pursue our course speedily, if we
expect to prevent gangrene.

Mortification, however, is still more apt to succeed the inflammatio
debilis, or inflammation of weakened parts; and, therefore, the
treatment of this will now more naturally come to be considered, as
forming a part of the prophylaxis of mortification, than in any other
place.

The most frequent instance which we have of the inflammatio debilis,
is the inflammation of parts which have been previously benumbed with
cold; but it may also be produced by the action of any of the common
exciting causes of inflammation, in weak and reduced habits, or by
bruises in sound parts, &c.

When a part has been exposed to much cold, it may inflame, from two
causes: First, the communication of action; secondly, the application
of subsequent stimulants, more especially heat. Both of these tend to
excite an action in the part, which is greater than its power would
naturally perform, and, therefore, it becomes diseased, or inflammation
is produced, and the little energy which did remain is soon destroyed.
The operation of the first cause is prevented by lessening the action
of the surrounding parts, by the application of moderate cold, whilst
we avoid motion, and whatever may tend to act directly on the part,
and co-operate with this cause. The operation of the second cause is
prevented by keeping away every agent which will tend to excite action,
or at least those which tend to do so suddenly. In the generality of
cases, it is perhaps most proper at first to do nothing; because,
whatever we apply, tends to excite a greater action than can be
sustained; we ought, therefore, to delay any remedy until the part
has begun to recover itself, and the action and corresponding power
has begun naturally to increase; we may then interfere, by applying
such remedies as increase the action, which are perhaps now more
useful, by preserving the ground which is gained, than by increasing
still farther the action. Of this kind is heat, which must, upon this
principle, be applied with great caution, and must, in its degree, be
nicely adjusted to the existing state of action. When a part, then, is
benumbed with cold, we ought at first to apply a degree of heat, very
little above that which the parts were formerly exposed to, which, in
one sense, may be said to be doing nothing; for this step is intended
merely to prevent farther injury. When this is continued for a short
time, we may suppose that the part has begun to act a little more in
a natural way, which is attended, as was formerly explained[69], with
a correspondent increase of injury. We then increase the heat, but
very slowly, and taking a long time to bring the part near its natural
temperature, being regulated by the progress which the part itself is
making; for the application of heat may be considered in two points of
view, in this case; first, as the removal of the injuring cause; and,
secondly, as a stimulus to action. If, then, the part do not recover
itself, in proportion to the removal of the hurtful cause, but remain
stationary, it is evident that a farther removal is at present useless,
and the stimulus which is consequently given is highly dangerous. By
these means, then, we proceed slowly toward recovery, and keep up the
ground which we have gained.

[69] See the preliminary dissertation.

If, however, the action of the part have been sunk very low, then
recovery is impossible, there being little or no energy, and so little
action, that it cannot increase itself toward the natural state. In
this case, our endeavours must fail, and will even kill the part sooner
than if we had let it alone; for the least increase of action destroys
the life of the part, which may, in this case, be compared to a dying
taper, which gives one brighter flash before it becomes for ever
extinguished.

If, on the other hand, the action have not originally been sunk so low
as to make the process toward death continue progressively, but the
remedies have been applied too quickly, or, from any cause, have failed
to produce this effect, then the action becomes inflammatory. The pain
becomes of a burning kind, there is a feeling of pulsation, and the
part becomes redder, or livid, whereas, before, it was bluish; from the
stagnation of the blood, there was no feeling of pulsation, or arterial
motion, and the sensation was that of a painful cold and weight. The
inflammatio debilis is now induced, and the danger is great, but still
there is a possibility of recovery, which is exactly in proportion to
the degree of previous diminution of action, and to the rapidity with
which the subsequent inflammatory action was induced, and the degree to
which it is raised; or, in other words, the danger is proportioned to
the disparity betwixt the action and the power.

The remedies for this disease are such as tend to induce an action
similar to the natural one, by which we remove the diseased one; for
we know of none which excite the natural action directly, otherwise
they would be of universal utility, and would, in the present instance,
be preferred to every other. The remedies which we employ with this
intention, are bark, opium, &c. internally, and vinous, or spiritous
applications externally. These, however, would be pernicious, were
there no inflammation present, because they would, by exciting action,
tend to induce this; but, when, the inflammatory action is once
induced, then, as they excite one more nearly resembling the natural
one, they are useful; for, on the one hand, they destroy the morbid
one, and, on the other, increase the power of recovery; but, for this
purpose, internal medicines, and good diet, must be given, as a source
whence the energy is to be renewed, by the renewal of the natural
action. Heat is of the most pernicious tendency in this complaint;
because it simply increases the exciting action, and, therefore,
makes the inflammatory action still more violent. The applications,
therefore, ought to be cold, as long as the morbid action continues;
but, when it is abating, and recovery is going forward, they may be
made a little warmer, as they will thus accelerate the healing process
which is taking place; but this requires much prudence.

Spirit of wine is one of the best applications in this disease, and is
one very generally employed. Camphor is frequently added to it, and
appears to increase its efficacy. Pledgets dipped in camphorated spirit
of wine, and applied to the part, will, if frequently renewed, in many
cases, remove the inflammation, and prevent gangrene; but, in every
instance, it at least relieves the pain, which uniformly returns, if,
when the inflammation is violent, we omit the application, or use a
weaker spirit, such as the proof spirit.

Essential oils, particularly that of turpentine, which is easiest
procured, are also useful, but are inferior to the alcohol.

Laudanum, in slight cases, is useful as a topical application; but,
if the inflammation be more severe, it must be mixed with rectified
spirit. A very useful application may be prepared by adding two ounces
of laudanum to a pound of the spt. vin. camph. of the pharmacopœia.

Internally, the bark must be exhibited in full doses, with such a
quantity of wine as the feebleness of the pulse points out; but we
must be prudent in this respect, because, if we give too much, we may
increase the local disease. As long as it does not increase the pain,
or quicken the pulse, it is to be considered as useful.

Opiates are extremely necessary in the inflammatio debilis, and, in
general, require to be given freely.

Soups, and other articles of nourishing diet, are absolutely requisite,
and ought to be given in small quantities at a time, but frequently
repeated.

By these means, we may frequently resolve the inflammation completely;
but, at other times, when we have gained a certain ground, the
inflammation terminates in the suppurative action; or, in other words,
when the parts have gained more strength, and the action has come more
nearly to resemble the inflammatio valida, which has continued for some
time, a similar termination takes place. This event cannot, perhaps,
in these cases, be prevented, and, although it may occasionally
protract the cure, yet it diminishes the danger, making mortification
less to be dreaded. The best treatment, in these cases, perhaps, is
to continue our usual applications, avoiding warm poultices until the
action be fully formed; then moderate heat may accelerate the progress
of the abscess toward the surface. The same internal medicines must be
exhibited, the anodynes, however, being gradually diminished as the
pain (which marks the necessity for their use) abates.

It too frequently, however, happens, that either our remedies fail,
or the proper ones are not assiduously and judiciously employed, in
which case mortification takes place. This requires the same treatment,
in whatever way it is induced, only its progress is, from certain
causes, more rapid[70] in one case than in another, and, therefore,
requires the more free use of the appropriate remedies; but the
general principle is, in every case, the same, and, therefore, I shall
here consider the disease indiscriminately, whether it succeeds the
inflammatio valida, or debilis; because, in both instances, the case
is exactly the same, only, in the first, the weakness which induces
mortification, is produced by the inflammation alone, whereas, in
the second, it existed to a great degree before the inflammation was
excited.

[70] It is more rapid in the inflammatio debilis than in the
inflammatio valida, and in very delicate parts than in parts which are
less so.

Mortification is to be prevented from succeeding the inflammatio
valida, by timely bleeding, and the use of the agentes dissimiles, by
which we procure resolution, or at least make the induction of the
purulent action more easy. In the inflammatio debilis, it is to be
prevented by remedies of an opposite nature.

When, however, these remedies fail, and mortification does take place,
our great object must be to prevent it from extending far, and from
injuring the system. These intentions are answered by the same remedies
which cure the inflammatio debilis; because the local treatment of
mortification is merely that of the inflammatio debilis; for it is
only the parts which are still alive, or inflamed, which can be acted
on by our remedies.

The remedies are either general or topical, and may be considered under
these divisions; but both must be used at the same time.

Many of the older writers, proceeding upon the humoural theories,
began their treatment of gangrene by bleeding and purging, after which
they prescribed theriaca, and other stimulating applications. Some
modern authors still adhere, in part, to this practice, and consider
the loss of blood to be advantageous in cases of incipient gangrene.
Mr. Bell, who is one of the latest writers on this subject, informs
us, that, when the “general symptoms of inflammation, particularly a
quick, full, or hard pulse, still continue violent, and especially
when the patient is young and plethoric, it then becomes absolutely
necessary, even although mortification may have commenced, to empty
the vessels a little by one general blood-letting,” which, “in such
cases, may in reality be considered as an antiseptic; and it does often
indeed, in this particular situation of mortification, prove more
powerfully so, than all the different articles in general enumerated
as such.” If, however, we consider the nature of mortification, and
the circumstances under which it is most likely to occur, we must
look upon this practice as dangerous, and must be permitted to doubt
whether the full hard pulse is to be met with after the commencement of
inflammation, or whether the symptoms of the inflammatio valida, (in
which alone bleeding is admissible) still continue violent, after one
portion of the inflamed part is evidently gangrenous. Is it reasonable
to suppose that one portion of the inflamed part shall be already dead,
or dying, and that yet the rest shall not have begun to suffer? or
that the action shall not have become converted into the inflammatio
debilis, (if it were not originally this)? This surely is not the time
for bleeding, purging, and debilitating remedies; but the part must be
considered as possessing the low inflammatory action, and the patient
as requiring suitable remedies. It may indeed be said by some, in
favour of bleeding, that the bark, in some instances, does not check
the progress of the disease; but it surely does not thence follow, that
it does positive injury, and that remedies of an opposite nature are
useful.

The Peruvian bark is, in many cases, one of the most useful internal
remedies. It was originally introduced into medicine, about one hundred
and fifty years ago, as a cure for intermittent fever; and its utility
in gangrene is said to have been discovered by its curing this disease
in a person who had it combined with ague, and who was taking the bark
on account of the latter complaint. For many years after it was known
in Europe, great prejudices prevailed amongst physicians against its
use, partly on account of its having been improperly administered, but
still more because it was so unfortunate as to cure diseases without
necessarily either sweating or purging the patient, a fact which could
be only ill explained, or rather scarcely allowed to be possible, by
the prevailing theories of physic. Accordingly, although the cases in
which it had been successful were by no means a secret, and although
severals had the courage to employ it, in spite of all speculative
arguments, yet neither Dr. Boerrhave, nor his commentator, Van Swieten,
thought it expedient either to recommend or prescribe it. Renewing the
motion of the stagnating blood by venesection, and the exhibition of
trifling remedies, which could scarcely be called cordial, although
sometimes dignified with that epithet, together with the external
application of ardent spirits, or oil of turpentine, constituted the
current practice in gangrene. These prejudices against the bark, which
originated in ignorance, and were supported by attention to a foolish
theory, continued long; but the want of a better remedy began at last
to make them gradually give way, and the success of empyrics who used
the bark soon completed their downfal.

The bark induces an action nearly similar to the natural one, which is
greatly injured, and, therefore, it gives a check to the progress of
the disease; but, if its operation be not assisted by nourishment, &c.
its good effects soon subside, because the materials whence new energy
can be drawn are withheld, and, therefore, the system cannot profit so
much by the establishment of the new action, and by the restoration
of the power of converting the vital principle of foreign matter into
nervous energy. The bark, then, is of service in two points of view:
First, it changes directly the action of the system, it induces, in
a considerable degree, an action somewhat similar to the natural
action, and, therefore, counteracts the general action of descent
which was taking place. Secondly, by inducing this action, it, to a
certain degree, produces the same effects for a time which would have
been produced by the natural action itself, or increases the power
of renewing vitality; for, in the preliminary dissertation, it was
mentioned, that the production of energy was exactly proportioned to
the perfection and healthiness of the existing action. The good effects
of bark, then, cannot be obtained without nourishment and free air.

It uniformly happens, however, that, in many instances, where the
action of the bark would be most beneficial, it is impossible to induce
it, owing to several causes, but particularly to its effect on the
stomach; for, in many instances, it produces sickness, or nausea, in
which case it can do no good, and ought to be abandoned. Momentary
sickness, after taking a dose of bark, is indeed a very general effect,
and does not materially injure its operation; but, whenever it is
either frequently vomited, or produces a sickness of considerable
duration, it must either be given in smaller quantities, or in a
different form, or at longer intervals; or if all of these fail, it
must be laid aside completely, because it not only cannot produce its
specific effect, but will even injure the remaining powers by its
effect upon the stomach.

The best form in which bark can be prescribed is that of powder, which
is more effectual than any tincture, or the extracts. This ought to
be exhibited in as great quantity as the stomach will bear, which
cannot be reduced to any certain scale. In general, an adult ought, if
possible, to take half a drachm, or two scruples, every forty minutes,
in the most palatable vehicle; for much depends upon the taste, owing
to the sympathy betwixt the mouth and the stomach; and, for this
reason, the same vehicle ought seldom to be used more than twice in
immediate succession; because, by changing the vehicle, we not only
change the taste, which has a tendency to prevent loathing, but also
modify the immediate action on the stomach, changing, to a certain
degree, the former impression, which was perhaps beginning to produce
sickness. Lemon juice and water, the different kinds of wines, punch,
pimento, cinnamon, and peppermint waters, milk, rose water, beer, &c.
afford us a variation which may be usefully employed.

The tincture and watery infusion of the bark, either separately or
mixed together, are frequently employed, when the powder is vomited;
but, as they must be given in very considerable quantities, in order to
produce any good effect, they are very apt to produce sickness, and
are likewise so inferior in power to the powder, that they are very
little to be trusted.

The extract with resin, is a better form than the tincture, or
infusion; and, where the powder is rejected, may be made into pills.

When the stomach rejects every form and preparation, it has been
proposed to give the bark in clysters, and this ought certainly to be
done rather than lose the effects of the remedy; but, given in this
way, its effects are more uncertain. From two drachms to half an ounce
of the powder of bark, may be diffused in three ounces of soup, or
mucilage, with fifteen or twenty drops of laudanum, and given as an
enema. This must be repeated at least every hour and a half, or two
hours, until the stomach can retain the medicine.

The wine is very usefully conjoined with the bark, and is even of
considerable use by itself, when the bark is rejected. Its operation is
more speedy than that of the bark, but it is perhaps more fugacious.
The quantity which is necessary to be given depends upon the effect of
the local disease upon the system, and on the inability to bear other
remedies. A table spoonful may be given in general every quarter of an
hour, unless it increase the pain, and frequency of pulse, and produce
restlessness, and heat of the skin. In these circumstances, we may be
certain that we have increased the quantity beyond the necessity[71].

[71] The necessity for this, and other remedies, is in general
proportioned to the continuance of the disease, and the progress which
it has made. In this, as in every other disease, we must be attentive
to the effects of our remedies, and consider these in forming our
opinion.

Opium is likewise an useful remedy in this disease, and ought never
to be omitted; because it not only diminishes the irritability, and,
consequently, the pain, but likewise, like the wine and the bark,
counteracts, by the induction of its peculiar action, the progress
of the inflammatio debilis, and, consequently, tends to check the
mortification. This medicine is most usefully exhibited in full doses,
which not only procure ease, but also frequently make the stomach more
readily bear other remedies. One grain of the extract, or twenty-five
drops of the tincture, may be given at once, and the dose repeated
whenever the action of the former subsides. After some time, each dose
must be increased one half, and presently doubled, in order to produce
the same effect as it did at first.

These remedies may give a temporary check to the disease; but, unless
nourishment be conjoined, in every possible form, they will not of
themselves be able to effect a cure, if the disease be tedious. Soups,
jellies, milk, sago, &c. must be assiduously given in small quantities,
and even thrown up as clysters, if the stomach cannot bear them.

Vegetable acids, fixed air, wort, &c. have been recommended in this
disease, probably upon the supposition of the existence of a putrescent
matter, or from their utility in scurvy. Wort, however, and fixed air,
do not appear to be of very great benefit in this disease, at least
they are by no means to be put in competition with other remedies of
more approved efficacy, or allowed to interfere with their exhibition.
The acid of lemons seems to be more generally useful than the carbonic
acid; and, perhaps, the nitrous acid would be equally useful with the
citric acid. These acids do not operate by counteracting putrefaction,
but by counteracting the action of descent, inducing a more healthy
action, and tending to excite ulceration, which is the mean employed
for separating the dead part, and producing restoration. For this
purpose, however, the acids must be given freely, otherwise no good is
done.

The local treatment is to be conducted on the same principle as in
the cure of the inflammatio debilis. Pledgets, dipped in the oil of
turpentine, tincture of myrrh, or rather in camphorated spirit of wine,
which is one of the best applications which can be used, ought to be
made use of.

These remedies can do little service when applied to the dead portion;
but, as the whole part does not die at once, there are always some
portions which are still in the inflamed state, and on which they act.
They likewise prevent the progress of the disease, by operating on
the skin which is contiguous to the gangrene. Every mortification, in
general, attacks the skin first; or, in other words, the inflammatio
debilis spreads faster along the skin than along the deeper parts; but,
when once the skin is inflamed, and mortifies, the disease extends to
a greater or less depth below the surface. Whatever, then, operates on
the surface, and prevents the progress of the inflammation, or cures
the part which is already inflamed, will tend to check the extension
of the disease, especially if the proper internal remedies be made use
of with a view to prevent the extension of the action of descent.

Formerly, in order to allow these remedies to come in contact with
the living parts, it was customary to make incisions through the dead
portion, and not unfrequently through part of the living substance.
But, as these cannot prevent the extension of the disease over a
greater surface, and, as the irritation which is given, and the
exposure of parts which have not yet assumed the ulcerative action,
tend to increase the inflammatio debilis, the practice must be
considered as improper[72]. It is now indeed almost universally laid
aside, owing, in a great measure, to the observations of the ingenious
Mr. Pott.

[72] The hot, and almost boiling oils, which were poured into these
incisions, contributed not a little to increase the disease.

Antiseptics, such as decoction of camomile flowers, &c. have been
recommended as external applications; but, whatever effects they may
have on the matter which is already dead, it is evident that they can
be of no service in preserving the living parts from suffering death.
All that can be expected from them is to check the putrefaction of
the dead substance, which they have very little power to do; and,
therefore, they can never come into competition with more valuable
remedies, such as the camphorated spirit of wine, &c.

When, by the use of the remedies already mentioned, the progress of
the gangrene is stopped, the ulcerative action is induced in the part
immediately adjoining to the dead portion, and a red line of separation
appears. By means of this ulcerative action, which takes place in
every point where the mortification stops, the dead part is separated
from the living, and comes away as soon as the bonds of dead muscular
fibres, tendons, &c. which unite them, are destroyed by putrefaction.
When this separation takes place, or when it is advanced so far as
to permit us to accelerate it by dividing the loose tendons, &c. the
exposed part must be dressed as an ulcer, or wrapped up in a poultice
of the same temperature with the human body.

If, however, the disease have penetrated deep, and destroyed the limb
so much as to render it impossible to cure it, or useless, if it were
possible, then amputation must be performed; but this, whatever desire
the patient may express, must not be practised until the mortification
be fully stopped, and the ulcerative action induced; because, if
performed sooner, the mortification seizes the stump, and the patient
is quickly killed. The system is likewise in such a state as to be
unable to sustain the action which is necessarily produced by the
operation. It is even improper to cut too near the diseased portion;
because the parts here, although the mortification be stopped, are so
weakened, that they are less apt to unite. The vessels often break out
soon after they are tied, and a new mortification is by no means an
unlikely occurrence. Even when the amputation is performed pretty far
up the limb, the corners of the stump frequently mortify, or become
livid; but a few doses of bark and wine stop the progress of the
disease.

Although it is a general rule that amputation is necessary whenever the
member is so destroyed as to become useless, and although this must
not be performed until the ulcerative action be induced, yet it must
not invariably be performed whenever this action takes place, because
sometimes at this period the patient is unable to sustain the general
action which the operation would produce. We must, therefore, if the
patient be much reduced by the extent, or long continuance of the
disease, rather delay until, by good diet, wine, &c. we have procured
an increase of strength; but, if we find that either the patient loses
ground, or his weakness remains stationary under this treatment, we
must then amputate; because, it is probable, that the continuance of
the dead portion in contact with the living is tending to induce still
the general action of descent[73].

[73] As an illustration of this rule, I may mention the following
case: A man, during a voyage to a cold climate, had both his feet
frost-bit, in consequence of which mortification ensued. In this state
he continued for two or three weeks, during which he received very
little medical aid. When I saw him, both his feet were mortified,
from the toes to about three inches above the ankle joints, his pulse
was feeble, very frequent, and intermittent, the strength was greatly
impaired, and the countenance sunk and ghastly. The ulcerative action
had been induced for some time, but the want of wine and proper diet
had prevented the system from gaining by the cessation of the local
disease. He began the use of the bark, opium, wine, and soups, which he
took very liberally, in consequence of which his pulse became slower,
and his strength increased. In two days, one of the ankle joints was
removed by clipping through the tendons, and, in a few days more, the
other came away. Amputation was now performed below the knee of the
right leg, the constitution, instead of gaining, rather beginning to
lose ground. The subsequent affection of the system was by no means
great, and, in about a week, he was much stronger; but, as the bones of
the ankle joint of the other leg were carious, he again began to sink.
Amputation was therefore performed on the left side, in about three
weeks after the first. During the cure, the wine, opium, and nourishing
diet, were freely prescribed.

When we do not deem it adviseable to amputate very soon after the
induction of the ulcerative action, it is sometimes useful to cut off
part of the black mortified portion, or perhaps to remove a joint, by
cutting through the remaining ligaments. In this way, we lessen the
fœtor, and make the patient more comfortable.

After making these observations on mortification, I shall conclude with
the following case:

A young woman, who lived at a considerable distance from Glasgow, was,
in May 1797, seized with erysipelas of the right foot and leg, which,
by her account, had been extremely violent, and very much neglected. On
the tenth day of the disease she was brought to town, and admitted into
the hospital. The foot was quite cold, the leg livid, and extremely
painful. Pledgets dipped in camphorated spirit of wine were applied to
the parts, and bark, wine, and opium, were prescribed, together with
oranges, &c. and gradually increased in quantity, until at last she
came to drink, besides soup, a couple of bottles of wine daily, at the
same time that she took eight grains of opium, and a very considerable
quantity of bark, in the twenty-four hours. By these means, the pulse
was soon brought down from one hundred and forty to one hundred and
eighteen strokes in the minute; but it was not until twenty days after
her admission that the ulcerative action was evidently induced. The
quantity of the medicine was now gradually diminished; and, in a few
days more, the separation being complete, the limb was amputated above
the knee. During the operation, I paid particular attention to the
saving of blood; and the circulation being destroyed in the parts below
the knee, there was scarcely any lost. At this time, she was still
taking a bottle of wine, with a considerable quantity of bark and
opium, daily. The wine was omitted after the operation; but she had a
drachm of laudanum, and continued to take the bark. In the evening the
same quantity of laudanum was repeated. Next day she was quite easy,
and had slept well; the pulse beat only one hundred in the minute. On
the third day the stump was dressed, when it was found (as was to be
expected[74]), that only a very imperfect adhesion had taken place:
One of the corners was also livid. The bark was therefore freely
continued, and six ounces of wine added daily; but the pulse having,
on the fifth day, risen to one hundred and ten, and the spot becoming
of a darker colour, she was allowed a pound of wine, which made the
pulse fall, and soon produced a separation of a small slough. In a
short time she went to the country cured. During the whole period of
the cure, the opium and wine which she took produced neither stupor,
nor the slightest appearance of intoxication. I at one time, when the
pain had for a couple of days been moderate, was willing to ascertain
the effects of a milder preparation than the camphorated spirit, and
substituted proof spirit in its place; but, in an hour, it was obliged
to be renewed, the pain having greatly increased.

[74] It is very seldom that a stump unites at first, if amputation be
performed on account of mortification; at least if the operation be
not delayed until the health and strength be fully re-established:
But this can very seldom be the case; for, in most cases, the state
of the bones, and the disease of the part itself, prevents recovery
from taking place beyond a certain degree, and also prevents us from
delaying beyond a limited time. The system, therefore, is not allowed
to recover fully from the tendency to the action of descent, and union
does not take place. In the case which was formerly mentioned, the
first stump did not adhere fully, but the second succeeded better,
because then the system suffered more from the state of the diseased
bones, &c. than from the previous mortification, and, therefore, it had
not the same inability to undergo the healing action.


_Of the Treatment of the Inflammatio Assuefacta._

After the inflammatio valida has continued for a considerable time,
if neither suppuration, nor any other termination be induced, it is
very apt to be converted into the state which has been called passive
inflammation, or which, on account of its most frequent cause, I have
called the inflammatio assuefacta. This action is, in several respects,
different from the acute inflammation, and resembles it only in its
general appearance. It may therefore, in one respect, be considered as
a termination of inflammation, being, strictly speaking, a new action,
or spurious inflammation.

This action succeeds the acute inflammation, sooner or later, in
different places; and, when once induced, each succeeding inflammation
of the same part is apt very quickly to terminate in the same
condition; or, if the renewal of the inflammation be very frequent,
this is at last induced without any previous acute inflammation.

A state somewhat similar to this, if not exactly the same, precedes
acute inflammation, as well as follows it; for, during the period
which intervenes betwixt the first formation of the action and its
perfection, the part remains in this state. We can sometimes observe
the augmentation and diminution of the redness and pain during the
systole and diastole of the arteries; and, by the use of the same
remedies which cure the inflammatio assuefacta, we can sometimes
prevent the farther progress of the disease.

Thus, pepper boiled in milk, is frequently used by the country people
as a cure for cynanche, during its incipient stage.

Bleeding, saturnine applications, and the other remedies which are
useful in the inflammatio valida et acuta, are hurtful here, and
increase the disease.

The agentes similes, on the contrary, are useful, and may be used
internally, or topically.

Internally, the bark, wine, and opium, with good diet, ought always
to be employed, if the part affected be very delicate, and sympathise
greatly with the constitution, or if the extent of the disease be great.

Locally, stimulating applications are the proper remedies; and the
strength and nature of these must depend upon the natural or acquired
delicacy of the part.

When the skin, or cellular substance, is affected with the inflammatio
assuefacta, spirit of wine by itself, or with the addition of a little
camphor, is a very useful application.

When the skin is not directly affected, but only the parts immediately
below it, as, for instance, the muscles in chronic rheumatism, or the
articulating surfaces of joints, we may sometimes, by applying cloths
dipped in laudanum, or strong diffusion of opium, propagate, from the
surface to a certain distance, the narcotic action, and alleviate
the disease; but, most frequently, we are obliged to trust entirely
to the effect of the sympathy of equilibrium, diminishing the action
of the internal parts, without any considerable change of nature, by
increasing that of the surface. Blisters and rubefacients, such as
volatile linamentol. terebrinth. cum camphora, &c. are the remedies
for this purpose.

The inflammatio assuefacta, when it affects delicate parts, covered
only with a thin skin, such as the throat, forming one of the most
frequent species of cynanche, is cured by gargling with port wine,
infusion of capsicum, and similar remedies.

When it affects the eyes, the use of stimulating and opiated
preparations have been long in use. The following is one of the best:

    R. Vini Albi uncias duas.
       Opii drachmam.
       Pulv. Gall. scrupulum. Macera per dies tres dein cola.

A drop or two of this may be let fall into the eye three times a day.

Electricity is recommended in the cure of this kind of inflammation;
but this, as well as heat, are doubtful remedies; for both seem to
increase actions without changing them, except in so far as the change
depends upon an increased degree. Cold, on the other hand, lessens the
power of recovery, if carried to any great degree; but, when slight, it
assists the operation of other remedies, by lessening the performance
of the existing action, which is morbid. All applications, therefore,
ought in general to be a little below the temperature of the part.

Whenever an inflammation does not manifest a tendency to any other
termination, but continues stationary, or perhaps becomes worse, under
the use of the remedies which we employ for the cure of the inflammatio
valida, we may consider that this action (or the inflammatio
assuefacta) has taken place, and that the nature of our applications
must be changed. Bark and wine, with anodynes, may be given internally,
whilst, if the situation of the part permit, suitable applications must
be made to it. By continuing this treatment, we frequently resolve the
inflammatio assuefacta; but, occasionally, it becomes again converted
into the true acute inflammation, in which case the continuance of
the same remedies will do hurt. The appropriate local remedies, such
as cold, saturnine preparations, &c. must be had recourse to, if the
part be external, whilst, if the pulse become hard, and more frequent,
or fuller, general remedies, such as bleeding in small quantity, may
be useful; but both local and general remedies must be used with
moderation, and pushed only a certain length, otherwise we defeat our
intention, and again speedily induce the inflammatio assuefacta, by
interfering with the powers of recovery. If this happen, we must again
have recourse to the proper remedies.




DISSERTATION III.


_On the Phagedenic, and some other Species of Specific Inflammation._

When any peculiar modification of the inflammatory action takes place,
specific inflammation is said to be produced; that is to say, the
action possesses some peculiar or specific qualities, independent
of the simple condition of inflammation; and these are generally
productive of evident and visible effects, which are characteristic
of their presence; but, until these effects, which are chiefly
observable in the appearance of the consequent ulceration, appear, it
is frequently impossible, from the symptoms of the inflammation alone,
to say that it is specific; because the evident effects, or symptoms of
the inflammatory action, such as heat, pain, redness, &c. admit of few
specific alterations, varying only in degree, and this variation taking
place often without any specific affection of the action[75].

[75] In most specific inflammations, if not in every one, the redness
is never of the bright scarlet colour, but always more or less purple,
or dusky; but this may take place without any specific action. The
sensation is also sometimes different.

The effects of the ulcerative action admit of greater variations than
those of the inflammatory, and, therefore, more readily show the
presence of specific action. The healthy ulcerative action exhibits
certain appearances which have been already described, and which are
easily known. The simple deviations which have been treated of, in
considering the different genera of ulcers, are also discoverable by
the effects, or peculiar symptoms. The specific deviations dependent
upon the presence of previous specific inflammation, or the application
of a morbid agent, after simple ulceration has been induced, may
also, in many cases, be detected and ascertained, by the variations
which take place in the aspect of the sore, the appearance of the
granulations, discharge, &c.; but these variations and appearances
consist so much in peculiar hues and qualities of the granulations,
which we have no words to convey an idea of, that it is impossible
to give an accurate description of a specific sore, but must see it
in order to obtain an idea of it. We may indeed say, that a sore is
ragged, has a fiery look, is surrounded with an erysipelatous margin,
and discharges a thin fœtid matter, but still we shall not convey the
idea of the specific appearance of the ulcer.

It is this specific appearance alone which characterises a specific
ulcer; and this, in each peculiar ulcer, is different; and a knowledge
of it can only be obtained by an attentive examination of many sores.
On this account, it is extremely difficult, in many instances, to
distinguish a specific ulcer, because the discrimination depends
altogether upon the recollection of the practitioner, and the
improvement which he has made of his former observations. It is indeed,
it may be thought, an easy matter to distinguish a simple ulcer by
negative characters, or the want of the peculiar aspect; but, as this
aspect is very arbitrary, and as the appearance of simple ulcers is,
as has been already described, very various, it is difficult to say,
without much judgment, whether the sore be simple or specific; for
the appearance of the one and of the other run imperceptibly into each
other. Even if it be ascertained to be specific, it is difficult often
to distinguish betwixt particular specific diseases, in so much, that
many are forced to take mercury for the cure of syphilis, who never had
that disease.

Besides the appearance of the sores, specific action likewise produces
a perceptible effect upon the scab which covers them, or the cicatrix
which is formed. Thus, scrophula is marked by a particular appearance
of the cicatrix, or of the scab. The venereal ulcer has likewise a
particular scab, and many cutaneous ulcers are best distinguished by
the scab. Other actions produce no considerable ulceration, but only
successive desquamation of the cuticle.

We may also sometimes discover specific action by the sensation of
which the action is productive. Thus, for instance, cancer produces a
burning kind of pain, which never attends simple ulceration.

Specific ulceration is also always surrounded with more or less simple
inflammation, or erysipelas, of the surrounding skin. In some cases the
margin is hard, in others ragged, &c.

It were much to be wished, that some more certain, and less arbitrary
criteria, than those which we possess of the presence of specific
action could be discovered; but, as yet, we know of no other which can
be applied universally. Some kinds, indeed, are so well marked, and so
peculiarly distinguished from simple sores, that they can be tolerably
well described, and easily discovered to be specific; but, there are
others which it is more difficult to ascertain, owing to the difficulty
of fixing the character of each individual action.

The number of specific inflammations is very great, and the causes
which produce them are often obscure. In the preliminary dissertation
it was mentioned, that, whenever any action existed strongly in any
one part, it tended to induce an inflammatory state. There are,
therefore, no general, or febrile diseases, which may not be attended
with peculiar inflammations. That typhus fever is attended with
local inflammatory action is pretty certain; but the presence of
specific inflammation is still more evidently seen in the different
exanthematous diseases. The diseases called cutaneous, afford us also
numerous instances of specific inflammation.

From the difficulty of discriminating betwixt diseases, which, although
essentially different from each other, yet possess a very great
similarity, we find, that the number of specific inflammations is
confined much within the true limits; for we find many confounded under
the name of herpetic, &c. which are radically different from each other.

Phagedena has been used by medical writers in a very extensive sense,
and has been made to comprehend diseases, which, strictly speaking,
cannot be considered phagedenic.

The phagedena is a suppurating sore, dependent upon the application
of a peculiar contagion. No granulations are formed, but both sets
of vessels yield a thin fluid. The surface of the sore has a jagged
appearance, dependent upon the irregularity of the absorption, and
not upon the deposition of organic particles, or granulations. The
colour of the surface is dark, but clear, or fiery. The surrounding
integuments are erysipelatous. The discharge is thin and serous, and
the pain considerable. This is divisible into two varieties: First, the
true phagedenic, which does not go deeper than the skin, but spreads
rapidly along the surface. This kind frequently stops in its progress
suddenly, and skins over as fast as it spread. Second, the noma, or
penetrating phagedena, which extends deeply, penetrating sometimes
perpendicularly down through the cellular substance to the muscular
fascia; at other times, proceeding more irregularly, penetrating
deeper at one part than another, and having its margins ending less
abruptly in the neighbouring skin. This never cicatrizes rapidly; but,
sometimes, when the sore assumes a healing appearance, it suddenly
becomes again diseased, and a considerable portion sloughs off. The
alternation of proceeding a certain length in the cure, and relapsing,
is frequently repeated, and often renders the disease very tedious.

The best application for the common phagedena is an ointment consisting
of an ounce of ung. resinos. and a drachm of red precipitate.

The application of caustic to the surface also frequently stops the
progress of the disease.

The hepatized ammonia, much diluted, is also very useful as a lotion.

The penetrating phagedena is more difficult to cure; for, even after
the diseased action is removed, the ulcer remains in an irritable,
or overacting date. The application which I have found most useful is
powdered opium, mixed with simple ointment, in the proportion of two
drachms of the former to an ounce of the latter. After the phagedenic
action ceases, the sore must be treated according to the genus of
simple ulcer to which it belongs.

When the sores seem to pursue their ravages obstinately, the most
effectual mean of stopping their progress (until we discover a specific
remedy, or one which can change the nature of the action), is to apply
the caustic to every part, and so freely, as to produce a pretty thick
slough. Whenever this appears to separate, precipitate must be applied,
in order, if possible, to prevent the recurrence of the diseased
action.

When any considerable vessel is eroded, by the continuance of this
disease, it must be tied beyond the diseased part; but we must be
careful that no matter from the sore gets upon the wound, otherwise it
will become diseased also. I have a preparation, in which a part of
the femoral artery was opened at the groin by this kind of sore, which
succeeded a venereal bubo. No operation, I understand, was attempted,
but compression alone used. The man died in a short time. Whether tying
the iliac artery, by cutting through Poupart’s ligament, would have
saved him, is difficult to say.

The true phagedena seems always to confine its action to a particular
spot[76]; but many of these diseases, which have been described under
the same name, appear to be capable of inducing a general action,
similar to the venereal disease, affecting different parts of the body
in succession. A case of this kind is related by Mr. Adams, in his
Observations on Morbid Poisons: A gentleman who had a small pustule on
the prepuce, squeezed it so as to make it burst, and soon afterwards
had connection with a woman whom he had long known. The sore remaining
without healing, he applied a solution of caustic, and had recourse to
mercurial frictions. But, notwithstanding these, the ulcer spread, and
soon reached the scrotum. The mercury was now laid aside, and bark,
with a good diet, were substituted, after which the ulcer put on a
healing appearance; but, before cicatrization took place, a feverish
fit supervened, with violent pain in the part. In the course of a
short time, however, the unfavourable symptoms disappeared, and a
healthy condition was again apparently induced. These paroxysms of
fever, and subsequent amendment, alternated with each other for a
considerable time, and each relapse was preceded by a livid appearance
round the sore. These appearances at last went off, and the sore
assumed more the aspect of the true phagedena. The cicatrizing process
now began at the upper part, and proceeded rapidly until almost the
whole sore was covered. But, nearly about this time, copper coloured
spots appeared on the hands, and the inside of the right thigh; and,
in a day or two afterwards, an ulcer appeared in the throat, with
“bumps” on the head. Shortly afterwards a node appeared on the tibia,
and the patient became bandy. The blotches speedily began to ulcerate,
and another appeared on the sternum. Mercury was now given freely,
and at first with apparent success, for the ulcers looked better,
and no new affection appeared; but, whenever the mercurial action
was beginning to be fully induced, the granulating appearance of the
surface was destroyed, and it became of a dusky colour, discharging
“bloody sanies.” The bones remained stationary. The medicine was
now discontinued, and the patient went to the country; but, on his
return, in about a fortnight, “his throat was again ulcerated[77].
Such of the old external ulcers as had not healed, threw up a kind
of fungus granulations.” The sore on the penis, which never had been
completely well, had spread to the size of a shilling, but had no
phagedenic, or specific appearance. Mercury was afterwards tried,
and some bones exfoliated from the nose. The ulcer healed; but, as
soon as he recovered from the effects of the mercury, new blotches and
ulcerations, with a new enlargement of the tibia, took place. “He is
now under his fifth mercurial course.”

[76] The neighbouring glands sometimes swell and suppurate, but they
heal kindly, and the disease proceeds no farther.

[77] From this, it would appear, that his throat had been at one time
healed.

In this case, mercury evidently was prejudicial, except toward the
end. It does not appear that the caustic had been freely applied to
the original local disease, which might have destroyed it. These
affections, which were by some considered as venereal, evidently
differed from that disease, in the rapidity of its progress, in the
appearance of the primary sore, and in the history of the whole of the
symptoms. We are as yet in the dark with regard to a specific remedy
for these, and similar affections.

There are several other ulcers, which appear upon the penis after
coition, which probably depend upon the application of a peculiar
contagion. These[78] are sometimes superficial and phagedenic; they
spread fast, and heal rapidly, frequently in the course of a night
after precipitate has been applied. At other times they are deeper, and
more like a little cup; the surface is smooth and glossy, without any
appearance of granulations; the discharge is thin, and the base and
margin quite soft. The best remedy is the caustic, with the subsequent
application, precipitate, or ung. hyd. nit. dilut. When buboes form, I
have always found them heal without the use of mercury. If, however,
the bubo be the first symptom which appears, as is sometimes the case,
(for the morbid agent is occasionally absorbed before it excites action
in the part to which it is applied), then it is generally much more
difficult to heal than when it is preceded by a local action, and
induced by the absorption of matter generated there.

[78] Many of these have been confounded with the venereal disease, and
treated accordingly.

It were much to be desired that they should be accurately described,
and one kind distinguished from another, for there are probably many
different species.

If these local, or primary symptoms, be not speedily removed, a general
disease is induced, as we see in the case already mentioned, and as
is proved by numberless other instances. These general affections
are marked by ulcerations of different parts; and the ulcers have a
different appearance, according to the nature of the morbid agent. In
some cases they are better and worse at intervals. Mercury has, in
almost all these cases, been used; but, although some are ameliorated
by it, yet others resist its action. At first, indeed, they generally
appear to heal; for the mercurial action, when forming, interrupts the
progress of the former diseased action; but, whenever the mercurial
action is fully induced, we sometimes find that the appearances change,
and the progress generally becomes quicker than formerly[79].

[79] Some actions cannot be induced during the continuance of others.
Other actions can, in these circumstances, be formed, and displace
completely the former action. A third set seem to give a modification
to the original disease: They change it to a certain degree; but the
change is not salutary, and they never displace it. The mercurial
action, when induced during the existence of some of the diseases
which I am describing, comes under the last, or third class. At first,
during the formation of the mercurial action, the former diseased
action is interrupted, in the same way as the natural action is injured
during the period of formation of other actions, when no peculiar
disease previously existed. On this account, the sore assumes a better
appearance; and, if the action be nearly terminating naturally (as some
actions do, and as the primary action in these diseases more readily
does than the secondary), it quickly heals up; but, if this be not the
case, the appearances soon change, and the disease becomes much worse.

There is a disease which is not unfrequently confounded with syphilis,
but which is distinct from it; I mean small ulcers about the mouths
of children, which are more like aphthæ than any thing else; but,
soon after their appearance, small blotches appear in the body, which
become first raised into a little flat vesicle, and then ulcerate
superficially. These ulcers have a watery appearance, not much unlike
tetters; but the appearance of the vesication, and dark colour of the
preceding blotches, prevent any confusion. Nurses who suckle these
children have generally small calyciform ulcers on the nipples, of
a pale colour, and discharging a thin watery matter. I have had no
opportunity of ascertaining what constitutional symptoms would be
produced by the continuance of the disease in the nurse, as I have
generally found that the application of diluted citrine ointment
to the nipple produced a cure, without any internal medicine. The
constitutional symptoms in the children were cured by the same local
applications, with small doses of calomel internally[80].

[80] There are some cases, described by different authors, of
affections of the nipples and breasts, in which the ulcers appear to
have been chiefly of the phagedenic kind.

I have likewise observed ulcers on the lips, throat, and mouth,
which at first had a very doubtful appearance; but they evidently
are distinct from syphilis, and belong to the suppurating sores.
When superficial, the buff-coloured matter, or inorganised substance
which covers them, has a fibrous, or thready appearance, the margins
are slightly tumid, and of a florid, or kind of pink colour. The
application of caustic, or burnt alum, is often sufficient of itself to
cure these; but small doses of mercury sometimes accelerate the cure.
At other times these sores penetrate deeper, and affect the bones. The
surface, which is deep, is covered with a thick yellow slough, like an
overacting ulcer. The margins are tumid, ragged, and of a light, or
pink colour. Sometimes the disease spreads along the gum, which becomes
soft, ulcerated, and separates from the teeth, which very frequently
become black, and, when the sockets are affected, drop out. I have not
had an opportunity of observing these sores go the length of inducing
constitutional symptoms. It is not easy to ascertain the cause of these
sores; sometimes they succeed the use of mercury; but, at other times,
it is impossible to blame any evident agent. The transplanting of teeth
sometimes has been the mean of inducing sores similar to these; and,
in these cases, the disease has generally passed for syphilis[81].
But although the venereal disease may have been inoculated in this
manner, it is certain, from the appearance of the ulcers, from their
rapid progress, and from the sudden effect produced by a very small
quantity of mercury, that the disease, which is commonly induced by
transplanting teeth, is not syphilitic.

[81] Cases of this kind may be found in Mr. Hunter’s Treatise on the
Venereal Disease, and in the third volume of the Medical Transactions.

Sibbens is another disease which has been very frequently confounded
with syphilis, and is by many considered to be only a variety of that
disease; but they evidently are different, as appears from the mode of
infection, and the properties of the contagion[82], the appearance of
the ulcers, their progress, and certain circumstances in their cure,
particularly their requiring less mercury than venereal ulcers in the
same state, and from their yielding readily to preparations of mercury,
which do not accomplish a cure of syphilis.

[82] This disease is communicated even by drinking out of the same
vessel with an infected person, even although that person have no sores
on the lips, but only in the throat. The contagion then must either be
dissolved in the saliva, or remain very powerful, even when reduced to
a state of halitus.

This disease appears first on the part which is most directly acted
on by the contagion. This part becomes red and inflamed, having
an erysipelatous appearance. Ulceration quickly takes place on a
particular spot, and spreads rapidly along the whole inflamed part.
The disease then advances more slowly; the erysipelatous appearance
spreads around the margin of the ulcer, and ulceration follows upon the
inflammation. In the course of some time (the precise period is not
fixed), the skin becomes affected with blotches, or sometimes clusters
of small pustules, the intervening space betwixt each being affected
with an erysipelatous inflammation. These spots soon ulcerate, and
the surface rises up into a fungous, which is irregular, and has an
aspect somewhat betwixt the look of the venereal sore and a very bad
scrophulous ulcer. The bones next become affected, particularly at the
articulating surfaces, which swell, and become carious. It is said that
the secondary ulcers in general appear first upon the genitals; but,
of all those whom I have examined, no affection of these parts had
taken place, from which I would infer, that the disease has no peculiar
tendency to affect these in preference to other parts. It is likewise
said that the disease sometimes disappears from one part, whilst it
breaks out in another; but this also I have never witnessed. The
primary ulcers also have no tendency, like some others, to change their
appearance, and become milder, or heal by continuance, but spread,
destroying the nose, orbits of the eyes, and face. The constitution
seems to suffer much more from this disease than from syphilis, in the
same length of time; for the patient soon assumes a pale sallow look;
and hectic comes on much sooner than in syphilis.

The cure of this disease is effected by washing the sores with
solution of corrosive sublimate, or dressing them with precipitate
ointment, at the same time that we use mercury internally, without
which no escharotic, or local application whatever will effect a
cure. In general, less mercury cures this disease than syphilis; and
it is worthy of remark, that permanent cures may be obtained by the
hyd. mur. corros. which is not the case with syphilis. When the bones
are affected, we must, in conjunction with the specific remedy, use
such applications as the state of the bone, considered as a simple
affection, will require.

The cynanche maligna, and scarlatina, are also diseases producing
ulceration in the throat. The sores are of the suppurating kind, a
thick lymphatic-looking, or inorganised substance being thrown out,
instead of organic particles, or granulations. This, in the former
disease, very soon becomes black, and putrefies; but the slough so
formed differs materially from that caused by gangrene; for, in this
disease, unless in the very last stages, there are no real gangrenous
sloughs. It is unnecessary here to make any particular observations on
these diseases.

Herpes[83] is a disease which is very frequent, and often prevents
large ulcers from healing, as these come to assume the action of
herpetic ulcers, although, from their magnitude and depth, they do not
put on the same appearance as when the disease is confined to the skin.
The large ulcers are of a dark sloughy appearance, discharge thin
matter, are painful, and are surrounded with herpetic ulcers, and scabs
in the skin. This is a very frequent disease on the legs, and is very
tedious. Bathing with warm sulphureous water is often of service, at
the same time that we dress the parts in the intervals with camphorated
ointment. Citrine ointment is also very useful; but the following
liquor is one of the best, and most effectual applications:

[83] There are many different divisions of herpes; as, for instance,
into the scurfy, scabby, miliary, &c.; but, for a description of these,
I must refer to the writers on the diseases of the skin.

    R. Pulv. Calcis Vivi Recen. unciam.
       Flor. Sulph. semiunciam.
       Aq. Font. sesquilibram. Coque ad dimidiam dein cola.

This ought to be applied with cloths to the parts.

When, by these means, the disease of the skin, and the specific action
of the ulcer is removed, pressure is often of service in completing
the cure.

There is a specific ulcer, which is met with most frequently on the
legs, and which is very troublesome. The skin becomes in several points
inflamed, or of a dark red colour. These parts speedily ulcerate, and
the sores belong to the suppurating kind, for no distinct granulations,
or organic particles, are formed; but the surface is smooth and glossy,
and the discharge thin and copious. These sores are generally pretty
deep, in proportion to their extent, or of a cup-like appearance. They
not unfrequently occur in scrophulous habits. Mercury, exhibited in
small doses internally, appears to be useful. Precipitate, as a local
application, generally answers very well; but, when the sores become
irritable, or spread under this treatment, hemlock poultices succeed
better.

There is a small ulcer, which sometimes is met with on the foot,
of an irregular shape, fiery appearance, and surrounded with thick
jagged margins, which, in particular parts, are white, and callous.
The neighbouring integuments are of a dark red colour. The discharge
is thin, and the pain considerable. Caustic, and afterwards the
application of the adhesive plaster, are the best local applications.
Internally, the use of hemlock is sometimes of service.

It occasionally happens, that, nearly about the same time, most of the
patients in a ward of an hospital shall have their ulcers rendered
unhealthy. They become foul, dark coloured, and spread: The discharge
is thin, and the pain is greater than formerly. The application of
cloths dipped in gastric juice is sometimes of service in these sores,
and is one of the best remedies; but, not unfrequently, the patient
must be removed to a different situation before a cure can be obtained.

Having made these detached remarks on some specific ulcers, I shall,
in the succeeding dissertations, consider, at greater length, others,
which are, in the general estimation, considered as more dangerous and
alarming.




DISSERTATION IV.


_On the Spongoid Inflammation._

The disease which I am now going to consider, has either not been
described at all by any author, or has, when it was noticed, been
considered as of a cancerous nature. It is perhaps one of the most
alarming diseases to which we are subjected; because, as yet, we know
of no specific remedy; and an operation can only be useful at a time
when it is very difficult to persuade the patient to submit to it.

I have named it the spongoid inflammation, from that spongy elastic
feel which peculiarly characterises the disease, and which continues
even after ulceration takes place.

This disease begins with a small colourless tumor, which, if there
be no thick covering over it, such as the fascia of a muscle, or the
aponeurosis of the foot, is soft and elastic, but tense if otherwise.
It is at first free from uneasiness; but, by degrees, a sharp acute
pain darts occasionally through it, more and more frequently, until
the sensation becomes continued. For a considerable time, the tumor
is smooth and even, but afterwards it projects irregularly in one or
more points; and the skin at this place becomes of a livid red colour,
and feels thinner. It here readily yields to pressure, but instantly
bounds up again. Small openings now form in these projections, through
which is discharged a thin bloody matter. Almost immediately after
these tumors burst, a small fungus protrudes, like a papilla, and this
rapidly increases, both in breadth and heighth, and has exactly the
appearance of a carcinomatous fungus, and frequently bleeds profusely.
The matter is thin, and exceedingly fœtid, and the pain becomes of the
smarting kind. The integuments, for a little around these ulcers, are
red, and tender. After ulceration takes place, the neighbouring glands
swell, and assume exactly the spongy qualities of the primary tumor. If
the patient still survive the disease in its present advanced progress,
similar tumors form in other parts of the body, and the patient dies
hectic.

On examining the affected parts after death or amputation, the
tumor itself is found to consist of a soft substance, somewhat like
the brain, of a greyish colour, and greasy appearance, with thin
membranous-looking divisions running thro’ it, and cells, or abscesses,
in different places, containing a thin bloody matter, occasionally in
very considerable quantity. There does not seem uniformly to be any
entire cyst surrounding the tumor, for it very frequently dives down
betwixt the muscles, or down to the bone, to which it often appears to
adhere. The neighbouring muscles are of a pale colour, and lose their
fibrous appearance, becoming more like liver than muscle. The bones
are uniformly caries, when in the vicinity of these tumors. If large,
they are found rough, and broken off into fragments; if small, they are
generally soft and porous. This tumor is sometimes caused by external
violence; but often it appears without any evident cause.

I know of no remedy which has a power of checking the progress of the
complaint, or removing it. Friction, with anodyne balsams, sometimes
gives relief in the early stages; but it does not seem to retard the
progress of the disease. Extirpation is the only remedy which has a
prospect of being successful; but it is only adviseable in the early
stages, whilst the disease is entirely local, and has not extended to
the neighbouring glands; for, after they become affected, the chance of
recovery is greatly diminished. It is, however, sometimes difficult to
persuade patients at this time to submit to amputation, or extirpation,
because the pain and inconveniences are inconsiderable; but the
operation ought to be urged with all the eagerness which a conviction
of its absolute necessity, and its precarious issue, if delayed, will
inspire.

After making these observations, I shall illustrate the subject with
the following cases, the first of which is intended to show the
difficulty of extirpating the disease, when the operation is delayed
after the first appearance of the tumor. In the second, we see the
destruction which the bones suffer by it, and the extent of parts
which it may affect. The third gives us an instance of the affection
of the glands: And the fourth, of the most advanced stage, or that in
which distant parts have suffered. The last is an instance of the good
effects of an early operation.


CASE I.

William Stirling, without any very evident cause, perceived a small
tumor on the top of the shoulder, about midway betwixt the termination
of the neck and the articulation of the humerus. This gradually
increased for some months, and by the time when I saw him was
larger than a goose’s egg: It was spongy and elastic, and attended
occasionally with pain.

Although the duration of the tumor was an unfavourable circumstance,
yet I undertook the operation. I made an incision through the whole
length of the skin, and dissected it off the tumor, (the upper part of
which was covered with a coat, or cyst), down to its base; but, when
I now began to separate it from the parts below, I found that it had
no defined bottom, but penetrated down betwixt the muscles, which were
soft, pale, and had lost their fibrous structure. I therefore cut off
the tumor close by the muscles, and then separating them with the back
of the scalpel, I removed with the finger as much of the tumor as I
could observe. Several arteries sprung; but these were pretty readily
tied, although the vessels were very tender. A troublesome oozing,
however, took place from many points of the diseased muscles. This was
moderated by applying the sponge dipped in cold water, after which the
skin was laid down, and its lips brought close together.

On dressing the patient on the third day after the operation, the skin
was found not to have united; but its lips were red and inflamed. In
this state it continued for several days, when the part began to grow
tumid, and discharge a thin fœtid matter. The skin then retracted still
more, and a fungus protruded, which gradually increased; but it was
smooth and regular, and of a pale colour, so that it rather had the
appearance of a superficial ulcer, raised up by a tumor from below,
than the ulcerated surface of a diseased substance itself. In this
state it continued for two or three months, when irregular projections
appeared on the ulcerated surface of the new tumor. These soon burst,
and a fungus protruded, of a carcinomatous appearance, and bleeding
very frequently and profusely. Swellings of the axillary glands
succeeded this, and the patient became much enfeebled, and evidently
hectic. As I have not heard of him for several weeks, I suppose that he
has died.

In this case a second tumor succeeded to the first, owing to the
impossibility of extirpating the whole, and this exactly resembled
the original one, except in having its surface covered from its
commencement with an ulcer; but this ulcer was not the specific one of
the spongoid inflammation.


CASE II.

John Overend was attacked with pain in the right thigh and loins, which
were considered as rheumatic. Shortly after the thigh was observed to
be elongated, and issues were applied over the hip joint, upon the
supposition of its being a common case of morbus coxarius. But no
considerable relief was obtained by this; on the contrary, the upper
part of the thigh swelled, whilst the lower part wasted, his appetite
diminished, his pulse was quickened, and he passed sleepless nights.
The thigh was rubbed with anodyne balsam, and draughts with laudanum
were given every night, but only with temporary benefit. For the course
of some months these complaints continued, with occasional remission
and aggravation. At last he began to complain of difficulty in making
water; and this soon ended in a complete retention. The catheter was
attempted to be passed; but although its point was bent, and directed
so as to correspond to any deviation of the prostate gland from its
right situation, it could not be introduced. By examining per anum, a
large elastic tumor could be felt in the pelvis, which was considered
as the bladder. A trocar was therefore passed up the rectum, and the
bladder attempted to be tapped. A considerable quantity of bloody
fluid came away; but he complained of no pain at the glans, which most
patients do when the bladder is wounded; and a considerable quantity of
high coloured fœtid urine was voided by the urethra, and continued even
afterwards to be passed, although with some difficulty. Within a week
after this the patient died.

On dissection, I found the hip joint to be completely surrounded with
a soft matter, resembling the brain, inclosed in thin cells, and here
and there cells full of thin bloody water; the head of the femoral
bone was quite carious, as was also the acetabulum. The muscles were
quite pale, and almost like boiled liver, having lost completely their
fibrous appearance, and muscular properties. On opening the abdominal
cavity, the same kind of substance was found within the pelvis; and
the greatest part of the inside of the bones of the affected side were
quite carious. Large cells were found in this diseased substance,
containing bloody water; and it was into one of these that the trocar
had entered when the bladder was attempted to be tapped.


CASE III.

James Walker received a stroke upon the outside of the foot,
immediately below the ankle joint. A small tumor instantly formed,
which continued stationary for several weeks, and gave him little
uneasiness; but afterwards it began to increase, and was attended
with a shooting pain. The tumor was elastic, pretty tense, and rather
irregular in its appearance. I was anxious to operate, but the man
would not give his consent. I therefore advised frictions with anodyne
balsam, which at first gave him relief, but soon lost its effect. For
several weeks I heard nothing of him; but, at the end of this time,
he again applied to me. The irregularities of the tumor were much
greater, more prominent, of a red colour, and one of them had burst:
From this a soft half-organised fungus protruded, and a bloody fluid
run out constantly. An operation was again urged, but the timidity of
the patient made him again refuse. A month after this he came under the
management of another surgeon. There were now three openings in the
tumor, from each of which protruded a broad cauliflower-looking fungus,
covered with thick fœtid matter; there was likewise a thin red serum
discharged from the margins of the ulcers. The tumor was as large as
a child’s head, and one of the inguinal glands was a little swelled.
The man now consented to lose his limb, and amputation was accordingly
performed. Whenever the turniquet was applied, a very copious stream
of veinous blood issued from the tumor; but this ceased when the veins
had emptied themselves. Unluckily it was considered as unnecessary to
extirpate the diseased gland.

On examining the leg, all the bones of the ankle joint were found to
be quite soft and carious; the tumor consisted of a soft substance,
resembling the brain, with light membranous intersections. The cyst on
the upper part was hard and thick, but beneath it was entirely wanting,
having either never been formed betwixt the tumor and the tendons
of the muscle, or having been destroyed. The former opinion is the
most probable; for I have never in any stage found the cyst continued
over the under or back part of the tumor, but it always terminated
imperfectly in the part on which the tumor was seated.

The wound healed as well as could be desired, but the gland became
rather larger, notwithstanding which no operation was urged. Two
months after this I was requested to visit him. The gland was now as
large as the head of a newborn child; it was soft and spongy, and had
at one part an irregular prominence, but the skin was not coloured.
The pulse was about one hundred and thirty, and the patient completely
hectic. In this situation I proposed nothing excepting nourishment. He
died in the course of a week after I saw him.


CASE IV.

The following case shows this disease in its most advanced stage. It is
extracted from the fifth volume of the London Medical Journal, and is
intituled, “An Account of the Fatal Effects produced by attempting to
remove a Ganglion by Seton.” It was drawn up by Mr. W. Dease, surgeon
in Dublin.

“In July 1781, a clergyman, aged thirty-seven, consulted me about a
moveable ganglion, of the size of a small nutmeg, situated between
the fore-finger and thumb of his right hand, near the wrist. He was
eager to have it removed, and had been advised, for this purpose, to
have a seton passed through it, as the best and most certain method;
but, as he was apparently a robust healthy man, and the ganglion was
attended with no pain, I advised him to consider it as a matter of no
consequence, and not to meddle with it. Four months after this I was
desired to visit him, and found him in a melancholy situation. A seton
had been passed through the ganglion, and the consequences were, that
the back of his hand had inflamed violently, that the ganglion had
rapidly and amazingly increased, and that the openings made by the
seton were filled with an ill-conditioned fungus, which sprung up as
fast as it was removed, and was attended with frequent hemorrhage, and
much pain. In consultation, it was agreed to remove this fungus by a
free incision, which was done, and the metacarpal bones appeared bare
and rough. Another opening was made through the thenar, and a seton
passed through it, in order more effectually to prevent the growth
of fungus. The bark was administered in large quantities, an opiate
was given at night, and due attention was paid to the regimen of the
patient. This method seemed to promise the most happy event. The fungus
appeared to be entirely destroyed, a laudable suppuration took place,
the swelling of the hand subsided, and the sores in a short time
were so contracted as to indicate their speedy cicatrization. These
favourable appearances, however, were not of long continuance; for,
after some time, the fungus began gradually to rise again, and any mode
of keeping it down, either by caustic, cutting, or pressure, seemed
to produce no permanent good effect, as it increased rapidly, and at
length degenerated into the most frightful cancerous fungus I have ever
seen. Every local application that has been recommended in similar
cases was tried in this, but without success; and internal remedies
proved equally inefficacious. He took, for a considerable length of
time, two ounces of bark in substance, in the course of twenty-four
hours, so that he took, in the whole, twenty-eight pounds of that
medicine. The extract of hemlock had also a fair trial, but produced no
apparent effect.

“When he had laboured under this complaint fifteen months, he was
advised to undergo the amputation of his hand; but before he would
consent to submit to this operation, he chose to have an account of
his case transmitted to the Royal Academy of Surgery at Paris, that
he might have their opinion of it: The result of which was, that
the members of the academy pronounced the fungus not cancerous, but
merely scorbutic. This decision, by the bye, should make us extremely
cautious in delivering our sentiments on similar occasions, without
seeing the patient, as much depends on the general appearance of the
sores in cases of this sort. The academy were of opinion, that the
disease was entirely local, and required only local treatment. For this
purpose, they advised that the fungus should be taken down by means
of euphorbium, savine, &c. and afterwards washed with salt water. If
this method proved ineffectual, recourse was to be had to the actual
cautery, from the application of which they seemed to expect the most
decisive advantages. To this mode of treatment the unhappy sufferer
submitted; and, during the space of six weeks, the fungus was almost
every day burnt down with the actual cautery; but his complaint all the
while continued to gain ground apace; so that being now disappointed
in all his expectations of relief from regular practitioners, he had
recourse to quacks of every denomination. The arsenic plaster of
Plunket was applied, and he was salivated for seven weeks. At length,
after undergoing the operation of a variety of nostrums, he again
placed himself under my care. In consultation, it was much doubted
whether amputation should now be thought of, as the patient seemed
to be in the last stage of a cancerous consumption. His limbs were
swelled, and his whole habit was wasted by the repeated hemorrhage from
the fungus, which was now so increased in bulk as to weigh down his
arm, and entirely cover the back of his hand. In short, after every
return of hemorrhage, it was apprehended that the next would put a
period to his sufferings.

“The hazard of the operation, and the little chance he had of its
proving successful, being explained to him, the unfortunate man
earnestly begged to be relieved from so hideous a load, even though he
should die under the operation. I therefore yielded to his entreaties,
and took off the hand a little above the wrist, in November 1782,
although there was a small indurated gland above the elbow. On
dissecting the hand immediately after I had taken it off, the fungus,
on being cut, appeared to be extremely similar to the substance of
the brain, and to arise from the metacarpal bones of the middle and
fore-finger. These bones were in part dissolved, and the other bones of
the hand were also in a morbid state.

“No accident occurred during the amputation; but soon after it, a
colliquative diarrhœa came on, which seemed to be increased by opiates
and astringents, but was at length checked with draughts of fixed
alkaline salt and lemon juice, swallowed in the act of effervescence.
He afterwards took the bark, drank seltzer water, and was allowed a
liberal use of wine. The suppuration for some time was ichorous and
bad, but he gained strength daily. At the end of seven weeks, the
stump was completely cicatrized, and the indurated gland above the
elbow had disappeared. He went into the country, drank goat’s whey,
bathed in the sea, became very corpulent, and seemed to be in perfect
health, but had somewhat of a sallow bloated appearance. He continued
well till July 1783, when he began to complain of pains in his back,
attended with rigidity. These pains, as they increased, extended down
his thighs and legs, and occasioned him to sleep ill at night. He grew
feverish, his pulse beat extremely quick, and his countenance acquired
a shining yellowish red colour, an appearance which I have remarked
to be characteristic of a cancerous habit. He now began to walk with
difficulty. I took a small quantity of blood from him, and found the
texture of the crassamentum extremely loose, and the serum in too
great quantity. He was very difficult to purge, and unfortunately was
under a constant necessity of taking medicines to procure the necessary
discharges. Antimonials in a variety of forms were given, and the bark
was again tried, as were all the medicines that are usually prescribed
in rheumatic cases. Blisters were applied, and issues cut in his
thighs, but all to no purpose. He was obliged to take to his bed in
August, and never after quitted it.

“It is difficult to form an idea of the constant and excruciating pain
this poor man suffered. Opium, though given in large doses, afforded
him but little relief, and at last none at all. He generally lay on
his back, fixed as it were to the bed, the least motion occasioning
the most intense pain. As the disease advanced, he complained of a
difficulty of passing his urine, which was loaded with a viscid mucus,
and he once discharged an oblong calculus; but at last he voided his
urine involuntarily, and sometimes even his fœces, but the latter
only rarely, when he had taken a purgative, which, as I have already
mentioned, was required to be of the most active kind, otherwise it
produced no effect.

“During the whole course of the disease, his pulse was rapid, but
his tongue was remarkably soft and florid. He was never delirious.
Latterly, he spit blood once or twice; his lower extremities became
very œdematous, and his back was covered with eschars; but these
dropped off, and the sores suppurated and healed kindly. Two months
before his death, his pains abated considerably. He died without pain,
March 4 1784, which was about two years and nine months from the time
the seton was passed, and a year and four months from the time he
underwent the amputation.

“His body was opened a few hours after his death. The abdominal viscera
appeared to be perfectly sound, and of their natural colour, except the
liver, which had a small steatoma on its convex surface, but was in
other respects healthy. The gall bladder was rather fuller of yellow
bile than it is generally found to be. The left kidney was enlarged,
and on dividing it longitudinally, much red gravel was found in its
pelvis, and the ureter seemed much lessened. The urinary bladder
was contracted, and its coats uncommonly thickened, but no sabulous
concretions were observed in it.

“On each side of the vertebræ lumborum, the lumbar regions were
rendered convex by a large cancerous deposition, which elevated the
psoæ muscles; and when the cellular investitures, which were condensed
into a cyst, were opened, the cancerous matter appeared in a large
quantity, in colour and consistence exactly resembling the fungus of
the hand, and not unlike the substance of the brain. The whole weighed
about five pounds; and when this was removed, the last vertebra of the
back, and the three first of the loins, were found to be in a softened,
eroded, and in some parts a totally dissolved state. There appeared
not the least mark of ichor, sanies, inflammation, or hardness of the
soft parts; nor were the mesenteric glands at all affected. The matter
seemed to have been really a cancerous exudation, and to be formed
chiefly of coagulable lymph. This cancerous mass seemed to possess a
remarkable dissolving power, which was exerted wholly on the bones, and
did not, as usual in cases of this sort, cause any schirrous hardness
of the surrounding soft parts.”


CASE V.

A woman, some time after receiving a blow on the leg, perceived a small
moveable tumor. It was soft, elastic, and seated on the outside of the
leg, about half way betwixt the knee and ankle joint. I made a small
incision through the skin down to the tumor, and dissected it off to
its base. I then dissected the substance off from the facia of the
muscle, and brought the skin together with adhesive plaster. It united
readily, and the patient was cured. The tumor was soft, like brain, of
a greyish colour, and greasy consistence.




DISSERTATION V.


_On the Scrophulous Inflammation._

Scrophula is a morbid condition, which has been called the opprobrium
of surgery, much more justly perhaps than any other disease, cancer
itself not excepted, for even this most dreadful disorder may be
removed by an early operation; but the nature of scrophula admits of no
treatment equally successful.

From the obscurity in which its causes are involved, and from no
certain method of cure being known, I can only make a few unconnected
remarks on this disease.

A scrophulous system is generally marked by a fine skin, delicate
complexion, light blue eyes, with opake sclerotica, and frequently
a swelling of the upper lip. At other times, especially in those
who belong to what has been called the melancholic temperament, the
complexion is darker, and the skin coarser; but in these, at least when
young, the face is generally tumid, and the look unhealthy.

In these systems, as will presently be observed, almost every disease
is different, in some points, from the same disease when it occurs in
a healthy person; but the action which more decidedly manifests this
modification, is the inflammatory, insomuch, that, by some, scrophula
and scrophulous inflammation have been confounded; and this disease
has been described only in so far as it has appeared conjoined with
inflammation. We have therefore almost always in the description
of scrophula a swelling of the glands, and subsequent ulceration,
or inflammatory affections of other parts of the body, detailed as
necessary and essential symptoms.

The scrophulous inflammation is marked by a soft swelling of the
affected part, which very frequently is one of the lymphatic glands.
The covering, or coat of the gland, becomes slightly thickened, and
its substance more porous and doughy[84]. The swelling increases,
and the doughy feel changes by degrees into that of elasticity, or
fluctuation, and a firm stool, or circumscribed hardened margin, can
be felt round the base of the tumor. The skin is slightly red. If,
at this time, an incision or puncture be made, either no matter, or
very little, is evacuated, the lips of the wound inflame and open,
displaying a sloughy-looking substance within, and betwixt this and
the skin a probe can often be introduced for some way all round. If,
however, the disease have been farther advanced, then there is very
little elasticity in the tumor, it is quite soft, rather flaccid, and
fluctuates freely; the skin becomes of a light purple colour, and small
veins may be seen ramifying on its surface. In some time after these
appearances are observed, the skin may be felt becoming thinner at
one particular part, and here it also generally becomes of a darker
colour, then it bursts, and discharges a thin fluid like whey, mixed
with a curdy matter, or thick white flocculi. The redness of the skin
still continues, but the aperture enlarges in proportion as the tumor
subsides, forming the scrophulous ulcer. The margins are smooth,
obtuse, and overlap the ulcer; they are of a purple colour, and rather
hard and tumid. The surface of the sore is of a light red colour; the
granulations are flabby and indistinct; and the aspect is of a peculiar
kind, which cannot be described. The discharge is thin, slightly ropy,
and copious, with curdy-looking flakes. The pain is inconsiderable.

[84] When the conglomerate glands are affected, the tumor is generally
hard and firm until matter forms.

When this ulcer has continued for some time, it either begins slowly
to cicatrize, or more frequently the discharge diminishes, and becomes
thicker; it then hardens into an elevated scab, of a dirty white, or
yellowish colour. This continues for a considerable time, and then
crumbles off, leaving the part covered with a smooth purple cicatrix.
This description corresponds to the mild scrophula, or the struma
mansueta of the older writers; but occasionally, especially if a bone
be diseased below the ulcer, the sore has a more fiery appearance, the
surface is dark coloured, the margins soft, elevated, and inflamed,
and sometimes retorted. The discharge is watery, the pain very
considerable, and the surrounding skin inflamed. This has been called
the struma maligna, and was said to be marked by the greater degree of
hardness and inequality in the tumor, varicose veins, and pulsatory
pain: It was likewise said to be contagious. But although occasionally
this state of the scrophulous ulcer be preceded by a hard and painful
tumor, yet it is not necessarily so, but rather seems to depend upon a
disease of the parts below, which generally are bones, cartilages, or
tendons in a morbid state; and hence this overacting scrophulous sore
is most frequent over the smaller joints, particularly the toes.

Sometimes the scrophulous abscess, after bursting, forms a sinus, the
mouth of which ulcerates, and assumes the appearance of the specific
ulcer; but the track of the sinus remains in a suppurating state. This
not unfrequently is connected with a diseased bone, or cartilage, or
tendon.

Scrophulous tumors and ulcers more readily disappear during the winter,
and return again on the approach of summer; but this is by no means an
universal law of the disease.

It is likewise observable, that swellings of the glands are very apt
to subside pretty rapidly in one place, and appear equally quickly in
some other glands, in the vicinity of these originally affected. Ulcers
likewise frequently heal upon the appearance of the disease in other
parts.

When the joints become affected, the cartilages swell, and the quantity
of the lubricating matter is increased; the tendons are surrounded with
a glairy matter, like the white of egg; and, lastly, the bone becomes
enlarged. These effects are attended with stiffness and pain in the
joint, which is sometimes intolerable, especially during the night, and
confined to a single spot, from the disease residing chiefly there. In
some time after this, small abscesses form in different parts of the
inflamed joint, which gives it a spongy elastic feel. These bursting
into one another, form a larger cavity, which communicates with the
articulating surface of the bones, and reaches to the skin, through
which a fluctuation may be felt. This abscess at last bursts, and
discharges a curdy matter. Long before this happens, the bone generally
ulcerates, and becomes rough. This disease is uniformly attended with
hectic, which terminates the patient’s misery.

Not unfrequently, in scrophulous people, eruptions appear on different
parts of the body, especially on the face, which is covered with
pustules of a dark red colour, suppurating slowly, and sometimes never.

At other times, we find incysted tumors on different parts of the body.
These may appear in any habit; but when they occur in scrophulous
people, they assume the specific action of the constitution; in which
case, instead of containing an uniform fluid, like thin jelly, of a
yellowish colour, as the simple incysted tumor does, they are filled
with a thick curdy purulent-looking matter, or with serum, containing
white flakes, little lumps, of a white substance.

All the causes capable of inducing simple inflammation will of
consequence induce the scrophulous inflammation, provided that the
inflammation be not induced in such a way, and in such organs as make
it heal rapidly, as will be afterwards noticed. Specific inflammation
is likewise modified when it takes place in a scrophulous constitution,
and is much more tedious in its cure. This is evidently seen in the
small pox and venereal disease.

Although the effects of a scrophulous constitution, in modifying
action, be most distinctly observed in the inflammatory action, yet
it does not operate exclusively on this; on the contrary, we find,
that typhus fever, and some other actions, which may exist without
any perfect local inflammation, are, cæteris paribus, more violent in
scrophulous habits than in others.

This constitution is more easily acted on by certain agents,
particularly such as tend to induce inflammation, than healthy
constitutions in the same circumstances. It would likewise appear,
that, on the contrary, there are other agents which operate with more
difficulty. It is in general observable, that scrophulous people are
less easily affected with mercury. On a few, indeed, it operates
readily; but, when we attend to the general habitude of these
people, we must consider the aptitude of some individuals to assume
the mercurial action to depend on some peculiarity of constitution,
unconnected with the scrophulous condition.

By the ancients, and many of the moderns, the pituita was considered
as the cause of scrophula, producing tumefaction, by stagnating in the
glands. When any of the bile became mixed with the pituita, then the
inflammation was more violent, and the ulceration deeper. Some latter
writers, convinced that a simple redundancy of any particular humour
could not produce scrophula, had recourse to the supposition of an
acrimony, which was productive of swelling and ulceration, and which
might “taint the whole fluids of the body[85].”

[85] Cullen’s First Lines, Vol. IV.

Others attempted to explain this disease, upon the principle of
debility existing in the whole body, but particularly in the lymphatic
system[86]. This is an idea still more puerile than the doctrine
of morbid humours, which, however unfounded, had several plausible
arguments to support it, and which was incontrovertible until the laws
of the animal economy were better understood. Simple debility never
can give rise to the marks of the scrophulous constitution; it cannot
produce ulcers of a nature and appearance so peculiar; neither can it
explain why particular parts are more apt to be affected than others;
because, if debility exist equally in every part of the absorbent
system, then every part ought to be alike diseased; and if it exist
only in particular parts, then it is necessary to point out some cause
of this partial debility. We likewise frequently observe very great
debility in this system, owing to general weakness, and yet no symptoms
of scrophula appear in consequence.

[86] Bell’s Treatise on Ulcers, p. 424.

Scrophulous people possess a peculiar constitution, and may therefore
be said to constitute, in one respect, a distinct variety of the
human race. This state is produced by a peculiar condition of the
semen (owing to the peculiarity of the system which forms it), or
of the female organs of generation, which possess the same general
nature with the body, of which they form a part. When the organs of
generation in both sexes are healthy, that is to say, similar in nature
to what may be considered as the proper nature of the human race,
taken as a distinct class of animals, then the semen stimulates the
ovarium to the formation of a healthy child, or one which possesses
a constitution, or susceptibility of performing, and having actions
induced in it, similar to that of the majority of mankind. In this
process, the ovarium is to be considered as a gland, and the semen as
its peculiar stimulus. If, however, either the nature of the gland, or
of its stimulus be changed, it is evident that the action induced must
be more or less modified, and the secretion or product changed to a
greater or less degree in its nature and properties. Were it possible
for a progeny to be produced by an intercourse betwixt the human and
the brute creation, they would possess a nature different from both, or
perform actions of a mixed kind. This may be observed with regard to
mules amongst brutes. In the same way, a healthy and scrophulous person
must produce a child which differs from a healthy one, in having a
certain peculiarity of constitution.

Agents produce different effects in different animals; thus the matter
of cow-pox applied to the cow and to man produce very different
appearances. Agents likewise, in the same genus of animals, produce
different effects, according to the peculiar constitution of the
individual. Thus, the matter of small-pox in some men produces only
a slight local sore, whilst in the generality it produces a general
disease, and eruption. The same disease affords an instance of changes
taking place in the constitution after birth, by the establishment of
certain actions; for it is rendered unsusceptible of the same action
being induced afterwards; and, in this respect, is brought to resemble
the constitution of a different genus of animals, with regard to that
disease. There are some constitutions, such as those called irritable,
in which certain symptoms of febrile, and other actions, are much
more violent than in people of a different description. In them, for
instance, typhus fever is attended with a very frequent pulse, and yet
the other effects of this action are not violent in the same proportion.

Peculiarity of constitution is often manifested by no evident sign, and
the modifications of actions induced are often marked by no perceptible
diseased phenomena, which may be considered as belonging exclusively
to that constitution. But, in the scrophulous constitution, there are,
in almost every instance, perceptible modifications of the formative
action[87], producing a peculiar appearance of the eye, countenance,
&c. as has already been mentioned; and although some diseased actions,
which receive modifications from this peculiarity of constitution, may
not be attended with obvious alterations, yet others, especially such
as are attended with an inflammatory condition, are distinctly changed.
It is these changes which constitute what in common language has been
called scrophula, which is merely a peculiarity of a common action
(namely, inflammation), which is dependent, not upon any particular
nature of the agent or exciting cause, but upon the peculiarity of
constitution, which is susceptible, by these agents, of such an action.

[87] The morbid condition of the formative action is very frequently
manifested in the bones, which are less perfect, that is to say,
softer, containing less calcareous earth, and later of being formed.
Thus, the teeth are longer of appearing; the bones of the head are
soft and yielding, and hence the head is large; the long bones bend
and lose their shape, or their extremities swell, and, from being
more vascular than their nature is fitted for, inflammation is very
apt to be induced. The yielding and increasing of the bones of the
cranium is likewise attended with a similar effect, for the brain
becomes too large in proportion to the rest of the body, and is very
apt to inflame, and have effusions formed into it. At other times, the
diseased state of the formative action appears most distinctly at the
surface, the skin being rough, and very apt to desquamate.

From what has been said, it will appear, that I consider the
scrophulous inflammation, or what has in common language been called
scrophula, merely as an accidental circumstance, occurring in a
scrophulous constitution; but it is by much the most dangerous and
troublesome effect of the peculiarity of constitution. It has likewise
a very evident effect in increasing this condition of the system;
for we find, that the probability of scrophula appearing in a child
is, cæteris paribus, correspondent to the presence or absence of
scrophulous inflammation in the parent; or, in other words, that
those who have either at the time of marriage, or before it, had
scrophulous inflammation, are more likely to have their children
strongly scrophulous, than others of the same family, who have not
had inflammation. It is likewise certain, that if, by any cure, we
can, for one or two generations, prevent the appearance of scrophulous
inflammation, the children will become less and less diseased, or have
less peculiarity of constitution; but if, by any accident, scrophulous
inflammation be in one of the descendents excited, even in a slight
degree, his immediate progeny will be more diseased than he himself
before the induction of the inflammation[88].

[88] Some gentlemen have denied that scrophula was a hereditary
disease; but it is unnecessary to offer any argument on this subject.

With regard to the exciting causes of scrophulous inflammation, I may
remark, that they are similar in kind to those capable of inducing
simple inflammation; but they frequently operate more powerfully; that
is to say, causes which would scarcely induce inflammation in a healthy
person, may induce a local disease, and inflammation, in a scrophulous
habit; because the different parts of the body perform their functions
less healthily in a strongly scrophulous person, and are more easily
deranged. In every system, those parts which are most delicate, or
require the greatest perfection of action in order to keep them right,
are most easily deranged. Now, in scrophulous people, the natural
action being modified, the body becomes more delicate, and is more
susceptible of derangement, especially those parts which naturally are
delicate[89], or require a perfection of action. The glands seem to
be amongst the most delicate organs; for they have not only to perform
the formative, or nutritive function, in common with every other part,
but they have also to perform a separate and distinct function, or
change the nature of certain fluids which are brought to them. It is on
account of the natural delicacy of the glandular system being increased
by the diseased condition of the general system, and of the exposure of
the lymphatic glands to the action of stimulating matter, taken up by
the absorbents on the surface, as, for instance, matter from scabs on
the head of children, that this species of inflammation most commonly
appears in the lymphatic system; but this system does not seem to be
the peculiar seat of the diseased condition, as some suppose, nor to
be otherwise predisposed to scrophulous inflammation, except in so
far as its natural delicacy is increased by the diseased condition
which it possessed, ab initio, in common with the rest of the body;
and consequently it is rendered less able to perform its functions
properly, the effect of which is, the induction of a new local diseased
action, or slow inflammatory action, by the slightest cause.

[89] This term is used here in a different sense from its common one,
which signifies sensibility, or delicacy with regard to sensation, and
capability of being acted on.

Besides the common exciting causes of inflammation, the particular
formation of organs may induce this disease, or at least make very
slight causes produce it. Thus, for instance, in people with a very
small narrow chest, the circulation of the blood must be performed
with greater action than in other circumstances, and thus may tend to
induce an inflammatory state. When the bones are very vascular, and
imperfectly formed, they are apt to have a morbid degree of action
excited in them by very slight causes; and the same holds true with
regard to any other part of the body which is imperfectly formed, or
which is not exactly fitted for the support and performance of its
requisite action[90].

[90] Parts which are improperly organised, or which are not in every
respect similar, both in their structure and constitution (by which
I mean, mode of acting in general), to what naturally they ought to
be, are not only less capable of performing their actions aright, but
likewise are to be considered as in some respect extraneous to the
human body, or, as it were, insulated, and do not correspond exactly to
other parts. They therefore receive less support from the neighbouring
parts, and, consequently, have their power diminished. The imperfection
of action consequent to these causes is proportioned to the morbid
condition of the part.

Scrophulous inflammation is in general dangerous and tedious, in a
degree proportioned to the effects and duration of simple inflammation
upon the same parts. Thus, simple inflammation of one of the conglobate
glands of the neck, is tedious, but not dangerous; and the same holds
true of scrophulous inflammation; but the duration of this is much
longer. Simple inflammation of the lungs, again, is dangerous; and
scrophulous inflammation is infinitely more so. Such parts as heal
easiest, when affected with simple inflammation, or ulceration, recover
soonest from scrophulous inflammation; and the same causes which
retard the one will retard the other also. Thus, the same cause which
renders a superficial simple ulcer unhealthy and chronic, will prevent
a superficial scrophulous ulcer from healing: But, if none of these
causes operate, then scrophulous inflammation, or ulceration, will
heal pretty readily, provided that simple inflammation, or ulceration
of the same parts, would do so; but, for this purpose, it must be
quickly induced; for all inflammation, or ulceration, which is slowly
induced, is slowly removed. As a confirmation of these positions,
we find, that a blister on a scrophulous person will heal readily,
because the inflammation is induced acutely, or with a certain degree
of quickness, and has, when the affection is simple, a promptitude
to heal, which manifests itself also in scrophulous people. In this
instance, the difference in the time required to heal the inflammation
in a sound and a scrophulous person is not perceptible; because the
affection, if simple, has a tendency to heal immediately. But, in a
deep wound, especially if contused, we find the difference more marked;
because here, although the constitution be healthy, the duration of
the disease is considerable; and, in a scrophulous person, the cure is
protracted still longer, and the sore assumes a specific appearance.
In diseases of the glands, the difference is still more perceptible;
because the disease, although simple, is longer in duration. In
affections of the bones and cartilages, the same is observed. When a
bone is fractured in a healthy person, it unites without inflaming;
and, in a scrophulous person, unless the diathesis be exceedingly
strong, it likewise does so, but the union is longer of taking place;
but, if a bone inflames in a sound person, the disease is very tedious;
and, in a scrophulous habit, it is infinitely more so. The same holds
true with regard to tendons and cartilages; and hence the greater
danger of a sprain in a scrophulous than a healthy person. From these,
and other facts, which it is altogether unnecessary to mention, it
fully appears, that scrophulous inflammation is tedious and dangerous,
in proportion to the progress and effects of simple inflammation and
its consequences, when it attacks the same parts; but this proportion
is not regular and uniform; but the duration increases, in a higher
ratio, in proportion as the simple inflammation and ulceration of
the same parts, and in the same circumstances, is tedious. Thus, a
deep wound in a healthy person is pretty long of healing; but, in a
scrophulous person, it is much more so. Simple inflammation of a gland
is still more tedious than the same extent of inflammation in cellular
substance; and scrophulous inflammation is still longer of running its
progress; but the proportion betwixt the duration of the scrophulous
inflammation, in these two cases, is not exactly as the duration of
the simple inflammation of the two, compared with each other, but is in
an increased ratio.

When scrophulous inflammation is excited in the vicinity of a part
already possessing this action, it occasionally removes the action from
that part, in the same way as inducing simple inflammation by a blister
in one part cures the same disease in another part in the vicinity. It
was an observation of this fact which made it be considered as part
of the description of scrophulous tumors and ulcers, that they not
unfrequently disappear in one place, whilst they show themselves in
another; but, in every instance, this disappearance is an effect, and
not a cause; for we uniformly observe, that, before it takes place, the
new part has begun to inflame or swell.

With regard to the diagnosis of scrophula, it is impossible to say
any thing satisfactory; because, as long as the inflammation remains
trifling, and the skin sound, it is very difficult, if not impossible,
to distinguish a scrophulous swelling from any other of a different
kind. Much assistance has been supposed to be derived from the
situation of the tumors, most of those which appear in the neck being
considered as scrophulous; but this is certainly a false principle.
From the same method of reasoning, most swellings in the groin have
been considered as venereal, whilst many are of a very different
nature, and not a few scrophulous. The best plan is to attend to the
appearance of the body in general, and to the presence or absence of
the sign of a scrophulous system; next, whether any ulceration be
present, by the absorption of matter, from which these swellings may
have been produced. If these be present in a system not possessing the
marks of scrophula, the probability of the tumor being scrophulous
is less; but, if the system be evidently scrophulous, then we must
consider, whether the glands, originally swelled by the absorption of
matter, have assumed the slow inflammation of a scrophulous nature,
or have assumed a different species of inflammation, dependent upon
the peculiarity of the matter; for they can scarcely be supposed to
be simply inflamed. Scrophulous swellings of the lymphatic glands
are generally soft and doughy, and frequently give the feel of
containing a fluid long before suppuration has taken place. They are
at first free from pain, and, in mild cases, even toward the end, the
pain is inconsiderable. When matter is formed, the skin generally
becomes purple, and then gives way in a small spot. Swellings of
the secreting glands are to be distinguished from schiro-cancer, by
the hardness being less, the pain very inconsiderable, the presence
of a scrophulous habit, and by the feel of fluctuation much earlier
than takes place in cancer. Upon the whole, the presumption of any
affection being scrophulous, is to be formed by the presence of the
marks of a scrophulous diathesis, and the absence of such symptoms
and appearances, whether antecedent or present, which characterise
inflammation of a different species, or make us suppose it to have
taken place, whether this be simple or specific. Scrophulous ulceration
is distinguished by its peculiar aspect, joined with the marks of a
scrophulous habit.


_Of the Treatment of the Scrophulous Inflammation._

If the foregoing reasoning be just, it will appear, that, in
scrophulous habits, our great attention ought to be directed to the
prevention of the scrophulous inflammation, which is to be done by
avoiding, as far as lies in our power, the operation of any agent
tending to excite inflammation. It has been observed, that, in
scrophulous systems, very slight causes were sufficient to produce
disease; because the parts on which they act possess a peculiar
constitution, and are less capable of performing their natural and
healthy functions properly, and therefore are sooner rendered diseased.
Inflammation may also be induced by the structure of the part being
such as to prevent it from carrying on its functions properly, and
therefore the same effect is produced as in the former case, where
the constitution, or mode of action, and not the evident structure or
mechanism of the part, was affected.

The lungs are to be prevented from assuming the scrophulous
inflammation, by avoiding, in the first place, all the common exciting
causes of pneumonia, such as cold, damp, &c. It is, in the next
place, to be prevented, by avoiding such causes as tend to increase
the circulation in the chest, or affect the function of respiration.
Hence, violent exercise, climbing ascents, intoxication, thick hazy
atmosphere, are to be guarded against.

The lymphatic glands are to be prevented from inflaming, by avoiding
exposure to cold, and to the other common causes of inflammation,
but especially by preventing the absorption of irritating matter,
such as matter from sores, and the like. A neglect of this is perhaps
one of the most frequent causes of scrophulous inflammation; for
swellings of the glands of the neck can very often be distinctly traced
to scald head, to ulcerations about the ears, little sores in the
mouth, caries of the teeth, or to the absorption of particles of food
allowed to remain and undergo fermentation in the mouth. The greatest
attention ought therefore to be paid to cleanliness. The head ought, in
scrophulous children, to be washed daily, and the sweat removed from
behind the ears; vermin ought to be diligently removed; but mercurial,
and acrid preparations, frequently used with that intention, ought to
be avoided.

The mesenteric glands are to be prevented from inflaming, by
supporting the action of the bowels, and preventing the formation
of irritating matter, which, when absorbed, may swell these glands.
Nourishing digestible diet, conjoined with rhubarb, and such remedies
as act as tonics, at the same time that they keep the belly easy,
are of use in this view; for the whole process of digestion is thus
supported, and neither the feculent part of the food, nor the mucus of
the intestines, become morbidly irritating.

The other parts of the body are to be prevented from inflaming, by
avoiding the usual causes of inflammation, and the action of whatever
may injure the healthy condition of the part, or impede the natural
action. Thus, the knee and ankle joint occasionally become affected
with scrophulous inflammation after fatigue, which injures the healthy
condition of the parts.

Besides these precautions, which are necessary in those of an evidently
scrophulous constitution, with regard to particular parts, it is
likewise useful to preserve as vigorous and perfect a performance
of the natural actions of the system, considered in the aggregate,
as possible, by which we lessen the risk of any one part becoming
diseased; for, whatever impedes or diminishes the performance of the
natural and healthy action of a part (and, in this case, the whole
body is to be considered as made up of parts), renders that part more
susceptible of disease, or derangement of its actions. Cleanliness,
pure air, warm and sufficient clothing, nourishing and digestible diet,
invigorating exercise, and a due proportion of sleep, are therefore
very powerful preventatives of this species of inflammation, insomuch,
that Dionis remarks, that seventy-five out of the hundred, who came to
be touched by the king, were children of the poor peasants.

When scrophulous inflammation does take place, then this invigorating
plan is had recourse to as a cure, whilst, in truth, it is most useful
as a prophylactic. The invigorating plan, which consists in the use
of good diet, moderate exercise, sea bathing, &c. is indeed useful at
this period, both because it tends to make the disease more easily
overcome, and prevents other parts from being injured; but its utility
is still greater as a prophylactic; and it does not appear to have any
certain efficacy in promoting the resolution of scrophulous tumors,
because these have naturally a strong disposition to advance slowly
to suppuration, and therefore are not readily affected by such means
as tend simply to strengthen the system, or support its actions,
because these do not change its peculiarity, or morbid modification,
which existed, ab origine. But, when the tumors have proceeded the
length of ulceration, then they have gone a step farther to a natural
termination; and, although the means which strengthen the system cannot
remove the scrophulous diathesis of the system, they may nevertheless
accelerate the cure of a chronic tedious ulcer, which is slowly tending
of itself to a termination.

The remedies called agentes similes operate more directly on the
scrophulous mode of action than those means which tend simply to
strengthen the system, and may be usefully conjoined with them, because
these agents tend to induce an action different from the scrophulous
one, at the same time that it possesses a certain coincidence with,
or general resemblance to the natural or healthy action. Hence, the
bark has been frequently found to be useful in the cure of scrophulous
inflammation, but oftener of ulceration than tumefaction of the
glands, for the reason mentioned above. It does not appear, however,
to possess, by any means, that certain power of curing scrophulous
affections which is attributed to it by Dr. Fothergill, and several
other authors; nor are we to suppose that it shall infallibly cure
scrophulous inflammation, or ulceration of parts, which, even when
affected with simple inflammation, are very difficult to be cured.
If we find it difficult to cure a simple inflammation, or ulceration
of a tendon, cartilage, or bone, we must not be disappointed if even
a specific remedy for scrophula (granting such a one ever to be
discovered) were to prove ineffectual in procuring a speedy restoration
to health. The bark is likewise often ineffectual, because it is
improperly administered. Given in small quantities, once or twice
a-day, as is frequently done, it may prove a stomachic, and increase,
like other tonic bitters, the power of the stomach, or the functions
dependent on it; but we never can thus obtain the benefits of the
specific action of the bark on the system. For this purpose, it must
be given liberally, in as great doses, and as frequently repeated as
can be done without producing continued sickness, or vomiting; and this
must be continued regularly, late and early, not for days, but perhaps
for weeks, at the same time that we prevent the action of such causes
as would counteract the effects of the bark, such as poor diet, bad
air, confinement[91], &c. Administered in this way, the bark may be
rendered really useful, not only in the cure of scrophulous ulceration,
but perhaps of many other diseases, whilst, in the common way of
prescribing it, little or no benefit is derived from it.

[91] See what has been said on this subject when treating of the cure
of mortification.

The muriated barytes has been recommended by Dr. Crawford[92], and has
of late been tried in France by M. Pinel[93] and others. It does not
appear to have any influence on tumid glands, or scrophulous tumors;
but occasionally it is serviceable in scrophulous ulceration. It is,
however, a medicine on which very little dependence can be placed, and
which fails in a great majority of instances[94].

[92] See the second volume of Medical Communications.

[93] Nosographie Philosophique, Vol. II. p. 238.

[94] When it is wished to prescribe it, the following is a very good
formula:

    R. Terræ Ponder. Salit. Chryst. gr. x.
       Aq. Font.
       Aq. Cassiæ utriusque uncias iii
       Syrupi Aurent. uncias ii.

Half an ounce of this may be given at first, twice or three times
a-day, and gradually increased to such quantity as the stomach can bear
without sickness.

The muriat of lime has been proposed by M. de Fourcroy; it is
given more liberally than the muriated barytes, but it is not more
efficacious.

Iron by itself, or mixed with the fixed or volatile alkalis, has also
been frequently employed, but with very little benefit[95].

[95] This metal was one of the principal ingredients in a remedy used
by the Marischal de Rougeres, which consisted of filings of iron, sal
ammoniac, salt of tartar, &c. Journal de Med. Tom. XL. p. 219.

Burnt sponge, millipedes, vitriolated tartar, and many other trifling
remedies, which were at one time in repute, are now deservedly
neglected.

Cicuta has been greatly recommended by Dr. Fothergill and others[96].
It has very little effect on scrophulous tumors, or mild ulcers; but,
when administered freely, it is sometimes of service in the irritable
fiery ulcer, which was by the older writers called struma maligna.

[96] This is highly recommended by M. Martcau. Journ. de Med. Tom. IV.
p. 121.

Mercury is another remedy, which at one time was much employed in
this disease; but few expect any benefit from it now. Gentle, or what
has been called alterative courses, are, however, still recommended
by many, with a view to satisfy the patient. Various preparations
have been used. Some exhibited the corrosive sublimate, others the
calomel, whilst the acetite of mercury, mixed with the powder of
vipers and earthworm, with the rust of iron, was much employed on the
continent[97]. Antimony has frequently been conjoined with this, but
without much benefit.

[97] Practique Moderne de Chirurger, par Ravaton, Tom. II. p. 3.

Nitrous acid has, I believe, in some cases, a considerable power over
scrophulous ulcers. From the trials which I have made with it, I am
inclined to attribute some effect to it in promoting the suppuration
of scrophulous glands, or tumors, and in disposing ulcers to heal. Two
or three drachms may be given daily, and continued for a fortnight,
provided no bad effect be produced by it, such as pulmonic affections,
&c. If, within this time, no melioration appear, we may give up this
medicine.

The hepatised ammonia, in the dose of eight or ten drops, three times
a-day, is sometimes useful in abating the pain, and changing the fiery
appearance of the irritable ulcer, or struma maligna.

The breathing of oxygene has been proposed as a cure for this species
of inflammation; but it will be extremely difficult for the advocates
of pneumatic medicine to point out any authentic case in which it was
really of benefit.

Much has been written concerning the local treatment of scrophulous
tumors and ulcers; but we are still very much in the dark with respect
to any efficacious method. Formerly, the extirpation of the gland, or
tumor, was advised by all; but, more lately, doubts have been started
concerning the propriety of the practice; and, by most practitioners,
it is now deemed unnecessary, if not dangerous.

In the writings of the ancients, as well as many of the older
writers on surgery in our own country, particularly in the works
of Mr. Wiseman, this practice is freely inculcated; and many cases
are detailed in which the tumor was extirpated with success. Even
in the present day, no surgeon dreads the consequence of removing
scrophulous joints, which, with regard to the present question, are to
be considered in the same light with the glands.

It is supposed, that, by extirpating superficial tumors, the disease
may be transferred to some of the more noble parts, and produce a more
fatal complaint. But, if it be admitted that these tumors do not appear
as necessary parts of scrophula, as the eruption of measles does of the
rubeolous fever, but only as accidental circumstances, or fortuitous
inflammations, rendered tedious and specific by the peculiarity of
the constitution, this supposition will appear to be groundless.
Even granting that scrophulous tumors did appear without any local
exciting cause, and were, in every respect, similar to the eruption of
exanthematous fevers, it will not thence follow, that removing the
local disease, after it has appeared, will make another part become
diseased; unless it be said that scrophula depends upon a particular
morbid humour, which, if denied an outlet in one place, must accumulate
in another, which is a supposition I will not trouble myself to refute.

The arguments, then, against the excision, are not to be drawn from
its danger, but from the pain which it produces, and from the number
of glands which must frequently be removed, and which might perhaps
be resolved without coming to suppuration. It is likewise at times
dangerous to extirpate these tumors, on account of their situation.

On the other hand, when only one gland is affected, when it is
superficial, and has continued so long, in spite of our remedies, that
there is little probability of resolving it, then, by extirpation, we
procure a speedy cure, and avoid a tedious disagreeable ulcer, and
unseemly cicatrix. The existence of the scrophulous inflammation, and
particularly the ulceration, has a tendency to increase the scrophulous
diathesis, or peculiar mode of action of the system. By cutting
this short, therefore, we prevent that evil, and render the system
less susceptible of the scrophulous inflammation, and the chance of
communicating the disease to the progeny less.

It may also be said, that the wound, after the extirpation, might not
heal readily; but the testimony of many writers, as well as what I
have observed myself, convince me that this is not the case; for the
readiness with which the skin unites and heals, when not previously
diseased, produces a speedy cure; whereas, had the diseased gland
remained below, and the specific inflammation been propagated to the
skin, the ulceration must have been tedious.

Upon the whole, then, in determining on the propriety of extirpation,
we must consider whether there be only one gland affected, or an
incipient disease in a chain of glands; and, if only one, whether there
be a probability of this one suppurating; and whether the advantage
of an early removal of the affected part will not be counterbalanced
by our losing the chance of restoring the part, and of preserving its
functions and utility, as, for instance, in scrophulous inflammation of
the breasts, testicle, joints, &c.

Caustics have been proposed with the same view as the incision; but
they are more tedious, produce extensive ulceration, greater pain, and
are much less certain than the operation.

Issues are recommended as a general remedy, to act as a drain to the
constitution, and to render the drying up of the ulcer safe. In this
point of view, they appear to be altogether useless and unnecessary;
but, when employed as part of the local treatment, they are much more
useful. The benefit arising from the use of issues, in the cure of
scrophulous inflammation of the bones and joints, is now so fully
established, by the practice of every surgeon, that it is useless to
insist upon it here. In these cases, it is necessary to insert the
issue, which is generally made with caustic, as directly over the
affected part as possible; and the size of this issue ought in general
to be correspondent to the extent of the disease. There are two
circumstances which greatly tend to render this practice efficacious,
and which ought to be fully attended to: First, that the disease be
allowed to gain as little ground as possible before the insertion of
the issue, or that the issue be inserted as early after the disease
is observed as the patient will permit. Second, that, during the
continuance of the issue, every circumstance be avoided which may
counteract its use, such as much use of the joint, or other species of
irritation. In diseases of the lower extremities, therefore, whatever
exercise produces pain must be carefully avoided; and, for the same
reason, in diseases of the spine, proper contrivances to relieve the
diseased bone from pressure are necessary to be conjoined with the
issue. It sometimes happens, that matter has either formed before the
insertion of the peas, or some time afterward. In this case, it either
comes to be discharged by an opening through the ulcerated surface, or
issue, or it bursts at a more dependent part. In the first situation,
no change of treatment is necessary; in the second, it is of service to
insert a pea over the mouth of the aperture, which has a tendency to
heal the part below, and prevent the formation of a tedious sinus. When
the part becomes free from pain, and the soft parts have subsided in
their swelling, and matter does not appear to be forming, or does not
continue to be formed, if it had already been secreted, we may consider
that the effect of the issue is now produced, and may begin gradually
to diminish its size.

Issues, employed as a local remedy, have hitherto been chiefly used
in diseases of the bones and joints, and sometimes in scrophulous
affections of the liver, or lungs; but it is reasonable to suppose
that they ought likewise to be useful in the cure of enlargements of
the glands, and other scrophulous tumors, if inserted in the immediate
vicinity of the part. The only objection to their use is the cicatrix
which they leave, and which, in certain situations, we would wish to
avoid. When the tumor is thickly covered with the integuments, the
issue may be made directly over it, by means of a blister, kept open by
savine ointment[98], or any other irritating preparation; but, when the
tumor is thinly covered, this will not succeed, as the inflammation
consequent to the insertion of the issue will be communicated to the
gland which is in immediate contact with the ulcerated surface. In
this case, a small pea issue, or seton, may be inserted by the side of
the tumor. In scrophulous inflammation of the glands of the neck, this
remedy is not adviseable, owing to the scar which it leaves; but, in
affections of the mammæ, and some other parts, it may be useful.

[98] This ointment may be prepared by macerating one part of recent
savine leaves bruised, in four parts of ung. resinos.; it is then to be
strained.

Blisters, frequently repeated, are sometimes, in slighter cases of
affections of the joints, used in place of issues.

Preparations of lead are frequently employed, and, where the tumor is
painful, are often of service. When the lymphatic glands are inflamed,
a saturnine solution[99], applied cold to the part, by means of a
compress of linen, and frequently renewed, has a tendency to abate
the pain and resolve the inflammation. These solutions are sometimes
employed warm, particularly in affections of the bones or joints; but
they do not, in these cases, seem to have any considerable superiority
over fomentations with warm water.

[99] The following may be used for this purpose:

    R. Ceruss. Acetat. drachmam unam.
       Aq. Rosar. uncias octo. Solve, dein cola.


Cloths dipped in cold water, sea water, or weak vegetable acids, have
also been used, and have a tendency to abate pain, but are inferior to
the saturnine solution.

Ether, applied with a pencil to the part, is also sometimes of service.

Sea salt, mixed with bile, has been recommended, but has very little
effect.

Camphorated liniment is very frequently used, in which case the part
is generally kept warm with flannel. It does not, however, appear
to possess any very great power of discussing these tumors; but the
friction which is made use of with these sometimes hastens the removal
of these tumors, and may be usefully alternated with the use of the
saturnine lotion. A mixture of ether and linimentum opiatum may be
employed for the same purpose.

Hemlock poultices were at one time in repute, but they have now lost
their character.

By these means, even after a small quantity of matter is formed in
the gland or tumor, we may discuss the tumor, or make it less; but,
if the quantity of matter should continue to augment, we may consider
resolution as out of the question. Our object must then be to bring
the part to suppuration as quickly as possible; because we not only
thus shorten a process which must be completed before the parts can be
healed, but also render the ulcerative action more healthy, and easier
induced; for the more quickly that the suppurative action is performed,
the sooner does the ulcerative action take place, and the more vigorous
is it, provided that no new cause render it unhealthy, as has formerly
been mentioned.

This advice, however, must not be adopted without some exceptions, and
must be chiefly confined to affections of the glands and cellular
substance, and ought not to be extended to the joints. In these
cases, even although a small quantity of matter form, we ought still
to endeavour to prevent general suppuration, and the bursting of an
abscess; because this would, instead of accelerating the cure, as is
frequently the effect in the other case, be attended with dangerous
consequences; we must therefore rather continue the use of the issues,
and endeavour to procure the absorption of what matter is already
formed.

The means employed for promoting suppuration were formerly poultices
of lily roots, honey, &c. alternated with fomentations prepared from
pomegranate seeds, and myrrh, and cypress leaves, or, occasionally,
stimulating plasters; but now the common bread and milk poultice is
advantageously substituted in place of these remedies. When the
process is very tedious, electricity is useful along with the poultices.

When these tumors have suppurated freely, and an abscess occupies
the whole of the gland, it is useful to evacuate the matter by a
small opening with a lancet, if there be no appearance of the abscess
bursting quickly, and the sooner this is done the better. When this is
done, a poultice should be applied until next day, the part is then to
be wiped clean and dry, and a small bit of lint, spread with simple
ointment, applied on the orifice. The surrounding red skin is to be
dulled with powdered cerussa[100], and then covered with dry lint. A
compress is to be laid over the whole, and moderate pressure employed.
These applications are to be renewed every day, or twice a-day,
according to the quantity of the discharge, and other circumstances;
and, at each dressing, the parts may be bathed with spirit of wine.
If this mode of dressing does not produce a cure, but the opening
enlarges, and the surface ulcerates, we must then employ the dressings
for a scrophulous sore.

[100] Keeping this skin dry has a tendency to prevent ulceration,
and abate the redness and inflammation. The cerussa may sometimes be
advantageously mixed with an eighth part of powdered camphire, which
promotes the removal of the superficial inflammation.

When, notwithstanding the use of issues, matter is formed in joints,
or, when these fail to procure the absorption of what was formed before
they were introduced, then one of two things must happen; either the
abscess must be punctured, or it must be allowed to burst of its own
accord. In general, I believe, it is most advantageous to allow the
abscess to burst, without any interference, except the continuance of
the issue, or the establishment of such new ones as circumstances,
particularly the situation of the pain, may point out. If, however, it
were at any time deemed proper to evacuate the matter, this ought to be
done with a small trocar, at different times, in the manner recommended
by Mr. Abernethy for the cure of lumber abscess. This is infinitely
preferable to the barbarous practice which even some surgeons high in
reputation advise and make use of, I mean the insertion of a seton
through the abscess of the joint[101].

[101] Bell on Ulcers, p. 471.

When the scrophulous suppuration ends in the ulcerative action, the
cure is generally tedious. It is even doubted by some how far it is
safe to attempt a speedy termination to the ulcer, as it is supposed,
that, in this case, the disease may be driven to some other part: And
so fearful are they of this dreadful event, that they are careful, by
issues and new artificial sores, to continue the discharge after the
original ulcer is healed.

If I have been right in my view of this disease, it will appear, that
this reasoning is false, and that the practice is both useless and
troublesome. Even those who propose and defend the practice, do so not
upon the principles of reason and judgment, or from logical deductions
from the theory which they give of the disease, but upon imaginary
apprehensions. We find, for instance, Mr. Bell saying, that, “till the
disease is eradicated from the habit, all that should in general be
done to the sores, is, to give as free and open vent to the matter as
possible[102].” From this, we should, without doubt, expect, that he
considered scrophula as dependent upon some peculiar humour which was
to be expelled; but just before we are told, that this disease depends
upon debility, particularly of the lymphatic system; a condition
which it is not customary to talk of eradicating, or rooting out, or
expelling. Upon the common principles of reasoning, Mr. Bell ought only
to have forbid healing the sores, until the system was strengthened,
otherwise the weakness would be driven or determined to some other part.

[102] Bell on Ulcers, p. 427.

Moderate pressure, by means of adhesive plaster, conjoined with the
application of cold water, is one of the best remedies for the mild
scrophulous ulcer, when it is situated so, that this can be used. When
it is not, then dusting the part thickly with cerussa, containing a
sixth part of powdered alum, may be had recourse to. A piece of dry
lint is next to be applied, and a compress bound down, with such
pressure as can be used. It is sometimes useful to dip the compress in
cold water, and renew it frequently.

The ceratum e lapide calaminari forms a very good dressing for this
sore, when it is intended to leave it to follow its own course.

As a stimulant, the unguentum resinorum, either alone, or mixed with
red precipitate, is often used; but it seldom is of service, and
often makes the sore irritable. If, however, the ulcer become very
indolent, this, or the citrine ointment, properly diluted[103], may
be of service. The same may be said of the other common stimulating
applications.

[103] This application forms a very useful remedy for the scrophulous
ulceration of the eye-lids, which we so frequently meet with.

Poultices made of bread and sea water have been recommended, but seem
to possess little power of accelerating the cure.

Solutions of alum, of blue vitriol, corrosive sublimate[104], of the
nitrites of copper, bismuth, and silver, are sometimes useful to wash
the sore with.

[104] This substance is the basis of a celebrated lotion for the face,
which is sometimes useful in chronic pustules, which are frequently of
a scrophulous nature. It promotes suppuration, the pustule then scabs,
and, when this falls off, the part is sometimes found sound below. It
is made by dissolving corrosive sublimate in an emulsion of bitter
almonds.

The recent leaves of the wood sorrel bruised, and applied raw to the
sore, is sometimes useful. The same may be said of cloths dipped in
lemon juice, or vinegar and water.

Saturnine ointment is much employed by some, for abating heat and pain;
but is inferior to compresses dipped in cold water.

Sometimes only the anterior part of a scrophulous tumor suppurates and
ulcerates, and the deeper part of it remains swelled and hard. In this
case, the bottom is generally covered with a slough, which comes slowly
away piecemeal, and is renewed for some time, until the tumor subsides,
partly by sloughing, partly by absorption, and partly by the subsidence
of the remaining inflammatory action. In this case, sprinkling the
surface lightly with precipitate, or blue vitriol, is of service; and
this may be alternated with the common warm poultice. When the surface
becomes cleaner, dry lint forms a very good dressing; and this may be
covered with a pledget of linen spread with cerate. Afterwards pressure
is useful.

The irritable overacting sore, or what has been called the struma
maligna, is very difficult to manage, especially as it is frequently
connected with a diseased state of the bones or tendons below.

The hepatized ammonia, diluted in the manner formerly mentioned, or
simple ointment, mixed with opium, are sometimes of use.

Poultices of bitter almonds, beat up with a little olive oil into a
fine pulp, and then warmed, occasionally relieve the pain, and make the
ulcer more healthy.

Carrot poultices, or warm poultices made of bread and strong decoction
of camomile flowers, are also sometimes of use.

Carbonic acid gas, or carbonated hydrogene, are sometimes of temporary,
rarely of permanent advantage.

Anodynes, internally, are useful here, as in other painful sores.

In all cases of scrophulous inflammation or ulceration, it is useful
to exhibit, alongst with the proper local treatment, such internal
medicines, and to attend to the constitution, in such respects as
may be deemed proper. Upon these points I have already made some
observations.

When the local disease cannot be cured, and has induced the scrophulous
hectic; when this cannot be removed by the means commonly employed, and
which have been mentioned in the dissertation on simple inflammation,
then the diseased part must be removed, if its situation permit.
This must not, however, be rashly done, but must be delayed until
we ascertain, that our remedies, general and local, (which must be
used with assiduity and care), are of no avail. It is not sufficient
that the hectic continues, and that other appearances are almost
stationary; they ought to be augmenting, in order to justify amputation
of a useful and important part; because every practitioner must have
observed the recoveries which take place, even after the hectic fever
has made considerable progress. On the other hand, we must not allow
the constitution to suffer too much, but must interfere, whenever
we perceive that our labours are fruitless, and that the hectic is
regularly and progressively increasing, and the strength sinking. When
this is observed, the only chance for life is an operation; and every
day this is delayed adds to the risk attending it; for there is a
degree of injury, more than which the constitution cannot sustain, and
which will prove fatal, even although the exciting cause be removed.
To fix the proper period requires judgment in the surgeon; but he
may be enabled to do so, by attending carefully to the state of all
the symptoms; for whenever these continue progressively to become
worse, and have reduced the patient already to a state of weakness,
which cannot be much increased without danger, he may consider it as
impossible to delay amputation longer with any hopes of success.

Having made these observations on this species of scrophula, I shall
now conclude, by shortly mentioning the mode of treatment adopted by
the older practitioners.

Bleeding, which at first was made use of according to the custom of
the day, was soon laid aside, on observing, that, in many cases, it
was manifestly hurtful, and in every instance useless. But although
the plan of general depletion was given up, yet local evacuations
were much insisted on; for they held it as absolutely requisite,
that the brain should be purged of its pituita, (the redundancy of
which produced the disease), by errhines, fomentations to the ears,
and the application of issues and sinapisms to the head. The stomach
was cleared of viscosities, by emetics of mustard or broom-seed;
the bowels, by aloes; and the skin and kidneys, by sudorifics and
diaphoretics.

Having thus procured a sufficient evacuation, the patient was desired
to smell a pomum odoratum, composed of styrax, amber, myrrh, aloes,
and many other ingredients; the vapours of which were supposed to get
up to the anterior ventricles of the brain, and dry them. Hunger and
thirst, by drying the juices, were decreed to be salutary. Every thing
was rendered nauseous with medicine. The bread was seasoned with anise
and fœnugrek seeds, and the drink consisted of decoctions of guaiac and
mastic wood, which last was “a friend to the brain and viscera[105].”
As a condiment to these medicated meals, Arnoldus de Villa Nova treated
his patients to the burnt sponge, mixed with salt and pepper.

[105] Laurent. de Strum. Nat. p. 67.

But these, and indeed all the medicines yielded by the materia medica,
were considered as trifling, and of no avail, when compared to the
miraculous power possessed by the king, who, with one touch of his
hand, could banish this dreadful disorder, and dry up all the sores. So
valuable did this royal prerogative appear in the eyes of many, that
it became a national controversy, whether it belonged to the French
or English; whilst the Romish and Protestant churches reciprocally
urged this prerogative of the king of the country where they were
established, as a manifestation from heaven of the justice of their
cause.

In France, the king touched publicly, at four dated feasts in the
year, preparing himself the day before by prayer and fasting; then
entering the apartment where the sick were arranged, the patients
were individually presented by the chief physician to his majesty,
who placed his hand upon their head, pronouncing these words, “Le Roy
te touch, et Dieu te guarit.” The sick then retire, and soon find a
manifest amendment. “In some the ulcers dry up; in others the swellings
diminish; and, wonderful to relate, in a few days, more than 500 out of
1000 are perfectly cured!”--“Hic hœrant philosophi, cœcutiunt medici,
stupet prophanum vulgus.”

Upon reading these accounts, we smile at the credulity of mankind; but
we pity them, when we learn, that near a thousand every year made weary
and expensive pilgrimages, from very distant countries, to purchase
this imaginary benefit.




DISSERTATION VI.


_On the Cancerous Inflammation._

The cancerous inflammation generally comes in slowly, in some glandular
part, which becomes rather harder, and somewhat larger[106], than it
ought to be; but the pain, for the most part, at first is trifling.
By degrees, both the hardness and swelling increase, and a pain, like
the pricking of needles, is felt in the part. This pain, after some
time, becomes more violent, darting through the whole of the gland,
and leaving a sensation, as if the part had been rudely wrung or
twisted. The tumor still remains moveable under the skin, which is
of the natural colour; but when the disease has continued a little
longer, a greater degree of inflammation takes place, and adhesions
are formed betwixt the skin and the gland, or the gland and the parts
below, at the same time that the pain becomes more continued. The
skin now becomes puckered, or drawn inward, and of a dirty or leaden
hue, which in time acquires more of the red, but is never of a bright
colour. The veins are varicose, and the tumor is, with difficulty,
moveable. When the skin becomes red, we may be able to discern a
superficial fluctuation, which proceeds from part of the gland forming
an abscess[107]. This at last bursts, and discharges a thin yellowish
matter, which frequently oozes out in very considerable quantity; the
orifice enlarges, and the sore penetrates, for a little way downward,
pretty rapidly, and the edges become hard, and overlap a small part
of the disk of the sore; but, soon after this, a fungus rises up; and
although, in some places, the ulcer may become deeper, yet its chief
progress is laterally.

[106] Although the affected gland becomes rather larger, yet the
surrounding cellular substance sometimes diminishes, and the
neighbouring glands are rather contracted, in which case the part seems
to be shrunk.

[107] This abscess sometimes, though very rarely, occupies the whole of
the gland, but oftener only a part of it; and if the gland be large,
there are sometimes several abscesses, of considerable size, which form
unconnectedly with each other, and burst separately.

The cancerous ulcer increases more or less rapidly, and is soon
attended with a burning pain; the surface is unequal, excavations
appearing in some parts, whilst in others a fungus rises up. The
colour is brown, but glistening or fiery. The granulations very soft
and indistinct. A thin ichor, of an abominable fœtor, is discharged in
great plenty, mixed with blood; whilst, in many parts, small pellicles,
like lymphatic exsudations, cover the sore. The surrounding skin is of
a dark purple colour, and the adjacent parts very hard. The margins,
which at first were overlapping the sore, in the course of a few days
are uniformly elevated, and frequently retorted and unequal, as if they
had been bitten by an animal; and over these the fungus frequently
shoots or protrudes, so that the sore assumes the appearance of a
cauliflower. This ulcer bleeds a little upon the slightest touch,
so that at every dressing the cloths are generally bloody; but, at
times, this bleeding is more alarming, proceeding from the bursting
of the diseased veins. These hemorrhages are, in some instances, very
frequent, and reduce the patient to the greatest weakness. Sometimes
they suddenly relieve the unhappy persons from all their woe.

Some time after the abscess forms, and frequently before ulceration
takes place, the neighbouring lymphatic glands swell, and become
affected with a similar action, and follow the same course with the
original sore; only in them the progress is generally more rapid.

After ulceration takes place, sometimes before it, if the abscess
be considerable, hectic fever takes place; the countenance becomes
sallow and unhealthy; the pulse quickens, and becomes small and sharp;
the strength fails; night sweats come on, and colliquative diarrhœa
hastens death.

The parts in which cancer most frequently appears, are the under lip,
the breasts of women, and the testicles of men: But there is no one
part of the body in which it may not occur, although most frequently it
is, in its original attacks, confined to secreting glands.

In the breasts, parotid glands, and some other conglomerate glands,
the disease begins as has been described; but on the skin, and in some
other parts, the progress is somewhat different. The skin, particularly
that of the face, is apt to have a small chronic pustule formed on it,
by the inflammation of one of the sebaceous glands, which, by degrees,
becomes harder, firmer, and more elevated. Soon afterwards, it becomes
rough, and of a warty appearance: It then ulcerates on the surface.
This is covered with a scale or scab, which repeatedly falls off, and
forms again upon the part, until it assume the appearance and character
of the cancerous sore. But, more frequently, the disease is not allowed
to follow this progress, the wart either being rubbed off accidentally,
or removed by ignorant persons. The part then forms a superficial
ulcer, which is slightly hollowed. It is of a glistening flabby
appearance, and the margins are hard, tumid, and a little turned back:
But after the disease has continued some time, the flabby appearance of
the sore is converted into fungus. We may, therefore, from this, and
other cases, conclude, that cancerous ulcers, which are formed without
previous abscess, form fungus more slowly than those which are formed
with them.

When the lips become cancerous, there is generally first perceived
an indurated lump, of greater or less bulk. The skin over it becomes
tender, frets, and is covered with a scurf or scab, which gradually
becomes elevated. Part falls occasionally off, but it is soon replaced.
This by degrees extends itself over the prolabium, and, after some
time, falls off entirely, leaving the part with all the common
characters of the cancerous ulcer. The pain is burning.

When the testicle becomes cancerous, it sometimes follows the common
course of cancer in other glands, beginning with hardness and shooting
pain in some part of the testicles or epidydimis, which gradually
forms an abscess, and ulcerates. But, at other times, soon after
the testicle becomes diseased, an effusion takes place within the
tunica vaginalis. In this case, the disease of the testicle becomes
complicated with hydrocele. It is distinguished by our feeling the
hardness of the epidydimis behind, or the hardness and inequality of
the testicle, when the water is drawn off. It likewise, after some
continuance, becomes more painful than a common case of hydrocele. If
the testicle be not extirpated in due time, the cord becomes hard and
swelled, and comes to ulcerate.

Cancer in the penis generally begins by a kind of warty tumor, and
follows the course of cancer in the face. Sometimes the penis becomes
just like a cauliflower, a large fungus extending from its ulcerated
extremity.

The uterus, in elderly women, is very frequently affected with
cancer[108]. It begins with a feeling of weight and uneasiness in the
lower part of the belly, and the natural discharge of the parts is
increased, so that the disease passes for fluor albus. By examination,
however, we may generally discover a hardness, and sometimes an
inequality, about the os uteri, and may discover the uterus to be
unequally enlarged. After some time, ulceration takes place, and
matter, mixed with a bloody fluid, is discharged. Occasionally,
considerable hemorrhages take place, which are not unfrequently
confounded with menorrhagia; but it may be distinguished by the
continued discharge of a bloody sanies during the intervals of the
hemorrhage; by the continual pain, and especially by our feeling the
projection of the os uteri into the vagina, in some places hard, and
in others soft, but rough, which shows ulceration. After some time,
the glands about the vagina swell; and that canal, in many places,
becomes considerably straitened. Hectic terminates the sufferings of
the patient. On opening the body, we find the uterus generally though
not always, considerably enlarged, with abscess and ulcers in different
parts of its substance. These ulcers, as well as those of the ovarium,
and, so far as I know, every gland in the internal cavities of the
body, have a less tendency to fungate, than cancerous ulcer on the
surface of the body.

[108] It has been said, that genuine cancer is very rare in the uterus,
and that the cases which pass for such are phagedenic. But although the
uterus may be affected with scrophulous inflammation, and phagedenic,
as well as some other specific affections, yet it must be admitted,
from an examination of cases, that the uterus is very frequently
attacked with true cancer. Its substance is found enlarged, hard, and
containing cancerous abscesses in different parts.

When inflammation attacks any organ, or part of the body, and leaves
a chronic tumor, this may assume, as will afterwards be mentioned, a
new inflammation, and may become affected with cancer; though it more
frequently happens, that it assumes the pseudo-cancerous action. The
symptoms and progress of cancer are much the same here as in the breast.

When the eye becomes cancerous, it, unless the disease begins in one of
the glands, such as the lachrymal, or those of Meibomius, is first of
all affected with simple inflammation, which destroys the whole texture
of the eye, and makes it of a different structure, rather resembling
a confused mass than a well organised body. The lucid cornea becomes
opake, and protrudes; the eye enlarges, is affected with a violent
deep-seated pain, and at last bursts, generally on the apex: From this
a fungous substance protrudes, which manifests all the symptoms of the
cancerous ulcer, and in a short time arrives at a great size.

When the nose becomes cancerous, the disease either begins in the
outside, with a small tumor or wart, as in other parts of the face, or
within, by a firm and somewhat painful polypous projection, which frets
on the surface, and soon assumes the cancerous ulceration.

The diagnosis of this disease is of the utmost importance; because
if we mistake cancer for some other disease, we not only neglect the
proper practice, but frequently are led to prescribe remedies which
do infinite harm. If, on the contrary, we mistake another disease for
cancer, we neglect the necessary means of cure, and may even be led to
extirpate a part which might be easily cured by gentler treatment.

Cancer may be confounded with scrophula, syphilis, and some other
affections, which have received no particular name.

There is an affection[109] which begins like cancer, by a hard
schirrus, either of a gland, or still more frequently of one of the
chronic tumors, which has been already mentioned as succeeding slow
inflammation. This remains, for a considerable time, hard, and free
from pain, and there is no puckering of the skin over it. By degrees,
some part of the surface becomes of a purple or livid colour, and
ulcerates. This ulcer remains long superficial; the edges are hard and
rounded; the discharge is thin; the surface is glossy, and no distinct
granulations can be seen; the pain is slightly smarting, but not
burning, and instead of being fungous, the sore is slightly hollowed
out below the level of the surrounding skin. By the continuance of
this affection, the gland is apt to shrink and diminish in size;
and generally where this takes place, the sore contracts and heals
with a very puckered unequal cicatrix, having, in some places, a
thick dark coloured scab covering it[110]. The neighbouring glands
become affected; but they are soft, and rather resemble the spongoid
inflammation than schirrous hardness: But I have never had an
opportunity of observing them proceed the length of ulceration. If the
continuance of the sore be long, the constitution is affected, and the
patient becomes hectic[111]. This kind of ulcer may be distinguished
from cancer, if we attend to the absence of the fungous, and peculiar
appearance of the cancerous sore, and the want of the burning pain:
But, before ulceration takes place, the two diseases may be confounded;
because there are no certain characteristics of schirro-cancer.

[109] To this specific affection, we may give the name of
pseudo-cancer, for want of a better designation.

[110] Of this nature was probably the ulcer mentioned by Mr. Wiseman,
at least if we may judge from his very short description: “It had eat
deep into her left breast, and was fixed to the ribs, but not with much
pain. In progress of time, the lips inverted, and united, as it were,
and lay covered with a crusty scab; the humour in the mean while spent
itself upon the nerves, &c. She lived long, and, in her latter age,
tolerably healthful.” Chirurg. Treatises, Vol. I. p. 165.

[111] Extirpation is the only certain cure of this disease; and it is
at all times the quickest and the best; but, by eschoritics, we may
sometimes procure cicatrization, at least if the gland have shrunk, and
most of its substance been destroyed.

This disease may attack the uterus, and is very apt to be confounded
with cancer; nor is it easy to distinguish them, as the parts are
unseen. There is never much enlargement. The ulcer is pretty smooth,
and the margins circular, hard, and glabrous. The pain is not very
considerable. The discharge is thin, copious, and of a yellowish
colour, but seldom bloody, unless when the disease has continued very
long.

The spongoid inflammation has been considered as cancerous by those
who have seen it; but the distinction betwixt the two is sufficiently
obvious: The one begins with a spongy elastic tumor, the other with a
firm hard lump.

Scrophula may be mistaken for cancer, when it appears in one of the
secretory glands, such as the breasts; at least as long as it remains
without ulceration. But the tumor generally enlarges more rapidly than
cancerous tumors, at least such as are not very painful. It is pretty
soft and doughy, the pain is inconsiderable, and we may generally
perceive the marks of a scrophulous habit. When ulceration takes place,
the opening is, for some time, sinous, and the matter discharged is
curdy, and without fœtor. When the ulceration extends along the skin,
it has not the fungous appearance of cancer, but the aspect of a
scrophulous sore, and the gland below appears sloughy. The pain is not
very considerable, and is not the burning kind.

Scrophulous inflammation may also attack the uterus, bladder, and
any of the internal organs. The uterus and bladder become thickened,
and contain abscesses in different parts, which point on the surface
of these viscera. They are filled with a thick white cheesy-looking
matter; and when they burst, they produce ulcers, with a foul surface,
and having the margins notched, and lying for a considerable way over
the disk of the sore.

The distinction betwixt cancer and the venereal ulcer is so very
striking, that it is scarcely possible for these diseases to be
mistaken for each other, if the discriminating marks of each be
attended to. The cancerous sore is always dark coloured; the surface
fiery, yet of a fungous nature; the discharge foul, and of an
intolerable smell; and the bottom and surrounding parts are hard and
painful. If there be not an open running sore, the part is covered with
a dry elevated scab, of a dark colour; the skin around this is livid,
and the neighbouring parts indurated. The base of the venereal sore is
much softer, the discharge is of a different nature, and its aspect so
peculiarly unlike the cancerous sore, that it is impossible to confound
them[112].

[112] It is to be regretted, that some who belong to our profession,
reason upon the nature of ulcers, not from appearances and
characteristic marks, but from the patients manner of life, or the idea
which they have formed of the country whence they come. I remember two
instances of people who came from the Hebrides, the one with a cancer
of the lip, the other with a cancerous ulcer on the neck, both fungous,
and possessing the burning pain, and every character of cancer; but
as the sibbens unluckily prevailed in that country, it was thought
that the patients might have received this infection, and accordingly
were, by a full consultation of surgeons, condemned to undergo a course
of mercury. The lip was, in three days, greatly worse; the mercury
was omitted, and the patient cured by an operation. The sore on the
neck was instantly exasperated, and the patient, to use the words of
Hildanus, “had her soul speedily sent to heaven.”

There is another disease, which is very apt to be confounded with
cancer, and which, at one period, resembles it very much. It begins
with a small tumor, like a phlegmon, of a dull colour, and without much
pain. This soon assumes a soft elastic feel, and bursts at the top; a
bloody matter oozes out, the lips of the orifice become tumid, and the
integuments ulcerate. The whole has a convex surface, the ulcerated
part being most prominent; and the sloping margins are red and painful:
The ulcer itself is foul, of a dark fungous appearance, and covered
with thick offensive matter, with sloughs in different parts; the
margins are hard, and lie, in a serrated manner, over part of the
sore: The pain is smarting. This sometimes spreads to a considerable
extent, and cuts off the patient. At other times, by the use of mild
dressings, good diet, and opium internally, the fungous surface sloughs
off by degrees, and shows a smooth red bottom, somewhat striated, and
of a glossy appearance, which contracts, and scabs over, like the
pseudo-cancer. The fungus, in this ulcer, never rises high; it is
generally slightly convex, being most prominent at the centre, and has
never the retorted trumpet-like appearance of some cancers.

Phagedena has sometimes, particularly on the yard, been confounded
with the cancerous sore. It has indeed the brown fiery colour, and
smarting pain, possessed by the cancerous ulcer; but it wants the
fungous appearance, which the cancer very soon assumes. It spreads
with greater rapidity, and is not surrounded by the same hardness. It
begins likewise more suddenly, and without any previous hard tumor. We
frequently hear of venereal buboes becoming cancerous; but this seldom,
if ever, happens; and phagedena has, in this case, been confounded with
cancer; for that spreading fiery honey-comb-like ulcer, which venereal
buboes sometimes turn into, is evidently of the phagedenic nature.

It was from allowing too great latitude to the description or
definition of cancer, as well as from the numerous divisions admitted
by the older writers, such as mild, raging, and the like, that many
diseases have come to be considered as cancerous, which are in their
nature perhaps radically different from it.

The mild cancer was said to begin slowly, with little pain, to continue
long indolent, and to ulcerate slowly: The ulcer was not very painful,
and frequently healed with a scab, or remained long stationary. This
evidently was not a cancerous disease, but the one which I have
described above. On cutting into this tumor, after extirpation, we find
it to be of a firm texture, the interstices filled with a kind oily
matter, and no cavities with thickened sides in its substance.

The malignant, or true cancer, begins with a hard schirrous tumor, with
frequent lancinating pain; the skin soon adheres to the gland, and
becomes slightly puckered, and of a livid or leaden colour; the veins
are more or less varicose, although the tumor be not large; and the
nipple, when the disease is in the breast, is generally drawn inward.
The integuments next become red, and a small opening forms, through
which is discharged a bloody serous-looking matter, generally in very
considerable quantities. The ulcer which succeeds this is, at first,
superficial, affecting only that part of the integuments which covered
the pointing of the glandular cyst or abscess. It is dark coloured
and fiery, like phagedena; but the edges are hard and ragged, and
overlap irregularly, in different spots, small parts of the surface
of the sore. In the course, however, of a few days, sometimes in a
few hours, a fungus protrudes, and increases more or less rapidly,
at the same time that the sore spreads laterally. This fungus is
very irregular, of a dark colour, and covered with sloughy-looking
pellicles. It generally sprouts out most toward the circumference,
so that the sore has often the appearance of the mouth of a trumpet;
or if the cavity in the middle be less, the fungus being less turned
out, it resembles a cauliflower. This fungus uniformly projects over
the margins, which are hard and red. The matter discharged is thin,
bloody, and exceedingly fœtid. On examining these glands, we find them,
in the commencement, to be hard, like a substance intermediate betwixt
gland and cartilage, and of an indistinct granulated structure. Soon
afterwards, we perceive small abscesses or cavities in different parts,
which are filled with a serous fluid, and the sides of which are hard
and firm, like gristle. These enlarge gradually, and new ones form; so
that were we to cut the gland, we should find it containing a great
number of these cavities[113]. Those which are nearest the surface of
the gland, generally enlarge most; and sometimes only one gains any
considerable size. Before this bursts, its sides become more opake, and
more blended with the rest of the gland, (which, where it surrounds
the abscess, becomes softer, rather more vascular, and more porous
or spongy than in other parts, and than it formerly was), unless it
distend beyond the substance of the gland, pushing the skin outward.
In this case, when it bursts, a great quantity of lymphatic matter
is discharged, and the part collapses, and then exhibits the usual
appearances of the cancerous ulceration: But, more frequently, we find
the abscess remain altogether in the gland, and only distend the skin
a little at the apex, where it points. When the abscess bursts, more
or less fluid is discharged, and immediately the inner surface begins,
like the orifice, to ulcerate. A fungus is produced from the sides of
the abscess, which fills up the cavity, and then protrudes from the
orifice. We, therefore, find, that when the cancerous abscess bursts,
the orifice at first assumes the appearance of a cancer which begins
in the cutis[114]; but very soon a fungus protrudes, and the ulcer
gradually becomes more convex, or more like a cauliflower.

[113] These are sometimes very irregular in their shape, and have their
sides very thin; so that, at first sight, they appear like cavities
formed by the separation of the fibres of the part.

[114] That is to say, the sore is rather flabby than fungous; for
cancerous ulcers which begin superficially, and without previous
abscess, remain a considerable time without forming fungus; but when an
abscess bursts, and the skin ulcerates in consequence, then the sore is
not superficial, but communicates with the abscess, which forms fungus
quickly.

These abscesses, with thick sides, are characteristic of cancer,
and are never found wanting in a cancerous gland. When they are not
present, we may be certain, that the tumor is a different kind of
schirrus. But although these be always found in the glands, and form
in them a certain mark of cancer, yet they are not necessary to the
existence of that disease; for the cancerous ulcer, like common ulcers,
may begin without previous abscess, as we observe in the cancer of the
skin, which, in nine cases out of ten, begins with excrescences like
warts.

By attending to these circumstances, we may generally form a pretty
just diagnosis. At the same time, it must be admitted, that,
occasionally, cases do occur, in which it is impossible to deliver a
decided opinion: Nor is it doubtful, that many ulcers are considered
as cancerous, which are of a different nature, and some of which admit
of a cure. In forming our judgment, we must be directed by the nature
of the first symptoms, and the history of the schirrous stage; by the
appearance and aspect of the fungus, and the other circumstances which
have been already described.

Concerning the peculiar state of the parts in cancer, or the proximate
cause, many opinions have prevailed; but these, however they might
differ in certain points, have almost unanimously agreed in admitting
obstruction as the chief cause of this disease.

Until lately, the melancholic humour was supposed to be the fluid which
was obstructed, and accumulated, in consequence of which it fermented,
and produced a burning ulcer; and whatever promoted the generation
of this humour, was currently admitted as a remote cause of cancer.
Women, says Ambrose Paré, are more subject to schirrus than men;
“because their liver is warmer, and their spleen being weaker, is less
able to purge the blood of choler.” Grief and chagrin, by promoting
the formation of this fiery fluid, were accordingly considered by the
celebrated Heister, as very apt to induce the “cancerous diathesis;”
and he slyly adds, by way of corollary, that “old maids, and women who
do not breed, are very subject to cancer in the breast[115].”

[115] Heister’s Institut. Vol. I. p. 229.

Concerning the particular changes which took place in the nature of
this obstructed humour, many different opinions prevailed. Some thought
it necessary, that the black bile should be charged with an acid,
and that this produced ulceration, when “its sharp cutting points
had surmounted and destroyed the volatile smegmatic and balsamic
salts of the blood.” Others conjectured, that by an “adustion or
over-concoction,” it grew sharp and burning: But Wiseman observes,
that it is more probable that it becomes somewhat arsenical. It
would, however, be useless to enumerate the different changes which
this imaginary humour was supposed to undergo. It is sufficient to
observe, that these were almost universally believed to depend upon the
previous stagnation, in consequence of obstruction; and this leading
point has uniformly been insisted on by every succeeding author,
whatever might have been his particular notion with regard to the
nature of the obstructed fluid, whether bile, blood, or lymph; and
even the anatomical structure of the part has been brought in support
of the doctrine of obstruction. One of the latest writers[116], though
he talks nothing of “coagulating acids[117],” yet insists fully on
this mechanical cause as the origin of cancer; “for,” says he, “the
circulation in the glands being carried on by a set of vessels much
more minute than those with which other parts of the body are supplied,
(let this be proved), obstruction will much more readily and easily
occur in them than in other parts.”--“When the substance of a gland
happens to be the part, a determination is made to this, being neither,
as is found by experience, so proper as the cellular substance, or
the formation of pus, nor, from its softness[118], so susceptible
of inflammation, as a membrane; an indolent hard swelling, called a
schirrus, comes, merely by the _obstruction_ and _distension_[119] of
its different vessels, very naturally to be produced.”

[116] Bell on Ulcers, p. 319.

[117] Dioni’s Chir. p. 248.

[118] Does inflammation depend upon the hardness or softness of the
inflamed part?

[119] One should expect, that the distension of the vessels would
diminish the cause of obstruction, or remove it altogether.

It is rather unlucky, that the advocates for obstruction have made it
the cause of simple inflammation, scrophula, cancer, &c.; and therefore
all these diseases ought to be nearly, if not entirely, similar in
their nature, and to require exactly the same means of cure.

Some surgeons, perhaps from a desire of singularity, or from a defect
of their organs of sight, declared, that they had detected little
worms in the parts, which, eating it up, produced all the disagreeable
symptoms of cancer; and that to their introduction the disease was
owing. The cure which they confidently proposed, was applying a piece
of cold veal to the part, which would tempt the animals to quit their
devastation. Others, perhaps originally from ridicule, though latterly
in sober earnest, told their readers, that there were no worms, but a
little wolf in the part, which might be made occasionally to show its
head, by holding a piece of meat before the ulcer.

Strange as this doctrine of living creatures producing cancer may
appear, it is nevertheless adopted by a late very ingenious writer.
When hydatids find their way into “a solid substance,” the consequence,
in his opinion, will be cancer; and the success of an operation will,
he conjectures, depend, in a great measure, upon these animals being
confined in a common cyst, for then they may be all removed; whereas,
if they be unconnected, some of the smaller ones may be allowed to
remain[120]. From the surface of the cyst, which contains the animal, a
fungus shoots out, and thus acts as a barrier between it and the skin;
or, if the animal have been in the stomach, it separates it from the
coats of that viscus, “preventing suppuration in the one instance, and
absorption in the other[121].” This suppuration, “and disposition to
fungate before the skin is broken,” if I understand him, is produced
by the death of the animal; for, says he, “if hydatids possess the
principle vitality during their transparent state, and their opacity is
the effect of the loss of that principle, would they not, in the latter
stage, stimulate the part in which they are situated to suppuration, as
we find the case with the Guinea worm when dead[122]?” Concerning the
manner in which these animals produce the symptoms of cancer, we are
told, that “this enlargement of a foreign body, in a solid substance,
and so extremely sensible as the breast, cannot but be attended with
intense pain, and frequent inflammation[123].” A doctrine not far
removed from that taught in the humoural schools, which maintained,
that the coagulation and inspissation of the fluids distended the
follicles of the glands, producing many cavities, and much pain[124].

[120] Adam’s Observations on Morbid Persons, p. 184.

[121] Idem, p. 185.

[122] Adam’s Observations on Morbid Persons, p. 184.

[123] Idem, p. 161.

[124] Van Swieten’s Commentaries, article Cancer.

That hydatids _may_ be formed on a cancerous gland, I shall not
dispute; but that they are generally to be met with, or are in any
respect essential to the disease, I cannot admit. In all the cancerous
breasts, testicles, and tumors, which I have examined, I never saw any
thing which could be considered distinctly as a hydatid; so that I
suspect, that under this name have been described the small cancerous
abscesses, with thick cartilaginous sides, which we so universally meet
with in schirro-cancerous glands. We likewise find cancer take place
in circumstances in which no hydatids can be found. Thus, for instance,
a cancerous wart being knocked off the face, a cancerous ulcer is
produced; but no hydatid is to be found at the base of the wart to
produce this.

When cancer has continued some time, it was believed that the matter
was absorbed, taken into the blood, and that all the humours were
speedily assimilated; and it was by this absorption and assimilation
that they explained the fatal and rapid progress of relapses, after
an apparent cure had been obtained. That matter is absorbed, is an
undeniable fact; but the only effect which is produced by this, is on
the lymphatic glands[125], which intervene betwixt the sore and the
heart; for, beyond these, the matter does not pass qua virus, but is
changed in its nature and properties, as is the case with every other
part or production of the animal, which is absorbed and formed into
part of the blood. Neither cancerous matter, nor variolous matter, nor
syphilitic matter, ever are formed in the blood, or ever can enter into
it, unless by means of an wounded vessel. This point I shall consider
more fully, when I come to treat of the venereal inflammation. Here I
shall only observe, that were the reverse true, then the contagious
matter must pass through every gland, and every portion of the
human form, in as much as the blood circulates in every point; and,
therefore, every spot should become diseased, and every part, in the
same circumstances, should become diseased at the same moment[126].
Disease is not spread in the living system mechanically, by the
absorption of matter, which is conveyed over the whole body, but by the
sympathetic connection of parts, which has been already explained, and
which will afterwards be farther illustrated. It is in consequence
of this, that a distant part shall become diseased, and yet all the
rest remain healthy; and even where every part becomes affected, and
a general disease is suddenly produced from a local sore, as, for
instance, in small-pox, there is no diffusion of matter, nor is it ever
conveyed beyond the lymphatic glands.

[125] Mr. Hunter supposes, that the mere absorption of schirrous
substance before matter be formed, will affect the glands; but it is
difficult to ascertain the certainty of this, as small abscesses are
formed very early. I have formerly mentioned, that every part of the
animal is changed in its nature, at the moment of being absorbed: If
so, schirrous substances lose all specific property, and cannot affect
the glands. Pus, again, being a foreign matter, is absorbed unchanged,
and continues so until it reaches the glands.

[126] It may be said, that different parts have different
susceptibilities of assuming the morbid condition; that the bones are
longer of becoming affected than the soft parts, &c. Admit this, and
still it must be explained, why every part of a similar structure, &c.
should not be affected at the same moment. All the glands should become
diseased at once; all the bones should inflame at the same time; and,
instead of finding one or two organs affected, in consequence of the
previous existence of a local disease, we should find the whole system
rapidly becoming diseased.

In this particular complaint, the consequence of sympathetic action,
or the propagation of action, is sometimes the induction of the
same disease in other parts; but most commonly the effect is the
establishment of the hectic, or diseased formative action; for an
explanation of which I refer to the dissertation on simple inflammation.

By examination, we find, that, in many instances, cancer is evidently
produced by the same causes which are capable of producing simple
inflammation; and, in every instance, I apprehend, that although the
causes may be obscure, yet they are exactly of the same nature. It
is, however, a general opinion, that this disease arises frequently
from some unknown and mysterious cause which we cannot detect, and
which, therefore, has been resolved into some constitutional taint,
or cancerous ferment. But, so far as we know, the constitution is
perfectly healthy in the commencement of this disease; nor is there
the smallest of that it resembles scrophula, in depending upon any
peculiarity of constitution, before the causes operate.

Blows, bruises, and other exciting causes of inflammation, are apt
to produce cancer; but, in many instances, we can detect no evident
local cause acting directly on the part. In the breast, for instance,
we frequently perceive cancer commence without the interference of
any topical agent. In these cases, however, we may uniformly detect
an irregularity or disappearance of the menstrual secretion. It was
formerly observed, that the uterus and mammæ exhibited very powerfully
the sympathy of equilibrium; and it is upon this doctrine, which it is
unnecessary farther to illustrate, that we are to explain the affection
of the breast, which so frequently takes place in consequence of the
cessation of the menses; for when the active state of the uterus is
lost, the action of the mammæ is preternaturally increased, and a
species of slow inflammation is induced. It is upon this principle only
that we can explain why cancers are so frequent at the cessation of
the menses[127]. It is ridiculous to suppose that this discharge acts
as a drain to the constitution, and carries off impurities, which would
otherwise collect elsewhere, and produce local diseases. The breast is
almost the only organ which becomes thus affected without any agent
acting directly upon the part alone; for, in most other instances, we
may detect the operation of such causes at least as tend to induce
simple affections of the same part; but, in both instances, the modus
operandi of the cause is alike, only circumstances are somewhat varied.

[127] It was supposed, that when the menses were obstructed, the
impurities were sent by communicating vessels to the breast, where they
lodged, and produced cancer. Vide Vesalii Opera, p. 1092. Fabricius de
Tum. p. 118.

Le Dran observes, that when schirrus, from any cause, takes place in
the breast, before the cessation of the menses, it uniformly becomes
more painful when any irregularity of that discharge occurs. Vide
Memoires de l’Acad. de Chirurg. Tom. III. p. 22.

When the inflammatory action is slowly induced, whether by a bruise,
or any other cause, acting directly on the part, or by sympathetic
union with another part, we find, that the tumor which is consequent
to this, seldom manifests a disposition to remove quickly, or assume
the healing process. The part neither performs any distinct and acute
inflammatory action, nor does it resume its natural condition and
appearance, but remains in a new state, different from either, which I
will call the state of simple schirrus[128]. If this state, which may
follow the application of the common exciting causes of inflammation
in any part, take place in cellular substance, or similar parts,
which are possessed of no glandular structure, then a chronic tumor is
produced, which is either slowly diminished by absorption, or at last
unable to carry on its actions in perfection, being, in some respect,
insulated, and deprived of the support of the surrounding parts[129];
a diseased action, or morbid performance of its actions, takes place;
a slow inflammatory condition is produced[130], and at last ulceration
succeeds. This, in general, forms pseudo-cancer, provided that the
constitution be simple, that is to say, healthy: But if it take place
in a scrophulous habit, the tumor is apt to become scrophulous, having
its morbid actions modified by the morbid condition of the system. If
this event take place in a lymphatic gland, instead of the cellular
substance, then the tumor is still more apt to become affected with
scrophulous inflammation, in consequence of even a very trifling
scrophulous modification of the habit. If this state be produced in
a secretory gland, the affection is somewhat different from that in
simple parts, or those which do not secrete; because the inflammatory
action becomes somewhat modified by the natural secreting action of
the part; and, in this point of view, the gland may be considered as
possessing a specific constitution, although the general constitution
be simple; for, naturally possessing a peculiar mode of action, it
follows, that new actions induced in such a part, ought to be performed
in a different manner from the same actions in parts which naturally
do not possess this peculiarity, and that the actions ought to be
specifically different. When these parts are attacked with acute simple
inflammation, it differs from inflammation in the cellular substance in
certain circumstances, and particularly in being much more tedious; but
when the nature of the part is still farther altered by the accession
of a slow inflammatory action, which operates in the manner above
described, then it assumes a specific inflammation, which ends in
ulceration. The exact, or specific nature, of this, is various; and the
state, which we call cancerous, is probably only one of the varieties
of this morbid inflammatory action; and whether the part shall assume
this variety, or some other variation, as, for instance, pseudo-cancer,
depends probably upon local circumstances, which we cannot as yet
detect or explain. If, however, the constitution possess any specific
mode of action, the tumor generally assumes nearly the same mode;
and, therefore, in scrophulous people, these tumors more frequently
become affected with scrophulous inflammation, than with cancer: At the
same time, if the previous change on the gland, induced by the slow
inflammatory condition, have been great, the scrophulous condition,
which it possesses in common with the rest of the system, becomes
modified in it, in the same way as the simple condition, in healthy
habits, is modified by the new or schirrous state of the gland; and,
therefore, the scrophulous inflammation is sometimes different, and the
ulceration more fungous than in other parts.

[128] Warts are, with regard to their power of acting, to be considered
in the same light with simple schirri.

[129] See the Note to p. 354.

[130] The simple schirrus now assumes that specific mode of
inflammatory action which it is to continue, and may now be called the
scrophulous or cancerous inflamed schirrus.

The causes, then, of simple inflammation, when they operate slowly,
or leave the part in a state neither inflamed nor healthy, give rise
to a chronic enlargement, and change of nature, which I have called
simple schirrus[131]. This performs, like every other part, certain
actions, which are intended for its own support, and which must make
a part of the general action of the system, or be in unison with the
rest of the body. But as its actions are different in nature from
those which any part of the body naturally ought to perform, and as
originally this organ, (which, from the changes induced on it, is to be
considered as new and extraneous), formed no part of the human frame,
there is not that connection betwixt it and the rest of the system,
which is necessary for its support. It, therefore, does not derive the
same aid and support from the neighbouring parts which natural organs
do, (for no part, or individual organ, can exist and support itself
singly, and independent of the rest), and, accordingly, must soon come
to suffer. It is unable to perform its necessary actions in perfection;
they become morbid, and of an inflammatory nature. The tumor is now an
inflamed schirrus; and this inflammation either assumes a modification,
from the specific nature of the constitution, or from the peculiar
nature of the tumor itself, which, as has been explained, is different
from the healthy state of the tumid part. We have, therefore, the
scrophulous, the cancerous, the pseudo-cancerous inflamed schirrus; and
the symptoms of these different kinds of schirri, and the appearance of
the ulceration, will, cæteris paribus, be modified by the nature of the
part affected. The same disease, therefore, exhibits slight variations
in different organs, as has been described in the history of cancer,
and might, therefore, were we inclined to multiply distinctions, be
considered as so many different diseases.

[131] Schirrus has generally been enumerated as one of the terminations
of inflammation; but it cannot, properly speaking, be considered as
such. There are only two kinds of termination, one in death, as, for
instance, gangrene; the other in recovery, which is accomplished either
directly by resolution, or indirectly by suppuration. Schirrus is not
produced by a perfect and complete cessation of inflammation, but by a
continuance of a low degree of inflammation, which renders the state
of tumefaction which attends it natural to the part, before it goes
off. This state, then, is not a termination of inflammation, but a
consequence of its continuance.

This disease is most apt to take place in elderly people, (in so much
that some consider it as peculiar to old age); because in them, parts
sustain injury of their actions worst, or are less able to recover
from them. Hence, two consequences follow: First, Simple schirrus is
more easily produced, resolution of inflammation being more difficult,
especially in parts which are, at all times, rather tedious in their
recovery, when inflamed: Second, The simple schirrus is more apt to
inflame, or have, what may be called, _its_ necessary actions impeded
and deranged. It must, however, be remembered, that there is no age
whatever exempted from this disease: I have seen it distinctly marked,
and attended with a fatal event, in children of five years old[132].

[132] I have known two cases of this kind; in both the eye was
affected. One boy had his eye extirpated; but a small part being left
by the surgeon at the angle, the disease returned, and proved fatal.
In another, the disease was in its incipient stage; but the relations
would not submit to an operation.

It is a controverted point, how far it is possible to produce cancer
by inoculation; some maintaining, that the application of cancerous
matter to a sound part will induce the disease; others, that it is
altogether harmless. Analogical evidence is certainly in favour of
the first opinion; because the majority of specific ulcers may be
inoculated, and have been so by accident. But, at the same time, it
must be admitted, that there are few well established cases of this
particular point. We find, however, that, like the venereal matter, the
cancerous, when absorbed, induces a disease in the lymphatic glands, of
a cancerous nature. We would, therefore, be led to conclude, that if
the matter be capable of inducing cancer by absorption, in a distant
part, it ought likewise to be capable of producing the same disease
in another person by inoculation. The same be said of the spongoid
inflammation, &c.

From these observations, it will, I presume, appear, first, That
when a part is incapable of performing the actions necessary for its
preservation in a state of health, it generally slowly assumes the
inflammatory state, which goes on to ulceration; but the part being
unable to support its natural action, can much less perform the actions
necessary for restoration from this morbid condition, which, therefore,
continues permanently and progressively increasing; that the nature of
this unhealthy action is not always the same, but admits of variations
dependent upon certain conditions in the previous state of the part
affected, with regard to which we are greatly in the dark. Cancer,
pseudo-cancer, spongoid inflammation, &c. are some of these variations.

Secondly, Cancer, and all these variations, are originally, in the
strictest sense of the word, local diseases, depending neither upon
any constitutional affection, nor the presence of any general cause.
They do, however, in progress of time, affect not only parts in their
vicinity, but also the system in general, producing, by means of
sympathetic actions, specific hectic affections, as has been formerly
explained, when treating of simple hectic. They likewise spread over
more surface in the part at first affected, and produce the same morbid
actions without variation, by means of the sympathia consociationis
serpens. They also induce a similar disease in the nearest lymphatic
glands, by absorption.


_Of the Prevention and Treatment of Cancer._

From what has been said, it will appear, that cancer is to be prevented
by using the most vigorous means for the removal of simple schirri,
upon their first appearance. Of these, local bleeding is the most
powerful, and ought to be freely employed. Next to this, an issue in
the neighbourhood of the part ought to be most depended on; and these
two remedies must be employed early, and continued carefully. Whenever
a simple schirrus arises, we ought to be on our guard, in whatever
situation it may be placed; but, if it occupy a secretory gland, we
require to be doubly vigilant. This, at first, is not painful, at least
the patient only complains of slight uneasiness shooting for a moment
through it. This circumstance too frequently prevents the patient from
attending to it; for where there is no inconvenience sustained, there
is little inducement to apply for assistance; and, not unfrequently,
an ill-judged modesty contributes to this delay. But, although the
patient may be little concerned at this period, yet the surgeon must
not observe the same indolence. Aware of the dangerous consequences of
allowing the tumor to follow its natural course, he will apply leeches
once and again, and insert an issue as near the part as possible. The
remedies called discutient have been much recommended at this stage;
such as sal ammoniac dissolved in vinegar; and this is sometimes
useful, but perhaps not more so than the vegetable acid by itself:
When it does not interfere with bleeding, it may be usefully employed.
By means of these remedies, we may frequently remove recent tumors,
which depend merely upon the enlargement of an organ, without any other
considerable change of structure. But it is more difficult to remove
tumors which are not produced by the mere enlargement of a part, but
depend upon a change of structure, or the formation of new parts; as,
for instance, warts, polypi, &c. The small indolent tumors, however,
which take place in the cellular substance, may sometimes be removed by
the early use of these remedies.

When these means have either been neglected, or fail when employed, and
the schirrus begins to inflame, there is little hope of performing a
cure by either local or general applications; and extirpation affords
the only chance of recovery which can be depended on. But, as it is
not always at the very first certain that the schirrus has assumed the
cancerous inflammation, and is not curable, the operation ought not to
be advised in the first instance, or upon the very first appearance
of the pain, or symptoms of commencing inflammation; on the contrary,
we ought to have recourse to local bleeding, the use of issues, mild
diet, and perhaps the use of cicuta; but if these remedies do not
evidently arrest the progress of the disease, diminish the pain very
considerably, and make the tumor perceptibly softer and less, in the
course of a few weeks, we ought, without hesitation, to advise the
removal of the part, which I shall presently consider.

The local bleeding is to be performed with leeches, which are
preferable to the scarificator, being attended with less irritation.
Three leeches may be applied to the part every second day, as has
been proposed by some writers on this disease. This practice must
be continued for a considerable time; and, during the intervals of
bleeding, cloths dipped in cold water ought to be applied. If, in the
course of a month, the tumor becomes freer from pain, and softer, we
may apply the leeches only every third day, and continue this for
another month, and afterwards either persist for some time longer in
the same way, or repeat the application at longer intervals, according
to circumstances. But if, on the contrary, the tumor become rather
larger, and more painful, as sometimes happens, when the disease is
farther advanced before we begin, and if the constitution suffer by the
repeated evacuations, we must desist.

Issues may be formed, either by introducing a small seton superficially
on each side of the tumor, or by blistering the part, and afterwards
keeping it open with savine ointment. The latter of these methods
is not admissible, when the disease has proceeded so far as to make
the skin adhere to the gland, and become puckered; indeed, at this
period, issues formed in any way ought never to be advised, unless
the operation will not be consented to; because the chance of their
producing a cure is very little, and we lose time by trusting to them.

Mild and spare diet has a very considerable influence over this
disease, in almost every period, and contributes greatly to retard its
progress. It ought therefore rigidly to be conjoined with the bleeding
and issues, in the commencement of the disease, and will tend to abate
the action in the part, and promote its resolution. The diet ought to
consist of stewed apples, or prunes, panada, and weak broths, with
bread. It has even been proposed to prohibit almost entirely the use of
solid food, and to allow the patient nothing but water for the course
of several weeks. This was much recommended by M. Pouteau, who was led
to make trial of it by the success attending the empirical practice
of an ecclesiastic. It was afterwards enforced by Callison; and more
lately abstinence has been favourably mentioned by Mr. Pearson, who
relates some cases of cancer, or appearance of cancer, in the uterus,
in which it produced very astonishing effects, abating the pain,
diminishing the swelling, and re-establishing the general health.

By means of these remedies, we may sometimes succeed in removing by
degrees a schirrus, after it has evidently begun to inflame, and
threatens to become cancerous. But if, notwithstanding these remedies,
the disease evidently continues to increase, or if, in the course of
a few weeks, they do not produce an evident effect, we cannot with
propriety delay the operation, which is the most certain method of
cure, and one which succeeds in a majority of instances, if early and
properly performed; nor ought any other method of treatment to be
proposed in opposition to it, unless in the very commencement of the
inflammatory state; and it is in this period only that I propose the
above treatment, unless the patient absolutely decline the operation;
for when the skin becomes puckered, and the inflammation has continued
clearly for a considerable time, without any measures being taken to
remove it, the success of any local or general remedy is exceedingly
precarious, and delay is not only useless, but frequently dangerous. It
has, however, been doubted by some very ingenious surgeons, whether it
was proper to advise the operation at any period, they believing, from
the number of relapses, that it was almost useless; whilst others have
been against the early performance of it, on the principle, that some
parts already diseased might not have, at this period, become evidently
affected; and, therefore, might inadvertently be allowed to remain.

The late Dr. Monro[133], from observing, that almost all the patients
on whom, to his knowledge, the operation had been performed,
relapsed, is inclined rather to adopt the palliative treatment, than
the extirpation. He takes for granted, that, in the generality of
cases, cancer depends upon some internal cause. In these cases, he
is decidedly averse from the operation, and advises it only when the
disease occurs owing to blows or hurts in young and healthy people.
But, in considering this opinion, we are to remember, that a great
many of these cases may be supposed to have been very far advanced
before any operation was performed; and likewise, that the method
of operating, in that period, was extremely unfavourable to a cure,
the wound being kept open, and suppurations and ulceration rather
encouraged than avoided. More lately, Mr. Hill of Dumfries has
published an account of cases, where the operation was performed in
more favourable circumstances, and of these not a seventh part suffered
a relapse. The present Dr. Monro gives even a more favourable account;
for, if I am not much mistaken, he observes, in his lectures, that not
one-third of the cases in which he had been consulted, had relapsed.
From my own observations, I cannot judge very accurately; because many
of those on whom I have operated, came from parts at a great distance,
and with which I had no intercourse; consequently, I could not hear of
the result of those cases: But of the cases, the sequel of which I have
heard, not a fifth part have relapsed; and in those the operation was
performed at a period when the axillary glands had become diseased, but
were not evidently so; and, therefore, were not extirpated; for, in all
of them, the disease reappeared in the lymphatic glands. But, even from
this relapse, the patients may be cured by a second operation. We may,
therefore, conclude, that, if the operation be early performed, the
majority will recover; and even although the disease should afterwards
appear in the lymphatic glands, the patient is not incurable; for we
frequently succeed in extirpating cancers, when the glands are very
much affected before we are applied to. I have operated in cases where
I was obliged to dissect the glands, from the axillary artery alongst
almost all its course in the armpit, and which reached well nigh to the
articulation.

[133] Med. Essays, Vol. V. p. 422.

With regard to the argument against the early extirpation, founded upon
the possibility of the disease having affected parts in the vicinity,
which have not yet evidently become diseased[134], I may observe, that,
upon the same principle, we ought not to operate until the axillary
glands swell; because they may be affected, although they be not yet
evidently enlarged; and, therefore, may give rise to a relapse. If we
only remove the single gland in the breast, which is hard, we doubtless
run a great hazard of a relapse; but, I apprehend, that this ought
never to be done, and that the whole of the glandular part of the
breast ought to be removed at once; because we thus more certainly
prevent a return of the disease, which we cannot otherwise, with any
certainty, do. The additional pain is very inconsiderable; and we can
derive very little advantage or benefit from leaving a part of the
mamma behind.

[134] Pract. Obs. on Cancerous Complaints, by Mr. Pearson, p. 50.

The caustic has been proposed, instead of the knife, for the removal of
cancer schirrus; but it is much less certain, more tedious, and even
more painful. Instead, therefore, of recommending itself to timorous
patients, this practice is still more to be dreaded than the excision,
which is more terrible in anticipation, than in the actual performance
of it.

The caustic most commonly, and indeed almost universally, employed,
is arsenic, mixed with various inert substances, and formed into a
paste or ointment[135]. This has been applied in two ways; first,
directly upon the skin, covering the schirrus, and then, after this
is destroyed, upon the schirrus itself, destroying it layer by layer;
second, directly upon the skin, and then, instead of applying it to the
gland, to put it round it on the surrounding cellular substance, and
by gradually destroying this round the gland, to turn out the schirrus
entire. This was the practice of Mr. Guy, who gained considerable
credit by his success; and, since his time, it has occasionally been
performed with success by some others[136].

[135] Arsenic mixed with sulphur, and powdered crow-foot, and made into
a paste with yolk of egg, forms Plunket’s composition. Mixed with forty
times its weight of powder of belladona, it forms an application which
some time ago was much in repute in North America.

[136] Justamond on Cancers, p. 141. This gentleman relates a case, in
which, by destroying the skin with lunar caustic, and then applying
arsenic, he removed the gland. The arsenic, in this instance, was fused
with antimony, in proportion of two parts of the first to one of the
last. This was powdered and mixed with equal parts of powdered opium,
and made into a liniment with yolk of egg.

This method, however, is liable to several material objections: It is
uncertain in its issue; for, if the gland be not completely removed,
the disease makes a rapid progress afterwards. It frequently happens,
that some smaller glands around the large one are affected; and
these are greatly irritated by the action of the caustic in their
vicinity: It is more painful than the operation with the knife; and the
subsequent process of healing, even granting the method to succeed in
removing the diseased part, is much more tedious than when the incision
is employed, and union by the first intention procured.

On all these accounts, but most especially on account of its
uncertainty, the method of cure by caustic can never be sanctioned by
any modern surgeon, much less can it ever be held up in opposition to
extirpation by the knife.

This practice, which has had many advocates for its employment in
schirrus, has been equally recommended in cases of cancerous ulcers;
but here it is still less admissible; for the extent of diseased parts
is generally greater; the neighbouring parts are affected to a greater
distance; indurated and diseased lymphatics frequently extend from the
breast to glands in the axilla. It is, therefore, next to impossible
to turn out the morbid parts, as “nuclei,” by destroying the substance
around them; and it is equally improbable that we shall, unless the
sore be very small, and the caustic very strong, be able to make it
slough off in successive layers. Farther we can propose no advantage to
ourselves, from employing caustic in preference to the scalpel; because
in every instance in which we can destroy the parts by means of this,
we can equally safely, infinitely more speedily, and with much less
pain, remove the parts with the knife. There is only one case in which
caustic is useful, and that is merely as an appendage to the operation
of excision. When we dissect off ulcers from parts where, owing to
the want of cellular substance, the skin is not lax enough to be
brought over the parts, or when so much of this has been removed, that,
although lax, it cannot be made to cover it, we may find it of service
to rub the bottom of the wound with lunar caustic, as we thus stop the
oozing of blood, and destroy any little portions of the diseased part
which we may have left.

For the purpose of destroying cancerous ulcers, many caustics and
escharotics have been proposed, such as the arsenic, corrosive
sublimate, lunar caustic, &c. Of these no one seems to possess a
preference over the rest, if we consider only their local action; but
some of them, especially arsenic, are apt to produce bad effects, and
that very unexpectedly, on the constitution.

After making these remarks upon the method of cure, I shall conclude
with some observations on different remedies, which have been proposed
as palliatives, where the operation is not admirable, or will not be
consented to, and which have even been supposed capable of changing the
mode of acting altogether, and producing of themselves a cure. These
remedies I shall divide into general and topical.

Of the general remedies, those which have been most frequently, and
with the greatest confidence, employed, are narcotics, such as the
cicuta, opium, nightshade, &c.

The cicuta is a medicine which was, at one time, in very high repute,
and owed its reputation to the experimenting talent of Storck, who
has written several libelli on this plant. According to him, cicuta
possesses very evident powers over cancer, and has cured a great many
cases; but, in less prejudised hands, it has been much less successful;
and even in many of the instances adduced by Baron Storck of its
utility, it is by no means proved, that the disease was really cancer.
The present opinion of the public seems to be very unfavourable with
regard to this medicine; and from the numerous instances in which it
has failed, this opinion seems to be very just. Alongst with the proper
local applications which have been formerly noticed, it sometimes is of
service in removing simple schirri[137]; but I have never found it of
any service when the schirrus had affirmed the cancerous inflammation,
much less when it has proceeded the length of ulceration. In the last
case, I have never found it even produce the temporary melioration
which many talk of.

[137] If I am not mistaken, the present Dr. Monro mentions, in his
lectures, one instance, in which a small schirrus appeared to be
removed by it; but whether this was simple or cancerous, I do not know.

The common way of exhibiting the hemlock, is to begin with small
doses, and increase these gradually, until they produce vertigo: For
this purpose, we may begin with two grains of the extract, or four of
the powder, recently prepared, twice or thrice a-day, and gradually
increase the quantity[138]. In this way, we find that some patients
have come to take an ounce of the extract daily; but if a much less
quantity than this produce no good effect, we may consider it as
useless to continue a remedy, which, in this dose, must injure the
constitution every day that it is continued. On the continent, the
hemlock has been used in the form of a bath; but it is so disagreeable,
that few can be brought to use it.

[138] As different parcels of this medicine may not be of the same
strength, it is prudent, when we begin a new supply, that we diminish
the dose at first, if it have formerly been very considerable. By not
attending to this, fatal effects have followed.

The belladona has been much recommended by Lambergen, who tried it in
many cases of cancer; but these trials, when repeated with attention,
have not been greatly in favour of the remedy. During its use, he kept
the bowels open with clysters, administered every second day. The
dose, at first, ought to be a grain of the dried leaves, made into a
pill. This, in the beginning, is to be given morning and evening, and
afterwards more frequently.

The hyocyamus has also been frequently used in cancer, and was very
much in repute with the ancients. I have tried it occasionally, but
with very little effect. The dose with which we begin, is two grains of
the extract.

The aconitum is a more powerful and dangerous narcotic, in so much that
a quarter of a grain of the extract is generally the dose with which we
begin.

The solanum dulcamara, Paris quadrifolia, phytolacca, &c. have been
likewise recommended and employed, but are now so little used, that it
is unnecessary to take any notice of them here[139].

[139] I have tried the hepatized ammonia, but without any benefit.

The laurus cerasus is a very powerful narcotic, and has been used, in
this particular complaint, by Richter, but with very little success.
The most common preparation of this medicine, is the distilled water;
but the dose of this is very uncertain. Some have, therefore, proposed
to give, for a dose, four or five grains of the fresh leaves infused in
a little water.

The digitalis has a considerable power of abating vascular action, and
may, therefore, be of use, in the same point of view with abstinence,
bleeding, &c. in abating the action of schirri; but concerning its
real utility in this disease, I cannot say any thing with certainty.

Opium is seldom employed with an intention of curing this disease,
although it is probable, that it possesses just as much power over
cancer, as those other narcotics which have been more frequently used.
It is, however, liberally employed with a view to abating the pain of
cancerous ulcers.

Tonic remedies have frequently been used in this disease; but although
they may sometimes improve the general health, yet they never produce
any effect upon the local disease. On this account, they are now very
seldom employed.

Arsenic is a medicine, which has, by some, been considered as a
specific against cancer[140]; but even those who maintain this, add,
that although they _believe_ and _think_ so, yet they have not been
able to administer it in such quantities as to produce any good effect.

[140] Justamond on Cancers.

Mercury[141] has also been recommended; but there is no fact more
certainly ascertained than this, that mercury uniformly exasperates
this disease, especially when it has proceeded the length of
ulceration. In this case, the sores enlarge rapidly, become much more
painful, and bleed frequently. It is worthy of observation, that those
who are affected with cancer, have in general the mercurial action
induced very easily and very speedily[142]; and the changes which take
place on the ulcer are equally rapid. This circumstance, of mercury
increasing the disease, in so marked a manner as it usually does, ought
not only to make surgeons careful of exhibiting this remedy, upon
slight suspicions of the sore being venereal[143], but may likewise
be attended to as a step toward the discovery of a better mode of
treatment for cancer than we yet possess; because if, at any time,
we discover the means of directly displacing and counteracting the
mercurial action, we may perhaps find the same to be useful in abating
the cancerous; these two actions appearing to possess some general
coincidence, from their mutual effect in increasing each other.

[141] Alongst with this, it was customary to prescribe decoctions of
guaiac, sarsaparilla, &c.

[142] It likewise continues very long after giving up the use of the
mercury.

[143] Some cases of this kind I have already mentioned.

Copper, in the form of cuprum vitriolatum, has been used in cancer; and
one case is recorded, in which it is said to have produced a cure; but
in every other case it has failed; and, from the violent effects which
it is apt to produce, considerable danger attends its exhibition.

Muriated barytes has been proposed as a cure for this disease; but now
none employ it with this expectation.

The same remedies which internally have been supposed to cure cancer,
have also been proposed as local applications.

Amongst the older practitioners, narcotics were very currently employed
as a dressing for cancerous sores. Vesalius used cloths dipped in
the juice of the solanum; whilst others employed it mixed with oil
of roses, and preparations of lead and antimony. Others had recourse
to the hyocyamus; whilst of late the cicuta poultices seem to have
superseded the use of most other narcotic preparations. These have,
undoubtedly, in many cases, abated the pain, and diminished the fœtor;
but this is all which can reasonably be expected from them; and even
this expectation will not always be realised.

Carrot poultices are still more useful, as they possess the property
of abating the fœtor, in a degree superior to the hemlock, and give
generally as much ease. This fœtor has been long compared to the smell
of hepar sulphuris, and lately has been supposed to arise altogether
from the formation of a substance of this nature, consisting of sulphur
and volatile alkali. As it has been too much the case in medicine, to
overlook causes, and attend to effects, so we are not to be surprised,
if we find some physicians proposing to cure cancer, by remedies
which shall decompose the matter which is yielded in that disease, or
destroy the effect of the morbid action, whilst the action itself is
overlooked[144]. From experiments made upon the hepatized ammonia, it
was found, that the oxygenated muriatic acid was the best agent for
decomposing it, and destroying its smell. This fluid was, therefore,
highly recommended as an application for cancerous sores; and, in many
instances, it will indeed be found to correct the fœtor, which is
certainly one advantage; but it never will perform a cure.

[144] Although the fœtor may depend upon the presence of hepatized
ammonia, yet this does no harm to the ulcer. On the contrary, I have
sometimes found the application of this fluid, when mixed with water,
have the effect of abating the pain.

Carbonic acid has been said not only to correct the fœtor, but also,
in some instances, completely to cure the disease. It was long ago
proposed by M. Peyrilhe, and of late it has again been brought
forward by Dr. Ewart, who has published a case in which it produced
cicatrization; but although, upon his recommendation, it has been
frequently employed, yet it has very seldom been of any considerable
service, and I have heard of no instance in which it produced any
permanent amendment. It would rather appear, that the opinion of M. de
Fourcroy was the just one: “After the first applications (says he),
the cancerous sore appears to assume a more favourable aspect, the
sanies which flowed from it becomes whiter, thicker, and purer, and the
flesh has a redder and fresher colour; but these flattering appearances
are deceitful, nor do they continue long, for the sore speedily
returns to its former state, and its progress goes on as before the
application.” The best method of applying this, is by means of a
bladder, the mouth of which is fastened round the sore, by means of
adhesive plaster. The air is introduced by a pipe inserted at the other
end. When first applied, the gas produces a sensation of coldness,
which is soon followed by a glowing heat, and abatement of the peculiar
pain of the sore. At other times, it, from the first, produces a
smarting, and makes the patient rather more uneasy. This is especially
the case if we use the fermenting poultice, instead of the air already
extricated.

Digitalis, applied either in poultices or infusion, has been said to
abate the pain, and meliorate the appearance of the sore; but, in this
respect, it seems to be very much on a level with cicuta.

Tar ointment, gastric juice, absorbent powders, and many other
applications, which it is unnecessary to enumerate, have been proposed;
but as their utility is by no means evinced, I shall not detain the
reader with any remarks upon them.

Caustic, and escharotic preparations, have been already considered.

Upon the whole, when the ulcer does not admit of being extirpated, all
which can be done, is to keep the sore clean, by washing it carefully,
and dressing it with some mild ointment, or using some of the poultices
or lotions already mentioned, if these do not gall the skin, at the
same time that we keep the patient easy by administering opium.

       *       *       *       *       *

Having now concluded these observations on the cancerous inflammation,
I should next proceed to the consideration of the venereal
inflammation; but the dissertations on this subject must be reserved
for another volume.


END OF VOL. II.


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